Chain-of-Adaptation: Surgical Vision-Language Adaptation with Reinforcement Learning

Large Vision-Language Models (LVLMs) use their vision encoders to translate images into representations for downstream reasoning, but the encoders often underperform in domain-specific visual tasks such as medical image diagnosis or fine-grained classification, where representation errors can cascade through the language model, leading to incorrect responses. Existing adaptation methods modify the continuous feature interface between encoder and language model through projector tuning or other parameter-efficient updates, which still couples the two components and requires re-alignment whenever the encoder changes. We introduce CRAFT (Codebook RegulAted Fine-Tuning), a lightweight method that fine-tunes the encoder using a discrete codebook that anchors visual representations to a stable token space, achieving domain adaptation without modifying other parts of the model. This decoupled design allows the adapted encoder to seamlessly boost the performance of LVLMs with different language architectures, as long as they share the same codebook. Empirically, CRAFT achieves an average gain of 13.51% across 10 domain-specific benchmarks such as VQARAD and PlantVillage, while preserving the LLM's linguistic capabilities and outperforming peer methods that operate on continuous tokens.

Large Vision Language Models (VLMs) excel at general visual reasoning but experience significant performance degradation when deployed in novel domains that exhibit substantial distribution shifts from their pretraining data. Existing domain adaptation methods rely on finetuning standard VLM components; however, depending on which components are updated, these approaches either limit the model's ability to learn domain-specific representations or cause catastrophic forgetting of previously acquired capabilities. We introduce Vision Contextualized Probing (VisCoP), a parameter-efficient adaptation framework that augments the VLM vision encoder with a compact set of learnable visual probes. By learning domain-specific visual representations through these probes while requiring only minimal updates to pretrained model components, VisCoP effectively adapts to new domains without sacrificing existing knowledge. We evaluate VisCoP across three challenging adaptation settings: cross-view (exocentric to egocentric), cross-modal (RGB to depth), and cross-task (human understanding to robot control). Across all scenarios, VisCoP consistently outperforms existing domain adaptation strategies, achieving superior target-domain performance while preserving the pretrained VLM's capabilities on the source domain. These results demonstrate that lightweight visual probing provides an effective and robust solution for adapting VLMs under substantial distribution shifts. Code, models, and evaluation protocols are available at https://github.com/dominickrei/VisCoP.

Recent advancements in self-supervised learning have led to powerful surgical vision encoders capable of spatiotemporal understanding. However, extending these visual foundations to multi-modal reasoning tasks is severely bottlenecked by the prohibitive cost of expert textual annotations. To overcome this scalability limitation, we introduce LIME, a large-scale multi-modal dataset derived from open-access surgical videos using human-free, Large Language Model (LLM)-generated narratives. While LIME offers immense scalability, unverified generated texts may contain errors, including hallucinations, that could potentially lead to catastrophically degraded pre-trained medical priors in standard contrastive pipelines. To mitigate this, we propose SurgLIME, a parameter-efficient Vision-Language Pre-training (VLP) framework designed to learn reliable cross-modal alignments using noisy narratives. SurgLIME preserves foundational medical priors using a LoRA-adapted dual-encoder architecture and introduces an automated confidence estimation mechanism that dynamically down-weights uncertain text during contrastive alignment. Evaluations on the AutoLaparo and Cholec80 benchmarks show that SurgLIME achieves competitive zero-shot cross-modal alignment while preserving the robust linear probing performance of the visual foundation model. Dataset, code, and models are publicly available at https://github.com/visurg-ai/SurgLIME.