Yes / To capture stakeholders’ theories concerning how and in what contexts robot-assisted surgery becomes integrated into routine practice. A literature review provided tentative theories that were revised through a realist interview study. Literature-based theories were presented to the interviewees, who were asked to describe to what extent and in what ways those theories reflected their experience. Analysis focused on identifying mechanisms through which robot-assisted surgery becomes integrated into practice and contexts in which those mechanisms are triggered. Nine hospitals in England where robot-assisted surgery is used for colorectal operations. Forty-four theatre staff with experience of robot-assisted colorectal surgery, including surgeons, surgical trainees, theatre nurses, operating department practitioners and anaesthetists. Interviewees emphasised the importance of support from hospital management, team leaders and surgical colleagues. Training together as a team was seen as beneficial, increasing trust in each other’s knowledge and supporting team bonding, in turn leading to improved teamwork. When first introducing robot-assisted surgery, it is beneficial to have a handpicked dedicated robotic team who are able to quickly gain experience and confidence. A suitably sized operating theatre can reduce operation duration and the risk of de-sterilisation. Motivation among team members to persist with robot-assisted surgery can be achieved without involvement in the initial decision to purchase a robot, but training that enables team members to feel confident as they take on the new tasks is essential. We captured accounts of how robot-assisted surgery has been introduced into a range of hospitals. Using a realist approach, we were also able to capture perceptions of the factors that support and constrain the integration of robot-assisted surgery into routine practice. We have translated these into recommendations that can inform future implementations of robot-assisted surgery.

XMARCUS: A Pathway Towards Remote Robotic Surgery Training}, is a compilation work of human-robot, human-artificial intelligence, and human-computer interaction. The thesis provides a technical overview of the history of robotic surgery, present innovation, and future impacts. We present a behaviorist overview and describe our view of the overall direction of robotic surgery to enhance surgical training. We also discuss application towards future directions of translational medicine, adoption of surgical tools, and innovation within medicine. XMARCUS indicates the possibility of another artificial intelligence winter within surgery domain and presents a direction towards surgical training. Our macroscopic perspective and development of demo applications on third-party consoles demonstrates how to enhance robotic surgery training, provide future directions of minimally invasive surgery, and further enhance medical education. We also present the argument for a definitive direction of applications of artificial intelligence, the breakdown of its very definition, along with its proper application, in order to connect both the surgical and software communities for further steps in translational medicine. XMARCUS is not only a pathway towards applicable accessibility for surgical training, but also is a framework to allow further innovation in translational medicine for robotic surgery. The thesis consists of 14 chapters divided into 3 parts. Part 1 provides a technical history background focused on the history of robotic surgery, the present hardware breakdown, applications and advancement of artificial intelligence and computer vision practices within the field. Part 2 highlights the disconnect between both surgical and software communities, and a pathway to integrating both fields towards translational medicine, specifically focusing on artificial intelligent practices by integrating machine learning for computer vision in the endoscopic space. Part 3 presents future research directions and important research questions to address, highlighting the future of surgery with the lack of physician accessibility to implementing artificial intelligence practices, focuses on providing an integration of remote robotic surgery training. / Master of Science / XMARCUS: A Pathway Towards Remote Robotic Surgery Training} is an avocation, proof of concept, and general overview of robotic surgery, its present predicament, and future impact of software engineering. There is an ever pressing need to integrate artificial intelligence practices within robotic surgery and minimally invasive surgery procedures. However, computing has faced a number of artificial intelligence winters with no viable means of application. Due to the lack of available data and machine learning models trained on such data, there is another permanence of an artificial intelligence winter, especially surgical applications. We also present the XMARCUS dataset, with over 12,000 images and a walk-through for crowdsource annotation process using Intel's OpenVino framework, where there has been less viable data. The focus is on the general overview of artificial intelligence, within the domain of machine learning for computer vision practices. This includes a discussion of virtual coaching and remote surgical training, specifically methods to further develop robotic surgery simulation software, in order to advance not solely the endoscopic space, but also the surgical training. Human-computer interaction models and theories, such as the Diffusion of Innovation, showcase the adaptation and timing of certain technologies, for viable application. We also present another concept focusing on the timing of technology to be introduced to help with translational medicine. Finally, we show an application in a series of proof concepts of remote virtual coaching for remote robotic surgical training including the psychomotor skills and FDA policy overview for implementing novel software practices to advance robotic surgery. With consideration towards remote surgery training and the universal push for creating credentialing and guidelines in robotic surgery, we discuss further disparities to showcase an ethical framework to enhance surgical training and implement novel software engineering practices.

