Open research questions in Surgical Simulation and Training

What the literature leaves open

• These include variabil- ity in imaging protocols, limited data specific to robotic 1 3Journal of Robotic Surgery (2026) 20:754 754 Page 12 of 13 applications, and the need for regulatory pathways to sup- port broader clinical adoption.

  Considerations for transoral robotic surgery with fluorescence imaging: a narrative review · 2026 · DOI

• Current trends in the medical, scientific, and industrial communities indicate continued expansion of applications and development of fluorescence imaging during robotic surgery. The following summarizes key developments and considerations for widespread implementation of fluorescence imaging during TORS.

  Considerations for transoral robotic surgery with fluorescence imaging: a narrative review · 2026 · DOI

• As telesurgical technology continues to evolve and gain complexity, future investigations should explore ways of creating smart ecosystems in surgery that will pro- vide the platform for adaptive robot control and personal- ized decisions. An additional area that needs to be explored in the future is the development of large-scale standardized data sets from surgeries in multiple centers. Adil M, Khurram Khan M, Ali A et al (2026) Toward Effective Communication Management in Cooperative Robotic-Enabled Healthcare Systems: Open Challenges and Future Research Directions.

  Artificial intelligence and machine learning in robotic, teleoperated, and remote surgery: a bibliometric and knowledge mapping analysis (2015–2025) · 2026 · DOI

• The future of pediatric surgery and anesthesiology lies in the integration of human expertise with technological innovation. Further research is required to validate AI models in pediatric populations and to assess the long-term safety and efficacy of robotic-assisted procedures (2,9,15). The challenge ahead is not whether artificial intelligence and robotics will be incorporated into pediatric perioperative care, but whether clinicians will guide their implementation responsibly, ethically, and collaboratively (5,13,14). Education and training programs must adapt to prepare clinicians for this evolving landscape.

  <b>ARTIFICIAL INTELLIGENCE AND ROBOTICS IN PEDIATRIC SURGERY: EMERGING CHALLENGES AND OPPORTUNITIES FOR PEDIATRIC ANESTHESIOLOGY</b><b></b> · 2026 · DOI

• texture,. This requires surgeons to rely entirely on visual cues to assess tissue handling, potentially increasing the risk of inadvertent tissue damage or inadequate suture tension. Next-generation systems are incorporating haptic feedback technology to restore tactile sensation,. The Senhance™ system currently offers haptic feedback, allowing surgeons tissue resistance and instrument-tissue interactions. Advanced haptic systems under development aim to provide more sophisticated tactile information, including and stiffness, temperature, surgical potentially precision and safety.

  ROLE OF ROBOTICS IN MINIMALLY INVASIVE SURGERY · 2026 · DOI

• w w w . i a j p s . c o m Page 408 IAJPS 2026, 13 (06), 407-418 Dasari Nirmala et al ISSN 2349-7750 neurosurgical biopsies in 1985, demonstrating the feasibility of robotic assistance in surgery [19].

  ROLE OF ROBOTICS IN MINIMALLY INVASIVE SURGERY · 2026 · DOI

• Prior studies evaluating tele-robotic platforms have reported mixed results, including longer operative times and, in some series, higher complication rates compared with conventional laparoscopy, especially regarding common bile duct injuries [3]. Further prospec- tive, multicenter studies are warranted to assess economic impact, surgeon ergonomics, learning curves, and broader safety outcomes, including adherence to safe cholecystec- tomy principles.

  Integration of a collaborative robotic platform in laparoscopic cholecystectomy: safety, feasibility, and operative time variability · 2026 · DOI

• Formal cost-effectiveness analyses—comparing MR against both traditional training and lower-cost alternatives such as video-based simulation—are warranted before recommending wide- spread implementation.

  Randomized controlled trial evaluating mixed reality technology for training scrub nurses in anterior cervical spine surgery · 2026 · DOI

• Currently, there are limited studies reporting on the automated identification of the Holy Plane and PAN using AI during laparoscopic rectal cancer surgery.

