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Andersen AG, Riparbelli AC, Siebner HR, Konge L, Bjerrum F. Using neuroimaging to assess brain activity and areas associated with surgical skills: a systematic review. Surg Endosc 2024; 38:3004-3026. [PMID: 38653901 DOI: 10.1007/s00464-024-10830-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 03/24/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Surgical skills acquisition is under continuous development due to the emergence of new technologies, and there is a need for assessment tools to develop along with these. A range of neuroimaging modalities has been used to map the functional activation of brain networks while surgeons acquire novel surgical skills. These have been proposed as a method to provide a deeper understanding of surgical expertise and offer new possibilities for the personalized training of future surgeons. With studies differing in modalities, outcomes, and surgical skills there is a need for a systematic review of the evidence. This systematic review aims to summarize the current knowledge on the topic and evaluate the potential use of neuroimaging in surgical education. METHODS We conducted a systematic review of neuroimaging studies that mapped functional brain activation while surgeons with different levels of expertise learned and performed technical and non-technical surgical tasks. We included all studies published before July 1st, 2023, in MEDLINE, EMBASE and WEB OF SCIENCE. RESULTS 38 task-based brain mapping studies were identified, consisting of randomized controlled trials, case-control studies, and observational cohort or cross-sectional studies. The studies employed a wide range of brain mapping modalities, including electroencephalography, functional magnetic resonance imaging, positron emission tomography, and functional near-infrared spectroscopy, activating brain areas involved in the execution and sensorimotor or cognitive control of surgical skills, especially the prefrontal cortex, supplementary motor area, and primary motor area, showing significant changes between novices and experts. CONCLUSION Functional neuroimaging can reveal how task-related brain activity reflects technical and non-technical surgical skills. The existing body of work highlights the potential of neuroimaging to link task-related brain activity patterns with the individual level of competency or improvement in performance after training surgical skills. More research is needed to establish its validity and usefulness as an assessment tool.
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Affiliation(s)
- Annarita Ghosh Andersen
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for Human Resources and Education, The Capital Region of Denmark, Ryesgade 53B, 2100, Copenhagen, Denmark.
- Department of Cardiothoracic Surgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
| | - Agnes Cordelia Riparbelli
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for Human Resources and Education, The Capital Region of Denmark, Ryesgade 53B, 2100, Copenhagen, Denmark
| | - Hartwig Roman Siebner
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Danish Research Centre for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
- Department of Neurology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Lars Konge
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for Human Resources and Education, The Capital Region of Denmark, Ryesgade 53B, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Flemming Bjerrum
- Copenhagen Academy for Medical Education and Simulation (CAMES), Center for Human Resources and Education, The Capital Region of Denmark, Ryesgade 53B, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Gastrounit, Surgical Section, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
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Paul KI, Mueller K, Rousseau PN, Glathe A, Taatgen NA, Cnossen F, Lanzer P, Villringer A, Steele CJ. Visuo-motor transformations in the intraparietal sulcus mediate the acquisition of endovascular medical skill. Neuroimage 2023; 266:119781. [PMID: 36529202 DOI: 10.1016/j.neuroimage.2022.119781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 11/16/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022] Open
Abstract
Performing endovascular medical interventions safely and efficiently requires a diverse set of skills that need to be practised in dedicated training sessions. Here, we used multimodal magnetic resonance (MR) imaging to determine the structural and functional plasticity and core skills associated with skill acquisition. A training group learned to perform a simulator-based endovascular procedure, while a control group performed a simplified version of the task; multimodal MR images were acquired before and after training. Using a well-controlled interaction design, we found strong multimodal evidence for the role of the intraparietal sulcus (IPS) in endovascular skill acquisition that is in line with previous work implicating the structure in visuospatial transformations including simple visuo-motor and mental rotation tasks. Our results provide a unique window into the multimodal nature of rapid structural and functional plasticity of the human brain while learning a multifaceted and complex clinical skill. Further, our results provide a detailed description of the plasticity process associated with endovascular skill acquisition and highlight specific facets of skills that could enhance current medical pedagogy and be useful to explicitly target during clinical resident training.
