Background: Endoscopic Retrograde Cholangio Pancreaticography (ERCP) is a technically demanding endoscopic intervention associated with increased risk of complications (bleeding and pancreatitis) and discomfort to the patient if not properly performed. Advanced medical simulators have introduced the possibility to train endoscopic surgeons in visuospatially difficult interventional procedures to proficiency levels without harming the patient. Visuospatial skills have been demonstrated to predict the performance of medical students and residents in virtual gastroscopy. Little has, however, been reported to what extent visuospatial ability play a role in the technically more advanced virtual ERCP. Methods: Ten endoscopists with varying ERCP experience were included. Prior to the virtual ERCPs in GI-mentor II, Simbionix® (ERCP: Cases 1 and 5, module 2) they performed two visuospatial tests: 1/ Card Rotation Test (CRT) and 2/ Picsor which both monitor the ability of the tested person to create a 3-D image from a 2-D presentation. The results of the visuospatial tests were correlated to the objective assessment parameters of the endoscopic simulator. Results: Total time to view the papilla correctly and Papilla contacts before first cannulation both correlated well with CRT (r2=0.56 P=0.05 and r2=0.78 P=0.01, respectively). There was also a strong correlation between Total time to view the papilla correctly and Papilla contacts before first cannulation and the picsor test (r2=0.75 P=0.01 and r2=0.64 P=0.03, respectively). The simulator could also discriminate between experts and residents regarding the parameters Total time to view the papilla correctly and Total time of the examination. Conclusion: Good visuospatial ability has a great impact on the performance of ERCP in an endoscopic simulator and seems to be irrespective of previous clinical ERCP experience.