ORIGINAL REPORTS

Is Video-Based Education an Effective

Method in Surgical Education?
A Systematic Review

Akgul Ahmet, MD, * Kus Gamze, MSc, PT,†,‡ Mustafaoglu Rustem, PhD, PT,§ and
Karaborklu Argut Sezen, MSc, PT║

*Department of Gerontology, Faculty of Health Sciences, Istanbul University, Istanbul, Turkey; †Division of
Physiotherapy and Rehabilitation, Institute of Health Science, Istanbul University, Istanbul, Turkey; ‡Department
of Physiotherapy and Rehabilitation, Mustafa Kemal University, Hatay, Turkey; §Department of Neurological
Physiotherapy and Rehabilitation, Faculty of Health Sciences, Istanbul University, Istanbul, Turkey; and
║
Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Istanbul University, Istanbul,
Turkey

OBJECTIVE: Visual signs draw more attention during the
learning process. Video is one of the most effective tool
including a lot of visual cues. This systematic review set out
to explore the influence of video in surgical education. We
reviewed the current evidence for the video-based surgical
education methods, discuss the advantages and disadvan-
tages on the teaching of technical and nontechnical surgical
skills.
METHODS: This systematic review was conducted accord-
ing to the guidelines defined in the preferred reporting
items for systematic reviews and meta-analyses statement.
The electronic databases: the Cochrane Library, Medline
(PubMED), and ProQuest were searched from their incep-
tion to the 30 January 2016. The Medical Subject Headings
(MeSH) terms and keywords used were “video,” “educa-
tion,” and “surgery.” We analyzed all full-texts, randomised
and nonrandomised clinical trials and observational studies
including video-based education methods about any sur-
gery. “Education” means a medical resident’s or student’s
training and teaching process; not patients’ education. We
did not impose restrictions about language or publication
date.
RESULTS: A total of nine articles which met inclusion
criteria were included. These trials enrolled 507 participants
and the total number of participants per trial ranged from
10 to 172. Nearly all of the studies reviewed report
significant knowledge gain from video-based education
Correspondence: Inquires to Argut Karaborklu Sezen, MSc, PT, Istanbul Universitesi,
Saglık Bilimleri Fakultesi, Fizyoterapi ve, Rehabilitasyon Bolumu, Demirkapı Cad.
Karabal Sk. 34740, Bakirkoy, Istanbul, Turkey; e-mail: sezen.karaborklu@istanbul.
edu.tr
techniques. The findings of this systematic review provide
fair to good quality studies to demonstrate significant gains
in knowledge compared with traditional teaching. Addi-
tional video to simulator exercise or 3D animations has
beneficial effects on training time, learning duration,
acquisition of surgical skills, and trainee’s satisfaction.
CONCLUSION: Video-based education has potential for
use in surgical education as trainees face significant barriers
in their practice. This method is effective according to the
recent literature. Video should be used in addition to
standard techniques in the surgical education. ( J Surg Ed
]:]]]-]]]. J
C 2018 Association of Program Directors in
Surgery. Published by Elsevier Inc. All rights reserved.)
KEY WORDS: surgery, medical education, resident, sys-
tematic review
COMPETENCIES: Medical Knowledge, Practice-Based
Learning and Improvement
INTRODUCTION
Knowledge and skills of surgeons are critical for surgical
success and the safety of patients in that operations may
cause several life threatening complications. Moreover,
surgical education is a lifelong learning process. There are
several problems that adversely affect the surgical learning
process, such as restriction of surgical training hours
through clinical work during training, increased information
with development of technology, new skill requirements
to implement new surgical technologies.1-3 Both surgical
educators and students/residents struggle with these
problems.

