Surgical neuroergonomics

By Daniel Richard Leff and Felipe Orihuela-Espina

In collaboration with Dr Daniel Leff from the Hamlyn Center for Surgical robotics at Imperial College of London we conduct research on surgical neuroergonomics.

Surgical Neuroergonomics”– seeks to capitalize on analyses of surgeons’ brain function to advance the understanding of learning, perception, and decision-making in surgery through the use of functional brain imaging technology. Applications of this research include neuromonitoring of surgeons to improve objective assessment, training of future surgeons, and neural biofeedback to enhance patient safety. 

Our research work in this arena can be sub-categorised, as follows: 

  • Expertise Development: to assess changes in cortical brain response associated with complex tasks acquisition and skills learning in surgery and develop neural markers of competence. 
  • Operative Decision-Making: to evaluate brain responses associated with operative decision-making and moderation of operative risk. 
  • Fatigue Assessment and Fatigue Amelioration:fatigue leads to poor decision-making, skills degradation, and clinical errors. We capitalise on non-invasive functional brain imaging to detect critical changes in operator brain function that are associated with fatigue and hypovigilance. 
  • Stress and Cognitive Load Assessment:to gain a better understanding of changes in the brain associated with dynamic temporal stress and cognitive workload. 
  • Neuroaugmentation: Using techniques such as transcranial stimulation to improve surgical performance. 

Current / Future Directions

The main thrust of the Lab’s current work is to build on our understanding of neural signatures of cognitive burden and cognitive overload. We have found that the brains of those who are sensitive to stress functions differently from those who maintain technical performance. 

See an example of this work here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6686757/

We see that this work could have major impact in supporting the transition from competence to independence neuromonitoring of recently graduated surgeons or those practicing independently for the first time as trainees (with feedback to senior surgeons), as well as have real OR applications through intelligent interfaces that feedback information about the cognitive load of the surgeon to improve patient safety. 

Realtime passive BCI applications are arguably most exciting but need investment to ensure the biomarkers are robust, reliable, repeatable and that we can classify these signals “on the fly” in near real time. Once proven, the sky is limit on what interfacing could be done (e.g. automated call for support, automatically lock the door to present disruption / distraction, turn off/ or turn on the radio, etc, etc).  

Wider Context: Neuromonitoring in Everyday Life 

There is interest right now in neural interfaces and pervasive neuromonitoring to evaluate performance and assess attention and concentration in everyday life. 

Kernel and Neuralink are good examples of this technology seemingly now in the mainstream for all sorts of applications. 

Selected Publications

  • Changes In Prefrontal Cortical Behaviour Depend Upon Familiarity On A Bimanual Co-ordination Task: An fNIRS Study. NeuroImage 2008; 39(2):805-13. PMID:17964187 DOI: 10.1016/j.neuroimage.2007.09.032 
  • Could variations in technical skills acquisition in surgery be explained by differences in cortical plasticity? Ann Surg 2008; 247(3): 540- 544. PMID: 18376201 DOI: 10.1097/SLA.0b013e31815fa42e 
  • ‘Circadian cortical compensation’. A longitudinal study of brain function during technical and cognitive skills in acutely sleep deprived surgical residents. Annals of Surgery 2010; 252(6):1082-90. PMID: 21107119 DOI: 10.1097/SLA.0b013e3181ff449c 
  • Enhanced frontoparietal network architectures following “gaze-contingent” versus “free-hand” motor learning. Neuroimage. 2013 Jan 1;64:267-76. Epub 2012 Aug 28. PMID:22960153. DOI: 10.1016/j.neuroimage.2012.08.056 
  • The impact of expert visual guidance on trainee visual search strategy, visual attention and motor skills. Front Hum Neurosci. 2015 Oct 14;9:526. eCollection 2015. PMID: 26528160. PMCID: PMC4604246. DOI: 10.3389/fnhum.2015.00526 
  • Contemplating the next manoeuvre – functional neuroimaging reveals intra-operative decision making strategy. Ann Surg. 2017 Feb;265(2):320-330. DOI: 10.1097/SLA.0000000000001651. 
  • Disparity in frontal lobe connectivity on a complex bimanual motor task aids classification of operator expertise. Brain Connect 2016 Jun;6(5):375-88. Epub 2016 Apr 12. PMID: 26899241. DOI: 10.1089/brain.2015.0350 
  • Persistent prefrontal engagement despite improvements in laparoscopic technical skills. JAMA Surgery 2016 Jul 1;151(7):682-4.  PMID: 27028901 DOI: 10.1001/jamasurg.2016.0050. 
  • Temporal stress in the operating room: brain engagement promotes “coping” and disengagement prompts “choking”. Ann Surg 2018 Apr;267(4):683-691.PMID: 2848968. DOI: 10.1097/SLA.0000000000002289 
  • Association of residents’ neural signatures with stress resilience during surgery. JAMA Surg. 2019 Aug 7:e192552. PMID: 31389994; PMCID: PMC668675. DOI: 10.1001/jamasurg.2019.2552 
  • Multitasking and time pressure in the operating room: impact on surgeons’ brain function. Ann Surg. 2020;10.1097/SLA.0000000000004208. DOI:10.1097/SLA.0000000000004208. 
  • Prefrontal transcranial direct-current stimulation improves early learning of technical skills in surgery.Brain Stimul. 2020 Nov- Dec;13(6):1834-1841. Epub 2020 Oct 31.PMID: 33130252 . DOI: 10.1016/j.brs.2020.10.013