Surgical Videos

Surgical procedures follow a phase-to-step hierarchy, yet the video-language models used to recognize them are evaluated with flat per-level metrics that ignore cross-level coherence and error structure. In this paper we make two contributions to address this problem, (i) we introduce SurgHiBench, the first hierarchy-aware evaluation suite for surgical video understanding, with three tasks measuring recognition, consistency, and severity across granularity levels. We evaluate a general-purpose CLIP model, a Euclidean surgical model, and, as second contribution: (ii) HyperSurg, a new hyperbolic model that enforces phase-step containment via entailment cones, across four (existing) datasets spanning three procedure types. The suite reveals that two models with the same accuracy can produce predictions of very different error severity, ranging from sibling confusions within the correct phase to unrelated cross-phase predictions. Hyperbolic geometry shifts predictions toward the correct procedural neighborhood, and these gains scale with the tree-likeness of each dataset's annotation hierarchy, providing a principled indicator when hierarchy-aware geometry helps.

The proposed pipeline integrates a representation-flow convolutional neural network with a dynamics- and uncertainty-aware tree-based Gaussian Process classifier. In this framework, latent motion dynamics are exploited both as discriminative representations and as a source of input uncertainty, enhancing robustness against temporal variations and abnormal motion transitions. Compared with conventional deep learning approaches, the proposed strategy requires less training data and offers improved computational efficiency. To further improve classification performance, we introduce novel semantic-aware compound kernels that effectively capture semantic, flow, and dynamic information embedded in surgical video features. In addition, uncertainty-aware kernels are developed to strengthen the robustness and practical applicability of the compound kernel framework. The proposed method is evaluated on two benchmark datasets, namely the JIGSAWS and the Cataract-LMM (Capsulorhexis) datasets. Experimental results demonstrate strong performance across both datasets, including the LOSO and LOUO evaluation protocols on JIGSAWS, including the subject-independent LOUO protocol on JIGSAWS, on which the framework attains a mean accuracy of \ph{96.9}%; results under the within-subject LOSO protocol are reported for comparability with prior work, achieving competitive accuracy while substantially reducing computational cost. Overall, the proposed pipeline provides an efficient and accurate framework for video-based surgical skill assessment.

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.

Learning reliable surgical manipulation policies is bottlenecked by the scarcity of action-labeled demonstrations: teleoperated surgical robot (e.g., dVRK) trajectories with synchronized kinematics are costly to collect, while surgical tasks demand precise contact handling, long-horizon reasoning, and bimanual coordination. Endoscopic video is comparatively inexpensive and abundant relative to synchronized video--kinematics trajectories, and a natural way to exploit it is to learn world models of surgical scenes. However, existing surgical world models use video primarily for simulation or policy evaluation, and rarely translate the learned dynamics into closed-loop control. This gap raises our central question: under a fixed budget of action-labeled demonstrations, does action-free video pretraining improve closed-loop surgical manipulation? To answer it, we introduce the Surgical World-Action Model (Surgical WAM), a unified generative model built on Cosmos Policy that jointly predicts future endoscopic observations and executable surgical robot action chunks. Surgical WAM first learns surgical visual dynamics from action-free video and is then fine-tuned on the fixed action-labeled budget; at deployment, it acts as a closed-loop, receding-horizon controller that executes a short prefix of each predicted action chunk and replans from the resulting observation. On a suite of four simulated surgical manipulation tasks, video pretraining improves the average success rate from 63.5% to 77.8%, including an absolute gain of 20 percentage points on PegTransfer, with the largest improvements on contact-rich and bimanual tasks. These results demonstrate that action-free video provides transferable visual dynamics priors for learning surgical robot control with limited action supervision, positioning data-efficient video pretraining as a practical path toward scaling up surgical robot learning.

Hysteroscopic surgical scene segmentation plays a pivotal role in understanding the hysteroscopic intraoperative environment as well as computer-assisted intervention. However, this task presents unique challenges due to the high morphological similarity among different lesions and the presence of artifacts such as specular reflections, motion blur, and fluid occlusions in surgical videos. In this work, we propose the first vision-language model (VLM)-based hysteroscopic surgical scene segmentation method, which performs pixel-wise localization for fifteen representative categories in hysteroscopic surgical scenes. Our VLM-hyster has a segmentation backbone that utilizes the pretrained image encoder for robust visual feature extraction, coupled with a transformer-based decoder for dense prediction. Moreover, we design category-specific text prompts and incorporate a masked distillation branch to filter out visual features with low correlation to the text prompts, enabling the model to focus more effectively on category-specific image regions and thereby enhancing segmentation performance. We collect a large multicentric hysteroscopic surgical scene dataset, containing 4,020 high-resolution images with detailed mask annotations, for model training and evaluation. Experimental results demonstrate that VLM-hyster substantially outperforms state-of-the-art AI models. Furthermore, extensive assessments by gynecologists, as well as multicentre and prospective validations, demonstrate VLM-hyster's robustness and generalizability. The results suggest that VLM-hyster earns considerable potential in enabling AI-assisted localization of surgical instruments and lesions in hysteroscopic surgeries. Code is available at https://github.com/viscom-tongji/VLM-hyster.

Reliable surgical planning requires models that move beyond recognizing the current surgical step or imitating expert demonstrations, and instead anticipate how instrument motion reshapes subsequent operative states. Most surgical video understanding methods focus on recognizing phases, actions, or workflow states, while providing limited support for explicitly modeling instrument motion. Conversely, existing tool motion prediction methods can forecast instrument trajectories, but they generally do not capture the coupled evolution of future surgical video states. World models offer a natural framework for jointly modeling visual state transitions and instrument motion dynamics. However, existing surgical world model studies remain largely centered on visual generation quality, relying on generation-oriented metrics such as FVD and CD-FVD. These metrics are poorly aligned with instrument motion planning, as they do not directly measure whether predicted trajectories are geometrically accurate, temporally coherent, or actionable for downstream planning. This limitation is partly structural, since the field lacks public datasets and standardized evaluation protocols that provide the benchmarking infrastructure needed to assess motion-centric capabilities in surgical world models. In this paper, we introduce SurgWMBench, a vision-based benchmark for short-horizon surgical motion planning and dynamics prediction. Given intraoperative image sequences and historical instrument trajectory, SurgWMBench evaluates both near-future instrument motion prediction and stability under continuous rollout or input perturbations.

