“Contemplating the Next Maneuver”: Functional Neuroimaging Reveals Intraoperative Decision-making Strategies

Using neuroimaging to assess brain activity and areas associated with surgical skills: a systematic review

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.

Physical and biophysical markers of assessment in medical training: A scoping review of the literature

PURPOSE

Assessment in medical education has changed over time to measure the evolving skills required of current medical practice. Physical and biophysical markers of assessment attempt to use technology to gain insight into medical trainees' knowledge, skills, and attitudes. The authors conducted a scoping review to map the literature on the use of physical and biophysical markers of assessment in medical training.

MATERIALS AND METHODS

The authors searched seven databases on 1 August 2022, for publications that utilized physical or biophysical markers in the assessment of medical trainees (medical students, residents, fellows, and synonymous terms used in other countries). Physical or biophysical markers included: heart rate and heart rate variability, visual tracking and attention, pupillometry, hand motion analysis, skin conductivity, salivary cortisol, functional magnetic resonance imaging (fMRI), and functional near-infrared spectroscopy (fNIRS). The authors mapped the relevant literature using Bloom's taxonomy of knowledge, skills, and attitudes and extracted additional data including study design, study environment, and novice vs. expert differentiation from February to June 2023.

RESULTS

Of 6,069 unique articles, 443 met inclusion criteria. The majority of studies assessed trainees using heart rate variability (n = 160, 36%) followed by visual attention (n = 143, 32%), hand motion analysis (n = 67, 15%), salivary cortisol (n = 67, 15%), fMRI (n = 29, 7%), skin conductivity (n = 26, 6%), fNIRs (n = 19, 4%), and pupillometry (n = 16, 4%). The majority of studies (n = 167, 38%) analyzed non-technical skills, followed by studies that analyzed technical skills (n = 155, 35%), knowledge (n = 114, 26%), and attitudinal skills (n = 61, 14%). 169 studies (38%) attempted to use physical or biophysical markers to differentiate between novice and expert.

CONCLUSION

This review provides a comprehensive description of the current use of physical and biophysical markers in medical education training, including the current technology and skills assessed. Additionally, while physical and biophysical markers have the potential to augment current assessment in medical education, there remains significant gaps in research surrounding reliability, validity, cost, practicality, and educational impact of implementing these markers of assessment.

Optical neuroimaging and neurostimulation in surgical training and assessment: A state-of-the-art review

Introduction

Functional near-infrared spectroscopy (fNIRS) is a non-invasive optical neuroimaging technique used to assess surgeons' brain function. The aim of this narrative review is to outline the effect of expertise, stress, surgical technology, and neurostimulation on surgeons' neural activation patterns, and highlight key progress areas required in surgical neuroergonomics to modulate training and performance.

Methods

A literature search of PubMed and Embase was conducted to identify neuroimaging studies using fNIRS and neurostimulation in surgeons performing simulated tasks.

Results

Novice surgeons exhibit greater haemodynamic responses across the pre-frontal cortex than experts during simple surgical tasks, whilst expert surgical performance is characterized by relative prefrontal attenuation and upregulation of activation foci across other regions such as the supplementary motor area. The association between PFC activation and mental workload follows an inverted-U shaped curve, activation increasing then attenuating past a critical inflection point at which demands outstrip cognitive capacity Neuroimages are sensitive to the impact of laparoscopic and robotic tools on cognitive workload, helping inform the development of training programs which target neural learning curves. FNIRS differs in comparison to current tools to assess proficiency by depicting a cognitive state during surgery, enabling the development of cognitive benchmarks of expertise. Finally, neurostimulation using transcranial direct-current-stimulation may accelerate skill acquisition and enhance technical performance.

Conclusion

FNIRS can inform the development of surgical training programs which modulate stress responses, cognitive learning curves, and motor skill performance. Improved data processing with machine learning offers the possibility of live feedback regarding surgeons' cognitive states during operative procedures.

