Surgical workflow analysis is essential in robot-assisted surgeries, yet the long duration of such procedures poses significant challenges for comprehensive video analysis. Recent approaches have predominantly relied on transformer models; however, their quadratic attention mechanism restricts efficient processing of lengthy surgical videos. In this paper, we propose a novel hierarchical input-dependent state space model that leverages the linear scaling property of state space models to enable decision making on full-length videos while capturing both local and global dynamics. Our framework incorporates a temporally consistent visual feature extractor, which appends a state space model head to a visual feature extractor to propagate temporal information. The proposed model consists of two key modules: a local-aggregation state space model block that effectively captures intricate local dynamics, and a global-relation state space model block that models temporal dependencies across the entire video. The model is trained using a hybrid discrete-continuous supervision strategy, where both signals of discrete phase labels and continuous phase progresses are propagated through the network. Experiments have shown that our method outperforms the current state-of-the-art methods by a large margin (+2.8% on Cholec80, +4.3% on MICCAI2016, and +12.9% on Heichole datasets). Code will be publicly available after paper acceptance.
The complexity and diversity of surgical workflows, driven by heterogeneous operating room settings, institutional protocols, and anatomical variability, present a significant challenge in developing generalizable models for cross-institutional and cross-procedural surgical understanding. While recent surgical foundation models pretrained on large-scale vision-language data offer promising transferability, their zero-shot performance remains constrained by domain shifts, limiting their utility in unseen surgical environments. To address this, we introduce Surgical Phase Anywhere (SPA), a lightweight framework for versatile surgical workflow understanding that adapts foundation models to institutional settings with minimal annotation. SPA leverages few-shot spatial adaptation to align multi-modal embeddings with institution-specific surgical scenes and phases. It also ensures temporal consistency through diffusion modeling, which encodes task-graph priors derived from institutional procedure protocols. Finally, SPA employs dynamic test-time adaptation, exploiting the mutual agreement between multi-modal phase prediction streams to adapt the model to a given test video in a self-supervised manner, enhancing the reliability under test-time distribution shifts. SPA is a lightweight adaptation framework, allowing hospitals to rapidly customize phase recognition models by defining phases in natural language text, annotating a few images with the phase labels, and providing a task graph defining phase transitions. The experimental results show that the SPA framework achieves state-of-the-art performance in few-shot surgical phase recognition across multiple institutions and procedures, even outperforming full-shot models with 32-shot labeled data. Code is available at https://github.com/CAMMA-public/SPA
Online surgical phase recognition has drawn great attention most recently due to its potential downstream applications closely related to human life and health. Despite deep models have made significant advances in capturing the discriminative long-term dependency of surgical videos to achieve improved recognition, they rarely account for exploring and modeling the uncertainty in surgical videos, which should be crucial for reliable online surgical phase recognition. We categorize the sources of uncertainty into two types, frame ambiguity in videos and unbalanced distribution among surgical phases, which are inevitable in surgical videos. To address this pivot issue, we introduce a meta-learning-optimized classification diffusion model (Meta-SurDiff), to take full advantage of the deep generative model and meta-learning in achieving precise frame-level distribution estimation for reliable online surgical phase recognition. For coarse recognition caused by ambiguous video frames, we employ a classification diffusion model to assess the confidence of recognition results at a finer-grained frame-level instance. For coarse recognition caused by unbalanced phase distribution, we use a meta-learning based objective to learn the diffusion model, thus enhancing the robustness of classification boundaries for different surgical phases.We establish effectiveness of Meta-SurDiff in online surgical phase recognition through extensive experiments on five widely used datasets using more than four practical metrics. The datasets include Cholec80, AutoLaparo, M2Cai16, OphNet, and NurViD, where OphNet comes from ophthalmic surgeries, NurViD is the daily care dataset, while the others come from laparoscopic surgeries. We will release the code upon acceptance.