L’objectif de notre travail était, d’une part, de déterminer l’impact du délai de transmission des informations en téléchirurgie robotique, et d’autre part, de valider le rôle du simulateur robotique dans la formation en chirurgie robotique. Deux études ont été réalisées pour la partie concernant le délai. Il a été prouvé que la performance chirurgicale se détériore exponentiellement lorsque le délai augmente. Il est préférable d’envisager un geste de téléchirurgie associé à un délai inférieur à 200 ms, et des délais plus de 800 ms ne sont pas adaptés à la téléchirurgie. D’autre part, les chirurgiens ont démontré la capacité de s’adapter au délai par l’entraînement. Dans la deuxième partie, nous avons développé un curriculum sur un simulateur robotique pour une procédure chirurgicale robotique d’urologie. Une autre étude a été réalisée pour déterminer la validité d’un nouveau simulateur robotique (le XTT) comme un outil d’évaluation des techniques d’assistance en chirurgie robotique. / The objectives of our work were, on the one hand, to determine the impact of data-transmission latency in robotic telesurgey, and on the other hand, to validate the role of robotic simulator in robotic surgery training. Two studies were realized in the part concerning latency. It was proved that surgical performance deteriorates exponentially as latency increases. It is preferable to perform telesurgey with a delay less than 200 ms. The delay higher than 800 ms is not suitable for telesurgery. On the other hand, surgeons had demonstrated the capacity to adapt to delay through training. In the second part, we developed a curriculum on a robotic simulator for a urologic surgical procedure. Another study was realized to determine the validity of a new robotic simulator (the XTT) as an evaluation tool of robotic surgical assistance skills.

