Sensorimotor Challenges in Minimally Invasive Surgery: A Theoretically-Oriented Review.

OBJECTIVE: This review surveys the literature on sensorimotor challenges impacting performance in laparoscopic minimally invasive surgery (MIS). BACKGROUND: Despite its well-known benefits for patients, achieving proficiency in MIS can be challenging for surgeons due to many factors including altered visual perspectives and fulcrum effects in instrument handling. Research on these and other sensorimotor challenges has been hindered by imprecise terminology and the lack of a unified theoretical framework to guide research questions in the field. METHOD: We conducted a systematic survey of the MIS literature, focusing on studies investigating sensorimotor challenges affecting laparoscopic performance. To provide a common foundation for cross-study comparisons, we propose a standardized taxonomy that distinguishes between different experimental paradigms used in the literature. We then show how the computational motor learning perspective provides a unifying theoretical framework for the field that can facilitate progress and motivate future research along clearer, hypothesis-driven lines. RESULTS: The survey identified diverse sensorimotor perturbations in MIS, which can be effectively categorized according to our proposed taxonomy. Studies investigating monitor-, camera-, and tool-based perturbations were systematically analyzed, elucidating their impact on surgical performance. We also show how the computational motor learning perspective provides deeper insights and potential strategies to mitigate challenges. CONCLUSION: Sensorimotor challenges significantly impact MIS, necessitating a systematic, empirically informed approach. Our proposed taxonomy and theoretical framework shed light on the complexities involved, paving the way for more structured research and targeted training approaches to enhance surgical proficiency. APPLICATION: Understanding the sensorimotor challenges inherent to MIS can guide the design of improved training curricula and inform the configuration of setups in the operating room to enhance surgeon performance and ultimately patient outcomes. This review offers key insights for surgeons, educators, and researchers in surgical performance and technology development.

Error-independent effect of sensory uncertainty on motor learning when both feedforward and feedback control processes are engaged.

Integrating sensory information during movement and adapting motor plans over successive movements are both essential for accurate, flexible motor behaviour. When an ongoing movement is off target, feedback control mechanisms update the descending motor commands to counter the sensed error. Over longer timescales, errors induce adaptation in feedforward planning so that future movements become more accurate and require less online adjustment from feedback control processes. Both the degree to which sensory feedback is integrated into an ongoing movement and the degree to which movement errors drive adaptive changes in feedforward motor plans have been shown to scale inversely with sensory uncertainty. However, since these processes have only been studied in isolation from one another, little is known about how they are influenced by sensory uncertainty in real-world movement contexts where they co-occur. Here, we show that sensory uncertainty may impact feedforward adaptation of reaching movements differently when feedback integration is present versus when it is absent. In particular, participants gradually adjust their movements from trial-to-trial in a manner that is well characterised by a slow and consistent envelope of error reduction. Riding on top of this slow envelope, participants exhibit large and abrupt changes in their initial movement vectors that are strongly correlated with the degree of sensory uncertainty present on the previous trial. However, these abrupt changes are insensitive to the magnitude and direction of the sensed movement error. These results prompt important questions for current models of sensorimotor learning under uncertainty and open up new avenues for future exploration in the field.

Metacognitive judgments during visuomotor learning reflect the integration of error history.

People form metacognitive representations of their own abilities across a range of tasks. How these representations are influenced by errors during learning is poorly understood. Here, we ask how metacognitive confidence judgments of performance during motor learning are shaped by the learner's recent history of errors. Across four motor learning experiments, our computational modeling approach demonstrated that people's confidence judgments are best explained by a recency-weighted averaging of visually observed errors. Moreover, in the formation of these confidence estimates, people appear to reweight observed motor errors according to a subjective cost function. Confidence judgments were adaptive, incorporating recent motor errors in a manner that was sensitive to the volatility of the learning environment, integrating a shallower history when the environment was more volatile. Finally, confidence tracked motor errors in the context of both implicit and explicit motor learning but only showed evidence of influencing behavior in the latter. Our study thus provides a novel descriptive model that successfully approximates the dynamics of metacognitive judgments during motor learning.NEW & NOTEWORTHY This study examined how, during visuomotor learning, people's confidence in their performance is shaped by their recent history of errors. Using computational modeling, we found that confidence incorporated recent error history, tracked subjective error costs, was sensitive to environmental volatility, and in some contexts may influence learning. Together, these results provide a novel model of metacognitive judgments during motor learning that could be applied to future computational and neural studies at the interface of higher-order cognition and motor control.

Camera realignment imposes a cost on laparoscopic performance.

There is an unresolved question about whether realigned visual feedback is beneficial or costly to laparoscopic task performance. We provide evidence that camera realignment imposes a reliable cost on performance across both naive controls and experienced surgeons. This finding clarifies an important ongoing discussion in the literature about the effects of camera realignment, which could inform the strategies that laparoscopic surgeons use in the operating room.

Enhanced visuomotor learning and generalization in expert surgeons.

Although human motor learning has been intensively studied for many decades, it remains unknown whether group differences are present in expert cohorts that must routinely cope with and learn new visuomotor mappings such as expert minimally invasive surgeons. We found that expert surgeons compensate for a visuomotor perturbation more rapidly than naive controls. Modelling indicates that these differences in expert behavioural performance reflects greater trial-to-trial retention, as opposed to greater trial-to-trial learning rate. We also found that surgeons generalize to novel reach directions more broadly than controls, a result which was subsequently confirmed by our modelling. In general, our findings show that minimally invasive surgeons exhibit enhanced visuomotor learning and spatial generalization.

