Objective This study evaluated the effect of active operative video annotation on surgical education, specifically focusing on implementability, knowledge acquisition, skill development, and confidence.

Background Resident duty hour restrictions necessitate more efficient surgical training, as steep learning curves in many procedures may result in residents completing training without gaining enough experience to perform them safely. Video annotation of operative videos, involving labeling of instruments and steps, might offer a secure and risk-free environment to improve surgical learning.

Methods A preclinical randomized controlled trial was conducted with novice neurosurgeons from multiple centres. Participants were assigned to annotate real-life operative videos or to the control group, who performed passive video review. At baseline and then following either video annotation or video review, both groups completed a simulated pituitary adenoma resection on a validated high-fidelity physical simulator and were assessed using knowledge quizzes, a modified Global Rating Scale (mGRS), and confidence surveys. Participants also completed an implementability questionnaire.

Results Fourteen participants completed the study. Psychometric surveys indicated 100% agreement on feasibility, acceptability, and appropriateness in the annotation group, significantly higher than the review group (p<0.001). Procedural knowledge score changes were significantly higher in the annotation group compared to the video review group (1.71, 95% CI: 0.19-3.41, p= 0.0479). The annotation group also significantly improved their operative performance from baseline, with mean mGRS increasing by 5.14 (95% CI: 2.36-7.93, p=0.004) versus 2.57 (95% CI: -1.30-6.44) (p=0.16) in the video review group. Confidence improved significantly in both groups (<0.05), with no significant difference between groups.

Conclusions Active video annotation is a feasible and acceptable tool for enhancing surgical education. It led to a higher change in knowledge score compared to passive video review and also improved skills and confidence from baseline, suggesting its suitability for integration into surgical training programs. Its impact, however, on real-world surgical performance and patient outcomes requires further study.

The authors have declared no competing interest.

Mr Marcus is funded by the NIHR Biomedical Research Centre at University College London. Mr Khan is supported by the NIHR Academic Clinical Fellowship

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

Only simulated data. Ethics approval was obtained from the University College London Research Ethics Committee for studies on simulation (26117/002)

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

Yes

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Yes

All data relevant to the study are included in the article.