Introduction
Intraoperative stressors can increase surgeons’ mental demands, precipitating technical performance decline and risking patient safety. However, the neural signatures of stress resilience among surgeons remain unknown. We aimed to compare activation in the prefrontal cortex (PFC)–important for attention and concentration–between residents demonstrating performance stability and those exhibiting performance decline when operating under time pressure.

Methods
Thirty-three surgical residents [median age (range) = 33 years (29 to 56), 27 males] performed a laparoscopic suturing task under ‘self-paced’ (no time restriction) and ‘time pressure’ (2-minute per knot time restriction) conditions. A composite deterioration score was calculated based on between-condition differences in technical performance, and subjects were divided into quartiles reflecting performance stability (Q1) and decline (Q4). Changes in oxygenated haemoglobin concentration (HbO2) measured at 24 prefrontal locations using functional near-infrared spectroscopy were compared between Q1 and Q4. Subjective workload was quantified using the Surgical Task Load Index (SURG-TLX).

Results
Under time pressure, Q1 residents demonstrated task-induced increases in HbO2 in the bilateral ventrolateral PFC (VLPFC), whereas Q4 residents demonstrated HbO2 decreases. The amplitude of activation (ΔHbO2) was significantly greater in Q1 than Q4 in the bilateral VLPFC (left VLPFC: Q1=0.44±1.36μM, Q4=-0.03±1.83μM; right VLPFC: Q1=0.49±1.70μM, Q4=-0.32±2.00μM). There were no significant between-group differences in SURG-TLX scores.

Conclusions
Resilience to intraoperative stress is associated with sustained prefrontal activation indicating preserved attention and concentration. In contrast, sensitivity to stress is marked by prefrontal deactivation suggesting task disengagement. Future work will aim to develop interventions that recruit prefrontal brain regions and enhance task engagement.