Surgical phase recognition from video is a technology that automatically classifies the progress of a surgical procedure and has a wide range of potential applications, including real-time surgical support, optimization of medical resources, training and skill assessment, and safety improvement. Recent advances in surgical phase recognition technology have focused primarily on Transform-based methods, although methods that extract spatial features from individual frames using a CNN and video features from the resulting time series of spatial features using time series modeling have shown high performance. However, there remains a paucity of research on training methods for CNNs employed for feature extraction or representation learning in surgical phase recognition. In this study, we propose a method for representation learning in surgical workflow analysis using a vision-language model (ReSW-VL). Our proposed method involves fine-tuning the image encoder of a CLIP (Convolutional Language Image Model) vision-language model using prompt learning for surgical phase recognition. The experimental results on three surgical phase recognition datasets demonstrate the effectiveness of the proposed method in comparison to conventional methods.
Endoscopic video-based tasks, such as visual navigation and surgical phase recognition, play a crucial role in minimally invasive surgeries by providing real-time assistance. While recent video foundation models have shown promise, their applications are hindered by (1) computational inefficiencies and (2) suboptimal performance caused by limited data for pre-training in endoscopy. To address these issues, we present EndoMamba, a foundation model designed for real-time inference while learning generalized spatiotemporal representations. First, to mitigate computational inefficiencies, we propose the EndoMamba backbone, optimized for real-time inference. Inspired by recent advancements in state space models, EndoMamba integrates Bidirectional Mamba blocks for spatial modeling within individual frames and vanilla Mamba blocks for past-to-present reasoning across the temporal domain. This design enables both strong spatiotemporal modeling and efficient inference in online video streams. Second, we propose a self-supervised hierarchical pre-training diagram to enhance EndoMamba's representation learning using endoscopic videos and incorporating general video domain knowledge. Specifically, our approach combines masked reconstruction with auxiliary supervision, leveraging low-level reconstruction to capture spatial-temporal structures and high-level alignment to transfer broader knowledge from a pretrained general-video domain foundation model. Extensive experiments on four downstream tasks--classification, segmentation, surgical phase recognition, and localization--demonstrate that EndoMamba outperforms existing foundation models and task-specific methods while maintaining real-time inference speed. The source code is available at https://github.com/TianCuteQY/EndoMamba.
Purpose: In this study, we investigate the training of foundation models using federated learning to address data-sharing limitations and enable collaborative model training without data transfer for minimally invasive surgery. Methods: Inspired by the EndoViT study, we adapt the Masked Autoencoder for federated learning, enhancing it with adaptive Sharpness-Aware Minimization (FedSAM) and Stochastic Weight Averaging (SWA). Our model is pretrained on the Endo700k dataset collection and later fine-tuned and evaluated for tasks such as Semantic Segmentation, Action Triplet Recognition, and Surgical Phase Recognition. Results: Our findings demonstrate that integrating adaptive FedSAM into the federated MAE approach improves pretraining, leading to a reduction in reconstruction loss per patch. The application of FL-EndoViT in surgical downstream tasks results in performance comparable to CEN-EndoViT. Furthermore, FL-EndoViT exhibits advantages over CEN-EndoViT in surgical scene segmentation when data is limited and in action triplet recognition when large datasets are used. Conclusion: These findings highlight the potential of federated learning for privacy-preserving training of surgical foundation models, offering a robust and generalizable solution for surgical data science. Effective collaboration requires adapting federated learning methods, such as the integration of FedSAM, which can accommodate the inherent data heterogeneity across institutions. In future, exploring FL in video-based models may enhance these capabilities by incorporating spatiotemporal dynamics crucial for real-world surgical environments.
Purpose: Automated Surgical Phase Recognition (SPR) uses Artificial Intelligence (AI) to segment the surgical workflow into its key events, functioning as a building block for efficient video review, surgical education as well as skill assessment. Previous research has focused on short and linear surgical procedures and has not explored if temporal context influences experts' ability to better classify surgical phases. This research addresses these gaps, focusing on Robot-Assisted Partial Nephrectomy (RAPN) as a highly non-linear procedure. Methods: Urologists of varying expertise were grouped and tasked to indicate the surgical phase for RAPN on both single frames and video snippets using a custom-made web platform. Participants reported their confidence levels and the visual landmarks used in their decision-making. AI architectures without and with temporal context as trained and benchmarked on the Cholec80 dataset were subsequently trained on this RAPN dataset. Results: Video snippets and presence of specific visual landmarks improved phase classification accuracy across all groups. Surgeons displayed high confidence in their classifications and outperformed novices, who struggled discriminating phases. The performance of the AI models is comparable to the surgeons in the survey, with improvements when temporal context was incorporated in both cases. Conclusion: SPR is an inherently complex task for expert surgeons and computer vision, where both perform equally well when given the same context. Performance increases when temporal information is provided. Surgical tools and organs form the key landmarks for human interpretation and are expected to shape the future of automated SPR.
