Sharing information for precise robotic surgery: integrating visualization and verbalization
Introduction
In this era of expanding robotic surgery and rapid technological advancement, several challenges are increasingly emerging in the operating room:
- Scenario 1: in robotic surgery, all team members can observe the surgical field in high definition. However, a junior doctor may hesitate to speak up—even when identifying a subtle anatomical variation—due to the absence of structured communication tools that support such contributions.
- Scenario 2: as robotic surgery becomes more widespread, surgeons are increasingly collaborating in shared operating environments. The quality of teamwork increasingly depends not only on technical proficiency but also on each surgeon’s communication style and non-technical skills (NTS). While many operating room staff recognize the importance of information sharing, consistent implementation remains difficult due to a lack of structured training or shared frameworks.
Robotic surgery offers improved precision, visualization, and reduced invasiveness. Recent advancements in robotic surgery have emphasized the need for standardized training and accreditation processes, which are essential for ensuring consistent and proficient robotic surgical practices (1). However, robotic surgery presents distinct challenges, particularly in team communication. Unlike traditional open or video-assisted surgery, robotic systems place the console surgeon in a physically and cognitively separate environment from the bedside assistants. This isolation can create barriers to effective collaboration and decision-making.
The behavioral tendencies of the console surgeon further complicate this dynamic (e.g., reduced real-time feedback and loss of direct haptic sensation may hinder teamwork). Assertive or overly independent behaviors can hinder the incorporation of team feedback. Similarly, indifference or resistance to alternative ideas or opinions may stifle collaborative learning and adaptability. In this context, structured information-sharing mechanisms are essential.
Visualization and verbalization provide the foundation for overcoming these challenges, enabling surgical teams to align on strategies, adapt intraoperatively, and optimize outcomes. This article addresses the aforementioned issues by exploring how structured information sharing can improve collaboration, precision, and outcomes in robotic surgery.
The need for information sharing in robotic surgery
Effective information sharing is critical in robotic surgery, where every team member’s understanding of the surgical strategy directly impacts patient outcomes. The physical separation of the console surgeon from the operative field heightens the risk of miscommunication, requiring robust systems to bridge this gap. Verbal and visual tools are indispensable for ensuring that everyone—from the console surgeon to bedside assistants and anesthesiologists—has a unified understanding of the surgical plan and objectives.
Understanding challenges in information sharing: the first step toward success teamwork
Before addressing strategies for effective information exchange during surgery, understanding the types and challenges involved is important. We can categorize the information that needs to be shared during surgery into three hierarchical layers based on sharing difficulties:
- Frame (bottom layer, easy level to share): foundational information, including anatomy, oncological evaluations, and functional data, establishes the surgical context. Everyone can access this objective data before, during, and after surgery. Requirement: team members must share common rules on what information is needed for surgery, who should gather it, and when it should be collected, along with basic interpretation guidelines (e.g., staging system, tumor location, safety range of pulmonary function, etc.).
- Game (middle layer, intermediate level to share): the surgical strategy based on the frame layer outlines specific approaches to achieve treatment goals. The surgical team should develop an optimal surgical strategy for each individual patient using all objective data, patient preferences, and provider-related conditions (such as skill, experience, room availability, and instrument access). Requirement: a personalized approach with regularly scheduled multidisciplinary meetings to create a documented, clear surgical plan for each patient that team members can quickly and explicitly share.
- Perspective (top layer, difficult to share): integrating diverse team viewpoints to refine and finalize the surgery. Although the team shares patient data and surgical strategies, individual surgeons may carry varying perspectives and interpretations. Respecting and sharing these viewpoints is vital for enhancing decision-making and cultivating a positive team environment. The team should honor diversity; expecting “same” opinions and “tame” attitudes unilaterally is unrealistic. Requirements include an open and psychologically safe work environment and established NTS (described later).
Figure 1 illustrates this hierarchy, emphasizing the increasing difficulty of sharing as the complexity of information grows. The figure legend clarifies the roles of ‘Frame’ (foundational information like anatomy and function), ‘Game’ (surgical strategy development), and ‘Perspective’ (team members’ viewpoints). It also highlights that verbalization and visualization are key drivers of effective communication. Accelerators, including structured meetings, open communication, and the use of three-dimensional (3D) imaging, support these drivers. This hierarchical model provides a structured framework for addressing surgical challenges, complementing traditional technical training with communication and decision-making strategies.