Controllable surgical world models can provide a generative foundation for surgical artificial intelligence and simulation by synthesizing realistic instrument--tissue interactions. However, existing methods lack a unified multimodal control paradigm, while direct fusion of heterogeneous visual conditions often causes anatomical distortion, instrument appearance drift, and temporally inconsistent interactions. In this work, we propose {Surg-UniWorld}, a unified surgical world model with multimodal control experts. Surg-UniWorld first constructs a {Hierarchical Surgical Anchor} from first-frame appearance and hierarchical semantic masks to preserve persistent scene identity, anatomical organization, and interaction boundaries. {Anchor-Relative Modality Experts} then interpret edge, depth, and optical-flow evidence relative to the shared anchor, capturing complementary boundary, geometric, and motion information. A {Multimodal Control Expert} further performs contribution-preserving stage-wise composition of the activated modality increments and generates control hints for the Wan2.2 video diffusion backbone. To support multimodal surgical world modeling, we further construct Cholec80-SurgWAM, a benchmark for controllable surgical video generation. Extensive experiments demonstrate that Surg-UniWorld consistently outperforms existing controllable video generation methods and surgical world-model baselines in generation quality, temporal consistency, and multimodal controllability.

Surgical procedures unfold as structured and recurring clinical events, whose real-time understanding via intraoperative surgical videos is critical for intraoperative decision-making and support. However, existing video understanding methods force a trade-off: autoregressive video-language models support comprehensive reasoning but are not practical for time-sensitive clinical applications, whereas contrastive models offer low latency but struggle with complex scene understanding. Recently, generative retrieval has been explored for general-domain video understanding, but transferring it to surgery is not trivial because near-identical visual appearances may indicate semantically distinct events, and the terminology involved is highly surgery-specific. To this end, we propose SurgNarrator, a new generative retrieval framework tailored for surgical video understanding. We construct a well-curated surgery-centric vocabulary from surgical captions to define a clinically meaningful retrieval space. We then adapt the pre-trained Qwen3-VL-Embedding-8B to learn discriminative clinical representations with a temporally-aware contrastive objective. During inference, a hierarchical, procedure-aware retrieval strategy narrows the search space to the relevant procedure type, delivering fast and effective responses. Our method is comprehensively evaluated on twelve benchmarks in a zero-shot setting and achieves consistent performance gains over state-of-the-art baselines, while reducing output-stage latency by more than two orders of magnitude compared with the generative baseline.

Visual world models typically learn future dynamics from a single observation stream, limiting their ability to model cooperative systems with multiple independently moving observers. We investigate this challenge in Mother--Child endoscopic retrograde cholangiopancreatography (ERCP), where two flexible scopes provide complementary yet role-dependent views without a calibrated stereo relationship. Unlike conventional multi-view fusion that assumes symmetric information exchange, we formulate \textbf{role-asymmetric dual-scope future prediction}, where cross-view evidence is selectively transferred according to the prediction target and its underlying spatial requirements. We propose \textbf{CrossScope}, a dual-stream surgical world model that preserves view-specific experts while enabling target-specific evidence routing through geometry-guided residual interactions. CrossScope learns two complementary communication directions: geometric motion cues from the Mother view guide Child-view future dynamics, while pose-aligned Child appearance supports Mother-view prediction only when valid spatial correspondence is established. This design allows each scope to contribute task-relevant evidence without compromising its view-specific representation. To evaluate this problem, we establish a paired dual-scope benchmark comprising synchronized phantom and real-world ERCP episodes, with evaluations assessing visual fidelity, structural preservation, target localization, and motion consistency. Experiments demonstrate that CrossScope consistently outperforms strong surgical video generation baselines, validating the importance of role-aware evidence routing for multi-observer visual world modeling.

Artificial Intelligence is increasingly applied to surgical video analysis for phase segmentation, skill assessment, and workflow optimization. A key challenge is the length of surgical recordings, often one to several hours, creating substantial computational burden. We previously developed Kinematics-Adaptive Frame Recognition (KAFR) for robotic surgery, showing that tracking tool motion effectively identifies informative frames while filtering redundant content. However, laparoscopic surgery introduces additional challenges: manual camera control causes frequent motion artifacts, and image quality is generally lower than robotic systems. This study evaluates whether KAFR generalizes to laparoscopic surgery using the Cholec80 benchmark, comprising 80 laparoscopic cholecystectomy procedures annotated for seven surgical phases. KAFR operates in three stages: a fine-tuned YOLO model detects and segments surgical tools; frames are adaptively selected based on tool displacement or velocity variation; and an X3D model classifies selected frames into surgical phases. KAFR achieved a 91.0% F1 score using only 0.58% of frames for phase classification, representing an approximately seven-fold reduction compared to typical 4% frame sampling, while maintaining performance comparable to LoViT (90.2%) and Trans-SVNet (89.7%). These results demonstrate that kinematics-based frame selection transfers effectively to the challenging laparoscopic environment.

Surgical video phase recognition is a fundamental task in computer-assisted intervention, supporting workflow understanding, intraoperative guidance, and surgical quality assessment. Although recent visual-temporal models have achieved promising progress, accurate and temporally coherent phase recognition remains challenging due to local visual ambiguity, transient prediction noise, and insufficient use of procedural semantics. To address these challenges, we propose HTT-Net, a Hierarchical Text-guided Transition modeling Network for surgical video phase recognition. The key idea is to introduce structured surgical semantic knowledge into phase-aware segment construction and semantic refinement. Specifically, we construct a hierarchical surgical semantic memory with intra-phase descriptions, inter-phase transition descriptions, and fine-grained semantic units. Based on this memory, the proposed Transition-Aware Segment Construction (TAS-Con) organizes frame-level evidence into coherent segment representations and handles boundary clips with inter-phase transition descriptions. Furthermore, we introduce Transition-Aware Segment Calibration (TAS-Calib), which calibrates phase-aware segment representations through hierarchical surgical semantics and improves discrimination under visual ambiguity without dense frame-level vision-language fusion. Experiments on Cholec80 and LCRS-100 demonstrate the effectiveness of HTT-Net for robust surgical video phase recognition.