While vision-language models like CLIP have advanced zero-shot surgical phase recognition, they struggle with fine-grained surgical activities, especially action triplets. This limitation arises because current CLIP formulations rely on global image features, which overlook the fine-grained semantics and contextual details crucial for complex tasks like zero-shot triplet recognition. Furthermore, these models do not explore the hierarchical structure inherent in triplets, reducing their ability to generalize to novel triplets. To address these challenges, we propose fine-CLIP, which learns object-centric features and lever- ages the hierarchy in triplet formulation. Our approach integrates three components: hierarchical prompt modeling to capture shared semantics, LoRA-based vision backbone adaptation for enhanced feature extraction, and a graph-based condensation strategy that groups similar patch features into meaningful object clusters. Since triplet classification is a challenging task, we introduce an alternative yet meaningful base-to-novel generalization benchmark with two settings on the CholecT50 dataset: Unseen-Target, assessing adaptability to triplets with novel anatomical structures, and Unseen-Instrument-Verb, where models need to generalize to novel instrument-verb interactions. fine-CLIP shows significant improvements in F1 and mAP, enhancing zero-shot recognition of novel surgical triplets.
Advancements in computer-assisted surgical procedures heavily rely on accurate visual data interpretation from camera systems used during surgeries. Traditional open-access datasets focusing on surgical procedures are often limited by their small size, typically consisting of fewer than 100 videos with less than 100K images. To address these constraints, a new dataset called Surg-3M has been compiled using a novel aggregation pipeline that collects high-resolution videos from online sources. Featuring an extensive collection of over 4K surgical videos and more than 3 million high-quality images from multiple procedure types, Surg-3M offers a comprehensive resource surpassing existing alternatives in size and scope, including two novel tasks. To demonstrate the effectiveness of this dataset, we present SurgFM, a self-supervised foundation model pretrained on Surg-3M that achieves impressive results in downstream tasks such as surgical phase recognition, action recognition, and tool presence detection. Combining key components from ConvNeXt, DINO, and an innovative augmented distillation method, SurgFM exhibits exceptional performance compared to specialist architectures across various benchmarks. Our experimental results show that SurgFM outperforms state-of-the-art models in multiple downstream tasks, including significant gains in surgical phase recognition (+8.9pp, +4.7pp, and +3.9pp of Jaccard in AutoLaparo, M2CAI16, and Cholec80), action recognition (+3.1pp of mAP in CholecT50) and tool presence detection (+4.6pp of mAP in Cholec80). Moreover, even when using only half of the data, SurgFM outperforms state-of-the-art models in AutoLaparo and achieves state-of-the-art performance in Cholec80. Both Surg-3M and SurgFM have significant potential to accelerate progress towards developing autonomous robotic surgery systems.
Surgical phase recognition from video enables various downstream applications. Transformer-based sliding window approaches have set the state-of-the-art by capturing rich spatial-temporal features. However, while transformers can theoretically handle arbitrary-length sequences, in practice they are limited by memory and compute constraints, resulting in fixed context windows that struggle with maintaining temporal consistency across lengthy surgical procedures. This often leads to fragmented predictions and limited procedure-level understanding. To address these challenges, we propose Memory of Surgery (MoS), a framework that enriches temporal modeling by incorporating both semantic interpretable long-term surgical history and short-term impressions. MoSFormer, our enhanced transformer architecture, integrates MoS using a carefully designed encoding and fusion mechanism. We further introduce step filtering to refine history representation and develop a memory caching pipeline to improve training and inference stability, mitigating shortcut learning and overfitting. MoSFormer demonstrates state-of-the-art performance on multiple benchmarks. On the Challenging BernBypass70 benchmark, it attains 88.0 video-level accuracy and phase-level metrics of 70.7 precision, 68.7 recall, and 66.3 F1 score, outperforming its baseline with 2.1 video-level accuracy and phase-level metrics of 4.6 precision, 3.6 recall, and 3.8 F1 score. Further studies confirms the individual and combined benefits of long-term and short-term memory components through ablation and counterfactual inference. Qualitative results shows improved temporal consistency. The augmented temporal context enables procedure-level understanding, paving the way for more comprehensive surgical video analysis.
