# VLM-Guided Iterative Refinement for Surgical Image Segmentation with Foundation Models

arXiv: https://arxiv.org/abs/2602.09252 · HTML: https://mlsanity.com/paper/2602.09252/

## Key facts

- No citing papers in the map yet (data through 14 Oct 2026).
- Builds on 17 of its 20 references that are in the map.
- First posted on arXiv 9 Feb 2026.

## Builds on (most cited first, 17 of 17)

- [Learning Transferable Visual Models From Natural Language Supervision](https://mlsanity.com/paper/2103.00020/) (2021)
- [Segment Anything](https://mlsanity.com/paper/2304.02643/) (2023)
- [SAM 2: Segment Anything in Images and Videos](https://mlsanity.com/paper/2408.00714/) (2024)
- [Qwen-VL: A Versatile Vision-Language Model for Understanding, Localization, Text Reading, and Beyond](https://mlsanity.com/paper/2308.12966/) (2023)
- [Image Segmentation Using Text and Image Prompts](https://mlsanity.com/paper/2112.10003/) (2021)
- [CRIS: CLIP-Driven Referring Image Segmentation](https://mlsanity.com/paper/2111.15174/) (2021)
- [2017 Robotic Instrument Segmentation Challenge](https://mlsanity.com/paper/1902.06426/) (2019)
- [SurgicalSAM: Efficient Class Promptable Surgical Instrument Segmentation](https://mlsanity.com/paper/2308.08746/) (2023)
- [Automatic Instrument Segmentation in Robot-Assisted Surgery Using Deep Learning](https://mlsanity.com/paper/1803.01207/) (2018)
- [TernausNet: U-Net with VGG11 Encoder Pre-Trained on ImageNet for Image Segmentation](https://mlsanity.com/paper/1801.05746/) (2018)
- [ISINet: An Instance-Based Approach for Surgical Instrument Segmentation](https://mlsanity.com/paper/2007.05533/) (2020)
- [Incorporating Temporal Prior from Motion Flow for Instrument Segmentation in Minimally Invasive Surgery Video](https://mlsanity.com/paper/1907.07899/) (2019)
- [TraSeTR: Track-to-Segment Transformer with Contrastive Query for Instance-level Instrument Segmentation in Robotic Surgery](https://mlsanity.com/paper/2202.08453/) (2022)
- [AdaptiveSAM: Towards Efficient Tuning of SAM for Surgical Scene Segmentation](https://mlsanity.com/paper/2308.03726/) (2023)
- [Text Promptable Surgical Instrument Segmentation with Vision-Language Models](https://mlsanity.com/paper/2306.09244/) (2023)
- [Deep Interactive Segmentation of Medical Images: A Systematic Review and Taxonomy](https://mlsanity.com/paper/2311.13964/) (2023)
- [MedUHIP: Towards Human-In-the-Loop Medical Segmentation](https://mlsanity.com/paper/2408.01620/) (2024)

## Abstract (arXiv)

Surgical image segmentation is essential for robot-assisted surgery and intraoperative guidance. However, existing methods are constrained to predefined categories, produce one-shot predictions without adaptive refinement, and lack mechanisms for clinician interaction. We propose IR-SIS, an iterative refinement system for surgical image segmentation that accepts natural language descriptions. IR-SIS leverages a fine-tuned SAM3 for initial segmentation, employs a Vision-Language Model to detect instruments and assess segmentation quality, and applies an agentic workflow that adaptively selects refinement strategies. The system supports clinician-in-the-loop interaction through natural language feedback. We also construct a multi-granularity language-annotated dataset from EndoVis2017 and EndoVis2018 benchmarks. Experiments demonstrate state-of-the-art performance on both in-domain and out-of-distribution data, with clinician interaction providing additional improvements. Our work establishes the first language-based surgical segmentation framework with adaptive self-refinement capabilities.