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Randomized clinical trial to evaluate mental practice in enhancing advanced laparoscopic surgical performance. BJS 2015; 102: 37-44.

Published: 21st October 2014

Authors: M. Louridas, E. M. Bonrath, D. A. Sinclair, N. J. Dedy, T. P. Grantcharov


Mental practice, the cognitive rehearsal of a task without physical movement, is known to enhance performance in sports and music. Investigation of this technique in surgery has been limited to basic operations. The purpose of this study was to develop mental practice scripts, and to assess their effect on advanced laparoscopic skills and surgeon stress levels in a crisis scenario.


Twenty senior surgical trainees were randomized to either conventional training or mental practice groups, the latter being trained by an expert performance psychologist. Participants' skills were assessed while performing a porcine laparoscopic jejunojejunostomy as part of a crisis scenario in a simulated operating room, using the Objective Structured Assessment of Technical Skill (OSATS) and bariatric OSATS (BOSATS) instruments. Objective and subjective stress parameters were measured, as well as non‐technical skills using the Non‐Technical Skills for Surgeons rating tool.


An improvement in OSATS (P = 0·003) and BOSATS (P = 0·003) scores was seen in the mental practice group compared with the conventional training group. Seven of ten trainees improved their technical performance during the crisis scenario, whereas four of the ten conventionally trained participants deteriorated. Mental imagery ability improved significantly following mental practice training (P = 0·011), but not in the conventional group (P = 0·083). No differences in objective or subjective stress levels or non‐technical skills were evident.


Mental practice improves technical performance for advanced laparoscopic tasks in the simulated operating room, and allows trainees to maintain or improve their performance despite added stress.

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Kirsty McFarlane

3 years ago

Does Mental Practice Training Really Enhance Advanced Laparoscopic Surgical Performance?

Dear Sir,

We read with great interest the article by Louridas et al. (1). The authors report on the impact of mental practice in enhancing advanced laparoscopic surgical performance and the ability to cope in a crisis scenario. As expected there was significant improvement in technical skills among those who underwent mental practice training in addition to conventional training using lectures, videos and MCQs, in comparison to those who had conventional training alone.

This study although interesting is not without limitations. The sample size was calculated based on difference in Objective Structured and Assessment of Technical Skill (OSATS) scores in the published literature between mentally trained and non-trained groups (2). However these scores were ignored during the randomisation stage, making the baseline OSATS score higher in the intervention arm and hence the benefits of ‘true’ randomisation were lost. The mental practice group with higher surgical experience may have been better equipped to improve their performance and cope with stress. Moreover, the interventional group was keenly followed in the 7 days interim period before assessment to ensure they practiced mental scripts; it is unclear if the conventional group watched videos or practiced in this interim period.

Recent studies have highlighted various adjuncts to training such as watching videos simulation training, pre-warming, mental training, etc. (3,4). This study does not decipher the individual effects of each of these adjuncts on enhancing surgical performance. There is definite need for well-designed multi-armed RCTs to include various contributing factors/training adjuncts, so as to evaluate the true benefit of mental practice in enhancing surgical performance.

Abdul R Hakeem
Kamal R Aryal

Department of General and Colorectal Surgery
James Paget University Hospital
Gorleston-on-Sea, Great Yarmouth
Norfolk, NR31 6LA

1. Louridas M, Bonrath EM, Sinclair DA, Dedy NJ, Grantcharov TP. Randomized clinical trial to evaluate mental practice in enhancing advanced laparoscopic surgical performance. Br J Surg 2015; 102(1): 37–44.
2. Arora S, Aggarwal R, Sirimanna P, Moran A, Grantcharov T, Kneebone R, Sevdalis N, Darzi A. Mental practice enhances surgical technical skills: a randomized controlled study. Ann Surg 2011; 253(2): 265–270.
3. Jalink MB, Heineman E, Pierie JP, Ten Cate Hoedemaker HO. The effect of a preoperative warm-up with a custom-made Nintendo video game on the performance of laparoscopic surgeons. Surg Endosc 2014 [Epub ahead of print].
4. Gurusamy KS, Nagendran M, Toon CD, Davidson BR. Laparoscopic surgical box model training for surgical trainees with limited prior laparoscopic experience. Cochrane Database Syst Rev 2014; 3: CD010478.