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.