Journal of Surgical Education
& 2018 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 1
Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jsurg.2018.01.014
 Visual signs draw more attention during the learning
process.4 Video is one of the most effective tools that
provide numerous visual cues. In fact, there is a correlation
between visual–spatial ability and surgical performance in
novices.5-7 In addition, improved visual appearance help
medical students to better understand the progress of
clinical procedures.8
In recent years, computer-based video instruction has
become an indispensable complement to the teaching of
basic surgical skills.9 Therefore, this review aims to explore
the effect of using videos on surgical education. In this
article, we review the current evidence on the video-based
surgical education methods and discuss its effectiveness on
the teaching of surgical skills.
METHODS
This systematic review was conducted following guidelines
defined in the preferred reporting items for systematic
reviews and meta-analyses statement.10 Data were collected
by searching electronic databases and scanning reference
lists of articles manually. The electronic databases, the
Cochrane Library, Medline (PubMED), and ProQuest were
searched from their inception date to January 30, 2016. In
addition, we handsearched the reference lists of included
articles. The Medical Subject Headings (MeSH) terms and
keywords that we used in our search were “video,”
“education,” and “surgery” (Appendix).
We searched all full-texts, randomised and non-rando-
mised clinical trials and case controlled studies including
video-based education methods about any surgery in the
database. In this paper, “education” is defined as the
training and teaching process of a medical resident or a
student. It does not mean the education of patients. In this
review, we did not impose any restrictions on thelanguage
and publication date of studies. We aimed to hand-search
for non-English publication bibliographies to extend the
search results.
We included the studies involving video training for
students or residents in any surgical specialty in the
database. Non-English publications, editorials, reviews,
cohort studies, technical reports, books, conference
abstracts, and case reports as well as studies involving
patient education were excluded. The eligibility determi-
nation was performed by a consensus, which consisted of
3 reviewers. One of the reviewers studied to extract the
data from the included full texts; and the other one
checked the extracted data. In the case of any disputes, the
third author made the final decision. Our review is
focused on the role of video-based education in surgery:
therefore, the search strategy is limited to identifying
articles that focus on surgical education.
The quality of included articles’ assessment follows
National Institute of Health guidelines on systematic review
2 Journal of Surgical Education
Volume ]/Number ]
] 2018
using standardized National Institute of Health Study
Quality Assessment Tools. Based on the questions of
the Quality Assessment Tools, two independent reviewers
(R.M. and G.K.) judged the overall quality of the study as
“good,” “fair,” or “poor.”11
RESULTS
Our search provided 258 articles. Once the duplicates are
excluded, a total of 207 articles were analyzed according to
their titles and abstracts. Then, 30 full text articles were
examined by the consensus, 29 fulltexts were analyzed,
where 18 of them were excluded due to the fact that video-
based method was not used directly in surgical education of
medical students or residents (n ¼ 16) and 4 other studies
were not clinical trials. Details of the eligibility process is
demonstrated in the Figure. We extracted relevant data
from 9 fulltexts included in our review.9,12-19
Study Characteristics
We provide the details of all included trials in Table 1.
Eight of the trials were randomized clinical trials9,12-16,18,19;
one of the trials was a case controlled study17; 7 of the trials
compared 2 methods,12-15,17-19 and 2 of trials included 3
groups.9,16
Participants
The 9 trials included a total of 507 participants, where the
total number of participants per trial ranged from 10 to
172. Most of the participants were students (n ¼ 402) and
the rest was residents or staff surgeons. Types of surgical
procedures in the studies covered here were laparascopic
cholecystectomy,14,19 cataract and glaucome surgery,12
dental surgery,16 urology-obstetrics and gynecology,17,18
and general surgery.15 The procedures for 2 of the studies
in the database were not clearly defined. Most of thestudies
especially focus on sturing and knot tying skills. Trials were
undertaken across a range of geographical locations includ-
ing the United States (n ¼ 4), UK, Canada, Australia,
Netherland, and Brazil.
Surgical Education Methods
Table 1 provides descriptions of the educational methods in
the reviewed studies. In this review, there were 6 clinical
trials that compared the video-based learning style to the
traditional learning style in surgical education. Traditional
education comprised verbal lectures, theoretical seminars,
training in the skills laboratory, verbal feedback by super-
visor surgeons, and text reading.13-17,19 In 3 of the studies,
the authors compared video settings to other surgical
education methods. For example, the first of these studies
compared 3D animations and video sequences to only video
 Idenficaon
Records idenfied through Addional records idenfied
database searching through other sources
(n = 251) (n = 7)

Records aer duplicates removed

(n = 207)
Records excluded (n = 178)
Screening

• Studies including paents’

educaon
Records screened • Studies not including video based
(n = 207) educaon
• Types of studies (editorials,
reviews, technical reports etc.)

