# Towards Unified Surgical Scene Understanding:Bridging Reasoning and Grounding via MLLMs

arXiv: https://arxiv.org/abs/2605.13530 · HTML: https://mlsanity.com/paper/2605.13530/

## Key facts

- No citing papers in the map yet (data through 14 Oct 2026).
- Placed in Clinical and biomedical applications, one of 17 directions in LLM reasoning.
- Builds on 17 of its 26 references that are in the map.
- First posted on arXiv 13 May 2026.

## Placed in

- LLM reasoning / [Clinical and biomedical applications](https://mlsanity.com/lr/clinical-and-biomedical-applications/)

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

- [Segment Anything](https://mlsanity.com/paper/2304.02643/) (2023)
- [Visual Instruction Tuning](https://mlsanity.com/paper/2304.08485/) (2023)
- [SAM 2: Segment Anything in Images and Videos](https://mlsanity.com/paper/2408.00714/) (2024)
- [Qwen3-VL Technical Report](https://mlsanity.com/paper/2511.21631/) (2025)
- [Expanding Performance Boundaries of Open-Source Multimodal Models with Model, Data, and Test-Time Scaling](https://mlsanity.com/paper/2412.05271/) (2024)
- [LISA: Reasoning Segmentation via Large Language Model](https://mlsanity.com/paper/2308.00692/) (2023)
- [GLaMM: Pixel Grounding Large Multimodal Model](https://mlsanity.com/paper/2311.03356/) (2023)
- [Sa2VA: Marrying SAM2 with MLLM for Dense Grounded Understanding of Images and Videos](https://mlsanity.com/paper/2501.04001/) (2025)
- [Rendezvous: Attention Mechanisms for the Recognition of Surgical Action Triplets in Endoscopic Videos](https://mlsanity.com/paper/2109.03223/) (2021)
- [Trans-SVNet: Accurate Phase Recognition from Surgical Videos via Hybrid Embedding Aggregation Transformer](https://mlsanity.com/paper/2103.09712/) (2021)
- [Surgical SAM 2: Real-time Segment Anything in Surgical Video by Efficient Frame Pruning](https://mlsanity.com/paper/2408.07931/) (2024)
- [CholecTriplet2021: A benchmark challenge for surgical action triplet recognition](https://mlsanity.com/paper/2204.04746/) (2022)
- [UniPixel: Unified Object Referring and Segmentation for Pixel-Level Visual Reasoning](https://mlsanity.com/paper/2509.18094/) (2025)
- [Exploring Segment-level Semantics for Online Phase Recognition from Surgical Videos](https://mlsanity.com/paper/2111.11044/) (2021)
- [Surgical Action Triplet Detection by Mixed Supervised Learning of Instrument-Tissue Interactions](https://mlsanity.com/paper/2307.09548/) (2023)
- [Real-time Instance Segmentation of Surgical Instruments using Attention and Multi-scale Feature Fusion](https://mlsanity.com/paper/2111.04911/) (2021)
- [Grounding Surgical Action Triplets with Instrument Instance Segmentation: A Dataset and Target-Aware Fusion Approach](https://mlsanity.com/paper/2511.00643/) (2025)

## Abstract (arXiv)

Surgical scene understanding is a cornerstone of computer-assisted intervention. While recent advances, particularly in surgical image segmentation, have driven progress, real-world clinical applications require a more holistic understanding that jointly captures procedural context, semantic reasoning, and precise visual grounding. However, existing approaches typically address these components in isolation, leading to fragmented representations and limited semantic consistency. To address this limitation, we propose SurgMLLM, a unified surgical scene understanding framework that bridges high-level reasoning and low-level visual grounding within a single model. Given surgical videos, SurgMLLM fine-tunes a multimodal large language model (MLLM) to support structured interpretability reasoning, which is used to jointly model phases, instrument-verb-target (IVT) triplets, and triplet-entity segmentation tokens. These tokens are then temporally aggregated and serve as prompts for a segmentation network, enabling accurate pixel-wise grounding of triplet instruments and targets. The entire framework is trained end-to-end with a unified objective that couples language-based reasoning supervision with visual grounding losses, promoting coherent cross-task learning and clinically consistent scene representations. To facilitate unified evaluation, we introduce CholecT45-Scene, extending CholecT45 dataset with 64,299 frames of pixel-level mask annotations for instruments and targets, aligned with existing triplet labels. Extensive experiments show that SurgMLLM significantly advances surgical scene understanding, improving the primary triplet recognition metric AP_IVT from 40.7% to 46.0% and consistently outperforming prior methods in phase recognition and segmentation. These results highlight the effectiveness of unified reasoning-and-grounding for reliable, context-aware surgical assistance.