Effective information sharing is not only required among surgeons but across the entire operating team. Team turnover during breaks or shift changes may further disrupt shared mental models, underscoring the importance of structured checklists to reinforce the frame, game, and perspective layers of communication.
Visualization: the power of 3D imaging
Advanced imaging technologies, particularly three-dimensional computed tomography (3D-CT), play a pivotal role in enhancing visualization and precision in surgery (2). By creating detailed, patient-specific models of the surgical site, 3D imaging allows the surgical team to:
- Understand complex anatomy: visualize the relationships between critical structures, such as blood vessels, bronchi, and tumors.
- Plan surgical steps: simulate the sequence of dissection, resection, and reconstruction.
- Facilitate team communication: provide a shared visual reference to ensure all team members are aligned.
We use specifically prepared 3D-CT images to simulate port placement and the sequence of hilar dissection with broncho-vascular stapling sites. This ensures precise execution and reduces intraoperative uncertainty. The ability to visually demonstrate these plans and discuss them during preoperative meetings fosters a deeper understanding among all team members.
Recently, novel 3D-CT workstations have emerged with advanced technologies. These include specialized surgery-oriented workstations for segmentectomy, one-click automatic 3D-CT extraction, and high-accuracy 3D imaging (even from non-enhanced CT scans). They also offer automatic volumetric analysis and a hilar dissection planning function that indicates proposed dividing sites of bronchovascular structures (3). Additionally, they offer 3D visualization of inter-lobar and segmental planes, as well as resection margins aligned with surgical procedures (3). These features facilitate lung resection-oriented anatomical analysis, significantly impacting surgical procedures. For instance, a volumetric study revealed that the complexity of the bronchial branching pattern influences the segmental volume of the right upper lobe (4). Another study demonstrated that pulmonary venous drainage patterns in the left upper lobe correlate with the specific anatomical configuration of the anterior segment (transverse versus non-transverse types) (5). These findings carry direct implications for surgical planning.
The develop, demonstrate, discuss, and share (3D-S) concept
The 3D-S concept—“Develop, Demonstrate, Discuss, and Share”—provides a systematic process for surgical planning and communication (6).
- Develop: creating a comprehensive surgical plan based on detailed patient-specific data, including 3D imaging.
- Demonstrate: presenting the plan using visual tools, such as 3D-CT models, to clearly explain each step of the procedure.
- Discuss: engaging the surgical team in collaborative discussions to refine the strategy and address potential challenges.
- Share: ensuring that all team members have a unified understanding of the plan to enhance intraoperative coordination and adaptability.
Our group originally introduced this concept for surgical planning and education in robotic thoracic surgery (6). In this commentary, we highlight its value not only for preoperative planning but also as a communication framework to align the surgical team. In practice, a fifth step—repeat—may be indispensable for reinforcing the shared plan throughout long or complex operations, leading to what we refer to as the “3D-S-R” approach.
NTS for better information sharing
Beyond information sharing, NTS training provides additional opportunities to enhance teamwork in robotic surgery (7). NTS encompasses situational awareness, decision-making, communication, and leadership—skills critical for effective teamwork that traditional surgical training often underemphasizes (8). Structured NTS programs, such as task-based training systems, can enhance team dynamics by:
- Improving situational awareness: training surgeons to anticipate the needs of the operation and communicate them proactively.
- Strengthening decision-making: encouraging evidence-based reasoning and collaborative input from the team.
- Enhancing communication: promoting clear, structured verbal exchanges to align all team members.
- Fostering leadership: preparing surgeons to lead with adaptability and inclusivity.
To advance the field of robotic surgery, we must integrate NTS training into existing educational frameworks. Institutions should develop standardized NTS curricula tailored to robotic surgery (9), combine technical and non-technical training for a holistic approach, and foster a culture of collaboration and continuous learning.
