Surgical phase recognition is key to context-aware computer-assisted feedback in vitreoretinal procedures, yet the scarcity of synchronized multimodal intraoperative data, particularly microscope views and intraoperative OCT, limits approaches that aim to replicate the multimodal integration surgeons perform naturally. Surgical narration, by contrast, is abundantly available online and offers rich semantic supervision. Prior work has mainly explored pairwise contrastive learning (e.g., intraoperative OCT-microscope or microscope-narration), leaving the joint modeling of all three modalities largely unexplored. We introduce a framework that uses microscope views as a shared anchor to bridge surgical narrations and intraoperative OCT (iOCT) without requiring a fully synchronized tri-modal dataset, leveraging real microscope-narration videos and a synthetic dataset of synchronized microscope video and tool-aligned iOCT pairs. Contrastive alignment transfers structural priors from the synthetic domain to real videos lacking iOCT, and a dual-head MS-TCN++ integrates the resulting embeddings for joint macro- and micro-phase prediction. Evaluated on real vitreoretinal surgeries, our framework improves macro-phase recognition over a zero-shot baseline (mean F1 0.38 to 0.53) and provides an exploratory route to estimating fine-grained instrument-tissue measurements that are not directly observable in real microscope video alone; these micro-phase estimates are validated quantitatively on synthetic data and shown only qualitatively on real surgery. To our knowledge, this is the first work to unify microscope view, iOCT B-scans, and surgical narrations in a shared latent space for surgical phase recognition.
Task-specific lightweight models for surgical phase recognition excel at capturing temporal dynamics but generalize poorly under domain shift. Conversely, surgical foundation models (FMs) offer superior transferability via large-scale pretraining, yet their lack of explicit temporal modeling often yields temporally inconsistent predictions, leading to degraded performance. To exploit the complementary strengths of both paradigms, we propose \textbf{La}rge-\textbf{S}mall \textbf{T}emporal adaptation (\textbf{LaST}), a novel large-small collaborative framework that enables zero-shot adaptation to unseen clinical domains. In LaST, the FM initiates the pipeline by generating frame-level phase priors that serve as initial weak supervision. To effectively utilize these noisy phase priors, we introduce an iterative temporal refinement scheme that integrates dynamic quality control to filter reliable predictions and dual-model cross-learning to mitigate confirmation bias. Simultaneously, the lightweight model leverages its intrinsic temporal modeling ability to progressively correct inconsistent predictions and enhance overall accuracy across iterations. At the end, a cycle replay strategy is employed to close the loop: the refined, more accurate predictions are utilized as upgraded supervision signals for the subsequent iterations, fostering a self-reinforcing evolution of both label quality and model capability. Extensive experiments demonstrate that LaST achieves robust adaptation to unseen domains for zero-shot surgical phase recognition, outperforming the baseline (PeskaVLP) by 24.85\%-43.17\% in accuracy and even surpassing fully supervised linear probing and several state-of-the-art few-shot approaches. Codes will be released at https://github.com/YIYIZH/LaST.
Hallucinations are a major concern for the integration of artificial intelligence into medicine, although less explored in the realm of medical image processing. Unlike problems in natural text understanding and reasoning therewith, determining whether or not predictions derived from biomedical images and signals is less intuitively clear. This article suggests that topological errors could constitute hallucinations in a way that can be more readily measured and thus regulated. Certain of these properties for certain types of problems, such as biomedical signal segmentation, can be rephrased as linear temporal logic predicates, a number of which can be explicitly enforced using probabilistic graphical models. Our simulations show the potential of these explicitly constrained predicates for the case of automatic surgical phase recognition in robot-assisted hysterectomy, improving accuracy by approximately 10% while removing the vast majority of topological errors, suggesting that mathematical guarantees of correctness can supplement other empirical forms of regulating machine learning in medical image computing and computer-assisted interventions.