• Hemel N Modi, Harsimrat Singh, Felipe Orihuela-Espina, Thanos Athanasiou, Francesca Fiorentino, Guang-Zhong Yang, Ara Darzi, and Daniel R Leff.
• Hamlyn Centre for Robotic Surgery, Imperial College London, London, United Kingdom.
• Ann. Surg. 2018 Apr 1; 267 (4): 683-691.

ObjectiveTo investigate the impact of time pressure (TP) on prefrontal activation and technical performance in surgical residents during a laparoscopic suturing task.BackgroundNeural mechanisms enabling surgeons to maintain performance and cope with operative stressors are unclear. The prefrontal cortex (PFC) is implicated due to its role in attention, concentration, and performance monitoring.MethodsA total of 33 residents [Postgraduate Year (PGY)1-2 = 15, PGY3-4 = 8, and PGY5 = 10] performed a laparoscopic suturing task under "self-paced" (SP) and "TP" conditions (TP = maximum 2 minutes per knot). Subjective workload was quantified using the Surgical Task Load Index. PFC activation was inferred using optical neuroimaging. Technical skill was assessed using progression scores (au), error scores (mm), leak volumes (mL), and knot tensile strengths (N).ResultsTP led to greater perceived workload amongst all residents (mean Surgical Task Load Index score ± SD: PGY1-2: SP = 160.3 ± 24.8 vs TP = 202.1 ± 45.4, P < 0.001; PGY3-4: SP = 123.0 ± 52.0 vs TP = 172.5 ± 43.1, P < 0.01; PGY5: SP = 105.8 ± 55.3 vs TP = 159.1 ± 63.1, P < 0.05). Amongst PGY1-2 and PGY3-4, deterioration in task progression, error scores and knot tensile strength (P < 0.05), and diminished PFC activation was observed under TP. In PGY5, TP resulted in inferior task progression and error scores (P < 0.05), but preservation of knot tensile strength. Furthermore, PGY5 exhibited less attenuation of PFC activation under TP, and greater activation than either PGY1-2 or PGY3-4 under both experimental conditions (P < 0.05).ConclusionsSenior residents cope better with temporal demands and exhibit greater technical performance stability under pressure, possibly due to sustained PFC activation and greater task engagement. Future work should seek to develop training strategies that recruit prefrontal resources, enhance task engagement, and improve performance under pressure.

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