The complexity and subjectivity of NTS concepts make it challenging for trainees to prepare and for instructors to assess. In response, we established a structured, task-based framework consisting of 28 items that cover situation awareness, decision-making, communication, and leadership. Each item is defined in an action-oriented manner that can be easily assessed using binary scoring (‘done’ or ‘not done’). The complete list of tasks is presented in Table 1. Additionally, to bridge the gap between simulation and real practice, we incorporated a seamless transition approach that integrates off-the-job simulation with on-the-job surgical training, where trainees first complete swine isolated heart-lung simulation training and must achieve “done” in at least 70% of instances for each NTS task, along with meeting technical skill requirements. Later, the same evaluation system is used during live surgeries (Figure 2). In our pilot implementation of this task-based NTS program during video-assisted thoracoscopic surgery (VATS), two trainees completed 10 simulation sessions followed by 29 clinical surgeries without major complications. Trainees reached ≥70% task completion before beginning clinical practice, and a mild correlation between NTS and technical skill scores (r=0.38, P=0.02), suggesting that this training system may enhance patient safety and that technical and NTS sets are complementary.
Table 1
| NTS categories | Key elements | Task descriptions | Binary scoring |
|---|---|---|---|
| Situation awareness | Preoperative information gathering | During the time-out, state the following information clearly and audibly: | |
| ⬥ The surgical plan, including the nature of the surgery, lymph node dissection, and frozen section plans [1] | [1] Done/not done | ||
| ⬥ Any potential issues or concerns based on the patient’s background (e.g., low PFT, etc.) [2] | [2] Done/not done | ||
| Intraoperative progress monitoring (information gathering and communication) | Communicate with anesthesiologists and nurses to collect necessary information and monitor patient status: | ||
| ⬥ Confirm with the anesthesiologist that the tracheal tube is appropriately placed and one-lung ventilation is functioning before opening the chest cavity [3] | [3] Done/not done | ||
| ⬥ Confirm changes in vital signs and ventilation status with the anesthesiologist throughout the procedure [4] | [4] Done/not done | ||
| ⬥ Timely share whether the general steps (e.g., hilar dissection, lymph node dissection, division of the intersegmental plane) are proceeding according to plan or not [5] | [5] Done/not done | ||
| Preemptive preparation | Interpret gathered information and anticipate potential complications: | ||
| ⬥ Request preparation of tools (e.g., stapler, drainage tube) in anticipation of the next steps [6] | [6] Done/not done | ||
| ⬥ Ensure that equipment necessary for hemostasis is readily available in the operating room before high-risk procedures (e.g., pulmonary artery dissection) [7] | [7] Done/not done | ||
| Decision-making | Basic process for decision making | Basic process (anatomy confirmation → prior announcement → double checking): | |
| ⬥ Continuously verify anatomical structures with the assistant surgeon [8] | [8] Done/not done | ||
| ⬥ Announce each step to the assistant surgeon before performing it [9] | [9] Done/not done | ||
| ⬥ Ensure the entire team double-checks decisions before taking action [10] | [10] Done/not done | ||
| Evidence-based decision making and sharing | Explain the following while providing reasons to share the evidence-based decision-making process: | ||
| ⬥ The sequential order of hilar dissection (e.g., PA, bronchus, followed by PV, etc.) [11] | [11] Done/not done | ||
| ⬥ The lymph node dissection plan [12] | [12] Done/not done | ||
| ⬥ The analysis of frozen section results and the subsequent steps [13] | [13] Done/not done | ||
| Considering options and reviewing plans | In the event of disagreement and/or surgical plan changes: | ||
| ⬥ Review available evidence, such as imaging studies (including 3D planning images), to verify the alternative plan and ensure team consensus [14] | [14] Done/not done | ||
| ⬥ Explain the rationale behind the change and communicate it clearly to the team [15] | [15] Done/not done | ||
| Communication and teamwork | Clear communication | During verbal communication: | |
| ⬥ Speak loudly enough to be heard throughout the operating room [16] | [16] Done/not done | ||
| ⬥ Enunciate your words clearly [17] | [17] Done/not done | ||
| ⬥ Avoid speaking too quickly [18] | [18] Done/not done | ||
| Confirming team members’ opinions | When exchanging opinions: | ||
| ⬥ Listen attentively and confirm your understanding after receiving guidance or advice [19] | [19] Done/not done | ||
| ⬥ Ensure that all surgical team members have had the opportunity to share their opinions [20] | [20] Done/not done | ||
| Sharing surgical progress | During benchmark procedures, such as vascular or bronchial divisions: | ||
| ⬥ Communicate the names of the vessels or bronchi being handled to the entire team, including scrub nurses, circulating nurses, anesthesiologists, and students [21] | [21] Done/not done | ||
