Towards measuring the challenge: a narrative review on existing concepts and parallels for surgical struggle

Moments of intraoperative struggling, termed as surgical struggle, are common yet variably labeled and poorly defined. Existing literature substitutes proxy terms, but no standardized definitions or metrics of struggle exist despite clear implications for patient safety, outcomes, and training.

A narrative review was undertaken to map how "surgical struggle" has been conceptualized and measured in the literature. The literature was screened using concept-adjacent proxies and parallels (e.g., operative difficulty, prolonged operative time, workflow disruptions, hesitancy, intraoperative kinematics, physiologic stress) identified through searches in PubMed and Google Scholar.

Existing measures each capture facets of struggle but not the moment itself. Operative difficulty, technical complexity, and surgical complexity are widely used terms that represent struggle. Prolonged operative time is objective but nonspecific. Robotic kinematic data (eg, idle bursts, path length, jerk, speed peaks) differentiates expertise and correlates with adverse intraoperative events, offering granular, real-time signals. Surgical workflow disruptions increase cognitive load and are associated with moments of struggle, while surgical hesitation represents pauses in operative period potentially highlighting struggling. Physiologic markers of struggling moments (eg, heart rate variability, galvanic skin response) are not routinely captured. Evidence supports a multilevel framework (micro, meso, macro) for surrogate measures of surgical struggle.

A standardized working definition of surgical struggle will establish the framework for identifying intraoperative struggle. This will enable video annotation and machine-learning pipelines for real-time detection of surgical struggle. A formal consensus process is warranted to establish a terminology, definition, thresholds, and reporting standards and to catalyze clinical adoption.