This study aims to advance surgical phase recognition in arthroscopic procedures, specifically Anterior Cruciate Ligament (ACL) reconstruction, by introducing the first arthroscopy dataset and developing a novel transformer-based model. We aim to establish a benchmark for arthroscopic surgical phase recognition by leveraging spatio-temporal features to address the specific challenges of arthroscopic videos including limited field of view, occlusions, and visual distortions. We developed the ACL27 dataset, comprising 27 videos of ACL surgeries, each labeled with surgical phases. Our model employs a transformer-based architecture, utilizing temporal-aware frame-wise feature extraction through a ResNet-50 and transformer layers. This approach integrates spatio-temporal features and introduces a Surgical Progress Index (SPI) to quantify surgery progression. The model's performance was evaluated using accuracy, precision, recall, and Jaccard Index on the ACL27 and Cholec80 datasets. The proposed model achieved an overall accuracy of 72.91% on the ACL27 dataset. On the Cholec80 dataset, the model achieved a comparable performance with the state-of-the-art methods with an accuracy of 92.4%. The SPI demonstrated an output error of 10.6% and 9.86% on ACL27 and Cholec80 datasets respectively, indicating reliable surgery progression estimation. This study introduces a significant advancement in surgical phase recognition for arthroscopy, providing a comprehensive dataset and a robust transformer-based model. The results validate the model's effectiveness and generalizability, highlighting its potential to improve surgical training, real-time assistance, and operational efficiency in orthopedic surgery. The publicly available dataset and code will facilitate future research and development in this critical field.
Accurate surgical phase recognition is crucial for advancing computer-assisted interventions, yet the scarcity of labeled data hinders training reliable deep learning models. Semi-supervised learning (SSL), particularly with pseudo-labeling, shows promise over fully supervised methods but often lacks reliable pseudo-label assessment mechanisms. To address this gap, we propose a novel SSL framework, Dual Invariance Self-Training (DIST), that incorporates both Temporal and Transformation Invariance to enhance surgical phase recognition. Our two-step self-training process dynamically selects reliable pseudo-labels, ensuring robust pseudo-supervision. Our approach mitigates the risk of noisy pseudo-labels, steering decision boundaries toward true data distribution and improving generalization to unseen data. Evaluations on Cataract and Cholec80 datasets show our method outperforms state-of-the-art SSL approaches, consistently surpassing both supervised and SSL baselines across various network architectures.
Robotic-assisted minimally invasive esophagectomy (RAMIE) is a recognized treatment for esophageal cancer, offering better patient outcomes compared to open surgery and traditional minimally invasive surgery. RAMIE is highly complex, spanning multiple anatomical areas and involving repetitive phases and non-sequential phase transitions. Our goal is to leverage deep learning for surgical phase recognition in RAMIE to provide intraoperative support to surgeons. To achieve this, we have developed a new surgical phase recognition dataset comprising 27 videos. Using this dataset, we conducted a comparative analysis of state-of-the-art surgical phase recognition models. To more effectively capture the temporal dynamics of this complex procedure, we developed a novel deep learning model featuring an encoder-decoder structure with causal hierarchical attention, which demonstrates superior performance compared to existing models.
Surgical phase recognition (SPR) is crucial for applications in workflow optimization, performance evaluation, and real-time intervention guidance. However, current deep learning models often struggle with fragmented predictions, failing to capture the sequential nature of surgical workflows. We propose the Neural Finite-State Machine (NFSM), a novel approach that enforces temporal coherence by integrating classical state-transition priors with modern neural networks. NFSM leverages learnable global state embeddings as unique phase identifiers and dynamic transition tables to model phase-to-phase progressions. Additionally, a future phase forecasting mechanism employs repeated frame padding to anticipate upcoming transitions. Implemented as a plug-and-play module, NFSM can be integrated into existing SPR pipelines without changing their core architectures. We demonstrate state-of-the-art performance across multiple benchmarks, including a significant improvement on the BernBypass70 dataset - raising video-level accuracy by 0.9 points and phase-level precision, recall, F1-score, and mAP by 3.8, 3.1, 3.3, and 4.1, respectively. Ablation studies confirm each component's effectiveness and the module's adaptability to various architectures. By unifying finite-state principles with deep learning, NFSM offers a robust path toward consistent, long-term surgical video analysis.