Base Teórica: A histerectomia ainda é um procedimento cirúrgico frequente. Nos últimos 25 anos, muitos esforços foram feitos para reduzir o número de histerectomias abdominais, como o avanço tecnológico, que permitiu cirurgias menos invasivas. Visando ampliar o uso da cirurgia minimamente invasiva, foi desenvolvida a cirurgia robótica, com a vantagem de facilitar o uso da laparoscopia proporcionando movimentos mais ergonômicos e precisos. Apesar de ser tecnologia recente e do alto custo, vem ganhando cada vez mais espaço na prática clínica. Dados sobre tempo cirúrgico e tempo de internação pós-operatória tem sido alvo de várias publicações, uma vez que afetam os custos do procedimento. Objetivo: O presente projeto visa à documentação da experiência inicial do Hospital de Clínicas de Porto Alegre na realização da histerectomia robótica, e comparação dos seus dados com outras vias de histerectomia já realizados no nosso meio. Métodos: Foi realizado estudo caso-controle para comparação de dados pré-operatórios, operatórios (como tempo cirúrgico total e sangramento) e pós-operatórios (tempo de recuperação pós-operatória, complicações, dor nas primeiras 24 horas após a cirurgia), em 80 pacientes, submetidas à histerectomia para tratamento de patologias uterinas benignas. Nós incluímos quatro grupos de pacientes: robótico, vaginal, abdominal e laparoscópico. O grupo robótico foi composto pelas primeiras 20 cirurgias realizadas em nosso hospital, e os grupos controle foram selecionados retrospectivamente a partir da data da última cirurgia robótica, constituindo uma amostragem não probabilística. Também foi realizado estudo transversal utilizando apenas as pacientes submetidas à cirurgia robótica em nosso serviço, para fins de documentação de nossa experiência inicial. Resultados: O grupo robótico foi responsável pelo maior tempo cirúrgico total (180,7 minutos), e pelo menor tempo de recuperação pós-operatória (23,7 horas), entre os quatro grupos. Não houve diferença entre os grupos na análise do sangramento transoperatório e das complicações pós-operatórias. Dados analisados sobre a dor pós-operatória não diferiram entre os grupos. No estudo transversal, foi demonstrada curva de aprendizado em tempo de docking e undocking, e houve correlação forte entre tempo cirúrgico total e índice de massa corporal da paciente. Conclusão: Análise do tempo cirúrgico total e do tempo de recuperação pós-operatória são relevantes, pois podem ser ferramentas necessárias para redução dos custos da cirurgia robótica. Nossa experiência inicial demonstra curva de aprendizado em alguns aspectos. / Background: Hysterectomy is a frequent surgical procedure. In the last 25 years, many efforts have been made to reduce the number of abdominal hysterectomies, such as the technological advances, which allowed less invasive procedures. Aiming to increase the use of minimally invasive surgery, the robotic surgery was developed, which advantage of more precise and ergonomic movements than laparoscopy. Although it is a recent and expensive technology, robotic surgery is gaining more space in clinical practice. Data from Total Surgical Time and Time of Postoperative Recovery has been target of publications, once they can affect the costs. Objective: The purpose of this study is to compare the surgical outcomes of patients undergoing robotic hysterectomy for benign cases to patients undergoing another types of hysterectomy performed in our institution. Methods: It was performed a case-control study to compare pre-operative, operative (as Total Surgical Time and bleeding) and postoperative (Time of Postoperative Recovery, complications, and pain at the first 24 hours after the surgery) in 80 patients undergoing hysterectomy for treatment of various benign uterine conditions. We have included four groups of patients: robotic, vaginal, abdominal and laparoscopic. The robotic group was composed by the first twenty patients undergoing robotic hysterectomy at our hospital, and the control groups were retrospectively selected from the date of the last robotic surgery, constituting a non-probabilistic sample. We also performed a crosssectional study with the 20 patients of robotic group, to document our initial experience. Results: The robotic group was responsible for the longer Total Surgical Time (180.7 minutes), and for the shortest Time of Postoperative Recovery (23.7 hours) among the four groups. There were no difference between the groups in analysis of estimated blood loss and postoperative complications. Data related to postoperative pain showed no difference between the groups. At cross-sectional study, it was demonstrated learning curve of docking and undocking times, and was found a strong correlation between Total Surgical Time and body mass index. Conclusion: Analysis of Total Surgical Time and Time of Postoperative Recovery are relevant, because they can be necessary tools to reduce the costs of robotic surgery. Our initial experience demonstrated learning curve in some ways.

Nurses who provide care in robotic surgery must have sufficient special training in the operation of the da Vinci robot to perform their roles with knowledge and confidence that can yield optimal patient outcomes. The local nursing practice problem in the project facility, and the focus of this doctoral project, was the lack of an evidenced-based robotics education program for registered nurses who participate in robotic surgery. The gap in practice was nurses' lack of knowledge, which interfered with the care provided to the robotic surgical population. The purpose of this project was to develop a staff robotics education program in order to answer the question if the implementation of an evidence-based robotics education program would improve nurses' knowledge in the practice of robotic surgery. The education program was developed using Knowles adult learning theory and information obtained from a comprehensive literature search. A planning team, consisting of local clinicians with expertise in robotic surgery, provided feedback and assisted with the development of the education program and accompanying competency checklist. Ten nurses received the education, and 90-100% of the nurses reported increased knowledge and confidence regarding practice in the specialty of robotic surgery following the education. Leadership at the project site have decided to require surgical nurses receive the robotic education upon their employment and annually thereafter. The social change resulting from the use of this evidence-based robotics education program could include increased nursing performance and therefore, decreased complications for patients undergoing robotic surgery.

No description available.

