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原文摘要

Reasoning about surgical video -- which phase is underway, which instruments act, and when events occur -- underpins operative documentation, workflow analysis, and skill assessment. Yet surgical visual question answering is still largely built on single frames and closed labels that cannot express a duration, an ordering, or a count, and the video models that lift the frame limit typically compress every clip the same way regardless of the question, discarding the temporal evidence the answer needs. Worse, the answers are structurally heterogeneous, spanning five incompatible structures -- binary, classification, multi-label, counting, and sentence-temporal -- that no single training signal scores uniformly well. We propose SurgQ-VLM, a two-stage model for surgical video question answering. Stage 1 trains a question-conditioned dual-stream (slow/fast) compressor for a LoRA-adapted Qwen2.5-VL-7B: cross-attention conditions both streams on the question, and each clip's visual tokens shrink 49x from the raw ViT patches (11x vs. post-merge backbone tokens). Stage 2 post-trains with GRPO under an answer-type-aware reward that scores each question on the metric matching its answer structure (micro-F1 for label sets, normalised error for counts, a content-timing blend for temporal windows). On a sealed 21,840-question test split over Cholec80 and CholecT50, SurgQ-VLM reaches 0.779 keyword accuracy and a 10x BLEU-4 gain over zero-shot; GRPO adds 2.5 pp K-Acc (2.0 pp attributable to the answer-type-aware reward), concentrated in the structurally hard types, with answer format unchanged (ROUGE-L). Code is available at https://github.com/DhruvMakwana/SurgQ-VLM.