Purpose: Surgical phase recognition (SPR) is an integral component of surgical data science, enabling high-level surgical analysis. End-to-end trained neural networks that predict surgical phase directly from videos have shown excellent performance on benchmarks. However, these models struggle with robustness due to non-causal associations in the training set, resulting in poor generalizability. Our goal is to improve model robustness to variations in the surgical videos by leveraging the digital twin (DT) paradigm -- an intermediary layer to separate high-level analysis (SPR) from low-level processing (geometric understanding). This approach takes advantage of the recent vision foundation models that ensure reliable low-level scene understanding to craft DT-based scene representations that support various high-level tasks. Methods: We present a DT-based framework for SPR from videos. The framework employs vision foundation models to extract representations. We embed the representation in place of raw video inputs in the state-of-the-art Surgformer model. The framework is trained on the Cholec80 dataset and evaluated on out-of-distribution (OOD) and corrupted test samples. Results: Contrary to the vulnerability of the baseline model, our framework demonstrates strong robustness on both OOD and corrupted samples, with a video-level accuracy of 51.1 on the challenging CRCD dataset, 96.0 on an internal robotics training dataset, and 64.4 on a highly corrupted Cholec80 test set. Conclusion: Our findings lend support to the thesis that DT-based scene representations are effective in enhancing model robustness. Future work will seek to improve the feature informativeness, automate feature extraction, and incorporate interpretability for a more comprehensive framework.
Capitalizing on image-level pre-trained models for various downstream tasks has recently emerged with promising performance. However, the paradigm of "image pre-training followed by video fine-tuning" for high-dimensional video data inevitably poses significant performance bottlenecks. Furthermore, in the medical domain, many surgical video tasks encounter additional challenges posed by the limited availability of video data and the necessity for comprehensive spatial-temporal modeling. Recently, Parameter-Efficient Image-to-Video Transfer Learning has emerged as an efficient and effective paradigm for video action recognition tasks, which employs image-level pre-trained models with promising feature transferability and involves cross-modality temporal modeling with minimal fine-tuning. Nevertheless, the effectiveness and generalizability of this paradigm within intricate surgical domain remain unexplored. In this paper, we delve into a novel problem of efficiently adapting image-level pre-trained models to specialize in fine-grained surgical phase recognition, termed as Parameter-Efficient Image-to-Surgical-Video Transfer Learning. Firstly, we develop a parameter-efficient transfer learning benchmark SurgPETL for surgical phase recognition, and conduct extensive experiments with three advanced methods based on ViTs of two distinct scales pre-trained on five large-scale natural and medical datasets. Then, we introduce the Spatial-Temporal Adaptation module, integrating a standard spatial adapter with a novel temporal adapter to capture detailed spatial features and establish connections across temporal sequences for robust spatial-temporal modeling. Extensive experiments on three challenging datasets spanning various surgical procedures demonstrate the effectiveness of SurgPETL with STA.
Surgical phase recognition is critical for assisting surgeons in understanding surgical videos. Existing studies focused more on online surgical phase recognition, by leveraging preceding frames to predict the current frame. Despite great progress, they formulated the task as a series of frame-wise classification, which resulted in a lack of global context of the entire procedure and incoherent predictions. Moreover, besides online analysis, accurate offline surgical phase recognition is also in significant clinical need for retrospective analysis, and existing online algorithms do not fully analyze the entire video, thereby limiting accuracy in offline analysis. To overcome these challenges and enhance both online and offline inference capabilities, we propose a universal Surgical Phase Localization Network, named SurgPLAN++, with the principle of temporal detection. To ensure a global understanding of the surgical procedure, we devise a phase localization strategy for SurgPLAN++ to predict phase segments across the entire video through phase proposals. For online analysis, to generate high-quality phase proposals, SurgPLAN++ incorporates a data augmentation strategy to extend the streaming video into a pseudo-complete video through mirroring, center-duplication, and down-sampling. For offline analysis, SurgPLAN++ capitalizes on its global phase prediction framework to continuously refine preceding predictions during each online inference step, thereby significantly improving the accuracy of phase recognition. We perform extensive experiments to validate the effectiveness, and our SurgPLAN++ achieves remarkable performance in both online and offline modes, which outperforms state-of-the-art methods. The source code is available at https://github.com/lxj22/SurgPLAN-Plus.
