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Objective:Laparoscopic skills degrade when telescope viewing axis deviates 90- to 180-degrees from the instrument working axis. Training under reverse viewing conditions is challenging but may impart skills relevant to general laparoscopy, even under forward viewing conditions. We tested whether training with a reverse viewing component more efficiently increases trainee laparoscopic skills than training under forward viewing conditions alone. Design:Single-blinded randomized control trial Setting:Laparoscopic virtual reality (VR) simulation lab Participants:PGY1 surgery residents Main Outcome Measures:Proficiency on all VR machine metrics as time, pathlength, errors (mean [95%CI]). Intervention:Residents were randomized to control (0-degree laparoscope view) and study (alternating 0-and 180-degree) on a VR simulator retract/dissection task (RD). After reaching proficiency (expert surgeon performance), residents performed a VR gallbladder excision task (GB) at maximum difficulty until proficiency was achieved. Results:11 Control and 10 Study participants completed all tasks. At start of GB performance, study group task time (330 [290-369] vs 475 [439-511] seconds; p<0.0001) and pathlength (401 [327-475] vs 699 [632-766] cm; p<0.0001) were shorter, with fewer errors (20 [15-26] vs 32 [26-37]; p=0.005) than controls. This effect persisted for task time through iteration 4, but pathlength and error differences diminished. There was no difference in number of iterations to achieve proficiency for time or errors between groups. Study group achieved pathlength proficiency more rapidly than controls (4.8 [4.6-5.0] vs 9.8 [8.7-11.0]; p=0.03). Conclusions:Addition of reverse viewing to training improved performance on a simulated clinical task compared to training with forward viewing. This was most evident for task time. However, this effect diminished rapidly with iterative training and there was no difference in task iterations to reach proficiency. Dyad training may confer a durable effect on movement efficiency.