Federated Learning for Surgical Vision in Appendicitis Classification: Results of the FedSurg EndoVis 2024 Challenge

Federated Learning (FL) in surgical video AI enables collaborative model training without sharing sensitive data. However, standard evaluation practices - selecting the "best" global model based only on validation data from participating hospitals - can lead to suboptimal deployment choices. We identify this critical failure mode as performance leakage, where the selected model overfits internal federation data and fails to generalize to unseen institutions. We propose GEN-Guard, a practical post-hoc framework to detect and correct generalization failures in federated surgical AI. It integrates Generalization Detection via Client-Blocked Evaluation (CBE), which validates performance on isolated client distributions to prevent performance leakage, and Generalization Correction through Disagreement-Aware Distillation (DAD), which learns adaptive feature-level corrections for cross-institutional robustness. Both components operate after standard FL convergence while providing robust support for zero-shot adaptation to unseen environments. We first quantify the severity of performance leakage, observing Model Selection Failures (MSFs) exceeding 80% under standard evaluation. GEN-Guard is evaluated on two multi-center clinical challenges: surgical phase recognition in laparoscopic cholecystectomy and polyp segmentation in colonoscopy. Across both datasets, GEN-Guard consistently corrects these failures, improving in-federation F1 scores by up to 2 points, unseen-institution performance by up to 3 points, and worst-case institutional performance by 3-9 points. Performance leakage represents a systematic and previously under-recognized risk in federated surgical AI. GEN-Guard provides a practical solution for detecting and correcting such failures. By improving cross-institutional robustness and zero-shot generalization, it strengthens the reliability of FL for real-world surgical deployment.

Federated learning (FL) holds great potential for medical applications. However, statistical heterogeneity across healthcare institutions poses a major challenge for FL, as the global model struggles both to generalize across unseen patient populations and to adapt to the unique data distributions of individual hospitals. This heterogeneity also exacerbates forgetting at both the global and local level, resulting in previous learned patient patterns to be misclassified after model updates. While prior work has largely treated generalization and personalization as separate challenges, we show that a better balance between the two can be achieved through selective alignment with the global model and a modified aggregation scheme, which together mitigate the effects of statistical heterogeneity. Specifically, we introduce FedKPer, which introduces knowledge personalization into the training stage of each local device. Afterwards, generalization is considered via the global model aggregation process, where local updates that are reliable and label-diverse are emphasized. We evaluate the performance of FedKPer, devising additional metrics that relate to common consequences of forgetting. Overall, we demonstrate FedKPer improves the generalization-personalization trade-off without sacrificing retention.

Federated learning (FL) enables collaborative model training without sharing raw patient data, but standard approaches such as FedAvg treat each client as a black box and provide no mechanism for isolating an adversarial contributor, auditing per-client influence, or honoring a departed participant's right to be forgotten. We present Fed-FBD (Federated Functional Block Diversification), a modular federated architecture that decomposes a ResNet backbone into six functional blocks (the stem, four residual groups, and the classification head) and maintains a warehouse of N color variants, each assembled from independently tracked and contributor-stamped blocks. Fed-FBD provides three capabilities absent in FedAvg: (i) architecturally guaranteed block-level isolation, so that an adversarial or mislabelled client cannot contaminate the clean colous; (ii) privacy-by-design, where membership inference advantage is already indistinguishable from chance before any privacy mechanism is applied; and (iii) surgical machine unlearning of a departed participant's contribution at sub-second cost and without retraining. Experiments on six MedMNIST-2D datasets, PathMNIST at 224x224, and CIFAR-10 show that Fed-FBD trades a modest 0.3%-3.1% IID accuracy gap on the adequately sized datasets for these guarantees, remains within 0.8%-4.0% of FedAvg at Dirichlet alpha=1.0 on three of four datasets, and confines all six adversarial attacks we study to the poisoned client's own blocks with at most +/-0.01 AUC drift on the clean colors.