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

Goble, Mary; Caddick, Virginia; Patel, Ronak; Modi, Hemel; Darzi, Ara; Orihuela-Espina, Felipe; Leff, Daniel R. · 2023 · Crossref

DOI: 10.3389/fnrgo.2023.1142182

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Summary

This narrative review examines the application of functional near-infrared spectroscopy (fNIRS) and neurostimulation in surgical training and assessment, aiming to define neural benchmarks for expertise and optimize cognitive performance. The authors address the limitations of traditional proficiency metrics, such as time-to-completion, which often fail to accurately classify surgical skill. By leveraging fNIRS—a non-invasive, radiation-free optical imaging technique that measures cerebral hemodynamics—the study explores how expertise, stress, surgical technology, and neurostimulation influence neural activation patterns. The review synthesizes literature from PubMed and Embase to identify gaps in surgical neuroergonomics and propose methods for real-time cognitive feedback in operating theaters. The analysis reveals distinct neural signatures differentiating novice and expert surgeons. Novices exhibit greater hemodynamic responses in the prefrontal cortex (PFC) during simple tasks, reflecting higher cognitive load and executive function engagement. As expertise develops, PFC activation attenuates, while activation shifts to motor regions such as the supplementary motor area (SMA) and primary motor cortex (M1), indicating improved efficiency and automaticity. Functional connectivity also differs, with experts showing stronger motor connectivity compared to the prefrontal connectivity seen in novices. Regarding cognitive workload, PFC activation follows an inverted-U curve relative to mental demand; activation increases with workload but attenuates once demands exceed cognitive capacity, a state associated with performance degradation under stress. The review further evaluates the impact of surgical tools and interventions. Robotic-assisted surgery induces greater PFC activation than laparoscopic surgery, suggesting higher initial cognitive engagement, though it may offer ergonomic benefits. Gaze-enhanced learning systems in robotic training accelerate the attenuation of PFC activation, potentially speeding skill acquisition. Additionally, transcranial direct-current stimulation (tDCS) is identified as a safe method to enhance motor performance and prevent stress-induced working memory impairment, although long-term effects and optimal stimulation parameters require further investigation. The significance of these findings lies in the potential to transform surgical training from outcome-based to process-based assessment. fNIRS can establish objective neural benchmarks for proficiency, surpassing traditional metrics in reliability. The authors conclude that integrating fNIRS with machine learning for real-time data processing could enable live cognitive feedback, allowing for the modulation of stress responses and individualized training. However, widespread clinical adoption depends on overcoming challenges in data standardization, artifact removal, and the development of robust algorithms capable of processing complex, real-world operating theater data.

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• neuro workload indices