LAUSR

Dear Editor On behalf of myself and my co-authors, I would like to thank Dr. David Hewson for his kind words and insightful remarks. As he points out, we have not assessed learning effects in our study into the spontaneous use of Underground, a serious game for training laparoscopic basic skills. Earlier work by our group and others, however, shows transfer of skills from Underground to other, validated laparoscopic simulators [1, 2]. Dr. Hewson additionally suggests the rate of laparoscopic skills acquisition for our participating residents may have increased, by way of training mental rotation ability through serious gaming. We think in our case this is unlikely, as the game dynamics of Underground do not involve the mental transformations needed to perform laparoscopic surgery. In Underground, the line of sight is identical to the line of action, which is not the case in laparoscopic surgery. The impact of individual differences such as spatial ability on surgical performance is one of the focuses of our group, and we are intrigued by the findings of Hewson et al. who report simple, unrelated mental rotation exercises improved performance in ultrasound-guided nerve blockade procedures [3]. At first glance, this seems counterintuitive, as similarity between the trained task and the transfer task is thought to be essential to the improvements in transfer task performance [4]. However, if ultrasoundguided nerve blockades are interpreted as a composite skill that involves mental rotation, this would explain the successful transfer from unrelated exercises to clinical skills found by Dr. Hewson. Previous research already has found a positive relation between visuospatial ability and minimally invasive surgery [5], and given that the test most commonly used to assess visuospatial ability is a mental rotation test, it would seem prudent to focus specifically on mental rotation in future research. The specific, quantified, and unbiased measurements provided by digital simulation and games are well suited to perform such research. Such work would help our training curricula become more effective and efficient by providing evidence-based frameworks for adaptive training.