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We define surgeon-controlled operative polyphony as the phase-bounded coordination of multiple partially independent technical control streams by one console operator within a distributed perioperative system. This critical narrative review and conceptual synthesis asks which technical functions can be concentrated coherently, where human-factors and team dependencies set limits, and how evaluation, training, and governance should respond. The piano is used as a question-generating model, not as evidence of clinical benefit. PubMed\/MEDLINE was searched from inception through 18 August 2026; targeted engineering, educational, neuroscientific, human-factors, and musicological searches and backward citation tracking supplemented retrieval. To analyze this control configuration, we propose the PIANO framework: Phase-specific control, Interface fidelity, Agency allocation, Neuromotor integration, and Orchestrated teamwork. Its scientific novelty lies in linking this control architecture to the PIANO framework: Phase-specific control, Interface fidelity, Agency allocation, Neuromotor integration, and Orchestrated teamwork. PIANO is an analytic and hypothesis-generating framework, not a score or credentialing standard. Concentrated control may shorten selected action loops, but any benefit depends on feedback, workload, shared situation awareness, explicit authority, and rescue capacity. The Competency-Based Assessment of Robotic Surgery Skills (CARS) curriculum provides initial validation evidence for domain-specific assessment of performer competence; repeated cases and use-specific evidence remain necessary for high-stakes decisions. Artificial intelligence (AI) may support phase recognition, feedback, assessment, and personalised training within a human-in-the-loop system. One surgeon may coordinate many operative voices; safe surgery remains a collective, patient-centered performance.<\/jats:p>","DOI":"10.1007\/s11701-026-04035-8","type":"journal-article","created":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T08:37:20Z","timestamp":1791362240000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["The robotic PIANO: a critical narrative review of surgeon-controlled operative polyphony, human factors, and robotic training"],"prefix":"10.1007","volume":"20","author":[{"given":"Luigi","family":"Marano","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mirko","family":"Barone","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mehmet 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