Electroencephalography can provide advance warning of technical errors during laparoscopic surgery

BACKGROUND

Intraoperative adverse events lead to patient injury and death, and are increasing. Early warning systems (EWSs) have been used to detect patient deterioration and save lives. However, few studies have used EWSs to monitor surgical performance and caution about imminent technical errors. Previous (non-surgical) research has investigated neural activity to predict future motor errors using electroencephalography (EEG). The present proof-of-concept cohort study investigates whether EEG could predict technical errors in surgery.

METHODS

In a large academic hospital, three surgical fellows performed 12 elective laparoscopic general surgeries. Audiovisual data of the operating room and the surgeon's neural activity were recorded. Technical errors and epochs of good surgical performance were coded into events. Neural activity was observed 40 s prior and 10 s after errors and good events to determine how far in advance errors were detected. A hierarchical regression model was used to account for possible clustering within surgeons. This prospective, proof-of-concept, cohort study was conducted from July to November 2021, with a pilot period from February to March 2020 used to optimize the technique of data capture and included participants who were blinded from study hypotheses.

RESULTS

Forty-five technical errors, mainly due to too little force or distance (n = 39), and 27 good surgical events were coded during grasping and dissection. Neural activity representing error monitoring (p = .008) and motor uncertainty (p = .034) was detected 17 s prior to errors, but not prior to good surgical performance.

CONCLUSIONS

These results show that distinct neural signatures are predictive of technical error in laparoscopic surgery. If replicated with low false-alarm rates, an EEG-based EWS of technical errors could be used to improve individualized surgical training by flagging imminent unsafe actions-before errors occur and cause patient harm.

Use of neuroimaging to measure neurocognitive engagement in health professions education: a scoping review

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.

Neuromonitoring Correlates of Expertise Level in Surgical Performers: A Systematic Review

Surgical expertise does not have a clear definition and is often culturally associated with power, authority, prestige, and case number rather than more objective proxies of excellence. Multiple models of expertise progression have been proposed including the Dreyfus model, however, they all currently require subjective evaluation of skill. Recently, efforts have been made to improve the ways in which surgical excellence is measured and expertise is defined using artificial intelligence, video recordings, and accelerometers. However, these aforementioned methods of assessment are still subjective or indirect proxies of expertise, thus uncovering the neural mechanisms that differentiate expert surgeons from trainees may enhance the objectivity of surgical expertise validation. In fact, some researchers have already suggested that their neural imaging-based expertise classification methods outperform currently used methods of surgical skill certification such as the Fundamentals of Laparoscopic Surgery (FLS) scores. Such imaging biomarkers would not only help better identify the highest performing surgeons, but could also improve residency programs by providing more objective, evidence-based feedback and developmental milestones for those in training and perhaps act as a marker of surgical potential in medical students. Despite the potential advantages of using neural imaging in the assessment of surgical expertise, this field of research remains in its infancy. This systematic review identifies studies that have applied neuromonitoring in assessing surgical skill across levels of expertise. The goals of this review are to identify (1) the strongest neural indicators of surgical expertise, (2) the limitations of the current literature on this subject, (3) the most sensible future directions for further study. We found substantial evidence that surgical expertise can be delineated by differential activation and connectivity in the prefrontal cortex (PFC) across multiple task and neuroimaging modalities. Specifically, novices tend to have greater PFC activation than experts under standard conditions in bimanual and decision-making tasks. However, under high temporal demand tasks, experts had increased PFC activation whereas novices had decreased PFC activation. Common limitations uncovered in this review were that task difficulty was often insufficient to delineate between residents and attending. Moreover, attending level involvement was also low in multiple studies which may also have contributed to this issue. Most studies did not analyze the ability of their neuromonitoring findings to accurately classify subjects by level of expertise. Finally, the predominance of fNIRS as the neuromonitoring modality limits our ability to uncover the neural correlates of surgical expertise in non-cortical brain regions. Future studies should first strive to address these limitations. In the longer term, longitudinal within-subjects design over the course of a residency or even a career will also advance the field. Although logistically arduous, such studies would likely be most beneficial in demonstrating effects of increasing surgical expertise on regional brain activation and inter-region connectivity.