Surgical video understanding is fundamental to navigation systems. Endoscopic perception is often hindered by a limited field-of-view and frequent instrument occlusions, making spatio-temporal context essential for robust inference. These challenges have motivated video models that aggregate information across frames. However, existing video models typically store past observations implicitly in learned feature representations, often requiring task-specific video training, substantial annotated data, and increased computational cost. We propose Stitch-Inferencer, a real-time, model-agnostic inference framework that replaces implicit feature memory with an explicit image-space panoramic canvas. By stitching valid observations across frames, Stitch-Inferencer preserves previously observed pixels in an online, instrument-free view, expanding the effective field-of-view and providing direct access to regions that are temporarily occluded or absent from the current frame. Downstream segmentation or tracking models are applied to a compact region of interest on the panorama, and their predictions are reprojected to the current frame, enabling existing models to exploit long-range context without retraining. Experiments on anatomy segmentation and point/box tracking demonstrate consistent improvements across diverse baselines while preserving real-time throughput. The stitching module alone runs at over 60 FPS, providing a practical inference-time solution to enhance endoscopic perception in computationally constrained intraoperative environments. Source code will be made publicly available.

Precise spatial-temporal annotation of laparoscopic videos is time-consuming and requires expert knowledge. We propose a human-in-the-loop knowledge acquisition framework that combines active learning with dual-loss optimization to significantly reduce the annotation effort needed for automatic localization and segmentation of objects in the surgical field. Our method employs a foundation model to generate temporally consistent class activation maps (CAMs) from video using two complementary training objectives: a weak supervision loss on video-level tool presence labels for weakly annotated data, and an image-level mask loss on human-corrected annotations obtained through active learning. Rather than requiring dense pixel-level annotation upfront, our pipeline iteratively proposes pseudo-masks that guide the expert annotator to refine the knowledge previously captured by the model. We demonstrate that our framework reduces the effort of surgical video annotation by 50% by the end of training in comparison to fully manual annotation. Through eliminating the need for large, fully annotated datasets from the start, this framework enables scalability to the development of surgical tool segmentation models. This iterative human-in-the-loop refinement supports efficient knowledge acquisition with minimal expert input, providing a practical and deployable strategy for expanding tool segmentation to larger, more diverse datasets and real-world clinical settings.

Surgical vision-language foundation models typically adopt educational materials, such as surgical lecture videos, to transfer surgical knowledge encoded in language into visual representations. These knowledge are multi-dimensional and hierarchical: fine-grained action cues appear in narration, mid-level key steps are summarized in subsection headings, and global procedural context, such as patient history and surgical strategy, is described in abstract texts. Prior work largely collapses these heterogeneous signals into a single flat embedding space, implicitly assuming independence across hierarchy levels. However, this is suboptimal because it ignores cross-level semantic containment, e.g., actions belong to steps, steps compose phases, weakens long-range dependency modeling. To this end, we propose a hyperbolic surgical video-language pre-training framework that explicitly preserves the hierarchical structure by mitigating structural false negatives induced by procedural context and enforcing semantic consistency between parent phases and their constituent child steps. Extensive experiments on multiple surgical benchmarks show consistent gains in zero- and few-shot phase recognition across procedures and institutions.

Vision foundation models such as SAM 3 can provide transferable object-level structure across diverse surgical video conditions, but segmentation outputs do not explicitly encode the action-conditioned semantics that define functional surgical landmarks. Estimating instrument extent and geometry differs from localizing the tip or anchor relevant to clipping, grasping, or dissecting. We investigate vision foundation model-enabled sparse action-aware landmark localization, using zero-shot, point-prompted structural masks to provide dense instrument-level context without manual pixel-level mask annotations. We propose a lightweight refinement framework that uses SAM 3 as a structural prior. A coarse multi-frame network predicts tip and anchor prompts, generating non-oracle masks that are fused with visual and heatmap features to refine functional landmark predictions. We compare direct mask-augmented supervision, prediction-derived mask-prior refinement, and auxiliary mask supervision to examine how vision foundation model-derived structure should enter a precision-oriented localization system. Experiments on 7,867 clips from 60 surgical videos spanning YouTube, Cholec80, HeiChole, SurgVU, and CRCD evaluate the approach under heterogeneous conditions. Without manual pixel-level mask annotations for training, the proposed model achieves overall F1 scores of 72.4% for tip and 58.0% for anchor localization. Directly imposing masks on heatmap targets biases learning toward broad tool regions, whereas prediction-derived priors and auxiliary supervision provide effective intermediate structural guidance for action-dependent landmark prediction.

We introduce SurgAtlas, the largest surgical video-language dataset to date, comprising 15,291 videos (2,391 hours) spanning 18 surgical specialties and over 5,000 procedure types, sourced entirely from publicly available YouTube content. SurgAtlas is also the first surgical video-language dataset to include open surgery at scale, with 6,182 open procedure videos alongside over 9,000 minimally invasive recordings, and the first to establish standardized benchmarks for open-surgery video understanding. We additionally provide an expert-validated subset with verified visual question-answer pairs across diverse open and minimally invasive procedures, serving as a clinically grounded benchmark for surgical reasoning. Compared with existing surgical video-language datasets, SurgAtlas provides one of the most diverse annotation schemas, combining segment-level captions, step- and phase-level descriptions, video-level surgical descriptions, and reasoning-oriented question-answer pairs organized within a hierarchical taxonomy. These annotations are constructed through an automated multi-tier pipeline with LLM-based enrichment and a staged VQA generation framework with explicit groundedness verification. The scale and diversity of SurgAtlas enable training surgical foundation models with broad procedural coverage: we finetune Qwen3-VL-8B through a two-stage captioning-then-instruction pipeline and achieve competitive or state-of-the-art results on multiple established surgical benchmarks, including phase recognition, triplet detection, and reasoning question answering. More broadly, SurgAtlas provides a large native public video corpus that can support future large-scale pretraining of multimodal surgical AI systems and contribute to the development of next-generation foundation models for surgery. Dataset publicly available at https://huggingface.co/datasets/filbel/SurgAtlas