| ⬥ Inform the team of the next step to ensure everyone is prepared [22] | [22] Done/not done | ||
| Leadership | Knowing the team members | Familiarize the team for successful surgery: | |
| ⬥ Know the names of all members in the operation room, including scrub nurses, circulating nurses, anesthesiologists, and students [23] | [23] Done/not done | ||
| ⬥ Introduce yourself and learn the names of any new team members [24] | [24] Done/not done | ||
| Task assignment through clear instructions | Assign appropriate tasks with clear instructions as a leader: | ||
| ⬥ Provide clear requests and instructions to all team members, including supervising surgeons [25] | [25] Done/not done | ||
| ⬥ When assigning tasks to students or resident doctors, explain the surgical situation based on their level of knowledge and experience [26] | [26] Done/not done | ||
| Managing stress and controlling emotions | Manage stress and control emotions: | ||
| ⬥ Maintain a steady tone and demeanor without becoming emotional or overbearing [27] | [27] Done/not done | ||
| ⬥ Stay composed and calmly clarify instructions when things do not go as expected, such as receiving the wrong instrument, the anesthesiologist struggling with one-lung ventilation, or communication difficulties with less experienced team members [28] | [28] Done/not done |
Done: task performed as described, without omission or error in at least 70% of instances during surgery. Not done: task not performed or performed indirectly in more than 30% of instances during surgery. 3D, three-dimensional; NTS, non-technical skills; PA, pulmonary artery; PFT, pulmonary function test; PV, pulmonary vein.
Our current program primarily targets the assessment and training of individual surgeons, and therefore it follows the principles of the established Non-Technical Skills for Surgeons (NOTSS) framework, which evaluates domains such as situation awareness, decision-making, communication, and leadership (8). While NOTSS is individual-focused, the Team Emergency Assessment Measure (TEAM) has been developed to assess whole-team performance in crisis situations, emphasizing leadership, teamwork, and task management (10). Compared with these frameworks, our task-based approach introduces a simplified binary evaluation (‘done/not done’), which facilitates structured learning and straightforward assessment. Although this project is centered on individual surgeons, we recognize the importance of team-level evaluation, and future iterations of this program could incorporate TEAM principles to address multidisciplinary team performance in robotic surgery.
Our proposed task-based framework complements the surgical safety checklist, which includes sign in, time out, and sign out, serving as a global standard for intraoperative communication and team coordination (11). While this commentary focuses on planning and routine workflow, applying NTS during complications is equally vital. Future efforts should adapt these frameworks for crisis scenarios, where effective communication and teamwork are important for safety.
Conclusions
Effective information sharing is important for successful robotic surgery. We propose three tiers of information: “Frame-Game-Perspective”. The 3D-S concept offers a sequential and coherent process for surgical planning that enhances information sharing, while advanced imaging technologies improve understanding and precision. As the field advances, integrating NTS training will further improve team dynamics, minimize errors, and enhance patient outcomes. Integrating these strategies will set new benchmarks in robotic surgery for precision, collaboration, and patient outcomes. Future research should focus on validating the 3D-S concept and NTS training model in broader surgical specialties and through multicenter prospective studies, potentially assessing outcomes such as surgical efficiency, complication rates, and team situational awareness scores. Establishing standardized assessment tools and longitudinal outcomes would further enhance the model’s utility. Although the features discussed above are based on experience with robotic thoracic surgery, these frameworks can potentially be adapted to other specialties such as urology and gynecology, as well as to other minimally invasive techniques like thoracoscopy and laparoscopy.
Acknowledgments
We sincerely thank the trainees, Mari Katsuno and Yuichi Oguchi, who took part in the initial educational program.
Footnote
Provenance and Peer Review: This article was commissioned by the Editorial Office, AME Surgical Journal. The article has undergone external peer review.
Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-67/prf
Funding: This work was supported in part by
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-25-67/coif). The authors have no conflicts of interest to declare.
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Cite this article as: Eguchi T, Kumeda H, Miura K, Hamanaka K, Shimizu K. Sharing information for precise robotic surgery: integrating visualization and verbalization. AME Surg J 2025;5:54.
