Artificial Intelligence for Workflow Analysis in Colorectal Surgery: A Multicentric, Cross-Procedural Development and Generalization Study

Minimally invasive colorectal surgeries (MIS-CRS) are characterised by significant variability and inconsistent outcomes. ColoWorkflow, a tool for the video-based assessment (VBA) of MIS-CRS workflow, was recently validated. However, manual VBA is time-consuming, limiting implementation. This study presents AI-ColoWorkflow, a deep learning model for automated surgical workflow analysis across MIS-CRS. Operative videos of MIS-CRS were collected from 4 centres and a publicly available dataset. Phases and steps were manually annotated according to ColoWorkflow. A deep learning model combining a fine-tuned DINOv3 vision transformer for per-frame visual feature extraction with a hierarchical multi-stage temporal convolutional network was jointly optimized for phase and step recognition. The model trained on pooled multicentric data, namely AI-ColoWorkflow was compared against centre-specific and procedure-specific models on a held-out test set. The following metrics were used for evaluation: macro F1 score, balanced accuracy, precision, and recall. AI-ColoWorkflow achieved a macro F1 of 73.01% $\pm$ 10.27 (balanced accuracy 73.43%) for phase recognition and 39.82% $\pm$ 7.06 (balanced accuracy 38.65%) for step recognition. The global model outperformed centre- and procedure-specific models in most experiments except procedure-specific step recognition. In the generalization analysis, mean F1 was 48.42% for phase recognition. AI-ColoWorkflow can reliably recognize MIS-CRS phases. A single model trained on pooled, multicentric, multi-procedural data generalises at least as well as and often better than centre- or procedure-specific models for phase recognition in MIS-CRS, while procedure-specific step models retain advantages for certain procedure types, motivating hybrid training strategies for future surgical AI development.

SPIRIT: Spatio-temporal Pairwise Relational Modeling of Instrument-Tissue Interactions for Surgical Action Triplet Recognition

Fine-grained understanding of surgical activity is essential for context-aware assistance in the operating room, including safety monitoring, adverse event identification, and skill assessment. Surgical action triplets, defined as tuples of the form <instrument, verb, target>, provide a structured description of instrument-tissue interactions. A key open problem, however, is how to learn triplet representations that remain reliable across institutions, where surgical video varies in acquisition conditions, surgeon style, tool usage, and tissue handling, while existing triplet datasets do not support explicit evaluation of center-wise transfer. To address this problem, we propose \textbf{SPIRIT}, a structured framework for surgical action triplet recognition designed to learn interaction representations that transfer more reliably across centers. Instead of treating each triplet as a flat class label, SPIRIT first learns spatio-temporal representations for instruments, verbs, and targets, then models their pairwise relations, and finally composes them into coherent triplet predictions, with multi-head distillation used to stabilize learning. To evaluate this setting, we establish \textbf{MultiBypass-4C-T40}, a multi-centric dataset for dense surgical action triplet recognition in Roux-en-Y gastric bypass across four geographically distinct centers, with auxiliary phase and step annotations. Across multiple evaluation protocols, SPIRIT consistently outperforms strong recent baselines, highlighting the value of explicit relational reasoning for multi-centric triplet recognition. Code will be available at https://github.com/CAMMA-public/multibypass-4c-t40.

GEN-Guard: Correcting Generalization Failures for Deployable Federated Surgical AI

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.

Federated Learning for Surgical Vision in Appendicitis Classification: Results of the FedSurg EndoVis 2024 Challenge

Purpose: The FedSurg challenge was designed to benchmark the state of the art in federated learning for surgical video classification. Its goal was to assess how well current methods generalize to unseen clinical centers and adapt through local fine-tuning while enabling collaborative model development without sharing patient data. Methods: Participants developed strategies to classify inflammation stages in appendicitis using a preliminary version of the multi-center Appendix300 video dataset. The challenge evaluated two tasks: generalization to an unseen center and center-specific adaptation after fine-tuning. Submitted approaches included foundation models with linear probing, metric learning with triplet loss, and various FL aggregation schemes (FedAvg, FedMedian, FedSAM). Performance was assessed using F1-score and Expected Cost, with ranking robustness evaluated via bootstrapping and statistical testing. Results: In the generalization task, performance across centers was limited. In the adaptation task, all teams improved after fine-tuning, though ranking stability was low. The ViViT-based submission achieved the strongest overall performance. The challenge highlighted limitations in generalization, sensitivity to class imbalance, and difficulties in hyperparameter tuning in decentralized training, while spatiotemporal modeling and context-aware preprocessing emerged as promising strategies. Conclusion: The FedSurg Challenge establishes the first benchmark for evaluating FL strategies in surgical video classification. Findings highlight the trade-off between local personalization and global robustness, and underscore the importance of architecture choice, preprocessing, and loss design. This benchmarking offers a reference point for future development of imbalance-aware, adaptive, and robust FL methods in clinical surgical AI.

Clinnova Federated Learning Proof of Concept: Key Takeaways from a Cross-border Collaboration

Clinnova, a collaborative initiative involving France, Germany, Switzerland, and Luxembourg, is dedicated to unlocking the power of precision medicine through data federation, standardization, and interoperability. This European Greater Region initiative seeks to create an interoperable European standard using artificial intelligence (AI) and data science to enhance healthcare outcomes and efficiency. Key components include multidisciplinary research centers, a federated biobanking strategy, a digital health innovation platform, and a federated AI strategy. It targets inflammatory bowel disease, rheumatoid diseases, and multiple sclerosis (MS), emphasizing data quality to develop AI algorithms for personalized treatment and translational research. The IHU Strasbourg (Institute of Minimal-invasive Surgery) has the lead in this initiative to develop the federated learning (FL) proof of concept (POC) that will serve as a foundation for advancing AI in healthcare. At its core, Clinnova-MS aims to enhance MS patient care by using FL to develop more accurate models that detect disease progression, guide interventions, and validate digital biomarkers across multiple sites. This technical report presents insights and key takeaways from the first cross-border federated POC on MS segmentation of MRI images within the Clinnova framework. While our work marks a significant milestone in advancing MS segmentation through cross-border collaboration, it also underscores the importance of addressing technical, logistical, and ethical considerations to realize the full potential of FL in healthcare settings.