Intraoperative Adverse Events (IAEs) detection is critical for improving surgical safety, with bleeding being among the most frequent events across many surgery types. Existing methods struggle to distinguish bleeding IAE from visually similar residual blood due to limited temporal reasoning. Moreover, modeling long surgical videos while preserving fine-grained temporal dynamics remains computationally challenging. We propose DBT-Bleed, a dual-branch multi-scale temporal modeling framework disentangling bleeding and normal representations using layer-wise temporal adapters for short- and long-term bleeding progression. To efficiently process long surgical videos without sacrificing fine-grained temporal information, we introduce HiRED, a Hierarchical Entropy-Driven frame selection strategy that retains temporally informative segments while removing redundancy. Experiments on the MultiBypass dataset demonstrate gains of 6.53% in F1, 5.62% in Recall and 9% in MCC values for bleeding IAE detection, consistently outperforming video-level baselines. Additionally, we evaluate cross-procedure generalization on a newly curated dataset from a different surgical procedure type, where DBT-Bleed demonstrates robust transferability by achieving gain of 6% in F1 and 8% in MCC under zero-shot setting. To support this evaluation, we introduce EndoPit-IAE, an Endonasal Pituitary Surgery dataset annotated for IAEs, representing the first IAE-annotated dataset in neurosurgery. Code will be made publicly available upon acceptance.

Accurate recognition of anatomical structures is essential for safe and effective minimally invasive surgery (MIS), yet it remains underexplored in surgical computer vision due to limited annotated data and methods tailored primarily to natural scenes. In this work, we present a combined dataset and model framework to advance anatomy-aware perception in MIS. First, we introduce ATLAS-120k, a large-scale clip-level semantic segmentation dataset comprising over 120,000 annotated frames from 100 surgical videos spanning 14 procedures and multiple modalities, including laparoscopic and robot-assisted surgery. The dataset captures substantial procedural variability and was created using a scalable annotation pipeline that integrates expert manual labeling, automated propagation, iterative refinement, and surgeon verification to ensure high-quality annotations. Second, we propose ATLAS (Anatomy Recognition with Context Learning using Foundation Representations), a video semantic segmentation model specifically designed for surgical anatomy recognition. Unlike conventional approaches that emphasize object tracking, ATLAS leverages foundation-model embeddings together with lightweight temporal reasoning to incorporate contextual cues such as procedure type, surgical phase, and short-term visual memory. This design enables temporally consistent and accurate predictions while maintaining real-time feasibility. Together, the dataset and model establish a practical foundation for robust surgical scene understanding and support the development of clinically applicable guidance systems for minimally invasive surgery. The models, dataset annotations and annotation platform are publicly available at: https://github.com/TimJaspers0801/ATLAS.

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.

Text-to-video retrieval in operating rooms (OR) is an enabling technology for OR safety, as it allows stakeholders to retrieve and inspect recordings of specific events. However, because the most safety-critical events may not follow the common structure, to unlock its full potential text-to-video retrieval must be able to handle implicit queries that require reasoning to identify the right video (e.g., the step right before clipping). However, existing methods rely on global embeddings that cannot reason over such queries. We propose OR3, a text-to-video retrieval method that converts clips into action-driven digital twins (ActDTs), grouping concurrent subject-action-object triplets under non-overlapping temporal intervals. Moreover, rather than cross-modal matching through paired encoders, OR3 performs imagination-based retrieval where an LLM generates hypothetical ActDTs from queries. This enables intra-modal matching via a single encoder trained with ActDT-tailored hard negatives. Finally, evidence-grounded refinement revises imagined ActDTs based on discrepancies with top candidates to capture procedure-specific patterns. We construct a benchmark from MM-OR with 276 implicit queries across four reasoning categories over 386 clips from robotic knee procedures. OR3 achieves 57.6 R@1 and 77.3 R@5, outperforming the strongest baseline. These results demonstrate that OR3 enables fine-grained discrimination between visually similar OR video clips through temporal action reasoning.

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.

Visual Question Answering (VQA) in robotic surgery, referred to as surgical VQA, requires high-level understanding of complex surgical scenes and the integration of visual perception with language reasoning, with the potential to support surgical training and intraoperative decision-making. Recent Vision-Language Models (VLMs) have shown promising performance through parameter-efficient fine-tuning; however, most existing approaches rely on coarse visual grounding, typically limited to bounding boxes, which fails to capture the fine-grained spatial structure of surgical objects. In this work, we propose a unified framework that jointly performs pixel-level segmentation and visual question answering within a single framework. Our approach integrates a VLM with a Segment Anything Model (SAM)-based decoder and represents scene elements as object tokens generated by the VLM. These object tokens guide answer prediction and are further projected to the SAM-based decoder to produce segmentation masks. By optimizing the object token embeddings through both segmentation and question answering objectives, the model learns spatially grounded representations that enhance visual reasoning while providing explicit pixel-level grounding. We evaluate the proposed method on the private RAMIE (Robot-Assisted Minimally Invasive Esophagectomy) dataset and the public EndoVis18 dataset, where it consistently outperforms baseline methods for surgical VQA. These results demonstrate that incorporating context-aware object tokens into vision-language models improves fine-grained surgical scene understanding.