Full-text arcles assessed Full-text arcles excluded (n = 20)

for eligibility • Not used directly video based
Eligibility

(n = 29) educaon of medical students or

residents (n = 16)
• Types of studies (n=4)

Studies included in
qualitave synthesis
(n = 9)
Included

Studies included in the

systemac review
(n = 9)

FIGURE. Flow diagram.

sequences.12 The second study assigned the students to 3
practice conditions: self-study with video; self-study with
interactive video; or the combination of self-study with
interactive video with the addition of subsequent expert
instruction.9 Third one compared the groups; simulator
exercise and peer feedback of video-recorded through a
social networking web page versus without video peer
feedback.18
Video-Based Education Versus Conventional
Education
In 4 of the studies there were significant improvements in
assessment scores, acquisition of surgical skills and techni-
ques in favor of video-based education groups.13,14,17,19
Authors of that study argue that using the video settings in
surgical education offered sufficient opportunities to inte-
grate theoretical and clinical understanding. In addition,
they found that the group with video-based education
completed the operations with significantly less verbal
support.19 However, the authors reported that there were
no significant differences between groups.15,16 Stain et al.
demonstrated that the video settings could be used as a way
of remote teaching and could allow students to receive
interactive lectures at distant clinical sites. The details are
reported in Table 1.
Video-Based Education Versus Other
Educational Methods
Carter et al.18 compared the simulator exercise with video
feedback to the simulator-only exercise. Study results
emphasized that video feedback was associated with better
simulation scores and provided benefits for acquisition and
improvement of technical skills.
Prinz et al.12 compared 3D animations and video
sequences with video-only sequences. There were significant
differences in topographical understanding (p ¼ 0.0001)
and in theoretical understanding (p ¼ 0.003) in the 3D
group compared with the video-only group.
Comparison of Video-Based Education
Techniques
Nousiainen et al. 9 compared three practice conditions:
self-study with video; self-study with interactive video;
or the combination of self-study with interactive video
with the addition of subsequent expert instruction.
Although all 3 groups demonstrated significant
improvements on both measures between the pretests
and posttests as well as between pretests and retention
tests, no significant differences were detected among the
3 groups.

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 4

Table 1. Details of Included Studies

Assessment
(TP: Time Points)
Study Participants Surgical Duration of (OM: Outcome
Study design (n) Procedures Learning Groups Education Measures) Results
Video based versus conventional education
Crawshaw Randomized Residents (54) Laparascopic Standard 18-minute video • TP: After completion Residents in the video group
et al.19 controlled cholecystectomy preparation of the case scored significantly higher in
trial Standard • OM: Resident perfor- total score (p ¼ 0.002) and
preparation. Plus mance by Global overall performance score
narrated assessment scale (p o 0.001).
instructional
video
Farquharson Randomized Medical Basic surgical skills Standard verbal Not clearly • TP: before feedback; There was a significant
et al.13 controlled students (48) feedback plus defined after feedback improvement in the mean
trial video • OM: objective stru- overall procedure score for
Standard verbal ctured assessment of standard verbal feedback plus
feedback alone technical skill; task video (p ¼ 0.003), but not for
specific checklist other group. There were
significant improvements in the
specific domains of instrument
familiarity, needle handling,
skin handling and accurate
Journal of Surgical Education
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apposition, in plus video group

(p o 0.05). The only
significant improvement in
standard verbal feedback
alone group was in an
organized approach to the
task (p ¼ 0.045).
Autry et al.17 Randomized Intern Urology-obstetrics Standard learning 4 weeks • TP: preintervention; There was significant
case physicians and gynecology 2 weeks after improvement at OSATS score
control (18) completion of the in the intervention group
clinical trial study compared with the standard
• OM; objective stru- learning group (p ¼ 0.04).
Standard learning ctured assessment of The standard learning group was
and remote technical skills less likely to practice knot-tying
teaching sessions (OSATS) score; than the intervention group
(video ınternet survey (p ¼ 0.007). The trainees and
communication) the instructors felt this method
of training was enjoyable and
helpful.
Journal of Surgical Education
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Van Det Randomized Surgical Laparascopic The usual 1-minute video • TP: after the study Skill improvement on the OSATS
et al.14 controlled residents cholecystectomy traditional master- clip × • OM: objective stru- global rating scale was
trial (10) apprentice model 7 stages/2 ctured assessment of significantly greater for the
(MAM) þ video- weeks technical skills trainees in the INVEST
enhanced technique; trainee’s curriculum compared to the
surgical training opinion MAM (p ¼ 0.02). The trainees
(INVEST) questionnaire in the INVEST group totally
The usual agreed with the statements that
traditional master- intraoperative video training is
apprentice model fun. The answers trainee’s
(MAM) opinion questionnaire in the
MAM group were similar and
not statistically different (p 4
0.05).
Dantas Randomized Dental students Dental surgery Active learning 15-minute video • TP: immediately after At the first evaluation, the text
et al.16 controlled (30) (interactive for group 3 the instruction; 30th group results were inferior
trial meeting, students day after the when compared to the active
were presented) instruction; 60th day learning (p ¼ 0.0002) and text
Text reading only after the instruction and video (p ¼ 0.0468)
Text reading and • OM: a self-evaluation groups. At the second
video test; observer’s evaluation, the text and video
demonstration checklist group’s results were worse
when compared to the active
learning ones (p ¼ 0.0008). At
the third evaluation the scores
did not differ among them.
Stain et al.15 Randomized Surgical General surgery Videoconference 6 hours/4 week • TP: after the study There were no significant
controlled clerkship (orthopedics, lecture • OM: quiz results differences in the mean scores
trial students urology, Conventional (% correct) of the individual quizzes or
(110) ophthalmology, lecture between the totals (p 4 0.05).
otolaryngology,
neurosurgery,
plastic surgery)
Video based versus other type education
Carter Randomized Resident Urology-obstetrics Simulator exercise 3 sessions /6 • TP: before and after The video feedback group scored
et al.18 controlled physicians and gynecology with peer feedback week the intervention; significantly higher than without
trial (41) of video-recorded after each session video feedback group at sessions
performance • OM: prestudy and 2 and 3 (p ¼ 0.009, and p ¼
Simulator exercise poststudy surveys 0.019, respectively). The mean
Without peer feed- (comfort level, time to complete the task was
back of video- satisfaction etc.); shorter for the video feedback
recorded simulator score and group than for without video
performance completion time feedback group during sessions
2 and 3 (p ¼ 0.004, and p ¼
0.006, respectively). Video
feedback group were more
comfortable with robotic surgery
5
 6

