SurgEye: Instruction Tuning-Free Perception-Reasoning Framework for Surgical Scene Understanding

Surgical scene understanding demands not only accurate predictions but also interpretable reasoning that surgeons can verify against clinical expertise. However, existing surgical vision-language models generate predictions without reasoning chains, and general-purpose reasoning models fail on compositional surgical tasks without domain-specific knowledge. We present Surg-R1, a surgical Vision-Language Model that addresses this gap through hierarchical reasoning trained via a four-stage pipeline. Our approach introduces three key contributions: (1) a three-level reasoning hierarchy decomposing surgical interpretation into perceptual grounding, relational understanding, and contextual reasoning; (2) the largest surgical chain-of-thought dataset with 320,000 reasoning pairs; and (3) a four-stage training pipeline progressing from supervised fine-tuning to group relative policy optimization and iterative self-improvement. Evaluation on SurgBench, comprising six public benchmarks and six multi-center external validation datasets from five institutions, demonstrates that Surg-R1 achieves the highest Arena Score (64.9%) on public benchmarks versus Gemini 3.0 Pro (46.1%) and GPT-5.1 (37.9%), outperforming both proprietary reasoning models and specialized surgical VLMs on the majority of tasks spanning instrument localization, triplet recognition, phase recognition, action recognition, and critical view of safety assessment, with a 15.2 percentage point improvement over the strongest surgical baseline on external validation.

Surgical scene understanding is a cornerstone of computer-assisted intervention. While recent advances, particularly in surgical image segmentation, have driven progress, real-world clinical applications require a more holistic understanding that jointly captures procedural context, semantic reasoning, and precise visual grounding. However, existing approaches typically address these components in isolation, leading to fragmented representations and limited semantic consistency. To address this limitation, we propose SurgMLLM, a unified surgical scene understanding framework that bridges high-level reasoning and low-level visual grounding within a single model. Given surgical videos, SurgMLLM fine-tunes a multimodal large language model (MLLM) to support structured interpretability reasoning, which is used to jointly model phases, instrument-verb-target (IVT) triplets, and triplet-entity segmentation tokens. These tokens are then temporally aggregated and serve as prompts for a segmentation network, enabling accurate pixel-wise grounding of triplet instruments and targets. The entire framework is trained end-to-end with a unified objective that couples language-based reasoning supervision with visual grounding losses, promoting coherent cross-task learning and clinically consistent scene representations. To facilitate unified evaluation, we introduce CholecT45-Scene, extending CholecT45 dataset with 64,299 frames of pixel-level mask annotations for instruments and targets, aligned with existing triplet labels. Extensive experiments show that SurgMLLM significantly advances surgical scene understanding, improving the primary triplet recognition metric AP_IVT from 40.7% to 46.0% and consistently outperforming prior methods in phase recognition and segmentation. These results highlight the effectiveness of unified reasoning-and-grounding for reliable, context-aware surgical assistance.

A capable surgical AI model should reason from visual evidence; yet, many existing surgical benchmarks can be partially solved without visual input, as models may exploit procedural priors or common anatomy-instrument interactions to infer answers from language alone. To address this, we introduce SUREON, a video question-answering (QA) dataset and benchmark designed to evaluate visually grounded surgical reasoning. Our pipeline generates QA pairs from narrated surgical academic videos, refines incorrect options using multiple models to reduce linguistic biases, and uses trained adversarial guessers to filter out questions answerable without visual evidence. The resulting dataset contains 76K training pairs covering 168 procedures and 10 specialties, alongside a benchmark of 340 questions across 10 categories verified by expert surgeons. Benchmarking leading commercial and open-source models shows that surgical visual reasoning remains largely unsolved--no model exceeds 53% accuracy and even expert surgeons reach only 64.9%. We also introduce SUREON-VLM, a baseline trained on our curated data that avoids language shortcuts, outperforms existing open-source models on SUREON, and matches larger specialist models on multiple standard surgical benchmarks. Our training ablations show that distractor refinement and blind curation strengthen visual grounding, increasing the multimodal gain from 8.7 to 29.1 percentage points while reducing the training set from 176.6K to 76K filtered samples. SUREON thus offers both a verified testbed for surgical visual reasoning and training data that strengthens visual grounding.