Directed information flow during laparoscopic surgical skill acquisition dissociated skill level and medical simulation technology

Abstract

Virtual reality (VR) simulator has emerged as a laparoscopic surgical skill training tool that needs validation using brain–behavior analysis. Therefore, brain network and skilled behavior relationship were evaluated using functional near-infrared spectroscopy (fNIRS) from seven experienced right-handed surgeons and six right-handed medical students during the performance of Fundamentals of Laparoscopic Surgery (FLS) pattern of cutting tasks in a physical and a VR simulator. Multiple regression and path analysis (MRPA) found that the FLS performance score was statistically significantly related to the interregional directed functional connectivity from the right prefrontal cortex to the supplementary motor area with F (2, 114) = 9, p < 0.001, and R2 = 0.136. Additionally, a two-way multivariate analysis of variance (MANOVA) found a statistically significant effect of the simulator technology on the interregional directed functional connectivity from the right prefrontal cortex to the left primary motor cortex (F (1, 15) = 6.002, p = 0.027; partial η2 = 0.286) that can be related to differential right-lateralized executive control of attention. Then, MRPA found that the coefficient of variation (CoV) of the FLS performance score was statistically significantly associated with the CoV of the interregionally directed functional connectivity from the right primary motor cortex to the left primary motor cortex and the left primary motor cortex to the left prefrontal cortex with F (2, 22) = 3.912, p = 0.035, and R2 = 0.262. This highlighted the importance of the efference copy information from the motor cortices to the prefrontal cortex for postulated left-lateralized perceptual decision-making to reduce behavioral variability.

Error-related brain state analysis using electroencephalography in conjunction with functional near-infrared spectroscopy during a complex surgical motor task

“…Notably, a distinction can be made between "internal monitoring" of error based on a predictive forward modeling framework [103] and "external monitoring" of error based on the action in the environment. In our prior work [46], we presented a perception-action model for brain-behavior analysis of laparoscopic surgical skill training. We showed the importance of the efference copy information from the motor cortices to the prefrontal cortex for postulated left-lateralized perceptual decision-making to reduce behavioral variability.…”

“…We showed the importance of the efference copy information from the motor cortices to the prefrontal cortex for postulated left-lateralized perceptual decision-making to reduce behavioral variability. Figure 1a shows the proposed perception-action link [46], where our optode montage (shown in Fig. 1b) captured the dorsal stream for action starting from action selection in the dorsolateral prefrontal cortex (PFC) to action sequencing in the supplementary motor area (SMA) to action performance in the primary motor cortex (PMC).…”

“…d Experimental setup in the laboratory with the subject performing the FLS "suturing and intracorporeal knot-tying" task (FLS complex task) Fig. 1 continued and action [34] that we presented in our prior work [46]. Relying on the sensory error feedback ("external monitoring" of error) does not allow preemptive error correction that is expected in skilled behavior so a forward (internal) model is expected to make sensory error predictions ("internal monitoring" of error) that can be used to continually update forthcoming motor commands [85] for error correction.…”

Brain-behavior analysis of transcranial direct current stimulation effects on a complex surgical motor task

“…Specifically, changes that accompany visuomotor learning can include decrease in the PFC activation while increased activation at the primary and secondary motor regions, the cerebellum and the posterior parietal cortex (James et al, 2013). Then, visuomotor learning in a novel environment, e.g., in the case of laparoscopic surgery, will need perceptual learning (Kamat et al, 2022a) that involves other brain networks (Dosenbach et al, 2007) such as dorsal attention network for visuospatial awareness and the salience network to direct attention to relevant stimuli, e.g., visuomotor task-errors. Therefore, appropriate brain targets for tDCS need to be selected from the nodes of the brain networks (Bressler and Menon, 2010) that are directly associated with the performance and learning of the specific visuomotor skill, viz., laparoscopic suturing with intracorporeal knot tying task (Walia et al, 2022b) in our current study.…”

“…functional near-infrared spectroscopy (fNIRS) (Nemani et al, 2018) and electroencephalography (EEG) (Ciechanski et al, 2019), and relating the brain activation changes to behavior can provide mechanistic insights. In particular, a distinction can be made between based on a predictive forward modeling framework (Wolpert and Miall, 1996) that can be modeled as error perception corrective action coupling (Kamat et al, 2022a;Walia et al, 2022a). Then, tDCS may facilitate mparator system in the cerebellum (Tanaka et al, 2020;Welniarz et al, 2021) event is sensed to drive the attention reorientation for skilled corrective action (Walia et al, 2022a).…”