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Affiliation(s)
- Katja I Paul
- Department of Neurology, Max-Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany; Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, University of Groningen, The Netherlands.
| | - Karsten Mueller
- Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, University of Groningen, The Netherlands; Department of Neurology, Charles University, First Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | | | - Annegret Glathe
- Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, University of Groningen, The Netherlands; Faculty of Medicine, University of Leipzig, Leipzig, Germany
| | - Niels A Taatgen
- Department of Neurology, Max-Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | - Fokie Cnossen
- Department of Neurology, Max-Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | - Peter Lanzer
- Mitteldeutsches Herzzentrum, Health Care Center Bitterfeld-Wolfen GmbH, Bitterfeld-Wolfen, Germany
| | - Arno Villringer
- Day Clinic for Cognitive Neurology, University of Leipzig Medical Center, Leipzig, Germany; Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, University of Groningen, The Netherlands; Berlin School of Mind and Brain, Humboldt-Universität zu Berlin; Faculty of Medicine, University of Leipzig, Leipzig, Germany; Center for Stroke Research Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Christopher J Steele
- Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, University of Groningen, The Netherlands; Department of Psychology, Concordia University, Montreal, Canada
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Toy S, Huh DD, Materi J, Nanavati J, Schwengel DA. Use of neuroimaging to measure neurocognitive engagement in health professions education: a scoping review. MEDICAL EDUCATION ONLINE 2022; 27:2016357. [PMID: 35012424 PMCID: PMC8757598 DOI: 10.1080/10872981.2021.2016357] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 11/19/2021] [Accepted: 12/07/2021] [Indexed: 06/14/2023]
Abstract
PURPOSE To map the current literature on functional neuroimaging use in medical education research as a novel measurement modality for neurocognitive engagement, learning, and expertise development. METHOD We searched PubMed, Embase, Cochrane, ERIC, and Web of Science, and hand-searched reference lists of relevant articles on April 4, 2019, and updated the search on July 7, 2020. Two authors screened the abstracts and then full-text articles for eligibility based on inclusion criteria. The data were then charted, synthesized, and analyzed descriptively. RESULTS Sixty-seven articles published between 2007 and 2020 were included in this scoping review. These studies used three main neuroimaging modalities: functional magnetic resonance imaging, functional near-infrared spectroscopy, and electroencephalography. Most of the publications (90%, n = 60) were from the last 10 years (2011-2020). Although these studies were conducted in 16 countries, 68.7% (n = 46) were from three countries: the USA (n = 21), UK (n = 15), and Canada (n = 10). These studies were mainly non-experimental (74.6%, n = 50). Most used neuroimaging techniques to examine psychomotor skill development (57%, n = 38), but several investigated neurocognitive correlates of clinical reasoning skills (22%, n = 15). CONCLUSION This scoping review maps the available literature on functional neuroimaging use in medical education. Despite the heterogeneity in research questions, study designs, and outcome measures, we identified a few common themes. Included studies are encouraging of the potential for neuroimaging to complement commonly used measures in education research and may help validate/challenge established theoretical assumptions and provide insight into training methods. This review highlighted several areas for further research. The use of these emerging technologies appears ripe for developing precision education, establishing viable study protocols for realistic operational settings, examining team dynamics, and exploring applications for real-time monitoring/intervention during critical clinical tasks.
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Affiliation(s)
- Serkan Toy
- Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dana D Huh
- The Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Joshua Materi
- The Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Julie Nanavati
- Welch Medical Library, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Deborah A. Schwengel
- Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Zagzoog N, Zadeh G, Lin V, Yang VXD. Perspective review on applications of optics in skull base surgery. Clin Neurol Neurosurg 2021; 212:107085. [PMID: 34894572 DOI: 10.1016/j.clineuro.2021.107085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/26/2021] [Accepted: 11/29/2021] [Indexed: 11/19/2022]
Abstract
The use of optic technology in skull base surgeries has the potential to revolutionize the field of medicine, particularly neurosurgery and neurology. Here, we briefly present the past, present, and future of skull-base surgery, with an emphasis on the applications of optical topography techniques. We discuss optical topography techniques such as functional near-infrared spectroscopy, optical diffusion tomography, and optical topographical imaging. Optical topography techniques are particularly advantageous when combined with other imaging methods. For instance, optical topography can be combined with techniques such as functional magnetic resonance imaging (fMRI) to combine the temporal resolution of optical topography with the spatial resolution of fMRI. Multimodal approaches will be critical to advance brain-related research as well as medicine. Structured light imaging techniques are also writing the future of 3-dimensional imaging. In short, optical topography can allow for non-invasive, high-resolution imaging that will provide real-time visualizations of the brain that are ideal for neurosurgery. From the limitations of traditional skull base surgeries to the newest developments in optical neuroimaging, here we will discuss the potential applications of optics in skull base procedures.
