The Suture-Action-Gaze Efficiency (SAGE) guidance framework reveals expert gaze-action coupling based on a case study...

Simple interrupted suturing is a foundational surgical skill, yet the expert micro-behaviors that support efficient performance remain undercharacterized, particularly in open surgery at the level of individual stitches. This study examined expert gaze-action coupling during simple interrupted suturing and developed an empirically derived behavioral framework to translate these patterns into structured training guidance. Eight board-certified surgeons performed 335 standardized simple interrupted sutures on artificial skin while wearing Tobii Pro Glasses 3. Gaze and video streams were synchronized and segmented into stitch-level motor events. Analyses were conducted at both the stitch and subject levels using mean comparison tests and mixed-effects models. Four reproducible expert micro-behaviors were identified. First, surgeons typically directed initial fixation toward functional instrument tips rather than handles. Second, the right-to-left insertion pattern was more frequently used and was associated with shorter insertion times than the right-middle-left pattern, whereas wound-edge squeezing showed a descriptive stitch-level association that did not remain significant in mixed-effects analysis. Third, complete three-wrap knots were associated with efficient knot tying, while additional wraps and incomplete knots prolonged execution. Fourth, re-grasping efficiency was associated more strongly with technique than with needle placement location, with Gather-in-Hand and Designated Needle Placement supporting faster transitions than Slide-and-Secure. These findings were synthesized into the Suture-Action-Gaze Efficiency (SAGE) framework. SAGE should be interpreted as an observational, expert-derived behavioral guide rather than a validated causal training model.