Structured Reasoning Agentic Framework for Interpretable Critical View of Safety Assessment

Surgical scene understanding is critical for computer-assisted intervention, yet laparoscopic cholecystectomy remains challenged by the complex anatomy of the hepatocystic triangle and the risk of bile duct injury. Existing methods for Critical View of Safety (CVS) assessment typically treat it as a holistic prediction task, mapping visual features directly to criterion-level labels. This black-box paradigm lacks explicit reasoning about anatomical relationships, limiting both interpretability and compositional generalization. To address this, we propose ReasonCVS, a structured reasoning agentic framework empowered by Vision-Language Models (VLMs) that decomposes CVS assessment into explicit, fine-grained anatomical verification. Specifically, we devise an Anatomical Scene Graph Abstraction (ASGA) that organizes anatomical entities and their spatial relationships into a structured representation. To operationalize this, we introduce a Rationale-Aware Reasoning Agent, powered by a Large Language Model (LLM) fine-tuned via rationale distillation. Functioning as a strict central decision-maker, it invokes VLM-driven Sub-criterion Verifier as a specialized perceptual tool to parse the graph and independently evaluate individual sub-criteria. Through calibrated soft reasoning, this agent synthesizes the tool-gathered distributed observations, yielding a final verdict alongside a traceable clinical rationale. Extensive experiments on the Endoscapes-CVS201 benchmark demonstrate that ReasonCVS achieves superior performance (68.1% mAP) over state-of-the-art while providing interpretable, criterion-level explanations for reliable surgical assessment.