  Artificial intelligence-guided computer-aided intervention system for laparoscopic rectal cancer surgery · 2026 · DOI

• The next phase of robotic MIS will likely be shaped less by hardware alone and more by integration with digital intelligence and advanced imaging. A systematic review of artificial intelligence in gastrointestinal surgery identified growing applications in training, workflow recognition, Page 5 of 7 482 decision support, image enhancement, navigation, and intraoperative guidance for both laparoscopic and robotic surgery. These developments could make robotic platforms more than dexterous tools; they could also become data-rich environments for real-time assistance and performance optimization. Image-guided robotics is another important frontier. A systematic review of ultrasound-guided robotic procedures suggests that robotic integration of intraoperative ultrasound may improve localization, orientation, and procedural efficiency in selected minimally invasive operations. If paired with augmented reality, anatomical mapping, and improved haptic systems, such innovations could further expand the complexity of cases manageable through MIS. The likely future is not autonomous surgery replacing surgeons, but progressively smarter robotic assistance that enhances judgment, precision, and training. The real value proposition will remain clinical: fewer conversions, safer dissection in confined anatomy, more consistent reconstructive quality, and broader access to complex MIS when infrastructure and training are in place. Cross-specialty synthesis: when does robotics truly expand MIS? Across specialties, a common pattern emerges. Robotic surgery appears most consequential when minimally invasive success is threatened by one or more of three factors: confined anatomy, high reconstructive or dexterity demand, and poor reproducibility of advanced laparoscopy. In urology, this is seen in pelvic dissection and nerve-sparing work during radical prostatectomy. In colorectal surgery, it is most relevant in low pelvic rectal operations where dissection is technically constrained. In thoracic and upper gastrointestinal surgery, the platform becomes more attractive as suturing, lymphadenectomy, or work around delicate structures grows more demanding. By contrast, when conventional laparoscopy already performs well in relatively standardized operations, robotic surgery may offer incremental rather than transformative benefit. This distinction helps explain why the evidence base can appear inconsistent. Robotics is least likely to show dramatic superiority in procedures already comfortably within the reach of laparoscopy, but more likely to demonstrate benefit when the minimally invasive pathway is threatened by conversion, technical compromise, or surgeon fatigue. The central contribution of robotic platforms is therefore not universal clinical dominance, but selective capability extension. They expand MIS by making difficult minimally invasive execution more feasible and more reproducible in precisely those operations where straight-stick laparoscopy is most mechanically and ergonomically constrained.

  How robotic platforms have expanded the boundaries of minimally invasive surgery: a narrative review · 2026 · DOI

• This work establishes that learning dynamic scene graph pro- totypes is a highly effective strategy for surgical workflow modeling, directly addressing the critical barriers of data scarcity and model opacity. We demonstrated that ProtoFlow achieves competitive accuracy while delivering exceptional robustness in limited-data, few-shot scenarios, significantly lowering obstacles for development in data-scarce clinical settings. Beyond data efficiency, ProtoFlow’s interpretability provides a tangible path toward the transparent AI sys- tems required for clinical adoption. The model automatically discovers clinically meaningful workflow variations, like Capsulorhexis sub-techniques, offering a verifiable founda- tion for analysis. This capability extends to complex, rare events: The model robustly identifies an unexpected Vitrec- tomy phase and provides granular, node-level explanations for complications like an iris prolapse. Such detailed, multi- level explanations are essential for building clinical trust. By uniting prototype-based interpretability with robust repre- sentation learning, ProtoFlow takes an essential step toward more explainable, reliable, and efficient AI solutions for next- generation surgical data science.

  ProtoFlow: interpretable and robust surgical workflow modeling with learned dynamic scene graph prototypes · 2026 · DOI

• Furthermore, in order to increase the reproducibility and applicability of the results, a more numerous and diverse cohort of cases should be examined and matched with a control group. Moreover, the integration of hemodynamic parameters into the holographic rendering, in order to combine patient-specific 3D interactive anatomical information to vessel-specific volume flow rates, flow velocity turbulences and shear stresses should be investigated. This role of MxR should be further explored.

  Mixed reality applied to surgical planning and tailoring of carotid endarterectomies · 2026 · DOI

• This scoping review is limited by the heterogeneity of study designs, outcome measures, and learner populations. Most studies assessed simulation-based outcomes rather than clinical performance or patient-level endpoints. Additionally, 1 3Journal of Robotic Surgery (2026) 20:526 the predominance of studies from high-income countries limits generalizability. Artificial intelligence applications remain underrepresented, and long-term skill retention and cost-effectiveness were infrequently evaluated. and acknowledgment of all original sources will be ensured, respecting copyright and intellectual property rights.