Objective Measures of Surgeon Non-Technical Skills in Surgery: A Scoping Review

OBJECTIVE

The purpose of this study was to identify, synthesize, and discuss objective behavioral or physiological metrics of surgeons' nontechnical skills (NTS) in the literature.

BACKGROUND

NTS, or interpersonal or cognitive skills, have been identified to contribute to safe and efficient surgical performance; however, current assessments are subjective, checklist-based tools. Intraoperative skill evaluation, such as technical skills, has been previously utilized as an objective measure to address such limitations.

METHODS

Five databases in engineering, behavioral science, and medicine were searched following PRISMA reporting guidelines. Eligibility criteria included studies with NTS objective measurements, surgeons, and took place within simulated or live operations.

RESULTS

Twenty-three articles were included in this review. Objective metrics included communication metrics and measures from physiological responses such as changes in brain activation and motion of the eye. Frequencies of content-coded communication in surgery were utilized in 16 studies and were associated with not only the communication construct but also cognitive constructs of situation awareness and decision making. This indicates the underlying importance of communication in evaluating the NTS constructs. To synthesize the scoped literature, a framework based on the one-way communication model was used to map the objective measures to NTS constructs.

CONCLUSION

Objective NTS measurement of surgeons is still preliminary, and future work on leveraging objective metrics in parallel with current assessment tools is needed.

APPLICATION

Findings from this work identify objective NTS metrics for measurement applications in a surgical environment.

Learning to diagnose X-rays: a neuroscientific study of practice-related activation changes in the prefrontal cortex

OBJECTIVES

Medical expertise manifests itself by the ability of a physician to rapidly diagnose patients. How this expertise develops from a neural-activation perspective is not well understood. The objective of the present study was to investigate practice-related activation changes in the prefrontal cortex (PFC) as medical students learn to diagnose chest X-rays.

METHODS

The experimental paradigm consisted of a learning and a test phase. During the learning phase, 26 medical students were trained to diagnose four out of eight chest X-rays. These four cases were presented repeatedly and corrective feedback was provided. During the test phase, all eight cases were presented together with near- and far-transfer cases to examine whether participants' diagnostic learning went beyond simple rote recognition of the trained X-rays. During both phases, participants' PFC was scanned using functional near-infrared spectroscopy. Response time and diagnostic accuracy were recorded as behavioural indicators. One-way repeated measures ANOVA were conducted to analyse the data.

RESULTS

Results revealed that participants' diagnostic accuracy significantly increased during the learning phase (F=6.72, p<0.01), whereas their response time significantly decreased (F=16.69, p<0.001). Learning to diagnose chest X-rays was associated with a significant decrease in PFC activity (F=33.21, p<0.001) in the left dorsolateral prefrontal cortex, the orbitofrontal area, the frontopolar area and the frontal eye field. Further, the results of the test phase indicated that participants' diagnostic accuracy was significantly higher for the four trained cases, second highest for the near-transfer, third highest for the far-transfer cases and lowest for the untrained cases (F=167.20, p<0.001) and response time was lowest for the trained cases, second lowest for the near-transfer, third lowest for the far-transfer cases and highest for the untrained cases (F=9.72, p<0.001). In addition, PFC activity was lowest for the trained and near-transfer cases, followed by the far-transfer cases and highest for the untrained cases (F=282.38, p<0.001).

CONCLUSIONS

The results suggest that learning to diagnose X-rays is associated with a significant decrease in PFC activity. In terms of dual-process theory, these findings support the notion that students initially rely more on slow analytical system-2 reasoning. As expertise develops, system-2 reasoning transitions into faster and automatic system-1 reasoning.

Multitasking and Time Pressure in the Operating Room: Impact on Surgeons' Brain Function

OBJECTIVE

To assess the impact of multitasking and time pressure on surgeons' brain function during laparoscopic suturing.

SUMMARY BACKGROUND DATA

Recent neuroimaging evidence suggests that deterioration in surgical performance under time pressure is associated with deactivation of the prefrontal cortex (PFC), an area important for executive functions. However, the effect of multitasking on operator brain function remains unknown.

