Continuous Monitoring of Mental Load During Virtual Simulator Training for Laparoscopic Surgery Reflects Laparoscopic Dexterity: A Comparative Study Using a Novel Wireless Device

Neta B. Maimon, Maxim Bez, Denis Drobot, Lior Molcho, Nathan Intrator, Eli Kakiashvilli, Amitai Bickel

Research output: Contribution to journalArticlepeer-review

6 Scopus citations


Introduction: Cognitive Load Theory (CLT) relates to the efficiency with which individuals manipulate the limited capacity of working memory load. Repeated training generally results in individual performance increase and cognitive load decrease, as measured by both behavioral and neuroimaging methods. One of the known biomarkers for cognitive load is frontal theta band, measured by an EEG. Simulation-based training is an effective tool for acquiring practical skills, specifically to train new surgeons in a controlled and hazard-free environment. Measuring the cognitive load of young surgeons undergoing such training can help to determine whether they are ready to take part in a real surgery. In this study, we measured the performance of medical students and interns in a surgery simulator, while their brain activity was monitored by a single-channel EEG. Methods: A total of 38 medical students and interns were divided into three groups and underwent three experiments examining their behavioral performances. The participants were performing a task while being monitored by the Simbionix LAP MENTOR™. Their brain activity was simultaneously measured using a single-channel EEG with novel signal processing (Aurora by Neurosteer®). Each experiment included three trials of a simulator task performed with laparoscopic hands. The time retention between the tasks was different in each experiment, in order to examine changes in performance and cognitive load biomarkers that occurred during the task or as a result of nighttime sleep consolidation. Results: The participants’ behavioral performance improved with trial repetition in all three experiments. In Experiments 1 and 2, delta band and the novel VC9 biomarker (previously shown to correlate with cognitive load) exhibited a significant decrease in activity with trial repetition. Additionally, delta, VC9, and, to some extent, theta activity decreased with better individual performance. Discussion: In correspondence with previous research, EEG markers delta, VC9, and theta (partially) decreased with lower cognitive load and higher performance; the novel biomarker, VC9, showed higher sensitivity to lower cognitive load levels. Together, these measurements may be used for the neuroimaging assessment of cognitive load while performing simulator laparoscopic tasks. This can potentially be expanded to evaluate the efficacy of different medical simulations to provide more efficient training to medical staff and measure cognitive and mental loads in real laparoscopic surgeries.

Original languageEnglish
Article number694010
JournalFrontiers in Neuroscience
StatePublished - 2021

Bibliographical note

Publisher Copyright:
Copyright © 2022 Maimon, Bez, Drobot, Molcho, Intrator, Kakiashvilli and Bickel.


  • EEG biomarker
  • brain assessment
  • cognitive load
  • laparoscopic operations
  • machine learning
  • mental load assessment
  • surgical simulator training


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