Cognitive frameworks for intraoperative surgical decision making: a systematic scoping review

Abstract Introduction Surgical outcomes are heavily influenced by intraoperative decisions, yet the cognitive processes underlying these decisions remain incompletely understood. This scoping review aims to map existing cognitive frameworks in the literature and identify gaps in our understanding of intraoperative decision-making. Method A systematic search of six databases, including PubMed, Embase, Scopus, Cochrane, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) identified studies examining cognitive processes in surgical decision-making across all surgical subspecialties and training levels. Articles focused on procedure-specific decisions or teaching of intraoperative decision making were excluded. Key themes were identified to highlight the most relevant concepts, and a final selection of studies were analyzed. Result In total, 5,501 articles were screened, 190 studies underwent full-text review, and 19 papers were chosen for final analysis. Five major themes emerged: (1) cognitive processing models, outlining how surgeons acquire and act on information; (2) essential skills and competencies; (3) balancing internal and external factors; (4) context-dependent decision-making; and (5) limitations of existing models. Decision-making was commonly described as a continuum between intuitive (experience-based, rapid) and analytical (deliberate, rule-based) strategies, with surgeons dynamically shifting between these approaches based on case complexity and time constraints. Discussion Intraoperative decision-making is a complex, dynamic process requiring surgeons to balance multiple factors while managing cognitive load. Enhancing awareness of these processes— through structured reflection, metacognition, and adaptability—may improve decision-making and surgical education.