The Nintendo DS has finally found some sturdy ground to walk on. It started out bumpy and a little uneven, but thanks to original DS games like Nintendogs, Phoenix Wright: Ace Attorney, Kirby: Power Paintbrush, Nanostray, Another Code: Two Memories and Lost in Blue, the little machine everybody loves to touch has come into its own. Rounding off that list is Atlus' new title Trauma Center: Under the Knife; a game that couldn't have found a better home than Nintendo's innovative handheld.

You play Dr. Derek Stiles, an up and coming surgeon who just wants to help people but has a lot to learn before he receives the respect he wants from his peers. Perhaps saying you play as Derek is the wrong phrasing; Trauma Center is very much story-based and you have no say in what direction it goes. You'll watch Derek fight with his peers and make countless wrong decisions early on in the game as he matures into a true surgeon. It wasn't expected, but the characters actually develop quite a bit here and you'll learn a great deal about not just Derek but the supporting cast as well. Unfortunately these story bits almost all take place in the same backdrops with the character currently talking appearing in front, just standing there. As the dialogue changes their picture occasionally does as well, but don't expect anything to actually grab your eyes other than the text. Voiceover during these sections doesn't exist either, as it would probably take up too much room on the cartridge - there is a lot of dialogue in the game.

When you do play as Derek, it's always during operations. Obviously the main appeal of the game, performing surgeries with the stylus is an ingenious idea that will really help the struggling DS's line-up stand out even more, especially when paired with a game like Phoenix Wright: Ace Attorney. You start almost every operation in the same way: you're briefed by a co-worker, usually your lovely nurse, and then you need to spread some antibiotic gel over a specific area before making an incision that lets you delve deeper into the anatomy of the subject. The game can be a bit graphic, but not overly so - for instance as you cut somebody open the body doesn't tear apart in real time, the cut is made after you've finished making a complete stroke with the stylus. This also makes mistakes a bit easier to swallow, as you're simply docked a few points for a sloppy incision (which doesn't actually happen if you're too sloppy) instead of seeing a horrible, bloody mess of a cut on the body.

There are a number of tools at your disposal right from the get-go and Trauma Center does an excellent job of making sure you know what each of them does. It even does so without making it feel like a training session, using hands-on experience within the first few operations for you to come to grips with the system. Tools include scalpels, lasers, plaster to cover wounds after an operation, a suture tool, clamps, and the previously mentioned fictional antibiotic gel that heals minor wounds and disinfects anything it comes into contact with. At first this seems like a decent medical simulator, having you cure a minor injury before you stitch up your patient and send him on his merry way, or working on a common problem such as a tumour. Then, things hot up as Derek discovers a gift that few doctors possess: The Healing Touch. With it Derek can slow down time briefly at critical moments, to work on a patient at inhuman speeds, however, being able to use this ability puts a great weight on Derek's shoulders and could ultimately be his downfall, at least according to Hope Hospital's CEO, who is now retired for mysterious reasons…

Beyond this, it quickly becomes apparent that a new form of disease is quickly spreading throughout the city and perhaps the world; known as GUILT, the man-made disease takes centre stage of the story, as medical-terrorism overruns your city and keeps poor Dr. Derek very busy. After seeing exactly what forms GUILT comes in, which range from giant spider-like creatures that build webs of doom inside the body to small creatures that constantly make lacerations within the victims lungs, you'll realise that Trauma Center is not really a medical simulator - at its core, it's a puzzle game wearing a sleek white medical coat that constantly bombards you with scenarios that are often moderately insane and twisted. Some of the infections and surgeries could make you cringe if you were to imagine it happening inside of your own body!

The balance between the medical theme and obvious puzzle game roots of Trauma Center is what makes the title unique and fun. The surgeries always have one solution, but getting there is far from a doddle, as you struggle to complete the operation while keeping vital signs stable, draining blood from gaping holes and not running out of time. Oh, and your assistants' absolutely love nothing more than giving you as little help as possible later in the game. Trauma Center is not easy, in fact it could very well be the toughest DS game yet. After constantly failing a few missions I would blame the game for not giving me enough information on how to complete it, something I really wanted to break the game in two for if the cartridges weren't so damn small! It soon became apparent that this was very intentional and helped make the game last longer, as I replayed a mission over and over, trying to figure out how to do it and, in essence, solve the puzzle.