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Affiliation(s)
- Nirmeen Zagzoog
- Institute of Medical Science, School of Graduate Studies, Faculty of Medicine, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Brain Sciences Program/Imaging Research, Sunnybrook Research Institute, Toronto, Ontario, Canada; Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
| | - Gelareh Zadeh
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Vincent Lin
- Department of Otolaryngology - Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada; Department of Otolaryngology - Head and Neck Surgery, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Victor X D Yang
- Sunnybrook Health Sciences Centre, Brain Sciences Program/Imaging Research, Sunnybrook Research Institute, Toronto, Ontario, Canada; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Ryerson University, Bioengineering and Biophotonics Laboratory, Toronto, Ontario, Canada
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Kamat A, Makled B, Norfleet J, Intes X, Dutta A, De S. Brain network effects related to physical and virtual surgical training revealed by Granger causality. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2021; 2021:1014-1017. [PMID: 34891460 DOI: 10.1109/embc46164.2021.9629680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
this study investigates the difference in effective connectivity among novice medical students trained on physical and virtual simulators to perform the Fundamental laparoscopic surgery (FLS) pattern cutting task (PC). We propose using dynamic spectral Granger causality (GC) in the frequency band of [0.01-0.07]Hz to measure the effect of surgical training on effective brain connectivity. To obtain the dynamics relationship between the cortical regions, we propose to use the short-time Fourier transform (STFT) method. FLS pattern cutting is a complex bimanual task requiring fine motor skills and increased brain activity. With this in mind, we have used high resolution functional near-infrared spectroscopy to leverage its high temporal resolution for capturing the change in hemodynamics (HbO2) in 14 healthy subjects. Analysis of variance (ANOVA) found a statistically significant difference in "LPMC granger causes RPMC" (LPMC→ RPMC) in the subject trained on these two simulator in the first 40 sec of the task. We showed that the directed brain connectivity was affected by the type of surgical simulator used for training the medical students.
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Kalun P, Dunn K, Wagner N, Pulakunta T, Sonnadara R. Recent evidence on visual-spatial ability in surgical education: A scoping review. CANADIAN MEDICAL EDUCATION JOURNAL 2020; 11:e111-e127. [PMID: 33349760 PMCID: PMC7749687 DOI: 10.36834/cmej.69051] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Understanding the relationships between structures is critical for surgical trainees. However, the heterogeneity of the literature on visual-spatial ability (VSA) in surgery makes it challenging for educators to make informed decisions on incorporating VSA into their programs. We conducted a scoping review of the literature on VSA in surgery to provide a map of the literature and identify where gaps still exist for future research. METHODS We searched databases until December 2019 using keywords related to VSA and surgery. The resulting articles were independently screened by two researchers for inclusion in our review. RESULTS We included 117 articles in the final review. Fifty-nine articles reported significant correlations between VSA tests and surgical performance, and this association is supported by neuroimaging studies. However, it remains unclear whether VSA should be incorporated into trainee selection and whether there is a benefit of three-dimensional (3D) over two-dimensional (2D) training. CONCLUSIONS It appears that VSA correlates with surgical performance in the simulated environment, particularly for novice learners. Based on our findings, we make suggestions for how surgical educators may use VSA to support novice learners. Further research should determine whether VSA remains correlated to surgical performance when trainees move into the operative environment.
