Background:This randomized controlled trial compared the efficacy of virtual-reality (VR) simulator training and surgical training on live pigs to explore the most effective and evidence-based training modality.Materials and methods:Thirty-six novice surgical residents without independent laparoscopic experience were randomly paired with a peer and randomized into three groups: VR simulator group (dyad training on LapSim VR simulators), pig surgery group (training on live, anesthetized pigs) and control group (training by a lecture on laparoscopic surgery, surgical videos and textbooks). After 6 h of training, all participants performed a simulated cholecystectomy procedure using a pig liver with adherent gallbladder working in pairs. All procedures were video-recorded and the recordings were saved on USB-sticks in a blinded fashion identifiable only by the unique participant number. All video-recordings were scored blindly and independently by two expert raters using the Global Operative Assessment of Laparoscopic Skills (GOALS) assessment instrument.Results:The performances in the three groups were significantly different,Pless than 0.001. Both the VR simulation training group and the live pigs training group performed significantly better than the control group, bothPvalues less than 0.001. However, there was no significant difference in the performance of the two simulation-based training groups,P=0.66.Conclusion:Novice surgical trainees can benefit from both VR simulator training and pig surgery simulation compared with traditional studying and there was no significant difference between the two modalities. The authors recommend that VR simulators should be used for basic training of laparoscopic skills and surgery on live animals should be reserved for higher-level surgical training.