A 4D Representation for Training-Free Agentic Reasoning from Monocular Laparoscopic Video

Fine-grained spatiotemporal reasoning on surgical videos is critical, yet the capabilities of Multi-modal Large Language Models (MLLMs) in this domain remain largely unexplored. To bridge this gap, we introduce SurgCoT, a unified benchmark for evaluating chain-of-thought (CoT) reasoning in MLLMs across 7 surgical specialties and 35 diverse procedures. SurgCoT assesses five core reasoning dimensions: Causal Action Ordering, Cue-Action Alignment, Affordance Mapping, Micro-Transition Localization, and Anomaly Onset Tracking, through a structured CoT framework with an intensive annotation protocol (Question-Option-Knowledge-Clue-Answer), where the Knowledge field provides essential background context and Clue provides definitive spatiotemporal evidence. Evaluation of 10 leading MLLMs shows: 1) commercial models outperform open-source and medical-specialized variants; 2) significant gaps exist in surgical CoT reasoning; 3) SurgCoT enables effective evaluation and enhances progressive spatiotemporal reasoning. SurgCoT provides a reproducible testbed to narrow the gap between MLLM capabilities and clinical reasoning demands. Code: https://github.com/CVI-SZU/SurgCoT.

Humans are born with vision-based 4D spatial-temporal intelligence, which enables us to perceive and reason about the evolution of 3D space over time from purely visual inputs. Despite its importance, this capability remains a significant bottleneck for current multimodal large language models (MLLMs). To tackle this challenge, we introduce MLLM-4D, a comprehensive framework designed to bridge the gaps in training data curation and model post-training for spatiotemporal understanding and reasoning. On the data front, we develop a cost-efficient data curation pipeline that repurposes existing stereo video datasets into high-quality 4D spatiotemporal instructional data. This results in the MLLM4D-2M and MLLM4D-R1-30k datasets for Supervised Fine-Tuning (SFT) and Reinforcement Fine-Tuning (RFT), alongside MLLM4D-Bench for comprehensive evaluation. Regarding model training, our post-training strategy establishes a foundational 4D understanding via SFT and further catalyzes 4D reasoning capabilities by employing Group Relative Policy Optimization (GRPO) with specialized Spatiotemporal Chain of Thought (ST-CoT) prompting and Spatiotemporal reward functions (ST-reward) without involving the modification of architecture. Extensive experiments demonstrate that MLLM-4D achieves state-of-the-art spatial-temporal understanding and reasoning capabilities from purely 2D RGB inputs. Project page: https://github.com/GVCLab/MLLM-4D.

Robotic-assisted surgery (RAS) is central to modern surgery, driving the need for intelligent systems with accurate scene understanding. Most existing surgical AI methods rely on isolated, task-specific models, leading to fragmented pipelines with limited interpretability and no unified understanding of RAS scene. Vision-Language Models (VLMs) offer strong zero-shot reasoning, but struggle with hallucinations, domain gaps and weak task-interdependency modeling. To address the lack of unified data for RAS scene understanding, we introduce SurgCoTBench, the first reasoning-focused benchmark in RAS, covering 14256 QA pairs with frame-level annotations across five major surgical tasks. Building on SurgCoTBench, we propose SurgRAW, a clinically aligned Chain-of-Thought (CoT) driven agentic workflow for zero-shot multi-task reasoning in surgery. SurgRAW employs a hierarchical reasoning workflow where an orchestrator divides surgical scene understanding into two reasoning streams and directs specialized agents to generate task-level reasoning, while higher-level agents capture workflow interdependencies or ground output clinically. Specifically, we propose a panel discussion mechanism to ensure task-specific agents collaborate synergistically and leverage on task interdependencies. Similarly, we incorporate a retrieval-augmented generation module to enrich agents with surgical knowledge and alleviate domain gaps in general VLMs. We design task-specific CoT prompts grounded in surgical domain to ensure clinically aligned reasoning, reduce hallucinations and enhance interpretability. Extensive experiments show that SurgRAW surpasses mainstream VLMs and agentic systems and outperforms a supervised model by 14.61% accuracy. Dataset and code is available at https://github.com/jinlab-imvr/SurgRAW.git .