METHODS

Twenty-nine surgical residents performed an intracorporeal suturing task under four conditions: 1) self-paced suturing, 2) time-pressured suturing, 3) self-paced suturing plus decision-making, and 4) time-pressured suturing plus decision-making. Subjective workload was quantified using the Surgical Task Load Index. Technical skill was objectively assessed using task progression scores, error scores, leak volumes, and knot tensile strengths. PFC activation was measured using optical neuroimaging.

RESULTS

Compared with self-paced suturing, subjective workload (au) was significantly greater in time-pressured suturing (146.0 vs 196.0, P < 0.001), suturing with decision-making (146.0 vs 182.0, P < 0.001), and time-pressured suturing with decision-making (146.0 vs 227.0, P < 0.001). Technical performance during combined suturing and decision-making tasks was inferior to suturing alone under time pressure or self-paced conditions (P < 0.001). Significant dorsolateral PFC (DLPFC) activations were observed during self-paced suturing, and ventrolateral PFC (VLPFC) deactivations were identified during time-pressured suturing. However, suturing in conjunction with decision-making resulted in significant deactivation across both the VLPFC and DLPFC (P < 0.05). Random effects regression analysis confirmed decision-making predicts VLPFC and DLPFC deactivation (z = -2.62, P < 0.05).

CONCLUSIONS

Performance degradation during high workload conditions is associated with deactivation of prefrontal regions important for attentional control, working memory, and cognitive flexibility, particularly during tasks involving simultaneous motor and cognitive engagement.

Methodological Approaches and Recommendations for Functional Near-Infrared Spectroscopy Applications in HF/E Research

OBJECTIVE

The objective of this study was to systematically document current methods and protocols employed when using functional near-infrared spectroscopy (fNIRS) techniques in human factors and ergonomics (HF/E) research and generate recommendations for conducting and reporting fNIRS findings in HF/E applications.

METHOD

A total of 1,687 articles were identified through Ovid-MEDLINE, PubMed, Web of Science, and Scopus databases, of which 37 articles were included in the review based on review inclusion/exclusion criteria.

RESULTS

A majority of the HF/E fNIRS investigations were found in transportation, both ground and aviation, and in assessing cognitive (e.g., workload, working memory) over physical constructs. There were large variations pertaining to data cleaning, processing, and analysis approaches across the studies that warrant standardization of methodological approaches. The review identified major challenges in transparency and reporting of important fNIRS data collection and analyses specifications that diminishes study replicability, introduces potential biases, and increases likelihood of inaccurate results. As such, results reported in existing fNIRS studies need to be cautiously approached.

CONCLUSION

To improve the quality of fNIRS investigations and/or to facilitate its adoption and integration in different HF/E applications, such as occupational ergonomics and rehabilitation, recommendations for fNIRS data collection, processing, analysis, and reporting are provided.

Use of prefrontal cortex activity as a measure of learning curve in surgical novices: results of a single blind randomised controlled trial

BACKGROUND

Neurobiological feedback in surgical training could translate to better educational outcomes such as measures of learning curve. This work examined the variation in brain activation of medical students when performing laparoscopic tasks before and after a training workshop, using functional near-infrared spectroscopy (fNIRS).

METHODS AND PROCEDURES

This single blind randomised controlled trial examined the prefrontal cortex activity (PFCA) differences in two groups of novice medical students during the acquisition of four laparoscopic tasks. Both groups were shown a basic tutorial video, with the "Trained-group" receiving an additional standardised one-to-one training on the tasks. The PFCA was measured pre- and post-intervention using a portable fNIRS device and reported as mean total oxygenated hemoglobin (HbOµm). Primary outcome of the study is the difference in HbOµm between post- and pre-intervention readings for each of the four laparoscopic tasks. The pre- and post-intervention laparoscopic tasks were recorded and assessed by two blinded individual assessors for objective scores of the performance.