  Extended reality and emerging artificial intelligence in orthopedic surgical training: a scoping review of educational outcomes · 2026 · DOI

• The future of Virtual Reality depends on the existence of sys- tems that address issues of ‘large scale’ virtual environments. In the coming years, as more research is done we are bound to see VR become as mainstay in our homes and at work. As the computers become faster, they will be able to create more real- istic graphic images to simulate reality better. It will be inter- esting to see how it enhances artificial reality in the years to come. It is very possible that in the future we will be communicating with virtual phones. Nippon Telephone and Telegraph (NTT) in Japan is developing a system which will allow one person to see a 3D image of the other using VR techniques. The future is virtual reality, and its benefits will remain im- measurable. CONCLUSION Virtual Reality is now involved everywhere. You can’t imag- ine your life without the use of VR Technology. In this paper we define the Virtual Reality and its history. We also define some important development which gives the birth of this new technology. Now we use mail or conference for communication while the person is not sitting with you, but due to technology distance is not matter.This technology give enormous scope to explore the world of 3D and your own imagination. It has many applications from product development to enter- tainment. It is still very much in the development stage with many users creating their own customized applications and setups to suit their needs. ACKNOWLEDGMENT I thank International Journal of Scientific & Engineering Re- search (IJSER), who motivates me to write my own first paper.

  Virtual Reality and Gamification for Assessing Technical Aptitude, Cognitive Abilities, and Personality Characteristics in Surgical Residency Selection: Validation Study · 2026 · DOI

• Accessed March 5, 2025 https://www.facs.org/media/cezf1xvo/surgi- calergonomicsrecommendations.pdf; 2022. ergonomics 16. Cerier E, Hu A, Goldring A, Rho M, Kulkarni SA. Ergonomics work- shop improves musculoskeletal symptoms in general surgery resi- dents. J Surg Res. 2022;280:567–574. 17. Epstein S, Tran BN, Capone AC, et al. The current state of surgical ergonomics education in U.S. surgical training: a survey study. Ann Surg. 2019;269:778–784. 18. Association of American Medical Colleges. Table B3. Number of active residents, by type of Medical School, GME specialty, and sex. Available at: https://www.aamc.org/data-reports/students-residents/ interactive-data/report-residents/2020/table-b3-number-active-resi- dents-type-medical-school-gme-specialty-and-sex. Accessed March 28, 2022. 19. Berguer R. Surgical technology and the ergonomics of laparoscopic instruments. Surg Endosc. 1998;12:458–462. 20. Adams DM, Fenton SJ, Schirmer BD, Mahvi DM, Horvath K, Nichol P. One size does not fit all: current disposable laparoscopic devices do the needs of female laparoscopic surgeons. Surg Endosc. not fit 2008;22:2310–2313. 21. Wong JMK, Carey ET, King C, Wright KN, King LP, Kho RM. A call to action for ergonomic surgical devices designed for diverse surgeon end users. Obstet Gynecol. 2023;141:463–466. 22. Matteson KA, Butts SF. ACOG Committee on Gynecologic Practice. Choosing the route of hysterectomy for benign disease. Committee Opinion No. 701. American College of Obstetricians and Gynecolo- gists. Obstet Gynecol. 2017;129:e155–e159. Downloaded for Anonymous User (n/a) at Kirikkale University from ClinicalKey.com by Elsevier on May 21, 2026. For personal use only. No other uses without permission. Copyright ©2026. Elsevier Inc. All rights reserved.

  Investigation of Hand Pain With Laparoscopy Among Gynecologic Surgeons · 2026 · DOI

• The paper describes interconnected AI applications combining phase recognition with safety assessment and instrument tracking with skill evaluation, but does not specify the architectural requirements, data fusion methodologies, or validation protocols needed to clinically implement these integrated intelligent surgical ecosystems in minimally invasive laparoscopy.

  Integrated Advances in Minimally Invasive Surgery: Ergonomics, Visualization, and Artificial Intelligence in Modern Laparoscopy · 2026 · DOI

• Advanced visualization systems (HD, 3D laparoscopy) show higher penetration than robotic surgery and AI in Latin America, but the paper does not address how visualization quality improvements should be systematically integrated with AI-based phase recognition and safety detection to create cost-effective intelligent surgical ecosystems in resource-limited settings.