Interlimb Generalization of Learned Bayesian Visuomotor Prior Occurs in Extrinsic Coordinates.

Recent work suggests that the brain represents probability distributions and performs Bayesian integration during sensorimotor learning. However, our understanding of the neural representation of this learning remains limited. To begin to address this, we performed two experiments. In the first experiment, we replicated the key behavioral findings of Körding and Wolpert (2004), demonstrating that humans can perform in a Bayes-optimal manner by combining information about their own sensory uncertainty and a statistical distribution of lateral shifts encountered in a visuomotor adaptation task. In the second experiment, we extended these findings by testing whether visuomotor learning occurring during the same task generalizes from one limb to the other, and relatedly, whether this learning is represented in an extrinsic or intrinsic reference frame. We found that the learned mean of the distribution of visuomotor shifts generalizes to the opposite limb only when the perturbation is congruent in extrinsic coordinates, indicating that the underlying representation of learning acquired during training is available to the untrained limb and is coded in an extrinsic reference frame.

Analysis of short-term reproducibility of arterial vasoreactivity by pulse-wave analysis after pharmacological challenge.

1. Pulse-wave analysis (PWA) is an established method to assess arterial wave reflections and arterial vasoreactivity in humans. A high short-term reproducibility of baseline augmentation index (AIx) has been reported. However, the short-term reproducibility of AIx changes following pharmacological challenge with either inhaled salbutamol (endothelium-dependent vasodilatation) or sublingual glyceryl trinitrate (GTN; endothelium-independent vasodilatation), using appropriate statistical methods, is largely unknown. 2. Baseline AIx and GTN- and salbutamol-mediated changes in AIx (all corrected for a heart rate of 75 b.p.m.) were measured on two separate occasions, 1 h apart, in 22 healthy controls (mean (+/-SD) age 52.0 +/- 13.4 years) and 11 elderly patients with chronic heart failure (CHF; 73.1 +/- 8.7 years). Reproducibility was assessed by measuring intraclass correlation coefficients (ICC), coefficients of variation (CV) and Bland-Altman plots. 3. Baseline AIx showed good short-term reproducibility with high ICC in both the control and CHF groups (0.90 and 0.87, respectively). In contrast, in the control and CHF groups, the ICC of GTN- (0.58 and 0.17, respectively) and salbutamol-mediated (0.18 and 0.04, respectively) changes in AIx were substantially low. The CV was relatively low for baseline AIx in control and CHF groups (25.0 and 22.5%, respectively), but not for GTN- (22.3 and 59.8%, respectively) or salbutamol-mediated (45.1 and 184.0%, respectively) changes in AIx. Bland-Altman analysis revealed poor reproducibility, with limits of agreement beyond either +15% or -15% for changes in AIx after GTN and salbutamol for both control and CHF groups. The changes in blood pressure and heart rate following pharmacological challenge were similar between the two measurements. 4. The poor reproducibility of changes in AIx following pharmacological challenge questions the use of this method in acute studies.

Symmetric dimethylarginine is an independent predictor of intradialytic hypotension.

BACKGROUND: Hemodialysis (HD) is associated with significant reductions in the plasma concentrations of the nitric oxide (NO) inhibitors N(G)-monomethyl L-arginine (L-NMMA), asymmetric dimethylarginine (ADMA), and symmetric dimethylarginine (SDMA). We sought to determine whether elevated concentrations of these NO inhibitors pre-HD and/or their acute decrease during HD might mediate intradialytic hypotension (IDH). METHODS: Systolic blood pressure (SBP), L-arginine, L-NMMA, ADMA, and SDMA were measured at the beginning (pre-HD) and at the end (end-HD) in 52 consecutive HD patients (age 64.4 +/- 13.4 years). IDH was defined as a SBP reduction of >20 mm Hg end-HD vs. pre-HD. RESULTS: Fourteen patients demonstrated IDH. The mean SBP reduction during HD in this group was -35 +/- 13 mm Hg compared to an increase of +2 +/- 12 mm Hg among the 38 patients without IDH (no-IDH). Baseline demographic, clinical, and biochemical parameters did not differ between the IDH and no-IDH groups. However, the IDH group had higher pre-HD SBP (155 +/- 17 vs. 132 +/- 14 mm Hg, P < 0.001), pre-HD plasma SDMA concentrations (1.98 +/- 0.61 vs. 1.64 +/- 0.46 micromol/l, P = 0.04), and greater SDMA reductions during HD (-0.78 +/- 0.43 vs. -0.56 +/- 0.32 micromol/l, P = 0.06) than the no-IHD group. After adjusting for pre-HD SBP, the odds of IDH occurring were higher with increased pre-HD SDMA plasma concentrations (OR = 1.31 per 0.1 micromol/l SDMA increase; 95% CI = 1.04-1.65, P = 0.02) and with decreases in SDMA during HD (OR = 1.39 per 0.1 micromol/l SDMA decrease; 95% CI = 1.02-1.91, P = 0.04). CONCLUSION: Increased pre-HD SDMA plasma concentrations and greater SDMA reductions during HD independently predict IDH after adjusting for demographic and clinical variables, pre-HD SBP, and other methylated forms of L-arginine.