SurgCheck: Do Vision-Language Models Really Look at Images in Surgical VQA?

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.

A generalizable foundation model for intraoperative understanding across surgical procedures

In minimally invasive surgery, clinical decisions depend on real-time visual interpretation, yet intraoperative perception varies substantially across surgeons and procedures. This variability limits consistent assessment, training, and the development of reliable artificial intelligence systems, as most surgical AI models are designed for narrowly defined tasks and do not generalize across procedures or institutions. Here we introduce ZEN, a generalizable foundation model for intraoperative surgical video understanding trained on more than 4 million frames from over 21 procedures using a self-supervised multi-teacher distillation framework. We curated a large and diverse dataset and systematically evaluated multiple representation learning strategies within a unified benchmark. Across 20 downstream tasks and full fine-tuning, frozen-backbone, few-shot and zero-shot settings, ZEN consistently outperforms existing surgical foundation models and demonstrates robust cross-procedure generalization. These results suggest a step toward unified representations for surgical scene understanding and support future applications in intraoperative assistance and surgical training assessment.

CurConMix+: A Unified Spatio-Temporal Framework for Hierarchical Surgical Workflow Understanding

Surgical action triplet recognition aims to understand fine-grained surgical behaviors by modeling the interactions among instruments, actions, and anatomical targets. Despite its clinical importance for workflow analysis and skill assessment, progress has been hindered by severe class imbalance, subtle visual variations, and the semantic interdependence among triplet components. Existing approaches often address only a subset of these challenges rather than tackling them jointly, which limits their ability to form a holistic understanding. This study builds upon CurConMix, a spatial representation framework. At its core, a curriculum-guided contrastive learning strategy learns discriminative and progressively correlated features, further enhanced by structured hard-pair sampling and feature-level mixup. Its temporal extension, CurConMix+, integrates a Multi-Resolution Temporal Transformer (MRTT) that achieves robust, context-aware understanding by adaptively fusing multi-scale temporal features and dynamically balancing spatio-temporal cues. Furthermore, we introduce LLS48, a new, hierarchically annotated benchmark for complex laparoscopic left lateral sectionectomy, providing step-, task-, and action-level annotations. Extensive experiments on CholecT45 and LLS48 demonstrate that CurConMix+ not only outperforms state-of-the-art approaches in triplet recognition, but also exhibits strong cross-level generalization, as its fine-grained features effectively transfer to higher-level phase and step recognition tasks. Together, the framework and dataset provide a unified foundation for hierarchy-aware, reproducible, and interpretable surgical workflow understanding. The code and dataset will be publicly released on GitHub to facilitate reproducibility and further research.