real left-field win here for atlus, adapting the grisly world of surgery to an arcade-like game designed by the digital devil saga staff and helmed by one of the designers of the hamtaro gba games. it's primarily a game of juggling various timers, specifically the main time limit, the drain on your patient's vitals, and the time until a new hazard spawns in that will increase the drain rate. kyriaki, the first of a set of viruses called GUILT that make up the second half of the game, best exemplifies this. it appears by creating an incision in the patient's tissue, which will bleed and thus increase the drain on the patient. locating one permanently requires using the ultrasound to locate it (preferably after creating the incision) and then cutting it out of the tissue with the scalpel, after it will which it will make another incision, leaving you with two extra cuts to deal with. to kill it, you target it with a laser for some amount of seconds, but leaving the laser in one place for too long will puncture the tissue, requiring you to drain the resulting hemorrhage and close the wound with healing gel. when multiple of these appear at once, you'll be put in uncomfortable circumstance of having to juggle your focus on each one as well as the various injuries you incur along the way, down to decisions such as "should I try to cut them out now or suture wounds while I wait for them to line up so I can cut them both out at once." choosing wrong can often mean a quick death for your patient, especially in particular scenarios where killing one on its own might lead to two more coming out from underneath and causing many extra incisions at once. reminds me of something like diner dash in an odd way.

draining vitals isn't a one-way street however, as you have two separate tools for increasing vitals in exchange for time. the primary one is your stabilization serum, which gives a quick burst of vitals in exchange for the time you take raising the plunger of the syringe to fill it; the amount you raise the vitals scales with the amount you fill into the syringe. alternatively, you can use the aforementioned healing gel, which lightly raises vitals as applied by rubbing the screen. both are limited resources that refill slowly when not being used and will refill completely after a short lockout when they deplete, and alternating between the two becomes a natural tendency in the later operations when simply fighting the virus on its own can't outpace the natural vitals drain. later levels extend these limitations to other tools as well: final boss savato repeatedly locks out your scalpel when severing the spider-virus's webs, and in its second phase managing your time remaining on the laser to both proactively deal damage to the virus itself as well as reactively dealing with mini-spiders it floods the tissue with imposes further considerations on when and where to strike. the best levels impose malleable rotations on the player, where multiple tools must be swapped between in series. these are rarely static, as the often twitchy viruses and the wounds they inflict will keep the player weaving in defensive maneuvers dynamically. learning this balance between offense and defense evokes the tension and precision of the real operating room.

the level of creativity on display with the operations is also worth applauding. the latter half of the game (especially the "boss rush" chapter six) begins to repeat itself a fair bit, but earlier on the game is more than happy to give one-off operations their own bespoke mechanics, from clots staggered in sequence traveling through winding veins to draining fluid from a man's lungs on an airplane undergoing heavy turbulence. the game even weaves in non-surgery elements just to keep things fresh, such as some hexagonal block puzzles and a mid-story bomb disposal. as with any game like this, duds rear their head as well. two of the GUILT strains become annoying for opposite reasons: triti and its rules for cell expansion (it's similar to conway's game of life) are poorly explained and tend to mandate a specific solution that will jeopardize the operation with any single mistake. conversely, deftera depends on two viruses colliding in order to vacuum out of the tissue, and while its random movement can be manipulated by using the gel as a fence of sorts, ultimately a good performance on these levels comes down to rolling lucky on getting good collisions back to back. falling back on more of a puzzle approach as in the former example or mechanics out of the player's hands as in the latter example can work when it's a singular operation or a break from the action, but given that both of these get repeated a few times apiece, it's hard to be quite as forgiving.