Surgical Video Question Answering (VideoQA) provides a promising paradigm for dynamic intraoperative interpretation, enabling real-time decision support and context-aware retrieval in clinical environments. Nevertheless, existing approaches are predominantly restricted to images or short clips, limiting their ability to model long-range procedural dynamics and causal dependencies across extended surgical workflows. To address this challenge, we propose SurgLQA, a unified long-horizon VideoQA framework for scalable surgical reasoning. This framework incorporates Faithful Temporal Consolidation (FTC), which leverages intrinsic temporal cues to construct compact long-range representations while preserving fine-grained temporal fidelity. Further, we develop Temporally-Grounded Multi-Policy Scaling (TMS), an adaptive test-time inference paradigm that strategically adjusts policy-level reasoning capacity within temporally grounded contexts. To facilitate systematic evaluation, we restructured a long-duration colonoscopy VideoQA benchmark, Colon-LQA, and conducted extensive experiments on Colon-LQA and REAL-Colon-VQA. Experimental results demonstrate that our approach achieves consistent performance gains in long-range reasoning with temporally grounded inference. Code link: https://github.com/RascalGdd/SurgLQA.
Despite recent advances in surgical vision-language models (VLMs), temporal reasoning remains limited because existing supervision is largely frame-centric. Frame-level scene graphs (SGs) have proven effective in providing structured representations of surgical environments but do not explicitly model the dynamics of surgical workflows. To explicitly model how surgical states evolve across time, we introduce a multi-level structured temporal supervision methodology that augments frame-level surgical SGs with object-level continuity, event-level interaction continuity, and procedure-level connectivity. We then execute temporal queries over the resulting spatio-temporal scene graphs (STSGs) to generate evidence-grounded question-answer pairs, which together form the STSG-VQA benchmark. Each question is linked to the temporal interval and STSG evidence used to derive its reference answer, enabling traceable verification. The benchmark contains 18,458 question-answer pairs across seven temporal categories. Fine-tuning Qwen3-VL-4B and Hulu-Med-4B with STSG-derived supervision improves question-level micro accuracy by 24.39 and 19.56 percentage points over their zero-shot baselines and by 16.50 and 14.25 points over static scene-graph supervision, respectively. These gains span all temporal categories, indicating that STSG-derived supervision helps surgical VLMs reason over temporally grounded interactions rather than isolated frames. The code and dataset will be made publicly available upon acceptance.
Surgical video question answering requires multi-step reasoning across semantic, spatial, and temporal dimensions. Existing methods architecturally compress videos into discrete token representations and couple visual perception with reasoning. This approach fragments continuous spatial-temporal relationships and has been shown to restrict multi-step reasoning capabilities. We introduce a reinforcement learning (RL) framework that trains large language models (LLMs) to decouple perception from reasoning by operating over digital twin representations constructed from surgical foundation models. Additionally, we introduce hierarchical representations across frame, temporal window, and procedure levels with probabilistic uncertainty estimates. Finally, we propose a novel reward that combines format validation with accuracy assessment through clinical plausibility evaluation and uncertainty-aware calibration for training. To demonstrate the capabilities of this approach, we introduce REAL-Colon-Reason, a colonoscopic benchmark with 2000 question-answer pairs across three complexity levels. We achieve state-of-the-art performance on REAL-Colon-Reason and two existing surgical VideoQA benchmarks REAL-Colon-VQA and EndoVis18-VQA.
Long Video Question Answering (LVQA) requires identifying sparse, query-relevant evidence within hours-long untrimmed videos. Existing approaches either process videos densely with large vision-language models (VLMs), incurring prohibitive computational cost, or rely on sparse caption-based reasoning, which often misses temporally localized and motion-centric evidence. We introduce TimeProVe, a cost-efficient hybrid framework for temporally grounded reasoning in long videos. TimeProVe first employs lightweight modules to generate action-grounded answer--evidence hypotheses and subsequently invokes an expensive VLM only for targeted verification. The core of our framework lies in the Action-based Candidate Evidence (ACE) module, which converts temporally localized actions into query-conditioned candidate answers and supporting evidence windows through lightweight LLM reasoning. We further introduce OpenTSUBench (OTB), an open-ended benchmark designed to evaluate temporally grounded reasoning in real-world Activities of Daily Living (ADL) scenarios. Experiments show that TimeProVe outperforms the strongest baseline on OTB by 7.3%, while reducing VLM calls by 75% and inference cost by 93%. Furthermore, without explicit temporal grounding training, TimeProVe achieves competitive performance on Charades-STA, and reaches state-of-the-art results when enhanced with grounding VLMs.