The adoption of Minimally Invasive Surgery (MIS) and Robot-Assisted MIS has resulted in the distortion of haptic cues surgeons rely on. The application of excessive force during port creation has lead to increased surgical access trauma. This study aims to quantify the forces experienced during port creation with a blunt-ended Threaded Visual Cannula (TVC) in an effort to ameliorate patient safety, provide a quantitative platform for surgeon training, and offer a gateway for the eventual automation of this problematic aspect of MIS. A method of determining the torque encountered during port creation was established. It was found that the magnitude of torque required to cannulate different materials was unique and was dictated by the friction observed at the tool/tissue interface. Furthermore, the ability to detect instantaneous changes in torque arising from the transition between two different media was not found to be possible with the current design of the TVC.

The adoption of Minimally Invasive Surgery (MIS) and Robot-Assisted MIS has resulted in the distortion of haptic cues surgeons rely on. The application of excessive force during port creation has lead to increased surgical access trauma. This study aims to quantify the forces experienced during port creation with a blunt-ended Threaded Visual Cannula (TVC) in an effort to ameliorate patient safety, provide a quantitative platform for surgeon training, and offer a gateway for the eventual automation of this problematic aspect of MIS. A method of determining the torque encountered during port creation was established. It was found that the magnitude of torque required to cannulate different materials was unique and was dictated by the friction observed at the tool/tissue interface. Furthermore, the ability to detect instantaneous changes in torque arising from the transition between two different media was not found to be possible with the current design of the TVC.

Ο σκοπός της διπλωματικής εργασίας ήταν η ανάπτυξη ενός μοντέλου Επαυξημένης Πραγματικότητας για την υποβοήθηση του χειρουργού-χειριστή ρομποτικού μηχανήματος. Το μοντέλο αυτό παρουσιάστηκε για την εύρεση του οπτικού πεδίου του ειδικού ενδοσκοπίου. Για τον σκοπό αυτό κατασκευάστηκαν δύο προγράμματα τα οποία μπορούν να χειριστούν ιατρικά δεδομένα και να προσφέρουν εικόνες από το εσωτερικό του μοντέλου του ασθενούς. Συγκεκριμένα, έγινε μελέτη των βασικών μεθόδων εφαρμογής Επαυξημένης Πραγματικότητας στην χειρουργική, όπως η εγγραφή του ασθενούς, η κατάτμηση των ιατρικών δεδομένων, η τρισδιάστατη ανακατασκευή τους και η ανίχνευση των ενδοσκοπικών εργαλείων και της κάμερας. Παρουσιάστηκε το πλήρες θεωρητικό μοντέλο εφαρμογής επαυξημένης πραγματικότητας και έγινε ανάλυση των επιμέρους διαδικασιών. Κατασκευάστηκαν με την βοήθεια της Matlab δύο προγράμματα με τα αντίστοιχα GUIs για τον προεγχειρητικό σχεδιασμό και την διεγχειρητική καθοδήγηση/επαύξηση αντίστοιχα. Τέλος έγινε δοκιμή των προγραμμάτων χρησιμοποιώντας 22 τομές μαγνητικής τομογραφίας (μορφής DICOM) εγκεφάλου με εμφανή καρκίνο στην αριστερή κοιλία. Επίσης καταγράφηκαν οι εικόνες και τα δεδομένα που παίρνουμε σε κάθε βήμα εφαρμογής των προγραμμάτων με στόχο την αξιολόγηση τους. Το μοντέλο αυτό κατασκευάστηκε με στόχο την εφαρμογή του σε επεμβάσεις μέσω του ρομποτικού μηχανήματος daVinci. Παρόλα αυτά η γενικότερη εφαρμογή της μεθοδολογίας που αναπτύσσεται μπορεί να βρει εφαρμογές και σε άλλες ενδοσκοπικές επεμβάσεις. / The purpose of this thesis was to develop a model of Augmented Reality to assist the surgeon-operator of a robotic machine. The model has been presented for finding the field of special endoscope. For this purpose we built two programs that can manipulate medical data and provide images of the interior of the patient’s model. Specifically, a study was done in the basic methods of Augmented Reality application in Surgery such as, the registration of the patient, the segmentation of medical data, their 3D reconstruction and the detection of endoscopic instruments and the camera. Has been presented the complete theoretical model for applying augmented reality and an analysis of individual procedures was done. Moreover we constructed with the help of Matlab two programs with their GUIs, for preoperative planning and intraoperative guidance/augmentation, respectively. Finally the programs were tested, using 22 MRI slices (format DICOM) with visible brain cancer in the left ventricle. Also were recorded images and data that we get at each step of programs implementation in order to evaluate them. This model was constructed to implement the operations through the daVinci robotic machine. Nevertheless, the general application of the methodology developed in this study may find applications also in other endoscopic procedures