RESULTS

16 Trained and 16 Untrained, right-handed medical students with an equal sex distribution and comparable age distribution were recruited. Trained group had an attenuated left PFCA in the "Precision cutting" (p = 0.007) task compared to the Untrained group. Subgroup analysis by sex revealed attenuation in left PFCA in Trained females compared to Untrained females across two laparoscopic tasks: "Peg transfer" (p = 0.005) and "Precision cutting" (p = 0.003). No significant PFCA attenuation was found in male students who underwent training compared to Untrained males.

CONCLUSION

A standardised laparoscopic training workshop promoted greater PFCA attenuation in female medical students compared to males. This suggests that female and male students respond differently to the same instructional approach. Implications include a greater focus on one-to-one surgical training for female students and use of PFCA attenuation as a form of neurobiological feedback in surgical training.

Association of Residents' Neural Signatures With Stress Resilience During Surgery

Importance

Intraoperative stressors may compound cognitive load, prompting performance decline and threatening patient safety. However, not all surgeons cope equally well with stress, and the disparity between performance stability and decline under high cognitive demand may be characterized by differences in activation within brain areas associated with attention and concentration such as the prefrontal cortex (PFC).

Objective

To compare PFC activation between surgeons demonstrating stable performance under temporal stress with those exhibiting stress-related performance decline.

Design, Setting, and Participants

Cohort study conducted from July 2015 to September 2016 at the Imperial College Healthcare National Health Service Trust, England. One hundred two surgical residents (postgraduate year 1 and greater) were invited to participate, of which 33 agreed to partake.

Exposures

Participants performed a laparoscopic suturing task under 2 conditions: self-paced (SP; without time-per-knot restrictions), and time pressure (TP; 2-minute per knot time restriction).

Main Outcomes and Measures

A composite deterioration score was computed based on between-condition differences in task performance metrics (task progression score [arbitrary units], error score [millimeters], leak volume [milliliters], and knot tensile strength [newtons]). Based on the composite score, quartiles were computed reflecting performance stability (quartile 1 [Q1]) and decline (quartile 4 [Q4]). Changes in PFC oxygenated hemoglobin concentration (HbO2) measured at 24 different locations using functional near-infrared spectroscopy were compared between Q1 and Q4. Secondary outcomes included subjective workload (Surgical Task Load Index) and heart rate.

Results

Of the 33 participants, the median age was 33 years, the range was 29 to 56 years, and 27 were men (82%). The Q1 residents demonstrated task-induced increases in HbO2 across the bilateral ventrolateral PFC (VLPFC) and right dorsolateral PFC in the SP condition and in the VLPFC in the TP condition. In contrast, Q4 residents demonstrated decreases in HbO2 in both conditions. The magnitude of PFC activation (change in HbO2) was significantly greater in Q1 than Q4 across the bilateral VLPFC during both SP (mean [SD] left VLPFC: Q1, 0.44 [1.30] μM; Q4, -0.21 [2.05] μM; P < .001; right VLPFC: Q1, 0.46 [1.12] μM; Q4, -0.15 [2.14] μM; P < .001) and TP (mean [SD] left VLPFC: Q1, 0.44 [1.36] μM; Q4, -0.03 [1.83] μM; P = .001; right VLPFC: Q1, 0.49 [1.70] μM; Q4, -0.32 [2.00] μM; P < .001) conditions. There were no significant between-group differences in Surgical Task Load Index or heart rate in either condition.

Conclusions and Relevance

Performance stability within TP is associated with sustained prefrontal activation indicative of preserved attention and concentration, whereas performance decline is associated with prefrontal deactivation that may represent task disengagement.

Temporal Stress in the Operating Room: Brain Engagement Promotes "Coping" and Disengagement Prompts "Choking"

OBJECTIVE

To investigate the impact of time pressure (TP) on prefrontal activation and technical performance in surgical residents during a laparoscopic suturing task.

BACKGROUND

Neural mechanisms enabling surgeons to maintain performance and cope with operative stressors are unclear. The prefrontal cortex (PFC) is implicated due to its role in attention, concentration, and performance monitoring.

