Could variations in technical skills acquisition in surgery be explained by differences in cortical plasticity?

UNLABELLED SUMMARY/BACKGROUND: Variations in technical performance in surgery are known to exist but are poorly understood. Gaining an appreciation of these differences may have implications for technical skills training, assessment, and selection. Investigators attempting to correlate technical skill with visuospatial or perceptual tests have failed to identify surrogate markers of surgical aptitude. Evidence from unrelated fields suggests that studying brain function may advance our understanding of disparate technical performance in surgery. METHODS A literature search was conducted to identify relevant studies assessing both motor skills learning and changes in brain function. RESULTS The brain is dynamic and patterns of activation vary with experience and training, a property referred to as "neuroplasticity." Functional neuroimaging studies of complex nonsurgical skills have demonstrated smaller, more refined neuronal networks in experts compared with novices. Novel unrefined performance places a significant burden on generic areas of attention and control such as the anterior cingulate cortex and the prefrontal cortex (PFC). These regions are recruited less as skills are performed with increasing automaticity. Persistent PFC activation has been shown to herald poor bimanual coordination learning in studies involving nonsurgical tasks. CONCLUDING HYPOTHESIS It is suspected that alterations in brain activation foci accompany a transition through phases of surgical skills learning and that those patterns of activation may vary according to technical ability. Validating this hypothesis is challenging because it requires studying brain function in ambulant subjects performing complex motor skills. In a surgical knot-tying study involving over 60 subjects of varying expertise, PFC activation was identified in novices but not in trained surgeons. Further work should aim to determine whether PFC activation attenuates in the context of learning success in surgery.