Describing What Surgeons See: Visual Orientation Strategies in Laparoscopic Cholecystectomy Across Imaging Conditions.

OBJECTIVE

This study examines how surgeons across different expertise levels describe their visual orientation strategies under white light and fluorescence imaging using indocyanine green (ICG) dye in laparoscopic cholecystectomy.

DESIGN

In this cross-sectional observational study, participants viewed a series of laparoscopic cholecystectomy video clips under white light and fluorescence imaging with ICG dye. Participants then responded to open-ended questions regarding their viewing strategies. Responses were analyzed using latent content analysis to identify visual orientation primary and subthemes.

SETTING

The study was conducted at the 2025 Society of American Gastrointestinal and Endoscopic Surgeons Meeting.

PARTICIPANTS

Seventy-one surgeons (38 attendings, 33 residents) participated in this study and were recruited from conference attendees. All participant completed the study procedures.

RESULTS

Visual orientation was identified as a layered, dynamic process incorporating perceptual and cognitive elements. Expertise influenced the depth and focus of orientation strategies. In white light, attendings prioritized identifying critical structures (26.3%). The top subthemes included establishing spatial orientation (17.9%), focusing on the surgical target (17.9%), and assessing strategy (17.9%). Residents focused on procedural activity (27.3%), with subthemes of establishing spatial orientation (39.1%), peripheral scanning (21.7%), and identifying anatomical landmarks (13%). Under fluorescence, both attendings (56.8%) and residents (71.9%) emphasized fluorescence cues.

CONCLUSION

Visual orientation strategies varied across levels of expertise and imaging condition. Attendings demonstrated a more target-focused approach to identify critical structures, while residents relied on salient cues and peripheral landmarks. Findings reveal the need for surgical training and visual support tools aligned with surgeons' perceptual-cognitive strategies to improve situation awareness and prioritization of visual cues.