Table 1 (continued)
Assessment
(TP: Time Points)
Study Participants Surgical Duration of (OM: Outcome
Study design (n) Procedures Learning Groups Education Measures) Results
(p ¼ 0.021) and expressed
greater satisfaction with the
learning experience (p ¼
0.014).
Prinz et al.12 Randomized Medical Cataract and 3D animations and Approximately • TP: immediately There were significant differences
controlled students glaucome surgery video sequences 10 minute × after the practice in topographical understanding
trial (172) Only the surgical 2 procedures • OM: a multiple (p ¼ 0.0001) and in theoretical
videos choice test of 19 understanding (p ¼ 0.003) in the
questions 3D group compared with the
only video group.
Comparison of video based education techniques
Nousiainen Randomized Medical Basic surgical skills Self-study with video Approximately • TP: before practice; Although all three groups
et al.9 controlled students (24) Self-study with 30 to 40 immediately after demonstrated significant
trial interactive video minute the practice; improvements on both measures
The combination of 4 weeks between the pretests and
self-study with • OM: retention test; posttests as well as between
interactive video expert-based pretests and retention-tests (p o
with the addition of assessments; 0.01), no significant differences
subsequent expert computer-based were detected among the
Journal of Surgical Education
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instruction assessments 3 groups.

Table 2. Methodological quality of studies
Questions

Trials Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14 Total Score

Crawshaw et al.19 Y Y Y N Y Y Y Y Y Y Y Y Y Y 13
Stain et al.15 Y N N N N U Y Y Y Y N U Y Y 7
Farquharson et al.13 Y Y Y Y Y U Y Y Y Y Y U Y Y 12
Autry et al.17 Y N N N N U N Y Y Y Y U Y Y 7
van Det et al.14 Y N N N N U Y Y Y Y Y N Y Y 8
Dantas et al.16 N N N N Y Y U U U Y N N Y N 4
Nousiainen et al.9 Y N N N Y Y U U U Y Y Y Y U 7
Prinz et al.12 Y Y N N N U Y Y Y Y N N Y Y 8
Carter et al.18 Y Y N N N Y N Y Y Y N U Y Y 8
Y, yes; N, no; U, unavailable.
Q1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT?
Q2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?
Q3. Was the treatment allocation concealed (so that assignments could Nt be predicted)?
Q4. Were study participants and providers blinded to treatment group assignment?
Q5. Were the people assessing the outcomes blinded to the participants group assignments?
Q6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, comorbid
conditions)?
Q7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
Q8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
Q9. Was there high adherence to the intervention protocols for each treatment group?
Q10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
Q11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
Q12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at
least 80% power?
Q13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
Q14. Were all randomized participants analyzed in the group to which they were originally assigned, that is, did they use an intention-to-treat
analysis?

