Slot2Text: Object-Centric Visual Tokenization for Efficient and Spatially Traceable Surgical MLLMs

Multimodal large language models (MLLM) for surgical scene understanding typically inject hundreds of dense visual tokens into a language model, leading to costly inference and limited spatial traceability for generated answers. We present Slot2Text, a dual-mode surgical MLLM that replaces dense representations of visual input with a compact set of regions encoded as slot latents. Instead of relying on contrastive alignment of the visual encoder with language, Slot2Text groups self-supervised vision features into a few regions--slots that are consumed by the language model as area-labeled visual tokens. Slot2Text-Fast uses the slot prefix to answer surgical questions. Slot2Text-Reason also identifies and locates areas relevant for reasoning, linking language outputs to corresponding slot tokens, masks or regions. Experiments on multiple visual question answering and visual grounding benchmarks show that Slot2Text-Fast is competitive with state-of-the-art baseline at a much lower cost, reducing the average total token consumption by a 91.8\% and the visual prefix from 1,295 to 47 tokens (a 96.4\% reduction). Slot2Text-Reason trades additional tokens and latency for explicit area identities, locations, and traceable spatial evidence. These results establish compact slot latents as an efficient default visual interface for surgical MLLMs, with grounded reasoning invoked when greater spatial traceability is required.

Active Learning for Efficient Annotation of Surgical Videos with Weak Supervision

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.

Future Slot Prediction for Unsupervised Object Discovery in Surgical Video

Object-centric slot attention is an emerging paradigm for unsupervised learning of structured, interpretable object-centric representations (slots). This enables effective reasoning about objects and events at a low computational cost and is thus applicable to critical healthcare applications, such as real-time interpretation of surgical video. The heterogeneous scenes in real-world applications like surgery are, however, difficult to parse into a meaningful set of slots. Current approaches with an adaptive slot count perform well on images, but their performance on surgical videos is low. To address this challenge, we propose a dynamic temporal slot transformer (DTST) module that is trained both for temporal reasoning and for predicting the optimal future slot initialization. The model achieves state-of-the-art performance on multiple surgical databases, demonstrating that unsupervised object-centric methods can be applied to real-world data and become part of the common arsenal in healthcare applications.

Disentangling spatio-temporal knowledge for weakly supervised object detection and segmentation in surgical video

Weakly supervised video object segmentation (WSVOS) enables the identification of segmentation maps without requiring an extensive training dataset of object masks, relying instead on coarse video labels indicating object presence. Current state-of-the-art methods either require multiple independent stages of processing that employ motion cues or, in the case of end-to-end trainable networks, lack in segmentation accuracy, in part due to the difficulty of learning segmentation maps from videos with transient object presence. This limits the application of WSVOS for semantic annotation of surgical videos where multiple surgical tools frequently move in and out of the field of view, a problem that is more difficult than typically encountered in WSVOS. This paper introduces Video Spatio-Temporal Disentanglement Networks (VDST-Net), a framework to disentangle spatiotemporal information using semi-decoupled knowledge distillation to predict high-quality class activation maps (CAMs). A teacher network designed to resolve temporal conflicts when specifics about object location and timing in the video are not provided works with a student network that integrates information over time by leveraging temporal dependencies. We demonstrate the efficacy of our framework on a public reference dataset and on a more challenging surgical video dataset where objects are, on average, present in less than 60\% of annotated frames. Our method outperforms state-of-the-art techniques and generates superior segmentation masks under video-level weak supervision.