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To evaluate the effectiveness of surgical simulation compared with other methods of surgical training.Surgical simulation (with or without computers) is attractive because it avoids the use of patients for skills practice and provides relevant technical training for trainees before they operate on humans.Studies were identified through searches of MEDLINE, EMBASE, the Cochrane Library, and other databases until April 2005. Included studies must have been randomized controlled trials (RCTs) assessing any training technique using at least some elements of surgical simulation, which reported measures of surgical task performance.Thirty RCTs with 760 participants were able to be included, although the quality of the RCTs was often poor. Computer simulation generally showed better results than no training at all (and than physical trainer/model training in one RCT), but was not convincingly superior to standard training (such as surgical drills) or video simulation (particularly when assessed by operative performance). Video simulation did not show consistently better results than groups with no training at all, and there were not enough data to determine if video simulation was better than standard training or the use of models. Model simulation may have been better than standard training, and cadaver training may have been better than model training.While there may be compelling reasons to reduce reliance on patients, cadavers, and animals for surgical training, none of the methods of simulated training has yet been shown to be better than other forms of surgical training.