Video-based assessment tool for workflow analysis in minimally invasive colorectal surgery: expert consensus-based development and multicentre validation of ColoWorkflow

Background: Minimally invasive colorectal surgery is characterized by significant procedural variability, a difficult learning curve, and complications that affect patient outcomes. Video-based assessment offers an opportunity to generate data-driven insights to reduce variability, optimize training, and improve surgical performance. This mixed-methods study aimed to develop and validate a video- based assessment tool for workflow analysis across minimally invasive colorectal procedures. Methods: An international steering committee panel of seven members coordinated a three-round modified Delphi process. Experts in colorectal surgery and video-based assessment were invited to reach consensus (≥ 70% agreement) on the phases and steps that describe workflows across colorectal surgery procedural videos. The resulting framework informed the development of ColoWorkflow. Four independent raters then applied ColoWorkflow to a multicentre video data set of laparoscopic and robotic colorectal procedures. Applicability and inter-rater reliability were evaluated. Results: Of 66 invited experts, 41 (62%) from 11 countries completed round 1, 40 (98%) completed round 2, 20 attended the final online consensus meeting, and all (40 of 40) approved the final workflow descriptors. Consensus was achieved on nine procedure-agnostic phases (port placement and abdomen exploration; vascular dissection and ligation, mesocolon/mesorectum dissection, additional lymphadenectomy; colon and/or rectum mobilization; colorectal transection; anastomosis; completion of operation; preplanned additional procedures; unplanned procedures; extracorporeal procedures) and 34 procedure-specific steps that describe colorectal surgery workflows. ColoWorkflow was developed and applied to 54 colorectal surgery videos (left and right hemicolectomies, sigmoid and rectosigmoid resections, and total proctocolectomies) from five centres in four countries. The tool demonstrated broad applicability, as all phase and step labels, except one, were represented in at least one video. Inter-rater reliability was moderate, with a mean Cohen’s κ value of 0.72 for phases and 0.67 for steps. Most discrepancies arose at phase transitions and step boundary definitions. Conclusion: Based on this preliminary work, ColoWorkflow is a promising tool for workflow analysis across minimally invasive colorectal procedures. Its adoption may help standardize training, accelerate competency acquisition, and advance data-informed surgical quality improvement.