  Integrated Advances in Minimally Invasive Surgery: Ergonomics, Visualization, and Artificial Intelligence in Modern Laparoscopy · 2026 · DOI

• The paper identifies that AI implementation in Mexico, Colombia, and Ecuador is constrained by data availability, digital integration, and regulatory frameworks, but does not specify which surgical datasets are missing, what interoperability standards for surgical data are needed, or what regulatory pathways should be developed for these middle-income contexts.

  Integrated Advances in Minimally Invasive Surgery: Ergonomics, Visualization, and Artificial Intelligence in Modern Laparoscopy · 2026 · DOI

• AI-based technical skill evaluation systems analyze instrument motion, speed, and precision, but the paper lacks specification of standardized benchmark datasets or validation protocols for comparing AI-generated skill assessments against expert observer ratings across different laparoscopic procedure types.

  Integrated Advances in Minimally Invasive Surgery: Ergonomics, Visualization, and Artificial Intelligence in Modern Laparoscopy · 2026 · DOI

• Instrument tracking systems for motion analysis and technical performance assessment have been proposed, but the paper does not specify datasets of instrument trajectories across different surgeon skill levels or standardized metrics for identifying inefficient movements in minimally invasive surgery workflows.

  Integrated Advances in Minimally Invasive Surgery: Ergonomics, Visualization, and Artificial Intelligence in Modern Laparoscopy · 2026 · DOI

• The equivalence between the tips of symmetric surgical tools (scissors, forceps) in standard COCO OKS metric has not been addressed in the baseline models, requiring a custom metric modification.

  ROBUST-MIPS: A Combined Skeletal Pose and Instance Segmentation Dataset for Laparoscopic Surgical Instruments · 2026 · DOI

• The authors lack the large-scale repeated annotations required to empirically calculate σi for each specific instrument keypoint type, necessitating a conservative strategy using maximum standard deviation from the COCO human pose dataset.

  ROBUST-MIPS: A Combined Skeletal Pose and Instance Segmentation Dataset for Laparoscopic Surgical Instruments · 2026 · DOI

• The models were originally designed for human pose estimation; their generalisability to surgical tool pose estimation, particularly regarding symmetric tool tips (Tip1 and Tip2), has not been fully addressed in existing frameworks.

  ROBUST-MIPS: A Combined Skeletal Pose and Instance Segmentation Dataset for Laparoscopic Surgical Instruments · 2026 · DOI

• Artificial intelligence is progressively reshaping ophthalmic surgi- cal training from experience-dependent apprenticeship toward objec- tive, data-driven competence development. Across the novice to expert continuum, current evidence supports the role of AI-enabled simulation, computer-visio, and registry-driven predictive modeling as assistive tools that enhance feedback consistency, accelerate skill acquisition, and enable scalable benchmarking. Importantly, these systems function most effectively when aligned with clearly defined educational objectives and human oversight, rather than as autono- mous decision-makers. design, where safety risks are minimal. However, translation into real-world assistance will require stringent safeguards, transparent reward structures, and clear boundaries that preserve surgeon authority. 10.4 Federated learning and cross-center collaboration Sustainable progress in AI-assisted surgical education will depend on access to diverse, high-quality data. Federated learning provides a viable pathway to train robust models across institutions while pre- serving patient privacy and data sovereignty. For ophthalmic surgery, federated infrastructures could reduce center-specific bias, improve generalizability across devices and populations, and facilitate interna- tional benchmarking of training outcomes. More broadly, recent pre- dictive modeling studies in other ophthalmic subspecialties have likewise highlighted the importance of heterogeneous datasets and external validation, reinforcing the need for cross-center collaboration before AI models can be adopted as dependable decision-support tools (53). Looking forward, the next phase of AI evolution in ophthalmic surgery will extend beyond task-specific models toward integrated, multimodal intelligence frameworks that operate across the full surgi- cal lifecycle. Beyond the scope of this review, AI-integrated robotic assistance and closed-loop control for ophthalmic microsurgery represent an important parallel track that will require dedicated evidence synthesis and prospective clinical validation. 10.1 Multimodal foundation models for surgical understanding Future AI systems are expected to transition from single- modality video analysis to multimodal foundation models that jointly learn from surgical video, instrument kinematics, force- feedback signals, intraoperative OCT, and perioperative clinical data. For training, this may enable richer competency assessment that integrates technical precision, temporal efficiency, and cogni- tive load. However, robust external validation and standardized data interfaces will be essential before these models can be safely deployed at scale. 10.2 Digital twins of ocular anatomy and personalized simulation Another promising direction is the development of digital twins of ocular anatomy, constructed from patient-specific imaging and continuously updated surgical data. Such virtual replicas could allow surgeons to rehearse procedures under realistic biomechanical condi- tions, explore alternative strategies, and anticipate complication path- ways before entering the operating room. For trainees, digital twins may bridge the gap between generic simulation and individualized anatomy, accelerating the transition from rule-based execution to situ- ational reasoning. In summary, AI-assisted ophthalmic surgical training is entering a transition from isolated tools toward interconnected intelligence systems. The greatest impact will likely arise not from full automation, but from thoughtfully designed human–AI collaboration that aug- ments perception, supports reflection, and reinforces clinical respon- sibility. Future research should prioritize prospective, multi-center studies that link AI-enabled training interventions to long-term patient outcomes, thereby ensuring that technological advancement translates into meaningful clinical benefit.

