Neuroimaging Guided Transcranial Electrical Stimulation in Enhancing Surgical Skill Acquisition. Comment on Hung et al. The Efficacy of Transcranial Direct Current Stimulation in Enhancing Surgical Skill Acquisition: A Preliminary Meta-Analysis of Randomized Controlled Trials. Brain Sci. 2021, 11, 707

Abstract

Surgical skill acquisition may be facilitated with a safe application of transcranial direct current stimulation (tDCS). A preliminary meta-analysis of randomized control trials showed that tDCS was associated with significantly better improvement in surgical performance than the sham control; however, meta-analysis does not address the mechanistic understanding. It is known from skill learning studies that the hierarchy of cognitive control shows a rostrocaudal axis in the frontal lobe where a shift from posterior to anterior is postulated to mediate progressively abstract, higher-order control. Therefore, optimizing the transcranial electrical stimulation to target surgical task-related brain activation at different stages of motor learning may provide the causal link to the learning behavior. This comment paper presents the computational approach for neuroimaging guided tDCS based on open-source software pipelines and an open-data of functional near-infrared spectroscopy (fNIRS) for complex motor tasks. We performed an fNIRS-based cortical activation analysis using AtlasViewer software that was used as the target for tDCS of the motor complexity-related brain regions using ROAST software. For future studies on surgical skill training, it is postulated that the higher complexity laparoscopic suturing with intracorporeal knot tying task may result in more robust activation of the motor complexity-related brain areas when compared to the lower complexity laparoscopic tasks.

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

“…In contrast, the fMRI studies showed additional activation of deeper brain structures, including the basal ganglia and cerebellum [80]. Future studies need to apply the perceptionaction system based on brain-behavior analysis during a learning curve study [25], where the chain of mental processes can depend on the task complexity [100], 707).…”

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

“…The experimental results of this study are conducive to the exploration of transcranial electrical stimulation 113 to facilitate learnability in medical simulators. For example, mobile brain-behavior analysis with fNIRS can capture the interaction between the angular gyrus (AG) and the middle frontal gyrus (MFG) that is underpinned by the dorsal superior longitudinal fascicle (SLF II) 114 , and the subjective sense of agency may be facilitated by neuroimaging-guided transcranial electrical stimulation 113 of the AG-MFG interactions 115 . The dorsal branch of the superior longitudinal fasciculus, which is responsible for visuospatial integration and motor planning, is linked to lateralized hand preference and manual specialization 116 .…”

“…Here, the premotor and motor areas were combined in the PMC (see Table S1), and the fNIRS optode montage could not distinguish the SMA proper from the preSMA brain regions, which may be important to better assess the temporal structure 124 of the perception-action coupling link 70 . Additionally, we did not investigate all of the subregions of the PFC, e.g., the ventrolateral PFC and inferior frontal gyrus (IFG), that may have essential functional interactions during FLS surgical skill acquisition 113 , where the feasibility of fNIRS' temporal resolution needs to be demonstrated in the future to capture the fast interactions that are expected via shorter frontal lobe connections 119 .…”

“…1b) from the supramarginal gyrus (SMG), where the left MFG and left inferior frontal gyrus (IFG) are more involved in more perceptually demanding FLS tasks, e.g., FLS suturing with intracorporal knot tying 117 . Here, the ventral stream of perception can be facilitated by neuroimaging-guided transcranial electrical stimulation 113 of SMG-IFG interactions 115 . Then, the coupling between the SMA and LPFC may be related to patterns of prelearned behavior performed in familiar environments 110 in the case of experts in the physical simulator.…”

“…Therefore, we aimed to capture the initial stage in FLS pattern cutting skill acquisition to investigate the action-perception link 70 when the perceptual model 7 is being developed. Here, transcranial electrical stimulation 113 may facilitate the development of internal models 121 as well as efference copy and corollary discharge, which may facilitate predictive internal signaling 89 .…”