BACKGROUND: Operational training is a key component of resident education. Recently, innovative virtual reality (VR) training methods have been introduced to enhance training efficiency. Image-based VR (IBVR), which incorporates cognitive load, is theorized to improve task performance. However, the impact of IBVR on learning outcomes requires further investigation. This study aims to assess the efficacy of IBVR compared to textbook-based VR (TBVR) in teaching operational skills to junior residents. METHODS: In a prospective cross-over pilot study, ten volunteers were randomly assigned to either the IBVR-TBVR or TBVR-IBVR group. Participants engaged in four learning sessions using either IBVR or TBVR modules during the first phase. Performance was assessed using quizzes, and Milestone/Direct Observation of Procedural Skills (DOPS) ratings on real patients. After one month, participants switched to the alternate VR module for further training. Cognitive load and stress were assessed during each session through questionnaires and heart rate variability (HRV). At the end of the study, learning satisfaction, experience, and overall effectiveness were evaluated using a global satisfaction scale, the AttrakDiff2 questionnaire, and group interviews. Qualitative data were analyzed using a thematic analysis framework. RESULTS: The IBVR module yielded significantly better Milestone (p = 0.04), and DOPS (p < 0.01) scores compared to TBVR. There were no significant differences in knowledge gain, cognitive load, or HRV between the two modules. TBVR was favored in terms of global satisfaction (p = 0.03), hedonic stimulation (p = 0.01), and hedonic identification (p = 0.03), whereas IBVR was perceived as a more immersive and enriching experience. The majority (70%) of participants reported a positive experience with IBVR, while 50% expressed positive feedback regarding TBVR. Thematic analysis identified two key themes: usability of instructional content and ease of engagement. CONCLUSION: Although TBVR yielded higher learner satisfaction and hedonic appeal, IBVR resulted in greater improvements in operational performance and was positively received by most participants. This proof-of-concept study highlights the complementary strengths of both VR approaches and calls for further research to validate these preliminary findings and inform the design of effective VR-based surgical education strategies. TRIAL REGISTRATION: Clinicaltrials.gov NCT03501641; https://clinicaltrials.gov/ct2/show/NCT03501641 ; date of registration: April 18, 2018.