Spending on robot surgery is expected to increase by $17 billion in the next 6 years. This new surgical treatment has challenged hospitals with higher costs and varying performance. Healthcare executives struggle balancing the adoption of medical innovations with managing healthcare costs. This dilemma can be further complicated by industry structures relative to capital-intensive medical innovations. This research explores the interaction between industry structure and customer value. Specifically, how can hospitals apply an understanding of supplier industry structure and customer value to improve the value of a robotic surgery program (RSP)? This industry study represents an exhaustive longitudinal review of over 15 years of public data relative to robotic surgery, across three distinct time periods. Within the research, industry structure is evaluated using Porter’s 5-forces model. A framework based upon contributions from Grönroos as well as Menon, Homburg, and Beutin is introduced to assess customer value based upon clinical, financial and strategic (CFS) value. The implications of periodic industry structure on customer value were examined to identify opportunities for hospital executives to increase RSP customer value. There were several empirical and theoretical findings from this research. First, in the face of increasing industry structure the identification of favorable forces may create opportunities to increase RSP value. Secondarily, exploring customer value through the lens of core, add-on, relational and transactional benefits in the sub-context of CFS value aids in the identification of market power influences on customer value. The implications of the absence of high levels of relational and transactional benefits without high levels of core and add-on benefits may influence avenues of pursuit in improving RSP value overall. The research also suggests that clinical and strategic value was present despite varying degrees of industry structure. Finally, this study represents an empirical joint analysis of industry structure and customer value in robotic surgery. Some proponents may find the introduction of an integrative model for measuring customer value in robotic surgery, applicable to other capital-intensive medical innovations or disruptive technologies at large.

Robotic surgery uses innovative technology to transcend a surgeon's skills when performing complex procedures. Currently, the only FDA approved robotic system is Intuitive's da Vinci Surgical System. While this system offers many advantages over other minimally invasive techniques, it also introduces a need for specialized training. Virtual reality simulators have emerged as valuable tools for standardized and objective robotic surgery skill training and assessments. In recent years, the idea of using video game technology in surgical education for laparoscopy has also been explored; however few have attempted to make a connection between video game experience and robotic surgical skills. Thus, the current study aims to examine the performance of video gamers in a virtual reality robotic surgery simulator. Furthermore, the video gamers' performance was compared to that of medical students, expert robotic surgeons, and "laypeople." The purpose of this study is to examine the hypothesis that video gamers acquire perceptual and psychomotor skills through video game play, similar to those used by robotic surgeons. Subjects completed a demographic questionnaire and performed three computer-based perceptual tests: a Flanker compatibility task, a subsidizing task, and a Multiple Object Tracking test. Participants then performed two warm-up exercises on the Mimic dV-Trainer to familiarize themselves with the system and eight trials of two core exercises to test their skills. After completing all trials, participants completed a post-questionnaire regarding their experience with the system. Expert video gamers (n=40), medical students (n=24), laypeople (n=42) and expert robotic surgeons (n=16) were recruited. Medical students and gamers were significantly faster than experts in the Flanker Task. The experts were significantly slower than the all other groups in the subsidizing task. Experts scored significantly higher, were significantly more efficient, and were significantly faster than laypeople, medical students, and gamers in the first trial of Ring & Rail 1 and Suture Sponge. In trial eight of Ring & Rail 1, experts scored significantly higher and were more efficient than laypeople. Experts were also significantly faster than all other groups. Experts scored significantly higher than laypeople and gamers in trial Suture Sponge. Experts were significantly more efficient and significantly faster than all other groups. Contrary to prior literature in laparoscopy, this study was unable to validate enhanced abilities of video gamers in a robotic surgery simulator. This study does further demonstrate that the transfer of skills developed through video game play is relevant to the surgical technique. This may be due to the differences of the systems and how the users interact within them. In a society where video games have become an integral past time, it is important to determine the role that video games play in the perceptual and psychomotor development of users. These findings can be generalized to domains outside of medicine that utilize robotic and computer-controlled systems, speaking to the scope of the gamers' abilities and pointing to the capacity within these systems.