Detecting anatomical structures in surgical video is essential for intraoperative safety frameworks such as the Critical View of Myopectineal Orifice (CVMPO) in inguinal hernia repair. While prominent structures like the Cooper's Ligament and Triangle of Doom are reliably detected by standard methods, smaller structures such as the epigastric vessels remain challenging due to their visual ambiguity and intermittent visibility. We observe that the spatial relationship between structures is anatomically constrained, and propose a Gaussian Spatial Prior (GSP) module that encodes this relationship as a compact, parametric bias injected into the self-attention of a DAB-DETR decoder. The prior is computed offline from training annotations as a small set of frozen Gaussian parameters and recomputed at each decoder layer using the iteratively refined reference points. On a dataset of inguinal hernia repair videos with 5-fold cross-validation, GSP improves dependent class detection by $+33.5\%$ ($\text{AP}_{50}$) over DAB-DETR and $+53.9\%$ over YOLOv26, while also improving anchor detection by $+6.0\%$. These gains are statistically significant across all folds ($p=0.012$, paired $t-$test).

Verbal feedback delivered by attending surgeons in the operating room plays a critical formative role in resident trainee skill acquisition. Yet, assessing the quality of trainer feedback and its effectiveness in influencing trainee behavior during live surgery remains a challenge. Prior studies assessed feedback content relying on extensive manual annotation by expert human raters and focused on developing broad taxonomies that overlook the qualitative aspects of feedback delivery such as clarity or urgency. Limited existing automated methods, including keyword analysis and topic modeling, also fail to capture these nuanced aspects. We introduce a two-stage LLM-based framework that discovers interpretable feedback quality criteria grounded in the context of surgical training. Our method uses multi-agent prompting and surgical domain knowledge injection to discover a small set of human interpretable scoring criteria (e.g., Encouraging, Urgent, Clear). These criteria are then used to automatically score live surgical feedback via an LLM-as-a-judge approach. Evaluation on 4.2k trainer feedback instances demonstrates that our AI-discovered criteria outperform prior content-based frameworks in predicting feedback effectiveness, including observed trainee behavioral adjustments and trainer approval. This work advances scalable, human-aligned assessment of communication quality in the operating room and provides a foundation for improving surgical teaching practices.

Understanding surgical workflow in real time is fundamental for intelligent surgical embodiment, where AI systems continuously perceive and respond as surgery proceeds. In the operating room, critical decisions depend on subtle, moment-to-moment changes, such as fine instrument movements and evolving tissue states, where even slight perceptual delays can limit assistance or compromise safety. Yet existing methods remain offline or operate at coarse temporal scales, generating descriptions only after processing clips, preventing immediate reaction. We address this by proposing SurgOnAir, a streaming vision-language model that processes frames sequentially without future access and progressively generates narration tokens as visual input arrives. SurgOnAir achieves fine-grained frame-to-token generation, enabling instant responsiveness to evolving surgical dynamics. Built upon our curated hierarchical dataset SurgOnAir-11k spanning action-, step-, and phase-level supervision, the model is trained to produce multi-level textual responses that reflect the inherent hierarchy of surgical procedures. Furthermore, special transition tokens are generated to explicitly mark state changes, allowing SurgOnAir to capture and signal key workflow transitions as they occur. Experiments show that SurgOnAir enables real-time understanding through a single vision-language model that unifies streaming across multiple hierarchies of the surgical workflow, generating superior and hierarchy-aware narrations. Code and dataset will be public.

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.

Accurate polyp segmentation in colonoscopy is essential for early colorectal cancer detection, yet real-world clinical environments pose persistent challenges such as motion blur, specular reflections, and illumination instability. Most existing methods are optimized on clean benchmark images and suffer noticeable performance degradation when deployed in authentic surgical scenarios. We propose DepthPolyp, a lightweight and robust segmentation framework based on pseudo-depth-guided multi-task learning and efficient feature modulation. The architecture combines hierarchical Ghost factorization for compact feature generation, Interleaved Shuffle Fusion for low-cost cross-scale interaction, and Dynamic Group Gating for adaptive group-wise feature weighting. Extensive experiments demonstrate that DepthPolyp achieves strong cross-dataset generalization when trained on degraded data and evaluated on both clean and noisy target domains, consistently outperforming lightweight baselines and remaining competitive with substantially larger models. In real surgical video evaluation on PolypGen, DepthPolyp achieves better segmentation performance than models up to $20\times$ larger while preserving real-time inference speed. With only 3.57M parameters and 0.86 GMACs, the proposed method runs at over 180 FPS on mobile devices, making it well suited for real-time deployment in resource-constrained clinical environments. Code and pretrained weights are available at: https://github.com/ReaganWu/DepthPolyp/

Online surgical phase recognition (SPR) underpins context-aware operating-room systems and requires committing to a prediction at every frame from past context alone. Surgical video poses three demands that natural-video recognizers do not jointly address: procedures span tens of thousands of frames, time flows non-uniformly as long routine stretches are punctuated by brief phase-defining transitions, and the visual domain is narrow so backbone features are strongly correlated across channels. Existing recognizers either let per-frame cost grow with elapsed length, or hold cost bounded but advance state at a uniform rate with channel-independent dynamics, leaving the latter two demands unaddressed. We present SurgicalMamba, a causal SPR model built on Mamba2's structured state-space duality (SSD) that holds per-frame cost at O(d). It introduces three SSD-compatible components that jointly address these demands: a dual-path SSD block that separates long- and short-term regimes at the level of recurrent state; intensity-modulated stepping, a continuous-time time-warp that adapts the slow path's effective rate to phase-relevant information; and state regramming, a per-chunk Cayley rotation that opens cross-channel mixing in the otherwise axis-aligned SSM recurrence. The learned rotation planes inherit a phase-aligned structure without any direct supervision, offering an interpretable internal signature of surgical workflow. Across seven public SPR benchmarks, SurgicalMamba reaches state-of-the-art accuracy and phase-level Jaccard under strict online evaluation: 94.6%/82.7% on Cholec80 (+0.7 pp/+2.2 pp over the strongest prior) and 89.5%/68.9% on AutoLaparo (+1.7 pp/+2.0 pp), at 238.74 fps on a single GPU. Ablations isolate the contribution of each component. The code is publicly available at https://github.com/sukjuoh/Surgical-Mamba.

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.

