Functional MRI-Compatible Laparoscopic Surgery Training Simulator Parisa Bahrami, 1 * Tom A. Schweizer, 1,2,3,4 Fred Tam, 5 Teodor P. Grantcharov, 2,4 Michael D. Cusimano, 2,4 and Simon J. Graham 5,6 During the past few years, laparoscopy has become the gold standard for some surgical procedures and its applications continue to expand. Because of multiple factors such as loss of tactile perception, two-dimensional visualization of the three-dimensional surgical field, and demanding bimanual hand–eye coordination, special training is required to achieve proficiency with laparoscopy. In this study, as the first step toward evidence-based development of strategies to improve the quality of laparoscopy training from brain activity and behavior relationships, a laparoscopy training simulator was developed for use in functional MRI. Experiments confirmed the functional MRI compatibility of the device. Representative behavioral and functional MRI results for two subjects showed the feasibility of using this simulator to investigate the brain activation associated with components of laparo- scopic task performance. To our knowledge, this is the first study that directly looks at the functional MRI brain activation during complex surgical training tasks. Magn Reson Med 65:873–881, 2011. V C 2010 Wiley-Liss, Inc. Key words: functional magnetic resonance imaging (fMRI); laparoscopy surgery; minimally invasive surgery; training In the past decade, the number of laparoscopic surgeries replacing open abdominal and pelvic surgeries has increased dramatically (1). In open surgery, maneuvers are performed with large incisions to the skin and the underlying muscles. In laparoscopy, all procedures are undertaken through small skin incisions. Carbon dioxide is introduced to inflate the abdominal cavity and increase the working space. An endoscopic camera and long, narrow surgical tools are also inserted, after which the surgeon views the surgical field under high magnifi- cation in a video display and operates with minimal trauma to the patient. This minimally invasive surgery reduces blood loss, pain, and morbidity, lowers risk of infection, and speeds recovery (2–5). To provide the benefits of laparoscopic surgery to patients without complications and side effects, it is cru- cial that surgeons acquire the complex skills specific to this technique. In open surgery, surgeons rely heavily on tactile feedback, depth perception, and hand–eye coordi- nation in a three-dimensional field of view. Laparoscopic surgery, however, involves reduced depth and tactile perception, two-dimensional (2D) visualization of the three-dimensional surgical field, and requires high bima- nual hand–eye coordination while performing proce- dures at the end of ergonomically altered instruments. Consequently, special training is required to learn lapa- roscopy (6), commonly provided to surgical residents through simulated sessions in surgical skills labs (7). Although sophisticated simulators exist that use vir- tual reality technology, the present work focuses on a simple, yet widely used surgical simulator. It is used as a training and an assessment tool as a part of the ‘‘Fun- damentals of Laparoscopic Surgery’’ (FLS) program (8). This simulator is low cost, approved, and available through the Society of American Gastrointestinal and Endoscopic Surgeons and the American College of Sur- geons and is widely used in residency programs (9). The simulator kit (Fig. 1) consists of: a white nonreflec- tive plastic box; a video camera; an interior stage simu- lating the surgical field where specific training tasks are undertaken; surgical tools; insertion points on the box surface; a video cable; and a video display (10). The video camera is mounted inside the box at a fixed posi- tion and angle to record the simulated surgical field and provide surgeons with visual feedback during train- ing tasks (11). There are five tasks performed with the FLS simulator, or ‘‘training box’’ (Fig. 2). In order of increasing complex- ity, the tasks are: (a) pegboard transfers, (b) pattern cut- ting, (c) placement of a ligating loop, (d) suturing with extracorporeal knot tying, whereby the knot is tied out- side the box and is pushed into the box using a knot pusher, and (e) suturing with intracorporeal knot tying, whereby the knot is tied entirely inside the box (9,11). Task performance is graded based on speed and accuracy. The score for an individual task is calculated by subtracting the task performance time from a preset upper time limit. A penalty score is then deducted from the time score to account for errors or inaccuracy. Consequently, higher scores indicate better perform- ance (11). These tasks are intended to improve the psychomotor skills necessary to perform laparoscopic procedures (12). 1 Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada. 2 Keenan Research Centre of the Li Ka Shing Knowledge Institute at St. Michael’s Hospital, Toronto, Ontario, Canada. 3 Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada. 4 Department of Surgery, Division of Neurosurgery, St. Michael’s Hospital, Toronto, Ontario, Canada. 5 Rotman Research Institute, Baycrest Hospital, Toronto, Ontario, Canada. 6 Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada. Grant sponsor: Natural Sciences and Engineering Research Council (NSERC), Canada. *Correspondence to: Parisa Bahrami, MHSc, BEng., The Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON M5S 3G9, Canada. E-mail: parisa.bahrami@utoronto.ca Received 6 May 2010; revised 3 August 2010; accepted 9 September 2010. DOI 10.1002/mrm.22664 Published online 4 November 2010 in Wiley Online Library (wileyonlinelibrary.com). Magnetic Resonance in Medicine 65:873–881 (2011) V C 2010 Wiley-Liss, Inc. 873