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Affiliation(s)
- Portia Kalun
- Department of Surgery, McMaster University, Ontario, Canada
| | - Krista Dunn
- Faculty of Medicine, Dalhousie University, Nova Scotia, Canada
| | - Natalie Wagner
- Department of Surgery, McMaster University, Ontario, Canada
- Office of Professional Development & Educational Scholarship, Faculty of Health Sciences, Queen’s University, Ontario, Canada
| | | | - Ranil Sonnadara
- Department of Surgery, McMaster University, Ontario, Canada
- Department of Surgery, University of Toronto, Ontario, Canada
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Balkhoyor AM, Awais M, Biyani S, Schaefer A, Craddock M, Jones O, Manogue M, Mon-Williams MA, Mushtaq F. Frontal theta brain activity varies as a function of surgical experience and task error. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2020; 2:e000040. [PMID: 35047792 PMCID: PMC8749254 DOI: 10.1136/bmjsit-2020-000040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 08/19/2020] [Accepted: 09/24/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Investigations into surgical expertise have almost exclusively focused on overt behavioral characteristics with little consideration of the underlying neural processes. Recent advances in neuroimaging technologies, for example, wireless, wearable scalp-recorded electroencephalography (EEG), allow an insight into the neural processes governing performance. We used scalp-recorded EEG to examine whether surgical expertise and task performance could be differentiated according to an oscillatory brain activity signal known as frontal theta-a putative biomarker for cognitive control processes. DESIGN SETTING AND PARTICIPANTS Behavioral and EEG data were acquired from dental surgery trainees with 1 year (n=25) and 4 years of experience (n=20) while they performed low and high difficulty drilling tasks on a virtual reality surgical simulator. EEG power in the 4-7 Hz range in frontal electrodes (indexing frontal theta) was examined as a function of experience, task difficulty and error rate. RESULTS Frontal theta power was greater for novices relative to experts (p=0.001), but did not vary according to task difficulty (p=0.15) and there was no Experience × Difficulty interaction (p=0.87). Brain-behavior correlations revealed a significant negative relationship between frontal theta and error in the experienced group for the difficult task (r=-0.594, p=0.0058), but no such relationship emerged for novices. CONCLUSION We find frontal theta power differentiates between surgical experiences but correlates only with error rates for experienced surgeons while performing difficult tasks. These results provide a novel perspective on the relationship between expertise and surgical performance.
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Affiliation(s)
- Ahmed Mohammed Balkhoyor
- School of Dentistry, University of Leeds, Leeds, UK
- Faculty of Dentistry, Umm Al-Qura University, Makkah, Saudi Arabia
- School of Psychology, University of Leeds, Leeds, UK
| | | | | | - Alexandre Schaefer
- Department of Psychology, Jeffrey Cheah School of Medicine and Health Sciences, Monash University, Selangor, Malaysia
| | - Matt Craddock
- School of Psychology, Lincoln University, Lincoln, UK
| | - Olivia Jones
- School of Psychology, University of Leeds, Leeds, UK
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Brain activation during laparoscopic tasks in high- and low-performing medical students: a pilot fMRI study. Surg Endosc 2019; 34:4837-4845. [PMID: 31754848 DOI: 10.1007/s00464-019-07260-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 11/11/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Up to 20% of medical students are unable to reach competency in laparoscopic surgery. It is unknown whether these difficulties arise from heterogeneity in neurological functioning across individuals. We sought to examine the differences in neurological functioning during laparoscopic tasks between high- and low-performing medical students using functional magnetic resonance imaging (fMRI). METHODS This prospective cohort study enrolled North American medical students who were within the top 20% and bottom 20% of laparoscopic performers from a previous study. Brain activation was recorded using fMRI while participants performed peg-pointing, intracorporeal knot tying (IKT), and the Pictorial Surface Orientation (PicSOr) test. Brain activation maps were created and areas of activation were compared between groups. RESULTS In total, 9/12 high and 9/13 low performers completed the study. High performers completed IKT faster and made more successful knot ties than low performers [standing: 23.5 (5.0) sec vs. 37.6 (18.4) sec, p = 0.03; supine: 23.2 (2.5) sec vs. 72.7 (62.8) sec, p = 0.02; number of successful ties supine, 3 ties vs. 1 tie, p = 0.01]. Low performers showed more brain activation than high performers in the peg-pointing task (q < 0.01), with no activation differences in the IKT task. There were no behavioral differences in the PiCSOr task. CONCLUSIONS This study is the first to show differences between low and high performers of laparoscopic tasks at the brain level. This pilot study has shown the feasibility of using fMRI to examine laparoscopic surgical skills. Future studies are needed for further exploration of our initial findings.