Thesis (MScEng)--Stellenbosch University, 2012. / ENGLISH ABSTRACT: This thesis describes the process of developing a user interface for a seven degree of freedom (DOF), minimally invasive surgical robot. For the first two main stages of the overall project, completed by previous students, a primary slave manipulator (PSM) and a secondary slave manipulator (SSM) were developed. The stage in this thesis concentrates on creating a joystick that can control the combined movement of the PSM and SSM. Background information on the field of robotic surgery, with specific reference to current systems’ user interfaces, is given and the technical aspects of the PSM and SSM are determined. This is followed by the motivation and main objectives of the thesis. Objectives were divided into the main categories of mechanical design, electronic design, control system design and testing. The mechanical design of the joystick progresses through a concept development stage, before a final seven DOF articulated arm design is presented and evaluated based on engineering specifications. Aluminium is used as the construction material; electromagnetic brakes are specified for each joint, leading to the final assembly, which is a constructed joystick fulfilling all requirements. The electronic design implements magnetic rotary encoders for the joystick’s position and orientation tracking as well as designs of the necessary power and control circuitry to enable correct joystick functioning. The interfacing of the PSM and SSM had to enable successful communication capabilities between the master and the slave. Several necessary adjustments were therefore made to the slave system, after which the joystick and robot were electronically interfaced to provide a direct serial communication line. For control system design, the joystick and robot were modelled according to the Denavit-Hartenberg principle, which allows direct relation between the position and orientation of the respective end effectors on the joystick and robot sides. Forward kinematic equations were then applied to the joystick; the desired position and orientation of the robot end effector were determined, and inverse kinematic equations were applied to these data to establish the robot’s joint variables. This stage ended with the development of two operational modes: one where only the SSM motors are controlled in order for the slave to follow the master’s movements, and the other where the PSM’s motors are controlled separately. The simultaneous control of all robot motors could not be demonstrated due to fundamental mechanical flaws in the PSM and SSM designs. Finally, testing was undertaken to demonstrate movement control of the robot by the joystick. The intuitiveness of the product was also tested successfully. The study ends with the presentation of the conclusions, the main conclusions being the successful development and testing of a joystick that controls the movement of a surgical robot, as well as the achievement of all main thesis objectives. / AFRIKAANSE OPSOMMING: Hierdie tesis beskryf die proses vir die ontwikkeling van ’n gebruikerskoppelvlak vir ’n sewevryheidsgraad-, minimaal indringende chirurgiese robot. In die eerste twee hoofstadia van die algehele projek, voltooi deur ander studente, is ’n primêre slaafmanipuleerder (PSM) en ’n sekondêre slaafmanipuleerder (SSM) ontwikkel. Die stadium in hierdie tesis konsentreer op die skep van ’n stuurstok waarmee die gekombineerde beweging van die PSM en SSM beheer kan word. Agtergrondinligting oor die gebied van robotiese chirurgie word verskaf, met spesifieke verwysing na die gebruikerskoppelvlakke van huidige stelsels, en die spesifikasies van die PSM en SSM word vasgestel. Daarna volg die beweegrede sowel as die belangrikste oogmerke van die projek. Die oogmerke is in die hoofafdelings van meganiese ontwerp, elektroniese ontwerp, beheerstelselontwerp en toetsing verdeel. Die meganiese ontwerp van die stuurstok behels ’n konsepontwikkelingstadium, wat uitloop op ’n finale sewevryheidsgraad-ontwerp, wat dan op grond van ingenieurspesifikasies aangebied en beoordeel word. Aluminium word as boumateriaal gebruik; elektromagnetiese remme word vir elke koppeling gespesifiseer, en die finale samestel is ’n gekonstrueerde stuurstok wat aan alle vereistes voldoen. Die elektroniese ontwerp behels die gebruik van magnetiese draaikodeerders om die stuurstok se posisie en oriëntasie te bepaal, sowel as meganismes met die nodige krag- en beheerstroombaanwerk om die stuurstok reg te laat funksioneer. ’n Koppelvlak tussen die PSM en die SSM moes suksesvolle kommunikasie tussen die meester en die slaaf bewerkstellig. Verskeie nodige aanpassings is dus aan die slaafstelsel aangebring, waarna die stuurstok en robot elektronies gekoppel is om ’n direkte reekskommunikasielyn te skep. Vir beheerstelselontwerp is die stuurstok en robot volgens die Denavit- Hartenberg-beginsel gemodelleer, wat ’n direkte verhouding tussen die posisie en oriëntasie van die onderskeie eindpunt-effektors aan die stuurstok- en robotkant daarstel. Voorwaartse kinematiese vergelykings is daarna op die stuurstok toegepas; die gewenste posisie en oriëntasie van die robotiese eindpunt-effektor is bepaal, waarna terugwaartse kinematiese vergelykings op hierdie data toegepas is om die robot se koppelingveranderlikes te bepaal. Hierdie afdeling word afgesluit met die ontwikkeling van twee bedryfsmodusse: een waar slegs die SSM-motore beheer word sodat die slaaf die meester se bewegings kan navolg, en die ander waar die PSM se motore afsonderlik beheer word. Die gelyktydige beheer van al die robotmotore kon nie getoon word nie weens fundamentele meganiese tekortkominge in die PSM- en SSM-ontwerp. Laastens is ’n toets uitgevoer om die bewegingsbeheer van die robot deur die stuurstok te toon. Die intuïtiwiteit van die produk is ook suksesvol getoets. Die studie sluit af met die projekgevolgtrekkings, waarvan die belangrikste die suksesvolle ontwikkeling en toetsing van ’n stuurstok is wat daarin slaag om die beweging van ’n chirurgiese robot te beheer, sowel as die verwesenliking van alle hoofprojekoogmerke.

