Unveiling the Algorithm: The Role of Explainable Artificial Intelligence in Modern Surgery

Artificial Intelligence (AI) is rapidly transforming surgical care by enabling more accurate diagnosis and risk prediction, personalized decision-making, real-time intraoperative support, and postoperative management. Ongoing trends such as multi-task learning, real-time integration, and clinician-centered design suggest AI is maturing into a safe, pragmatic asset in surgical care. Yet, significant challenges, such as the complexity and opacity of many AI models (particularly deep learning), transparency, bias, data sharing, and equitable deployment, must be surpassed to achieve clinical trust, ethical use, and regulatory approval of AI algorithms in healthcare. Explainable Artificial Intelligence (XAI) is an emerging field that plays an important role in bridging the gap between algorithmic power and clinical use as surgery becomes increasingly data-driven. The authors reviewed current applications of XAI in the context of surgery-preoperative risk assessment, surgical planning, intraoperative guidance, and postoperative monitoring-and highlighted the absence of these mechanisms in Generative AI (e.g., ChatGPT). XAI will allow surgeons to interpret, validate, and trust AI tools. XAI applied in surgery is not a luxury: it must be a prerequisite for responsible innovation. Model bias, overfitting, and user interface design are key challenges that need to be overcome and will be explored in this review to achieve the integration of XAI into the surgical field. Unveiling the algorithm is the first step toward a safe, accountable, transparent, and human-centered surgical AI.