UC Researchers Pool Their Expertise to Solve a Surgery Challenge

It’s been called Band-Aid surgery or keyhole surgery – and when it’s recommended to a patient, it can be a big relief. That small incision means less pain, a reduced risk of infection and a faster recovery, compared with traditional, open surgery. But for the surgeon who’s using tools instead of hands that can feel their way to the problem, as well as cameras and monitors requiring their eyes to look away from where they’re working, these operations can trigger more stress and a higher mental workload than the traditional open surgeries. A one-of-a-kind team of University of Cincinnati researchers is exploring how to address these challenges with the support of a $25,000 University Research Council Interdisciplinary Grant.

The new University Research Council Interdisciplinary Grant Program blends the diverse expertise of UC researchers and lays the groundwork for research that could open opportunities for federal funding. The program also exemplifies how UC is growing its research excellence and forming key relationships and partnerships as part of the UC|21 Strategic Plan.

This particular research proposal, titled “Managing Cognitive Workload and Stress in Minimally Invasive and Robotic Surgery Interfaces,” involves a team represented by psychology researchers from the McMicken College of Arts and Sciences; urologic surgeons in the College of Medicine; the College of Engineering; and the UC Center for Surgery Innovation, a partnership between the Colleges of Medicine and Engineering that’s exploring and inventing new surgical procedures and technologies to benefit worldwide patient care.

“Our researchers are internationally known for their expertise in perception, motor control, workload, stress, medical product design and surgery,” says Michael Riley, associate professor of psychology. “Our team possesses the expertise to enable significant progress in identifying problematic features of minimally invasive surgery and robotic surgery interfaces, and in designing and testing new technologies to overcome these problems.”

The project was geared toward examining the effects of training and experience on the stress and workload encountered while performing exercises with a laparoscopic training box – a practice device that uses instruments identical to those used during surgery – as well as performing exercises with the da Vinci surgical robot that is dedicated to research and training at the UC Center for Surgery Innovation. The test subjects performing the exercises included 15 medical students in the College of Medicine.

The exercise consisted of using the tools in both machines to pick up a small rubber ring, about the size of a tip of a pinkie finger, and to loop the ring around a little rubber cone. The exercise is called a peg-transfer task, and is commonly used for developing minimally invasive surgical skills. The students were told to move as many rings as fast as they could over 12-minute intervals on both the da Vinci and the training box.

Martina Klein, a doctoral candidate in psychology, supervised the exercises, and then followed up with assessments of motor-performance and a stress-assessment questionnaire created by UC Psychology Professor Gerald Matthews. This Dundee Stress State Questionnaire (DSSQ) can determine mental stress, arousal, concentration, fatigue and self-esteem. Another assessment examined how the exercises affected cognitive workload – the degree of specific cognitive “resources” required to perform the task, such as spatial attention and concentration, manual concentration and short-term memory.

"Although we cannot impose or mimic the stress that we experience during operations upon our patients during an inanimate laboratory exercise, stress and cognitive effort associated with the tasks to be performed under laparoscopic conditions (i.e., indirect vision of the instruments via TV monitor, reduced range of motion imposed by straight laparoscopic instruments that move around a point of fixation at the entry into the box), do vary between individuals and with change in simulation set-up," according to James Donovan, MD, chief of the UC Division of Urology.

The researchers say they were expecting that with a two-dimensional camera at a 90-degree angle, the laparoscopic training box would be more stressful and would impose more workload than the da Vinci robot. They explain that the da Vinci robot has a more intuitive interface and an advanced visual display, so it eases somewhat the burden placed on hand-eye coordination by minimally invasive surgery. But they say the

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of stress associated with the box simulator was a key discovery. “Some people were so determined about adjusting to the environment that they didn’t want to stop,” says Klein, “and others, once they finished, reported they wanted to get out of there as fast as possible.” She adds that this is the first study to compare the stress and workload associated with different types of minimally invasive surgery interfaces. While the data confirmed the expectation that the laparoscopic training box was more stressful, a surprising discovery was that two interfaces had identical workload profiles – they drew on exactly the same kinds of cognitive processing resources.

“During laparoscopy, there’s a demand for eye-hand coordination as you look at a screen and operate inside the patient’s body,” explains project collaborator Krishnanath Gaitonde, MD, assistant professor of urology. “There’s decreased feedback – your tissue feel is not there and the instruments are rigid. The robotics have three-dimensional vision and the instruments move like your own wrist, but there is still a demand for hand-eye coordination as you look into a screen and use your hands to operate,” says Gaitonde, who specializes in minimally invasive and robotic surgery.

“One of the ultimate goals of this research would be to develop methods to allow people to learn these techniques faster, because it does require a considerable amount of experience for surgeons to become proficient,” says Riley. He says other avenues of future research could explore ways to develop exercises that improve cognitive processing skills that are required by minimally invasive surgery.

“Laparoscopy is the current standard of care for many surgeries performed in the United States. More operations will be adapted to laparoscopic or other minimally-invasive techniques,” adds Donovan. “We are faced with the challenge of teaching minimally invasive surgery to our residents without sacrificing their experience skills in open operative procedures. This is a challenge for the future,” Donovan says.

“Previously, people never looked at the psychological aspect and mental stress of surgeons, and now it’s gradually becoming an important element in our training,” says Gaitonde. “I hope we have more collaboration like these in the future, because a well-trained and mentally relaxed urologic surgeon is a safer surgeon. Improving the mind, the instrument and the technology roles in surgery – it all makes sense.”

Interdisciplinary Grant Partners: Managing Cognitive Workload and Stress in Minimally Invasive and Robotic Surgery Interfaces

McMicken College of Arts and Sciences

• Martina Klein, doctoral candidate in psychology
• Michael Riley, associate professor, psychology
• Gerald Matthews, professor, psychology
• Joel Warm, professor, psychology

College of Medicine

• James Donovan, MD, chief of the division of urology
• Krishnanath Gaitonde, MD, assistant professor of urology

College of Engineering

• William Ball, professor and chair, biomedical engineering

Center for Surgical Innovation

• Charles Doarn, executive director