METHODS

A total of 33 residents [Postgraduate Year (PGY)1-2 = 15, PGY3-4 = 8, and PGY5 = 10] performed a laparoscopic suturing task under "self-paced" (SP) and "TP" conditions (TP = maximum 2 minutes per knot). Subjective workload was quantified using the Surgical Task Load Index. PFC activation was inferred using optical neuroimaging. Technical skill was assessed using progression scores (au), error scores (mm), leak volumes (mL), and knot tensile strengths (N).

RESULTS

TP led to greater perceived workload amongst all residents (mean Surgical Task Load Index score ± SD: PGY1-2: SP = 160.3 ± 24.8 vs TP = 202.1 ± 45.4, P < 0.001; PGY3-4: SP = 123.0 ± 52.0 vs TP = 172.5 ± 43.1, P < 0.01; PGY5: SP = 105.8 ± 55.3 vs TP = 159.1 ± 63.1, P < 0.05). Amongst PGY1-2 and PGY3-4, deterioration in task progression, error scores and knot tensile strength (P < 0.05), and diminished PFC activation was observed under TP. In PGY5, TP resulted in inferior task progression and error scores (P < 0.05), but preservation of knot tensile strength. Furthermore, PGY5 exhibited less attenuation of PFC activation under TP, and greater activation than either PGY1-2 or PGY3-4 under both experimental conditions (P < 0.05).

CONCLUSIONS

Senior residents cope better with temporal demands and exhibit greater technical performance stability under pressure, possibly due to sustained PFC activation and greater task engagement. Future work should seek to develop training strategies that recruit prefrontal resources, enhance task engagement, and improve performance under pressure.

Robotic Surgery Improves Technical Performance and Enhances Prefrontal Activation During High Temporal Demand

Robotic surgery may improve technical performance and reduce mental demands compared to laparoscopic surgery. However, no studies have directly compared the impact of robotic and laparoscopic techniques on surgeons' brain function. This study aimed to assess the effect of the operative platform (robotic surgery or conventional laparoscopy) on prefrontal cortical activation during a suturing task performed under temporal demand. Eight surgeons (mean age ± SD = 34.5 ± 2.9 years, male:female ratio = 7:1) performed an intracorporeal suturing task in a self-paced manner and under a 2 min time restriction using conventional laparoscopic and robotic techniques. Prefrontal activation was assessed using near-infrared spectroscopy, subjective workload was captured using SURG-TLX questionnaires, and a continuous heart rate monitor measured systemic stress responses. Task progression scores (au), error scores (au), leak volumes (mL) and knot tensile strengths (N) provided objective assessment of technical performance. Under time pressure, robotic suturing led to improved technical performance (median task progression score: laparoscopic suturing = 4.5 vs. robotic suturing = 5.0; z = - 2.107, p = 0.035; median error score: laparoscopic suturing = 3.0 mm vs. robotic suturing = 2.1 mm; z = - 2.488, p = 0.013). Compared to laparoscopic suturing, greater prefrontal activation was identified in seven channels located primarily in lateral prefrontal regions. These results suggest that robotic surgery improves performance during high workload conditions and is associated with enhanced activation in regions of attention, concentration and task engagement.

A decade of imaging surgeons' brain function (part II): A systematic review of applications for technical and nontechnical skills assessment

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.

Paradigm shift: cognitive surgery

In the last hundred years surgery has experienced a dramatic increase of scientific knowledge and innovation. The need to consider best available evidence and to apply technical innovations, such as minimally invasive approaches, challenges the surgeon both intellectually and manually. In order to overcome this challenge, computer scientists and surgeons within the interdisciplinary field of "cognitive surgery" explore and innovate new ways of data processing and management. This article gives a general overview of the topic and outlines selected pre-, intra- and postoperative applications. It explores the possibilities of new intelligent devices and software across the entire treatment process of patients ending in the consideration of an "Intelligent Hospital" or "Hospital 4.0", in which the borders between IT infrastructures, medical devices, medical personnel and patients are bridged by technology. Thereby, the "Hospital 4.0" is an intelligent system, which gives the right information, at the right time, at the right place to the individual stakeholder and thereby helps to decrease complications and improve clinical processes as well as patient outcome.