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.Electronic supplementary materialThe online version of this article (10.1007/s10439-018-2049-z) contains supplementary material, which is available to authorized users.

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.

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.

Thank you for providing us with an opportunity to revise our manuscript entitled Multitasking and Time Pressure in the Operating Room: Impact on Surgeons' Brain Function (ANNSURG-D-20-01211).technical performance. This functional neuroimaging study demonstrates that stressinduced performance deterioration among surgeons is associated with deactivation of brain regions important for attentional control, working memory and cognitive flexibility, particularly during tasks involving simultaneous motor and cognitive engagement.

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.

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.

Groin USS is highly sensitive, and patients could be referred for USS by GPs when clinical examination findings are equivocal or negative. If USS is also negative, patients may be managed conservatively in primary care setting if they remain asymptomatic. Positive clinical examination findings appear to have a greater influence in the decision to treat surgically.

A 75-year-old woman presented with a presumed urothelial carcinoma of the right renal pelvis. A radical nephroureterectomy was carried out and histological analysis of the specimen revealed lymphoepithelioma-like carcinoma. This is the seventh reported case of this normally nasopharyngeal tumour found in the renal pelvis. These tumours have a distinct histological appearance comprising sheets of undifferentiated syncytial cells on a background of lymphoid stroma. We review the pathological features of lymphoepithelioma-like carcinoma and make arguments for managing these tumours in a similar way to urothelial carcinoma.