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Karabanov AN, Irmen F, Madsen KH, Haagensen BN, Schulze S, Bisgaard T, Siebner HR. Getting to grips with endoscopy - Learning endoscopic surgical skills induces bi-hemispheric plasticity of the grasping network. Neuroimage 2018; 189:32-44. [PMID: 30583066 DOI: 10.1016/j.neuroimage.2018.12.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 12/12/2018] [Accepted: 12/14/2018] [Indexed: 10/27/2022] Open
Abstract
Endoscopic surgery requires skilled bimanual use of complex instruments that extend the peri-personal workspace. To delineate brain structures involved in learning such surgical skills, 48 medical students without surgical experience were randomly assigned to five training sessions on a virtual-reality endoscopy simulator or to a non-training group. Brain activity was probed with functional MRI while participants performed endoscopic tasks. Repeated task performance in the scanner was sufficient to enhance task-related activity in left ventral premotor cortex (PMv) and the anterior Intraparietal Sulcus (aIPS). Simulator training induced additional increases in task-related activation in right PMv and aIPS and reduced effective connectivity from left to right PMv. Skill improvement after training scaled with stronger task-related activation of the lateral left primary motor hand area (M1-HAND). The results suggest that a bilateral fronto-parietal grasping network and left M1-HAND are engaged in bimanual learning of tool-based manipulations in an extended peri-personal space.
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Affiliation(s)
- Anke Ninija Karabanov
- Danish Research Centre for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Hvidovre, Denmark, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.
| | - Friederike Irmen
- Danish Research Centre for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Hvidovre, Denmark, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark; Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Germany
| | - Kristoffer Hougaard Madsen
- Danish Research Centre for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Hvidovre, Denmark, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark; Department of Applied Mathematics and Computer Science, Technical University of Denmark, Denmark
| | - Brian Numelin Haagensen
- Danish Research Centre for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Hvidovre, Denmark, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Svend Schulze
- Gastrounit Surgical Division, Centre for Surgical Research (CSR), Copenhagen University Hospital Hvidovre, Denmark
| | - Thue Bisgaard
- Gastrounit Surgical Division, Centre for Surgical Research (CSR), Copenhagen University Hospital Hvidovre, Denmark
| | - Hartwig Roman Siebner
- Department of Neurology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark; Institute for Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Kok E, De Bruin AB, van Geel K, Gegenfurtner A, Heyligers I, Sorger B. The Neural Implementation of Surgical Expertise Within the Mirror-Neuron System: An fMRI Study. Front Hum Neurosci 2018; 12:291. [PMID: 30079016 PMCID: PMC6062624 DOI: 10.3389/fnhum.2018.00291] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 06/29/2018] [Indexed: 11/30/2022] Open
Abstract
Motor expertise is an important aspect of high-level performance in professional tasks such as surgery. While recently it has been shown that brain activation as measured by functional magnetic resonance imaging (fMRI) within the mirror-neuron system (MNS) is modulated by expertise in sports and music, little is known about the neural underpinnings of professional, e.g., surgical expertise. Here, we investigated whether and (if so) how surgical expertise is implemented in the MNS in medical professionals across three levels of surgical qualification. In order to answer the more specific research question, namely, if the neural implementation of motor expertise develops in a linear or non-linear fashion, the study compares not only brain activation within the MNS related to action observation of novices and experts, but also intermediates. Ten novices (medical students), ten intermediates (residents in orthopedic surgery) and ten experts (orthopedic surgeons) watched 60 video clips (5 s each) of daily-life activities and surgical procedures each while their brain activation was measured using a 3-T fMRI scanner. An established localization procedure was followed to functionally define the MNS for each participant individually. A 2 (video type: daily-life activities, surgical procedures) × 3 (expertise level: novice, intermediate, expert) ANOVA yielded a non-significant interaction. Furthermore, separate analyses of the precentral and parietal part of the MNS also yielded non-significant interactions. However, post hoc comparisons showed that intermediates displayed marginally significantly lower brain activation in response to surgery-related videos within the MNS than novices. No other significant differences were found. We did not find evidence for the hypothesis that the brain-activation level in the MNS evoked by observing surgical videos reflects the level of surgical expertise in the professional task of (orthopedic) surgery. However, the results suggest a potential non-linear relationship between expertise level and MNS-activation level.
