Accurate counting of surgical instruments in Operating Rooms (OR) is a critical prerequisite for ensuring patient safety during surgery. Despite recent progress of large visual-language models and agentic AI, accurately counting such instruments remains highly challenging, particularly in dense scenarios where instruments are tightly clustered. To address this problem, we introduce Chain-of-Look, a novel visual reasoning framework that mimics the sequential human counting process by enforcing a structured visual chain, rather than relying on classic object detection which is unordered. This visual chain guides the model to count along a coherent spatial trajectory, improving accuracy in complex scenes. To further enforce the physical plausibility of the visual chain, we introduce the neighboring loss function, which explicitly models the spatial constraints inherent to densely packed surgical instruments. We also present SurgCount-HD, a new dataset comprising 1,464 high-density surgical instrument images. Extensive experiments demonstrate that our method outperforms state-of-the-art approaches for counting (e.g., CountGD, REC) as well as Multimodality Large Language Models (e.g., Qwen, ChatGPT) in the challenging task of dense surgical instrument counting. The code and dataset is available at https://github.com/rishi1134/CoLSR.git

We present RASO, a foundation model designed to Recognize Any Surgical Object, offering robust open-set recognition capabilities across a broad range of surgical procedures and object classes, in both surgical images and videos. RASO leverages a novel weakly-supervised learning framework that generates tag-image-text pairs automatically from large-scale unannotated surgical lecture videos, significantly reducing the need for manual annotations. Our scalable data generation pipeline gathers 2,200 surgical procedures and produces 3.6 million tag annotations across 2,066 unique surgical tags. Our experiments show that RASO achieves improvements of 2.9 mAP, 4.5 mAP, 10.6 mAP, and 7.2 mAP on four standard surgical benchmarks respectively in zero-shot settings, and surpasses state-of-the-art models in supervised surgical action recognition tasks. We will open-source our code, model, and dataset to facilitate further research.