  Artificial intelligence assisted simulation and surgical video analytics for ophthalmic surgery training and competence development · 2026 · DOI

• CONCLUSIONS: This work validates STAR as a viable surgical telementoring platform, which could be further explored to aid in scenarios where life-saving care must be delivered in a prehospital setting.

  Telementoring in Leg Fasciotomies via Mixed-Reality: Clinical Evaluation of the STAR Platform · 2020 · DOI

Most-cited papers in Surgical Simulation and Training

• Association Between Implementation of a Medical Team Training Program and Surgical Mortality · JAMA · 2010 · 829 citations
• A systematic review of immersive technology applications for medical practice and education - Trends, application areas, recipients, teaching contents, evaluation methods, and performance · Educational Research Review · 2021 · 236 citations
• Shadow Learning: Building Robotic Surgical Skill When Approved Means Fail · Administrative Science Quarterly · 2018 · 216 citations
• The IDEAL framework for surgical robotics: development, comparative evaluation and long-term monitoring · Nature Medicine · 2024 · 150 citations
• Artificial intelligence and augmented reality for guided implant surgery planning: A proof of concept · Journal of Dentistry · 2023 · 116 citations
• Current and future applications of artificial intelligence in surgery: implications for clinical practice and research · Frontiers in Surgery · 2024 · 76 citations
• Three-dimensional virtual planning in mandibular advancement surgery: Soft tissue prediction based on deep learning · Journal of Cranio-Maxillofacial Surgery · 2021 · 70 citations
• A Review of Training Research and Virtual Reality Simulators for the da Vinci Surgical System · Teaching and Learning in Medicine · 2015 · 61 citations
• Surgical Simulation: Virtual Reality to Artificial Intelligence · Current Problems in Surgery · 2024 · 59 citations
• Continued Validation of the O-SCORE (Ottawa Surgical Competency Operating Room Evaluation): Use in the Simulated Environment · Teaching and Learning in Medicine · 2016 · 58 citations

Most recent work

• Artificial intelligence assisted simulation and surgical video analytics for ophthalmic surgery training and competence development · Frontiers in Medicine · 2026
• Evolving surgical teams in the age of artificial intelligence and robotics · Frontiers in Science · 2026
• Under the Microscope: Expert Novice Gaze Differences During Suturing ETRA019 · Proceedings of the ACM on Human-Computer Interaction · 2026
• EasyVis2: a real-time multi-view 3D visualization system for laparoscopic surgery training enhanced by a deep neural network YOLOv8-pose · Updates in Surgery · 2026
• Real-time Computer Vision Assisted Navigation for Endoscopic Pituitary Surgery: Iterative Development and Comparative Preclinical Evaluation · medRxiv · 2026
• When metrics eclipse meaning: Rethinking success in academic surgery · The American Journal of Surgery · 2026
• Expanding Horizons in Craniomaxillofacial Reconstruction: The Role of Exoscopic Microsurgery in Head and Neck Surgery · Craniomaxillofacial Trauma & Reconstruction · 2026
• ROBUST-MIPS: A Combined Skeletal Pose and Instance Segmentation Dataset for Laparoscopic Surgical Instruments · Scientific Data · 2026
• Integrated Advances in Minimally Invasive Surgery: Ergonomics, Visualization, and Artificial Intelligence in Modern Laparoscopy · IECCMEXICO · 2026
• Virtual Reality in Spinal Surgery: Development of an Educational Module Focused on Vertebroplasty · Bratislava Medical Journal · 2026

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