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Affiliation(s)
- Ellen Kok
- School of Health Professions Education, Maastricht University, Maastricht, Netherlands
| | - Anique B De Bruin
- School of Health Professions Education, Maastricht University, Maastricht, Netherlands
| | - Koos van Geel
- School of Health Professions Education, Maastricht University, Maastricht, Netherlands
| | - Andreas Gegenfurtner
- School of Health Professions Education, Maastricht University, Maastricht, Netherlands.,Institut für Qualität und Weiterbildung, Technische Hochschule Deggendorf, Deggendorf, Germany
| | - Ide Heyligers
- School of Health Professions Education, Maastricht University, Maastricht, Netherlands.,Department of Orthopedic Surgery, Orbis Medisch Centrum, Sittard, Netherlands
| | - Bettina Sorger
- Department of Cognitive Neuroscience, Maastricht University, Maastricht, Netherlands
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Modi HN, Singh H, Yang GZ, Darzi A, Leff DR. A decade of imaging surgeons' brain function (part II): A systematic review of applications for technical and nontechnical skills assessment. Surgery 2017; 162:1130-1139. [PMID: 29079277 DOI: 10.1016/j.surg.2017.09.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Functional neuroimaging technologies enable assessment of operator brain function and can deepen our understanding of skills learning, ergonomic optima, and cognitive processes in surgeons. Although there has been a critical mass of data detailing surgeons' brain function, this literature has not been reviewed systematically. METHODS A systematic search of original neuroimaging studies assessing surgeons' brain function and published up until November 2016 was conducted using Medline, Embase, and PsycINFO databases. RESULTS Twenty-seven studies fulfilled the inclusion criteria, including 3 feasibility studies, 14 studies exploring the neural correlates of technical skill acquisition, and the remainder investigating brain function in the context of intraoperative decision-making (n = 1), neurofeedback training (n = 1), robot-assisted technology (n = 5), and surgical teaching (n = 3). Early stages of learning open surgical tasks (knot-tying) are characterized by prefrontal cortical activation, which subsequently attenuates with deliberate practice. However, with complex laparoscopic skills (intracorporeal suturing), prefrontal cortical engagement requires substantial training, and attenuation occurs over a longer time course, after years of refinement. Neurofeedback and interventions that improve neural efficiency may enhance technical performance and skills learning. CONCLUSION Imaging surgeons' brain function has identified neural signatures of expertise that might help inform objective assessment and selection processes. Interventions that improve neural efficiency may target skill-specific brain regions and augment surgical performance.
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Affiliation(s)
- Hemel Narendra Modi
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Harsimrat Singh
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Guang-Zhong Yang
- Hamlyn Centre for Robotic Surgery, Imperial College London, London, United Kingdom
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; Hamlyn Centre for Robotic Surgery, Imperial College London, London, United Kingdom
| | - Daniel Richard Leff
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; Hamlyn Centre for Robotic Surgery, Imperial College London, London, United Kingdom.
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Modi HN, Singh H, Yang GZ, Darzi A, Leff DR. A decade of imaging surgeons' brain function (part I): Terminology, techniques, and clinical translation. Surgery 2017; 162:1121-1130. [PMID: 28807409 DOI: 10.1016/j.surg.2017.05.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 05/19/2017] [Accepted: 05/31/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Functional neuroimaging has the potential to deepen our understanding of technical and nontechnical skill acquisition in surgeons, particularly as established assessment tools leave unanswered questions about inter-operator differences in ability that seem independent of experience. METHODS In this first of a 2-part article, we aim to utilize our experience in neuroimaging surgeons to orientate the nonspecialist reader to the principles of brain imaging. Terminology commonly used in brain imaging research is explained, placing emphasis on the "activation response" to an surgical task and its effect on local cortical hemodynamic parameters (neurovascular coupling). RESULTS Skills learning and subsequent consolidation and refinement through practice lead to reorganization of the functional architecture of the brain (known as "neuroplasticity"), evidenced by changes in the strength of regional activation as well as alterations in connectivity between brain regions, culminating in more efficient use of neural resources during task performance. CONCLUSION Currently available neuroimaging techniques that either directly (ie, measure electrical activity) or indirectly (ie, measure tissue hemodynamics) assess brain function are discussed. Finally, we highlight the important practical considerations when conducting brain imaging research in surgeons.