Methodological Quality of Studies
Studies included in this review had fair to good quality. The
methodological quality of the studies ranged from 4 to 13
on a scale from 0 to 14 points. Table 2 provides an overview
of the methodological quality of the included studies.
DISCUSSION
This systematic review investigates the usage and benefits of
video-based education for surgical training. Although there
is a growing interest in education methods that are not
conventional, there is currently only a few clinical studies
with limited quality. This review detected 9 trials that
assessed the utility of video-based methods as educational
tools for surgical training.
Several studies reported significant knowledge and surgi-
cal skill gains from the usage of video-based education
method in addition to any conventional techniques. The
overall methodological quality of the reviewed studies was
considered as fair to good with an average score of 8.2
(range: 4-13) on the National Institute of Health Study
Quality Assessment Tools.11 The methodological failure of
the studies included the lack of concealed allocation,
providers blinding, assessor blinding and similar baseline
characteristics and sample size. For these reasons, it is
required blinding studies for confident results.
In several studies,13,14,17,19 video-based education was
reported to be superior to conventional education. Accord-
ing to Crawshaw et al.,19 watching an instructional video
before surgery may shorten the learning curve of trainees
and improve safety. Farquharson et al.13 indicated that
usage of video in addition to verbal feedback has benefits of
providing internal feedback that would improve the learning
experience and is fundamental to surgical skills. In addition,
Autry et al.17 used video-based remote sessions for cross-
continental education of surgical trainees. This type of
teaching is a good way to foster ongoing collaboration and
to help build a meaningful relationship between depart-
ments with significant geographical constraints. In van Det
et al.14 it is reported that video plus conventional education
improved learning, made it easier to use in daily practice,
and costed very little extra time.
Additional video to simulator exercise and 3D animations
were found to be more effective methods to teach surgicals
skills.12,18 The authors in these studies argue that video
feedback helps promote faster acquisition of skills and
accelerates the learning curve as well as satisfaction.18 Prinz
et al.12 state that the use of multimedia in e-learning is
indispensable. Based on these findings, it can be concluded
that additional video-based education has benefical effects

Journal of Surgical Education
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] 2018 7

on training time, learning duration, acquisition of surgical
skills, and trainee’s satisfaction. As is widely known, a
person usually retains only 10%-15% of what is read,
10%-20% of what is heard, and 20%-30% of what is seen.
However, when audio and video materials are presented side
by side, it is found that the retention of knowledge increases
to 40%-50%.12 This is another positive effect of video-
based education. In contrast Dantas et al.16 and Stain
et al.15 did not find any significant evidence in favor of
the video-based education in comparison to conventional
methods. However, they used self-evaluation tests as well as
quizzes, which are not appropriate tools in educational
assessment whichmay negatively affect their results. Fur-
thermore, Nousiainen et al.9 compared the self-study with
video, self-study with interactive video, and the combina-
tion with the addition of expert instruction methods. They
did not find any significant difference among the 3 groups.
Based upon these findings, video may be useful without
expert instructions in cases where limited opportunities exist
such as due to geographical constraints.
Video-based education is very satisfying tool in surgical
education, especially in case-based procedures. However,
some drawbacks may occur. Some details may underesti-
mated during video-based education. For instance, students
are being focused the whole procedure and may miss some
technical details. To underline some minor, but important
points, an instant image may be more effective than moving
pictures.
This systematic review has several limitations due to the
heterogeneity of the studies with respect to outcome
measurements, educational levels and number of partici-
pants. Based on such heterogeneity, it remains difficult to
accurately assess the clinical effect of any surgical education
methods.
Future research should focus on better characterizing the
link between the use of surgical video and overall surgical
skills. This would require larger, blinded prospective trials
with long-term follow-up. In addition, future research
should give priority to the integration of standardized
assessment tools which facilitates the surgical performance
and skill of students/residents.
CONCLUSION
In conclusion, video-based education can provide substan-
tial benefits in surgical education by reducing the significant
barriers that the trainees face in their practice. The findings
of this systematic review provide fair to good quality studies
to demonstrate significant gains in knowledge compared
with traditional teaching. It is also found that additional
video to simulator exercise or 3D animations has beneficial
effects on training time, learning duration, acquisition of
surgical skills, and trainee’s satisfaction. In summary, video-
based surgical education method is effective according to the
8 Journal of Surgical Education
Volume ]/Number ]
] 2018
recent findings in the literature. Video-based education
should supplement the standart techniques in the surgical
education.
APPENDIX: SEARCH STRATEGY
For the Pubmed database the following combination was
used: “video[tiab]” AND “education[tiab]” AND “surgery
[tiab]” in clinical trials.
For the Cochrane Library database the following combi-
nation was used: “video” AND “education” AND “surgery”
in Title, Abstract, Keywords in trials.
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