Decoding the surgical scene: A scoping review of scene graphs in surgery.

As surgical AI transitions from pixel-level detection to complex reasoning, Scene Graphs (SGs) offer the structured, relational representations necessary to decode dynamic surgical environments. This PRISMA-ScR-guided scoping review systematically maps the evolving landscape of SG research in surgery, analyzing 52 primary studies to chart applications and methodological shifts. Our analysis reveals rapid growth, yet uncovers a critical 'data divide': internal-view research (e.g., triplet recognition from endoscopic video) accounts for 79% of studies and predominantly uses real-world 2D video, while external-view operating room modeling relies heavily on simulated data. Methodologically, we identify a decisive shift from foundational graph neural networks to specialized foundation models and generative AI, which together now account for approximately 50% of research in 2025. Crucially, our synthesis suggests that Scene Graphs are evolving from simple descriptors into essential 'neuro-symbolic guardrails', providing the structured, verifiable intermediate representation needed to prevent hallucinations in increasingly autonomous Surgical Foundation Models. Despite this promise, a major translational gap remains: none (0/52) of the reviewed studies have proceeded to prospective clinical validation. We conclude that bridging this gap requires moving beyond standard computer vision metrics; we therefore propose the 'Validation Trinity' - prioritizing Semantic Query Success, Latency-Aware Accuracy, and Safety-Critical Recall - as the necessary evaluation framework to bring graph-based surgical AI into clinical practice.