• Robin Sawaya, Abdulgadir Bugdadi, Hamed Azarnoush, Alexander Winkler-Schwartz, Fahad E Alotaibi, Khalid Bajunaid, Gmaan A AlZhrani, Ghusn Alsideiri, Abdulrahman J Sabbagh, and Rolando F Del Maestro.
• Neurosurgical Simulation Research and Training Centre, Department of Neurosurgery, Montréal Neurological Institute and Hospital, McGill University, Montréal, Québec, Canada.
• Oper Neurosurg (Hagerstown). 2018 Jun 1; 14 (6): 686-696.

BackgroundThe force pyramid is a novel visual representation allowing spatial delineation of instrument force application during surgical procedures. In this study, the force pyramid concept is employed to create and quantify dominant hand, nondominant hand, and bimanual force pyramids during resection of virtual reality brain tumors.ObjectiveTo address 4 questions: Do ergonomics and handedness influence force pyramid structure? What are the differences between dominant and nondominant force pyramids? What is the spatial distribution of forces applied in specific tumor quadrants? What differentiates "expert" and "novice" groups regarding their force pyramids?MethodsUsing a simulated aspirator in the dominant hand and a simulated sucker in the nondominant hand, 6 neurosurgeons and 14 residents resected 8 different tumors using the CAE NeuroVR virtual reality neurosurgical simulation platform (CAE Healthcare, Montréal, Québec and the National Research Council Canada, Boucherville, Québec). Position and force data were used to create force pyramids and quantify tumor quadrant force distribution.ResultsForce distribution quantification demonstrates the critical role that handedness and ergonomics play on psychomotor performance during simulated brain tumor resections. Neurosurgeons concentrate their dominant hand forces in a defined crescent in the lower right tumor quadrant. Nondominant force pyramids showed a central peak force application in all groups. Bimanual force pyramids outlined the combined impact of each hand. Distinct force pyramid patterns were seen when tumor stiffness, border complexity, and color were altered.ConclusionForce pyramids allow delineation of specific tumor regions requiring greater psychomotor ability to resect. This information can focus and improve resident technical skills training.

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