AI for Quality Assurance in the Operating Room

Recent Artificial Intelligence (AI) models have matched or exceeded human experts in several benchmarks of biomedical task performance, but surgical benchmarks in particular are often missing from prominent medical benchmark suites. Since surgery requires integrating disparate tasks, generally-capable AI models could be particularly attractive as a collaborative tool if performance could be improved. On the one hand, the canonical approach of scaling architecture size and training data is attractive, especially since there are millions of hours of surgical video data generated per year. On the other hand, preparing surgical data for AI training requires significantly higher levels of professional expertise, and training on that data requires expensive computational resources. These trade-offs paint an uncertain picture of whether and to-what-extent modern AI could aid surgical practice. In this paper, we explore this question through a case study of surgical tool detection using state-of-the-art AI methods available in 2026. We demonstrate that even with multi-billion parameter models and extensive training, current Vision Language Models fall short in the seemingly simple task of tool detection in neurosurgery. Additionally, we show scaling experiments indicating that increasing model size and training time only leads to diminishing improvements in relevant performance metrics. Thus, our experiments suggest that current models could still face significant obstacles in surgical use cases. Moreover, some obstacles cannot be simply ``scaled away'' with additional compute and persist across diverse model architectures, raising the question of whether data and label availability are the only limiting factors. We discuss the main contributors to these constraints and advance potential solutions.

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.

The introduction of new technologies, such as surgical robots, is driving the vision of a connected, smart operating room (OR). However, realizing this vision requires a deep understanding of surgical workflows, which relies on realistic datasets capturing the actions of all OR personnel from both full room and surgical field perspectives. Acquiring such data in real ORs is prohibitively challenging due to factors such as ethics committee approvals, limited space for camera installation, and sterility regulations preventing the use of tracking markers. We present a step-by-step methodology for re-enacting complete surgical procedures in a reconstructed OR. This approach enables the creation of repeatable and annotatable workflow datasets for training activity recognition models, generating scene graphs, and formalizing surgical process models. Developed for robot-assisted ophthalmic surgery, our methodology combines expert consultation, structured workflow formalization, OR reconstruction, role-based training, real OR observation, and iterative recording with post-take debriefing. We provide concrete recommendations to allow other research groups to seamlessly adopt this methodology for their own surgical domains.