Automated, clinician-grade assessment reports for surgical procedures could reduce documentation burden and provide objective feedback, yet remain challenging due to the difficulty of aligning dense spatio-temporal video representations with language-based reasoning and the scarcity of high-quality, privacy-preserving datasets. To address this gap, we establish a benchmark comprising 214 high-quality simulated surgical videos paired with surgeon-authored evaluation reports. Building on this resource, we propose a Perception-Alignment-Reasoning framework for surgical video report generation, featuring Hi-GaTA, a novel lightweight temporal adapter that efficiently compresses long video sequences into compact, LLM-compatible visual prefix tokens through short-to-long-range temporal aggregation. For robust visual perception, we pretrain Sur40k, a surgical-specific ViViT-style video encoder on 40,000 minutes of public surgical videos to capture fine-grained spatio-temporal procedural priors. Hi-GaTA employs a temporal pyramid with text-conditioned dual cross-attention, and improves multi-scale consistency through cross-level gated fusion and an increasing-depth strategy. Finally, we fine-tune the LLM backbone using LoRA to enable coherent and stylistically consistent surgical report generation under limited supervision. Experiments show our approach achieves the best overall performance, with consistent gains over strong Multimodal Large Language Model (MLLM) baselines. Ablation studies further validate the effectiveness of each proposed component.

Real-time video streaming is crucial in surgical teleoperation, yet reproducible evaluation under realistic network impairments remains limited. This paper presents VISTA, a benchmark designed to study how impairments along the forward video path affect received video quality, temporal continuity, and human task performance. VISTA employs Linux Traffic Control with NetEm and a Gilbert-Elliott loss model to emulate five network conditions: Hospital LAN, 5G Urban, 4G Rural, LEO Satellite, and GEO Satellite. The benchmark integrates a standardised peg transfer task with synchronized measurements of network quality of service (QoS), objective video quality (PSNR, SSIM, and VMAF), and temporal continuity through freeze rate, while maintaining a stable reverse control channel. Across 375 experimental trials, network degradation substantially reduced teleoperation performance: success rate decreased from 97% in Hospital LAN to 79% in 5G Urban, 35% in 4G Rural, 71% in LEO Satellite, and 12% in GEO Satellite, while mean task completion time for successful trials increased from 80 s in Hospital LAN to 117 s in 5G Urban, 211 s in 4G Rural, 152 s in LEO Satellite, and 255 s in GEO Satellite. These findings show that network impairments have a direct impact on task completion and success in surgical teleoperation, and provide a reproducible basis for evaluating teleoperation video under realistic network constraints. Source code available at https://github.com/Dzxx623/VISTA.

Action-conditioned surgical video generation is a critical yet highly challenging problem for robotic surgery. The core difficulty is that low-dimensional control vectors must precisely govern complex image-space evolution. In this work, we propose a kinematic-to-visual lifting paradigm that converts articulated kinematics into a unified set of five image-aligned control modalities. Building on this representation, we introduce a hierarchically routed visual control framework that selectively activates the most relevant control modalities and motion scales. Instead of uniformly applying all control signals, our model performs hierarchical routing to dynamically allocate conditioning capacity. We further design kinematic-prior-guided routing loss functions to ensure physically meaningful, temporally stable, and efficient expert utilization. To improve efficiency, we propose a budgeted training and inference scheme that leverages routing-induced sparsity. By selectively discarding low-significance control pathways during training and execution, our approach enables adaptive computation that is complementary to standard distillation. We additionally construct a new benchmark with curated articulated annotations, obtained through human-in-the-loop semantic labeling and differentiable pose tracking, providing realistic supervision for action-conditioned surgical video generation. Extensive experiments demonstrate that our method consistently improves action faithfulness, visual fidelity, and cross-domain generalization over diverse baselines. Moreover, our efficient variant achieves substantial reductions in latency while maintaining strong control accuracy.

High-fidelity surgical video generation can greatly improve medical training and the development of AI, adapting these generative models for precise video editing remains a formidable challenge. Modifying surgical attributes, such as instrument tissue interactions or procedural phases is challenging due to the strict anatomical and temporal constraints. In this paper, we propose OphEdit, a novel training-free framework for the text-guided editing of ophthalmic surgical videos. Our approach leverages a deterministic second-order ODE inversion pipeline to capture Attention Value (V) tensors from the original video. By selectively injecting these stored tensors into the conditional Classifier-Free Guidance (CFG) branch during the denoising phase, OphEdit rigorously preserves the intricate anatomical geometry of the eye while seamlessly mapping text-driven semantic modifications onto the video stream. Clinical evaluations demonstrates that OphEdit effectively handles complex surgical transformations, such as instrument swaps and procedural variations, with superior structural fidelity and temporal consistency compared to natural-domain video editors. Our work represents the first application of training-free video editing in the ophthalmic surgical domain, offering a scalable solution for generating diverse, annotated medical datasets without the need for exhaustive manual recording or costly model fine-tuning. The code and prompts can be accessed at https://github.com/ophedit/OphEdit

Purpose: Vision-language models (VLMs) have shown promising performance in surgical visual question answering (VQA). However, existing surgical VQA datasets often contain linguistic shortcuts, where question phrasing implicitly constrains the answer space. It remains unclear whether reported performance reflects visual understanding or reliance on such linguistic shortcuts. Methods: We introduce SurgCheck, a diagnostic benchmark for quantifying linguistic shortcut reliance in surgical VQA. SurgCheck employs a paired-question design in which each surgical frame is associated with an original question containing entity names and a less-biased counterpart that removes these names while preserving identical visual content and ground-truth answers. The resulting performance gap provides a diagnostic signal of shortcut reliance. To ensure that the less-biased question remains well-defined even without entity names, four grounding cues are incorporated: bounding box, arrow, spatial position, and periphrasis. We evaluate both general-purpose and surgical-specific VLMs under zero-shot and fine-tuned settings on SurgCheck. To evaluate open-ended zero-shot responses, we introduce an LLM-as-a-judge evaluation protocol. Results: Using SurgCheck, we observe consistent performance degradation on less-biased questions across five VLMs, despite identical visual inputs. Text-only ablation reveals minimal performance drops for action and target prediction, indicating that action and target prediction is largely driven by linguistic shortcuts rather than visual reasoning. Conclusion: SurgCheck provides a controlled diagnostic framework that exposes failure modes masked by linguistic bias in existing surgical VQA benchmarks. Our findings demonstrate that strong benchmark performance does not necessarily imply faithful visual understanding, underscoring the need for bias-aware evaluation in surgical VQA.

