Exploring the Effect of Pre-surgery Simulated Warm-up and Mental Visualisation in Reducing Musculoskeletal and Cognitive Demands Experienced by Surgeons Performing Robot-assisted Laparoscopic Surgery

BACKGROUND There is an increased utilisation of minimally invasive surgery (MIS) by virtue of it being more beneficial to patients, however, an increase in musculoskeletal (MSK) demands is observed when the modality of standard laparoscopic (LS) techniques are used compared with robot-assisted laparoscopic techniques (RALS). Studies have further highlighted that RALS is significantly associated with decreased musculoskeletal demands for surgeons, including findings from our recent study exploring the demands of RALS and LS surgery (MURALS study - NCT04477746).

Although most studies additionally observe that surgeons experienced less cognitive demands with RALS, the MURALS study on the other hand found that the favourable MSK effects associated with RALS come with a "cost" of concomitantly increasing surgeons' attentional demands. This finding is associated with the design of the robotic console's viewing cart which has a binocular design displaying high-definition 3-dimensional images similar to virtual reality headsets, thereby requiring fusion of images from both eyes to produce clear images of the operating field through the process of stereopsis. Also, this design of the viewing cart additionally acts to isolate the visual senses and block out other distractions within the surgeon's visual field.

The modern technology of RALS, therefore, offers better ergonomic advantages which could protect surgeons from adverse MSK effects and potentially prolong their surgical careers. The consequent effect of this would be an increase in the years' surgeons remain in active duty thereby being able to operate and provide life-changing treatments to an additional number of patients over the span of their careers.

Warm-up exercises, such as aerobic or stretching exercises and performing simulated tasks, all represent types of interventions associated with improved task performance, decreased completion times, and reduced errors. Warm-up exercises are routinely practiced by athletes before competing and amongst musicians and dancers prior to performances which are complex psychomotor tasks requiring high cognitive function and coordinated motor skill. Similarly, surgeons performing fundamental surgical skills like suturing performed simulations on mobile devices or on surgical simulators prior to being assessed using validated global rating scales like the Kundhal or Reznick scale demonstrated improved task performance, also consistent with the findings in a systematic review on the effect of warm-up exercises on surgical performance.

Another simple and inexpensive tool utilised by athletes to enhance performance is mental visualisation or mental imagery which is the cognitive rehearsal of tasks in the absence of physical movements for the purpose of mental rehearsal, relaxation or goal-setting purposes. Whilst athletes experience a myriad of different mental states during task performance, this technique of mental imagery has been shown to improve optimal performance in athletes by inducing, a flow state - which is characterized by automatic information processing without conscious thinking by suppressing prefrontal cortex activity temporarily. There is also an association between mental imagery and an observed greater power of alpha waves especially associated with the parietal (somatosensory processes) and occipital (visual processes) cortex. Studies in neurophysiology have clearly established that the neuroplastic changes observed during mental visualisation are similar to those which occur when physically performing tasks, due to the fact that performed or imagined movements stimulate the same neurons, engaging comparable patterns of connectivity between cortical motor regions.