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Affiliation(s)
- Hemel Narendra Modi
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Harsimrat Singh
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Guang-Zhong Yang
- Hamlyn Centre for Robotic Surgery, Imperial College London, London, United Kingdom
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; Hamlyn Centre for Robotic Surgery, Imperial College London, London, United Kingdom
| | - Daniel Richard Leff
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; Hamlyn Centre for Robotic Surgery, Imperial College London, London, United Kingdom.
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Abstract
PURPOSE OF REVIEW Robotically assisted laparoscopy has been introduced in the armamentarium of gynaecologic oncology surgeons. A lot of studies compared robotic surgery and laparotomy when the real issue is to demonstrate the interest and added value of robotically assisted laparoscopy versus standard laparoscopy. In this review, we will describe the most meaningful indications and advantages of robotically assisted laparoscopy in gynaecologic oncology. RECENT FINDINGS The learning curve for advanced procedures in robot-assisted laparoscopy is shorter and easier than with the standard laparoscopy, especially for beginners. In most of the series, operating time is longer with robot, but complication rates are often decreased, especially in obese patients with a conversion rate to laparotomy that is decreased compared with standard laparoscopy. Robot-assisted laparoscopy can be used for surgery of high-risk endometrial cancer, staging of early-ovarian cancer, and pelvic exenteration in case of recurrent malignancies. Furthermore, more recent robots allow performing sentinel node biopsy in endometrial or cervical cancer using fluorescence detection with indocyanine green. SUMMARY The spreading of robotic surgery led to an enhancement of minimal invasive surgical approach in general, and to the development of new indications in gynaecologic oncology. The superiority of robot-assisted laparoscopy still has to be demonstrated with properly designed trials.
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Hruska P, Krigolson O, Coderre S, McLaughlin K, Cortese F, Doig C, Beran T, Wright B, Hecker KG. Working memory, reasoning, and expertise in medicine-insights into their relationship using functional neuroimaging. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2016; 21:935-952. [PMID: 26537964 DOI: 10.1007/s10459-015-9649-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 10/25/2015] [Indexed: 06/05/2023]
Abstract
Clinical reasoning is dependent upon working memory (WM). More precisely, during the clinical reasoning process stored information within long-term memory is brought into WM to facilitate the internal deliberation that affords a clinician the ability to reason through a case. In the present study, we examined the relationship between clinical reasoning and WM while participants read clinical cases with functional magnetic resonance imaging (fMRI). More specifically, we examined the impact of clinical case difficulty (easy, hard) and clinician level of expertise (2nd year medical students, senior gastroenterologists) on neural activity within regions of cortex associated with WM (i.e., the prefrontal cortex) during the reasoning process. fMRI was used to scan ten second-year medical students and ten practicing gastroenterologists while they reasoned through sixteen clinical cases [eight straight forward (easy) and eight complex (hard)] during a single 1-h scanning session. Within-group analyses contrasted the easy and hard cases which were then subsequently utilized for a between-group analysis to examine effects of expertise (novice > expert, expert > novice). Reading clinical cases evoked multiple neural activations in occipital, prefrontal, parietal, and temporal cortical regions in both groups. Importantly, increased activation in the prefrontal cortex in novices for both easy and hard clinical cases suggests novices utilize WM more so than experts during clinical reasoning. We found that clinician level of expertise elicited differential activation of regions of the human prefrontal cortex associated with WM during clinical reasoning. This suggests there is an important relationship between clinical reasoning and human WM. As such, we suggest future models of clinical reasoning take into account that the use of WM is not consistent throughout all clinical reasoning tasks, and that memory structure may be utilized differently based on level of expertise.