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.

Surgical video understanding is a crucial prerequisite for advancing Computer-Assisted Surgery. While vision-language models (VLMs) have recently been applied to the surgical domain, existing surgical vision-language datasets lack in capturing and evaluating complex, interleaved spatial-temporal dynamics. Creating large scale datasets that accurately represent fine-grained spatial-temporal relationships in surgical videos is challenging due to costly manual annotations or error-prone generation using large language models. To address this gap, we introduce the SurgSTU-Pipeline, a deterministic generation pipeline featuring temporal and spatial continuity filtering to reliably create surgical datasets for fine-grained spatial-temporal multimodal understanding. Applying this pipeline to publicly available surgical datasets, we create the SurgSTU dataset, comprising 6711 video clips densely extended with 150k fine-grained spatial-temporal question-answer samples. Our comprehensive evaluation shows that while state-of-the-art generalist VLMs struggle in zero-shot settings, their spatial-temporal capabilities can be improved through in-context learning. A fine-tuned VLM on the SurgSTU training dataset achieves highest performance among all spatial-temporal tasks, validating the dataset's efficacy to improve spatial-temporal understanding of VLMs in surgical videos. The project is available here: https://lennart-maack.github.io/SurgSTU-project

Surgical procedures are inherently complex and risky, requiring extensive expertise and constant focus to navigate evolving intraoperative scenes. Computer-assisted systems such as surgical visual question answering (VQA) offer promises for education and intraoperative support. Current surgical VQA research largely focuses on static frame analysis, overlooking rich temporal semantics. Surgical video question answering is further challenged by low visual contrast, its highly knowledge-driven nature, diverse analytical needs spanning scattered temporal windows, and the hierarchy from basic perception to high-level intraoperative assessment. To address these challenges, we propose SurgTEMP, a multimodal LLM framework featuring (i) a query-guided token selection module that builds hierarchical visual memory (spatial and temporal memory banks) and (ii) a Surgical Competency Progression (SCP) training scheme. Together, they enable effective modeling of variable-length surgical videos while preserving procedure-relevant cues and temporal coherence, and better support diverse downstream assessment tasks. To support model development, we introduce CholeVidQA-32K, a surgical video question answering dataset comprising 32K open-ended QA pairs and 3,855 video segments (approximately 128 h total) from laparoscopic cholecystectomy. The dataset is organized into a three-level hierarchy -- Perception, Assessment, and Reasoning -- spanning 11 tasks from instrument/action/anatomy perception to Critical View of Safety (CVS), intraoperative difficulty, skill proficiency, and adverse event assessment. In comprehensive evaluations against state-of-the-art open-source multimodal and video LLMs (fine-tuned and zero-shot), SurgTEMP achieves substantial performance improvements, advancing the state of video-based surgical VQA. The project page is available at: https://camma-public.github.io/SurgTEMP/

Recent Artificial Intelligence (AI) models have matched or exceeded human experts in several benchmarks of biomedical task performance, but surgical benchmarks in particular are often missing from prominent medical benchmark suites. Since surgery requires integrating disparate tasks, generally-capable AI models could be particularly attractive as a collaborative tool if performance could be improved. On the one hand, the canonical approach of scaling architecture size and training data is attractive, especially since there are millions of hours of surgical video data generated per year. On the other hand, preparing surgical data for AI training requires significantly higher levels of professional expertise, and training on that data requires expensive computational resources. These trade-offs paint an uncertain picture of whether and to-what-extent modern AI could aid surgical practice. In this paper, we explore this question through a case study of surgical tool detection using state-of-the-art AI methods available in 2026. We demonstrate that even with multi-billion parameter models and extensive training, current Vision Language Models fall short in the seemingly simple task of tool detection in neurosurgery. Additionally, we show scaling experiments indicating that increasing model size and training time only leads to diminishing improvements in relevant performance metrics. Thus, our experiments suggest that current models could still face significant obstacles in surgical use cases. Moreover, some obstacles cannot be simply ``scaled away'' with additional compute and persist across diverse model architectures, raising the question of whether data and label availability are the only limiting factors. We discuss the main contributors to these constraints and advance potential solutions.

Early screening via colonoscopy is critical for colon cancer prevention, yet developing robust AI systems for this domain is hindered by the lack of densely annotated, long-sequence video datasets. Existing datasets predominantly focus on single-class polyp detection and lack the rich spatial, temporal, and linguistic annotations required to evaluate modern Multimodal Large Language Models (MLLMs). To address this critical gap, we introduce Colon-Bench, generated via a novel multi-stage agentic workflow. Our pipeline seamlessly integrates temporal proposals, bounding-box tracking, AI-driven visual confirmation, and human-in-the-loop review to scalably annotate full-procedure videos. The resulting verified benchmark is unprecedented in scope, encompassing 528 videos, 14 distinct lesion categories (including polyps, ulcers, and bleeding), over 300,000 bounding boxes, 213,000 segmentation masks, and 133,000 words of clinical descriptions. We utilize Colon-Bench to rigorously evaluate state-of-the-art MLLMs across lesion classification, Open-Vocabulary Video Object Segmentation (OV-VOS), and video Visual Question Answering (VQA). The MLLM results demonstrate surprisingly high localization performance in medical domains compared to SAM-3. Finally, we analyze common VQA errors from MLLMs to introduce a novel "colon-skill" prompting strategy, improving zero-shot MLLM performance by up to 9.7% across most MLLMs. The dataset and the code are available at https://abdullahamdi.com/colon-bench .