BACKGROUND: Hysterectomies are one of the most frequently performed surgical procedures in the United States. There are a wide variety of diagnoses that require a patient to obtain this procedure, but the majority of hysterectomies are performed for benign indications. Currently, gynecologists do not follow a standardized protocol surrounding postoperative laboratory ordering, and healthcare professionals can order a wide range of tests as often as they choose. Extraneous laboratory orders are disruptive to the patients’ well-being and risk their health following surgery. These orders are costly for hospital systems, take up precious time of hospital employees, and influence the course of patient treatment only in extremely rare circumstances. There are few studies that develop exclusion criteria for patients who may not require a laboratory test following surgery. Though systems to predict postoperative hematocrit have been created, they are complicated and difficult to use. The few studies that were performed are yet to be accepted by the medical community, in part because of their limited scope. This study will be the first to incorporate the results of robotic surgery in the analysis. OBJECTIVE: The purpose of this study is to determine concrete parameters to indicate that a patient is in need of postoperative laboratory work and at risk for anemia or transfusion. We aim to develop two comprehensive models that guide surgical practitioners to identify the cases which do not require laboratory data. METHODS: A total of 1027 gynecologic surgeries were performed at Saint Francis Hospital and Medical Center between April 1, 2014 and May 31, 2016. This retrospective study extracted data from EPIC EMR according to 42 variables preconceived to be the leading indicators of postoperative hematocrit and overall healing. Five healthcare professionals were surveyed to identify the variables that influence their postsurgical patient assessments and their decisions to order blood testing. This information was developed into score sheets with differing levels of stringency. Correlation highlighted 14 of the initial 42 variables as contributors to postoperative hematocrit and an equation model was built. Stepwise linear regression was used for univariate and multivariate analyses, from which we created our equation to predict all patients’ postoperative hematocrit. RESULTS: Out of the 1027 initial cases, a total of 602 cases were identified as hysterectomies for benign indications. Survey data gave the highest value to urine output and heart rate as key indicators of postoperative anemia. From the survey data, two clinical scoring sheets with differing stringency were created to guide practitioner laboratory ordering. These sheets gave parameters of heart rate and urine output the largest correlative weight in determining postoperative hematocrit. However, based on regression analysis, parameters of age (AGE), body mass index (BMI), preoperative platelet count (PPC), estimated blood loss during surgery (IO EBL), preoperative hematocrit (PHCT) and postoperative fluid bolus orders (POSTOP FB) proved to be the key variables impacting postoperative hematocrit (POSTOP HCT). These items were translated into the equation: POSTOP HCT = 22.51 – 0.40*POSTOP FB – 0.01*IO EBL + 0.25 PHCT + 0.09*BMI + 0.06*AGE – 0.01*PPC (R-squared = 0.310). CONCLUSIONS: This study aims to decrease superfluous laboratory testing, as well as to contribute to a larger conversation considering the potential merits of clinical judgement in a data-driven healthcare system. We have created a number of comparable strategies in order to reduce the number of unnecessary blood draws: two clinical scoring sheets and an equation. The score sheets indicate when to order additional testing. These sheets are representative of a range of surgical practitioners’ conventional clinical judgement. The equation serves as an evidence-based guide for determining postoperative hematocrit following benign gynecologic surgery. These predictive mechanisms will be validated and a superior method determined as our research continues with prospective application. We eventually expect to use the most accurate mechanism to reduce postoperative blood testing following all surgeries.