Endoscopic Submucosal Dissection (ESD) is a minimally invasive procedure initially developed for early gastric cancer treatment and has expanded to address diverse gastrointestinal lesions. While computer-assisted surgery (CAS) systems enhance ESD precision and safety, their efficacy hinges on accurate real-time surgical phase recognition, a task complicated by ESD's inherent complexity, including heterogeneous lesion characteristics and dynamic tissue interactions. Existing video-based phase recognition algorithms, constrained by inefficient temporal context modeling, exhibit limited performance in capturing fine-grained phase transitions and long-range dependencies. To overcome these limitations, we propose SPRMamba, a novel framework integrating a Mamba-based architecture with a Scaled Residual TranMamba (SRTM) block to synergize long-term temporal modeling and localized detail extraction. SPRMamba further introduces the Hierarchical Sampling Strategy to optimize computational efficiency, enabling real-time processing critical for clinical deployment. Evaluated on the ESD385 dataset and the cholecystectomy benchmark Cholec80, SPRMamba achieves state-of-the-art performance (87.64% accuracy on ESD385, +1.0% over prior methods), demonstrating robust generalizability across surgical workflows. This advancement bridges the gap between computational efficiency and temporal sensitivity, offering a transformative tool for intraoperative guidance and skill assessment in ESD surgery. The code is accessible at https://github.com/Zxnyyyyy/SPRMamba.
Surgical phase recognition has become a crucial requirement in laparoscopic surgery, enabling various clinical applications like surgical risk forecasting. Current methods typically identify the surgical phase using individual frame-wise embeddings as the fundamental unit for time modeling. However, this approach is overly sensitive to current observations, often resulting in discontinuous and erroneous predictions within a complete surgical phase. In this paper, we propose DACAT, a novel dual-stream model that adaptively learns clip-aware context information to enhance the temporal relationship. In one stream, DACAT pretrains a frame encoder, caching all historical frame-wise features. In the other stream, DACAT fine-tunes a new frame encoder to extract the frame-wise feature at the current moment. Additionally, a max clip-response read-out (Max-R) module is introduced to bridge the two streams by using the current frame-wise feature to adaptively fetch the most relevant past clip from the feature cache. The clip-aware context feature is then encoded via cross-attention between the current frame and its fetched adaptive clip, and further utilized to enhance the time modeling for accurate online surgical phase recognition. The benchmark results on three public datasets, i.e., Cholec80, M2CAI16, and AutoLaparo, demonstrate the superiority of our proposed DACAT over existing state-of-the-art methods, with improvements in Jaccard scores of at least 4.5%, 4.6%, and 2.7%, respectively. Our code and models have been released at https://github.com/kk42yy/DACAT.
We introduce VidLPRO, a novel video-language (VL) pre-training framework designed specifically for robotic and laparoscopic surgery. While existing surgical VL models primarily rely on contrastive learning, we propose a more comprehensive approach to capture the intricate temporal dynamics and align video with language. VidLPRO integrates video-text contrastive learning, video-text matching, and masked language modeling objectives to learn rich VL representations. To support this framework, we present GenSurg+, a carefully curated dataset derived from GenSurgery, comprising 17k surgical video clips paired with captions generated by GPT-4 using transcripts extracted by the Whisper model. This dataset addresses the need for large-scale, high-quality VL data in the surgical domain. Extensive experiments on benchmark datasets, including Cholec80 and AutoLaparo, demonstrate the efficacy of our approach. VidLPRO achieves state-of-the-art performance in zero-shot surgical phase recognition, significantly outperforming existing surgical VL models such as SurgVLP and HecVL. Our model demonstrates improvements of up to 21.5\% in accuracy and 15.7% in F1 score, setting a new benchmark in the field. Notably, VidLPRO exhibits robust performance even with single-frame inference, while effectively scaling with increased temporal context. Ablation studies reveal the impact of frame sampling strategies on model performance and computational efficiency. These results underscore VidLPRO's potential as a foundation model for surgical video understanding.