Accurate and efficient tracking of surgical instruments is fundamental for Robot-Assisted Minimally Invasive Surgery. Although vision-based robot pose estimation has enabled markerless calibration without tedious physical setups, reliable tool tracking for surgical robots still remains challenging due to partial visibility and specialized articulation design of surgical instruments. Previous works in the field are usually prone to unreliable feature detections under degraded visual quality and data scarcity, whereas rendering-based methods often struggle with computational costs and suboptimal convergence. In this work, we incorporate CMA-ES, an evolutionary optimization strategy, into a versatile tracking pipeline that jointly estimates surgical instrument pose and joint configurations. Using batch rendering to efficiently evaluate multiple pose candidates in parallel, the method significantly reduces inference time and improves convergence robustness. The proposed framework further generalizes to joint angle-free and bi-manual tracking settings, making it suitable for both vision feedback control and online surgery video calibration. Extensive experiments on synthetic and real-world datasets demonstrate that the proposed method significantly outperforms prior approaches in both accuracy and runtime. Source code and data are available at https://github.com/hanyang-hu/online_dvrk_tracking.

While foundation models have advanced surgical video analysis, current approaches rely predominantly on pixel-level reconstruction objectives that waste model capacity on low-level visual details, such as smoke, specular reflections, and fluid motion, rather than semantic structures essential for surgical understanding. We present SurgMotion, a video-native foundation model that shifts the learning paradigm from pixel-level reconstruction to latent motion prediction. Built on the Video Joint Embedding Predictive Architecture (V-JEPA), SurgMotion introduces three key technical innovations tailored to surgical videos: (1) motion-guided latent masked prediction to prioritize semantically meaningful regions, (2) spatiotemporal affinity self-distillation to enforce relational consistency, and (3) spatiotemporal feature diversity regularization (SFDR) to prevent representation collapse in texture-sparse surgical scenes. To enable large-scale pretraining, we curate SurgMotion-15M, the largest surgical video dataset to date, comprising 3,658 hours of video from 50 sources across 13 anatomical regions. Extensive experiments across 17 benchmarks demonstrate that SurgMotion significantly outperforms state-of-the-art methods on surgical workflow recognition, achieving 14.6 percent improvement in F1 score on EgoSurgery and 10.3 percent on PitVis; on action triplet recognition with 39.54 percent mAP-IVT on CholecT50; as well as on skill assessment, polyp segmentation, and depth estimation. These results establish SurgMotion as a new standard for universal, motion-oriented surgical video understanding.

Surgical future prediction, driven by real-time AI analysis of surgical video, is critical for operating room safety and efficiency. It provides actionable insights into upcoming events, their timing, and risks-enabling better resource allocation, timely instrument readiness, and early warnings for complications (e.g., bleeding, bile duct injury). Despite this need, current surgical AI research focuses on understanding what is happening rather than predicting future events. Existing methods target specific tasks in isolation, lacking unified approaches that span both short-term (action triplets, events) and long-term horizons (remaining surgery duration, phase transitions). These methods rely on coarse-grained supervision while fine-grained surgical action triplets and steps remain underexplored. Furthermore, methods based only on future feature prediction struggle to generalize across different surgical contexts and procedures. We address these limits by reframing surgical future prediction as state-change learning. Rather than forecasting raw observations, our approach classifies state transitions between current and future timesteps. We introduce SurgFUTR, implementing this through a teacher-student architecture. Video clips are compressed into state representations via Sinkhorn-Knopp clustering; the teacher network learns from both current and future clips, while the student network predicts future states from current videos alone, guided by our Action Dynamics (ActDyn) module. We establish SFPBench with five prediction tasks spanning short-term (triplets, events) and long-term (remaining surgery duration, phase and step transitions) horizons. Experiments across four datasets and three procedures show consistent improvements. Cross-procedure transfer validates generalizability.

Developing generalizable surgical AI requires multi-institutional data, yet privacy constraints preclude direct data sharing, making Federated Learning (FL) a natural candidate. Its application to complex, spatiotemporal surgical video remains largely unbenchmarked. We present the FedSurg Challenge, the first international initiative dedicated to FL in surgical vision, as a proof-of-concept evaluation using a multi-center dataset of laparoscopic appendectomies (subset of Appendix300). Three participant submissions were evaluated on generalization to an unseen clinical center and center-specific local adaptation, alongside centralized, Swarm Learning, parameter-efficient fine-tuning baselines, and reference classifiers. Our analysis identifies temporal modeling as the architectural factor most consistently associated with generalization to the unseen center, although effects vary across metrics. Classifier collapse arises from both the global model's failure to transfer under domain shift and unconstrained fine-tuning on small, imbalanced local datasets, motivating structured personalized FL for center-specific adaptation. Absolute performance remains far from clinical viability: even with all data pooled centrally, the task reached a 26.31% F1-score on the unseen center. Paired permutation tests resolve only large differences, and no adaptation comparison reaches significance at this sample size. By characterizing these limitations, this work establishes a methodological reference point for privacy-preserving surgical video AI.

Innovations in digital intelligence are transforming robotic surgery with more informed decision-making. Real-time awareness of surgical instrument presence and actions (e.g., cutting tissue) is essential for such systems. Yet, despite decades of research, most machine learning models for this task are trained on small datasets and still struggle to generalize. Recently, vision-Language Models (VLMs) have brought transformative advances in reasoning across visual and textual modalities. Their unprecedented generalization capabilities suggest great potential for advancing intelligent robotic surgery. However, surgical VLMs remain under-explored, and existing models show limited performance, highlighting the need for benchmark studies to assess their capabilities and limitations and to inform future development. To this end, we benchmark the zero-shot performance of several advanced VLMs on two public robotic-assisted laparoscopic datasets for instrument and action classification. Beyond standard evaluation, we integrate explainable AI to visualize VLM attention and uncover causal explanations behind their predictions. This provides a previously underexplored perspective in this field for evaluating the reliability of model predictions. We also propose several explainability analysis-based metrics to complement standard evaluations. Our analysis reveals that surgical VLMs, despite domain-specific training, often rely on weak contextual cues rather than clinically relevant visual evidence, highlighting the need for stronger visual and reasoning supervision in surgical applications.

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 .