Expert Consensus on Criteria for the Automated Assessment of Laparoscopic Camera Navigation

Purpose: Accurate assessment of the Critical View of Safety (CVS) during laparoscopic cholecystectomy is essential to prevent bile duct injury, a complication associated with significant morbidity and mortality. While large vision-language models (LVLMs) offer flexible reasoning, their predictions remain difficult to audit and unreliable on safety-critical surgical tasks. Methods: We introduce Sum-of-Checks, a framework that decomposes each CVS criterion into expert-defined reasoning checks reflecting clinically relevant visual evidence. Given a laparoscopic frame, an LVLM evaluates each check, producing a binary judgment and justification. Criterion-level scores are computed via fixed, weighted aggregation of check outcomes. We evaluate on the Endoscapes2023 benchmark using three frontier LVLMs, comparing against direct prompting, chain-of-thought, and sub-question decomposition, each with and without few-shot examples. Results: Sum-of-Checks improves average frame-level mean average precision by 12--14% relative to the best baseline across all three models and criteria. Analysis of individual checks reveals that LVLMs are reliable on observational checks (e.g., visibility, tool obstruction) but show substantial variability on decision-critical anatomical evidence. Conclusion: Structuring surgical reasoning into expert-aligned verification checks improves both accuracy and transparency of LVLM-based CVS assessment, demonstrating that explicitly separating evidence elicitation from decision-making is critical for reliable and auditable surgical AI systems. Code is available at https://github.com/BrachioLab/SumOfChecks.

Verbal feedback delivered by attending surgeons in the operating room plays a critical formative role in resident trainee skill acquisition. Yet, assessing the quality of trainer feedback and its effectiveness in influencing trainee behavior during live surgery remains a challenge. Prior studies assessed feedback content relying on extensive manual annotation by expert human raters and focused on developing broad taxonomies that overlook the qualitative aspects of feedback delivery such as clarity or urgency. Limited existing automated methods, including keyword analysis and topic modeling, also fail to capture these nuanced aspects. We introduce a two-stage LLM-based framework that discovers interpretable feedback quality criteria grounded in the context of surgical training. Our method uses multi-agent prompting and surgical domain knowledge injection to discover a small set of human interpretable scoring criteria (e.g., Encouraging, Urgent, Clear). These criteria are then used to automatically score live surgical feedback via an LLM-as-a-judge approach. Evaluation on 4.2k trainer feedback instances demonstrates that our AI-discovered criteria outperform prior content-based frameworks in predicting feedback effectiveness, including observed trainee behavioral adjustments and trainer approval. This work advances scalable, human-aligned assessment of communication quality in the operating room and provides a foundation for improving surgical teaching practices.

Achieving high levels of surgical skill through effective training is essential for optimal patient outcomes. Automated, data-driven skill assessment holds significant potential to improve surgical training. While machine learning-based methods are increasingly popular for assessing skills in minimally invasive surgery, their application to open surgery remains limited. We present the results of a dedicated MICCAI challenge designed to benchmark and advance vision-based skill assessment in open surgery. The challenge dataset comprises videos of an open suturing training task recorded with a static GoPro camera in a dry-lab setting, with instrument trajectories available in addition to the primary video modality. The OSS Challenge was hosted over two consecutive years, comprising two and three independent tasks, respectively: (1) classifying skill level into four classes, (2) predicting the full Objective Structured Assessment of Technical Skills across eight categories, and (3) tracking hands and surgical tools. Participants submitted diverse solutions including deep learning-based video models, tracking-driven methods, and hybrid approaches. General-purpose spatiotemporal video models consistently achieved the strongest performance, though conceptually diverse approaches reached competitive levels when well-executed. Predicting fine-grained OSATS scores remains challenging but benefits substantially from increased training data. Keypoint tracking proves difficult given frequent occlusions and out-of-frame instances, limiting current applicability for motion-based skill analysis. This work benchmarks innovative and diverse solutions for surgical skill assessment, highlighting both the promise and current limitations of video-based evaluation in open surgery and identifying critical directions for advancing automated skill assessment toward clinical impact.