Put Your Finger on it: The role of Explicit Cognitive Strategies in Laparoscopic Surgery.

Abstract

This brief commentary highlights the importance of understanding the nature of explicit strategy (or heuristic) use in laparoscopic surgery including why such strategies might be useful and/or necessary in the first place. The use of strategies and other tricks warrants careful experimental investigation to determine their precise impact, and how they can be most effectively leveraged to improve surgical training. Experienced laparoscopic surgeons are familiar with the unsettling phenomenon of making a particular instrument movement (or sequence of movements), only to find that the movement of the instrument tip deviates greatly from their intention. In laparoscopic surgery, at least in complex laparoscopic surgery where the relationship between the camera and instrument ports can vary widely, these surprises can happen frequently. A common example occurs when the laparoscope faces the operator and, although upward hand motion produces the expected downward deflection of the instrument tip (reflective of the normal sensorimotor mapping in laparoscopic surgical contexts), leftward motion produces leftward tip motion and rightward motion produces rightward tip motion. Contending with this mismatch can be challenging for the surgeon. The surgeon is often so absorbed in the laparoscopic image as to feel completely present “within” the laparoscopic domain, oblivious to the screen to the extent that they may reposition their head to look behind a structure. The surgeon must deliberately shift their frame of reference to the outside world by pressing the abdominal wall with their finger at the location they want the instrument tip to go. Applying pressure to the abdominal wall with one’s hand seems to recruit proprioception as another source of information for “where things are.” The technique has the added benefit of bringing degrees of freedom from beyond the instrument, effectively delivering tissue to the instrument rather than having the instrument find the tissue; it is a subtle but powerful technique. This simple action seemingly provides both proprioceptive information and a useful visual reference that can improve target localization and simplify the motor control task. “Stop looking at the screen and look at the patient for a moment” can be a useful admonition. Ask “where do you want the instrument to go?” In surgery, useful tricks like this are called “heuristics.” In the scientific field of motor learning, they are called “explicit cognitive strategies,” which are thought to augment slower, implicit forms of learning in the motor system that tend to occur below the purview of conscious awareness.1 For example, prism goggles that shift the entire visual field to the right by a few degrees perturb the normal relationship between movements and the resulting sensory feedback.2 This change in the sensorimotor mapping immediately causes movement errors. Over successive attempts, the motor system gradually recalibrates this mapping so that movements become accurate once again—a process known as “sensorimotor adaptation.”3 When the shift or perturbation is large enough and human subjects become aware of it, they can volitionally compensate for the perturbation by using an explicit aiming strategy (eg, “If I aim to the left, I’ll be on target”). More generally, there is evidence that explicit strategies can serve as “instructional nudges” during the learning of new motor skills, helping to scaffold lower-level processes of motor skill acquisition and consolidation.4 For this reason, incorporating information about these and other related strategies into training programs could help reduce the learning curve for acquiring the complex hand-eye coordination skills needed for laparoscopic surgery. Although surgical expertise has been the topic of considerable experimental and theoretical investigation,5,6 there are a number of important aspects of skilled surgical performance that remain unexplored.7 This brief commentary highlights the importance of understanding the nature of explicit strategy (or heuristic) use in laparoscopic surgery including why such strategies might be useful and/or necessary in the first place. Second, if strategy use confers performance benefits, there is an important need to document these strategies as well as the specific contexts in which they are useful so that this information can be communicated consistently to trainees. Finally, the use of strategies and other tricks warrants careful experimental investigation to determine their precise impact, and how they can be most effectively leveraged to improve surgical training.