The actions you're required to pull off aren't the difficult part of Trauma Center; in fact, most of them involve nothing more than a few brisk movements. Suturing up wounds requires you to move the stylus in a zigzag motion, rubbing the antibiotic gel just needs some quick scribbles and making cuts is just a matter of a quick slash. Even injecting various medicines only involves moving the stylus up a bit before holding it down over a certain area quickly. It isn't the individual actions that make the game hard; it's doing them all at the incredibly fast pace of the game that makes it challenging.

If you like your games tough then Trauma Center is going to please you. The last collection of levels perhaps match Astroboy: Omega Factor in terms of difficulty, especially considering the fact that both games love to lead you through a long level only for you to fail and replay it all again. Trauma Center is very heavily based on trial and error and though in most games that would be a bad thing, it does help this to become one of the DS's longest and most replayable titles yet.

Not only does the game toss other non-surgical puzzles at you periodically (such as a basic mind puzzle or something like defusing a bomb), but each challenge gives you a rating (up to S) for your performance and, of course, each can be replayed again at any time to better your original score. So after completing the nearly 10 hour story mode (where some levels are nothing more than dialogue), you'll still have something to strive for that is not easily obtainable.

The variety of surgeries changes and varies enough to keep you from getting too bored, however overall it is a bit lacking. There are only a few different strains of GUILT viruses, so you have to operate on the same ones quite a few times, but at a greater difficulty and speed for each new occasion. For players who dislike certain operations this is a big problem, because you not only have to do it again, but a hell of a lot better than you did it before. In the end though, the missions in Trauma Center are a completely new experience and the game lasts just long enough that you won't get too sick of the objectives before the end.

The graphics don't make a huge impact on the game for the most part. From the outside, the bodies on the operating table don't stand out as overly good looking, which is what you'd expect from the 3D capabilities of the DS, but once you get inside the bodies you probably won't care how good or bad the game looks, and since not everybody is an expert on physical anatomy it's hard to tell how accurate the insides actually are, but they do get the point across and you'll almost always know what you're operating on… almost. The backdrops and cityscapes that populate the cut scenes and the in-betweens, on the other hand, look particularly good and are very animé-influenced. Both the 3D city view and traditional 2D anime backgrounds look good and the character stills that pop up on the top screen capture the anime-vibe and storyline perfectly with their colourful and very Japanese design.

This is all beautifully complemented by a wonderful soundtrack. The music here really fits the situations well, be it an intense operation or that resting period where you take deep breath after a successful operation. Voiceover work is almost non-existent outside of the usual "Ready?", "Doctor!", "What the…?", "What are you doing!?", and "Derek!" that take place during operations. If only there was a "You can't cut that!" or a "That's not what the laser is for!" voiceover! The sounds of suturing, slicing, gelling and all that messy stuff are done well, always in context, although people around you will have a tough time figuring out what in the world is happening on that little screen. Some of the effects sound really bizarre if you have no idea what they're supposed to represent!

Outside of the problems I've already mentioned, the other mishaps are mostly just inconveniences rather than problems, such as the excessive dialogue in some areas of the game, or the fact that actually reading what your assistant says during a tense operation is nearly impossible if your goal is to actually save the person with their body cut open on the table.

Trauma Center: Under The Knife succeeds in creating an engaging story full of equally engaging characters that will push you to complete the game just to see where it goes and what kind of sadistic surgery you'll have to perform next. The difficulty is enough to make some people give up entirely, but it also makes the game a long lasting pick-up-and-play title that you can attempt to complete every so often once you do get tired of the sometimes repetitive surgeries. Though it does have some flaws that usually would mark a game down a bit, Trauma Center still stands tall for being a one-of-a-kind experience for that owners of the DS are dying for. At the time of writing, no UK release date has been officially announced by developer/publisher Atlus, although we're assured that it is destined to reach these shores sooner or later. In the meantime, the region-free game should be no problem to import for anyone looking for a challenging, innovative and story-driven DS title with some good longevity.

Reviewed by Christopher Martin for AceGamez (All Rights Reserved).