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Affiliation(s)
- Pam Hruska
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Olav Krigolson
- Neuroscience Program, Centre for Biomedical Research, and School of Exercise Science, Physical, and Health Education, University of Victoria, Victoria, BC, Canada
| | - Sylvain Coderre
- Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kevin McLaughlin
- Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Filomeno Cortese
- Seaman Family MR Research Centre, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Christopher Doig
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Tanya Beran
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Bruce Wright
- Division of Medical Sciences, University of Victoria, Victoria, BC, Canada
| | - Kent G Hecker
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
- Department of Veterinary Clinical and Diagnostic Sciences, Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada.
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15
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Hruska P, Hecker KG, Coderre S, McLaughlin K, Cortese F, Doig C, Beran T, Wright B, Krigolson O. Hemispheric activation differences in novice and expert clinicians during clinical decision making. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2016; 21:921-933. [PMID: 26530736 DOI: 10.1007/s10459-015-9648-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 10/25/2015] [Indexed: 06/05/2023]
Abstract
Clinical decision making requires knowledge, experience and analytical/non-analytical types of decision processes. As clinicians progress from novice to expert, research indicates decision-making becomes less reliant on foundational biomedical knowledge and more on previous experience. In this study, we investigated how knowledge and experience were reflected in terms of differences in neural areas of activation. Novice and expert clinicians diagnosed simple or complex (easy, hard) cases while functional magnetic resonance imaging (fMRI) data were collected. Our results highlight key differences in the neural areas activated in novices and experts during the clinical decision-making process. fMRI data were collected from ten second year medical students (novices) and ten practicing gastroenterologists (experts) while they diagnosed sixteen (eight easy and eight hard) clinical cases via multiple-choice questions. Behavioral data were collected for diagnostic accuracy (correct/incorrect diagnosis) and time taken to assign a clinical diagnosis. Two analyses were performed with the fMRI data. First, data from easy and hard cases were compared within respective groups (easy > hard, hard > easy). Second, neural differences between novices and experts (novice > expert, expert > novice) were assessed. Experts correctly diagnosed more cases than novices and made their diagnoses faster than novices on both easy and hard cases (all p's < 0.05). Time taken to diagnose hard cases took significantly longer for both novices and experts. While similar neural areas were activated in both novices and experts during the decision making process, we identified significant hemispheric activation differences between novice and expert clinicians when diagnosing hard clinical cases. Specifically, novice clinicians had greater activations in the left anterior temporal cortex and left ventral lateral prefrontal cortex whereas expert clinicians had greater activations in the right dorsal lateral, right ventral lateral, and right parietal cortex. Hemispheric differences in activation were not observed between novices and experts while diagnosing easy clinical cases. While clinical decision-making engaged the prefrontal cortex (PFC) in both novices and experts, interestingly we observed expertise related differences in the regions and hemispheres of PFC activation between these groups for hard clinical cases. Specifically, in novices we observed activations in left hemisphere neural regions associated with factual rule-based knowledge, whereas in experts we observed right hemisphere activation in neural regions associated with experiential knowledge. Importantly, at the neural level, our data highlight differences in so called type 2 clinical decision-making processes related to prior knowledge and experience.
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Affiliation(s)
- Pam Hruska
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kent G Hecker
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
- Department of Veterinary Clinical and Diagnostic Sciences, Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada.
| | - Sylvain Coderre
- Undergraduate Medical Education, Cumming School of Medicine, Calgary, AB, Canada
| | - Kevin McLaughlin
- Undergraduate Medical Education, Cumming School of Medicine, Calgary, AB, Canada
| | - Filomeno Cortese
- Seaman Family MR Research Centre, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Christopher Doig
- Department of Critical Care Medicine, Cumming School of Medicine, Calgary, AB, Canada
| | - Tanya Beran
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Bruce Wright
- Division of Medical Sciences, University of Victoria, Victoria, BC, Canada
| | - Olav Krigolson
- Neuroscience Program, Centre for Biomedical Research, School of Exercise Science, Physical, and Health Education, University of Victoria, Victoria, BC, Canada
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