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However, the association between technique and outcomes remains poorly defined. Existing workflow analyses focus on broad procedural steps and phases, but a more detailed, action-level approach is needed to capture skill-related variation. While AI shows promise in automating workflow analysis, its use at the action level is limited. This study develops and validates a reproducible action-level classification ontology for endoscopic pituitary adenoma resection, establishing the structured annotation foundation required for future AI-based workflow and skill analysis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Endoscopic videos of primary pituitary adenoma resections were collected from two high-volume international pituitary centres. A multi-disciplinary panel of neurosurgeons and data scientists iteratively reviewed and annotated surgical actions to establish a standardized classification system. Actions were categorized into triplets (instrument, target, verb), with additional temporal annotations. To evaluate framework reliability, an independent annotator followed a structured annotation guide, and inter-annotator agreement was measured using Cohen\u2019s Kappa.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      A consensus-based classification ontology was developed, comprising 9 verbs, 12 instruments, and 7 targets from the review of 18 endoscopic pituitary adenoma resections (9 microadenomas, 9 macroadenomas). Action distribution differed between micro- and macroadenomas, with grasping being the predominant action in microadenomas (72% of right-hand frames) and blunt dissection and traction dominating macroadenomas. The left hand primarily performed non-meaningful movements (88% of macroadenoma frames, 55% of microadenoma frames), while the right hand was responsible for more deliberate tool\u2013tissue interactions. Inter-rater reliability analysis demonstrated substantial to near-perfect agreement (\n                      <jats:italic>\u03ba<\/jats:italic>\n                      \u2009=\u20090.69\u20130.95), confirming the reproducibility of the annotation system.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>While acknowledging that conclusions remain limited by dataset size and validation stability, this study establishes a robust and interpretable action classification ontology for pituitary adenoma resection. The ontology enables high-quality, standardized labelling for future computer-vision AI works, and lays the groundwork for evaluating whether action-level annotation improves surgical outcome prediction and automated skill assessment.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s11548-026-03614-2","type":"journal-article","created":{"date-parts":[[2026,4,11]],"date-time":"2026-04-11T06:28:15Z","timestamp":1775888895000},"page":"1763-1773","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Action classification for endoscopic pituitary adenoma resection: a consensus-based study"],"prefix":"10.1007","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0520-6206","authenticated-orcid":false,"given":"Joachim","family":"Starup-Hansen","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Danyal Z.","family":"Khan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adrito","family":"Das","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joao Paulo","family":"Almeida","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sophia","family":"Bano","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anouk","family":"Borg","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kevin","family":"Cleary","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Neil","family":"Dorward","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Juan C.","family":"Fernandez-Miranda","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eduardo","family":"Torres-Rodr\u00edguez","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Danail","family":"Stoyanov","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Recai","family":"Yilmaz","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter","family":"Weir","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel A.","family":"Donoho","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hani J.","family":"Marcus","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,4,11]]},"reference":[{"issue":"2","key":"3614_CR1","doi-asserted-by":"publisher","first-page":"81","DOI":"10.1023\/B:PITU.0000004798.27230.ed","volume":"6","author":"MD Johnson","year":"2003","unstructured":"Johnson MD, Woodburn CJ, Lee Vance M (2003) Quality of life in patients with a pituitary adenoma. 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