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Femoroacetabular impingement (FAI) has been increasingly recognized as a cause of early hip osteoarthritis. FAI is characterized by pathologic contact between the femur and acetabular rim during hip join movement, caused by morphological abnormalities. Arthroscopic technique has become increasingly popular for FAI surgical treatment because of its minimal invasiveness. However, it involves cumbersome procedures and over- or under-resection are likely to occur. To tackle this issue, robot-assisted FAI arthroscopy is a well suited approach because it results in high accuracy and reproducible surgical outcomes. This dissertation provides new approaches and methods for the current challenges in the development of robot-assisted FAI arthroscopy. The study has three objectives: 1) to develop a robust calibration method for the A-mode ultrasound probe used for noninvasive bone registration, 2) to develop a bone registration simulator for verifying the registration accuracy and consistency for any given registration point-pattern, and 3) to develop a hip range of motion simulation system that returns the virtual range of motion and determines the bone resection volume. Carefully designed calibration procedures and simulation experiments have been conducted during the study of this research. From the experimental results, the developed ultrasound calibration method successfully reduces the registration errors and is proved to be robust. The results from the registration simulator indicate that the pattern with widely distributed points lead to better registration accuracy and consistency. The hip range of motion simulation system results in acceptable accuracy and successfully generates the resection volume. With further modifications, the ultrasound probe can be successfully calibrated with the developed method, and will be applied for noninvasive bone registration. The registration simulator can also be served as a useful tool for determining the optimized registration point-pattern, which can lead to reduced surgical trauma and registration time. Finally, the developed range of motion simulation system can allow the surgeon to evaluate the surgical outcome and to determine the resection volume even before the surgery begins. To conclude, this dissertation provides useful approaches, methods, and software for developing robot-assisted FAI arthroscopy.

Cette thèse s’intéresse aux effets des technologies d’assistance robotique sur l’expertise individuelle et collective des médecins dans un bloc opératoire de chirurgie gastrique. Notre recherche est fondée sur l’analyse de l’émergence des routines organisationnelles et de leur mise en évidence en mobilisant l’approche naturaliste de la décision. D’un point de vue managérial, nos résultats démontrent que la technologie introduite atténue l’expertise individuelle en dégradant respectivement la détection des signes cliniques et la coordination au sein de l’équipe. Nous établissons des recommandations concernant la mise en œuvre d’une technologie dans le cadre des équipes restreintes. Notre méthodologie consiste à fusionner des sources hétérogènes : entretiens, observation in situ, vidéos, débriefing, auto-confrontation... elle ouvre ainsi la voie à de nouvelles stratégies d’analyse de données jusqu’à lors essentiellement utilisées en psychologie. Enfin, nos contributions théoriques ont permis un enrichissement de l’approche naturaliste en lui adjoignant les rôles tenus par le leader et la mise en évidence du rôle de l’expertise individuelle dans la formation de nouvelles routines fonctionnelles. / The aim of this research is the understand the effect of a new technology, a robotic system, on the individual and collective expertise of practitioners in bariatric surgery. Our analysis is based on the emergence of organizational routines while taking into consideration naturalistic decision making approach. From the managerial perspective, our results demonstrate that the implementation of this technology decrease individual expertise. This is done through the degradation of individual situation awareness and coordination between team members. We established recommendations for an efficient technology implementation by restricted teams. Our methodology consists of mixing heterogenic sources: interviews, observations, videos, debriefing with auto-confrontation… this opens the door for new analysis strategies till now used mainly in psychology. Finally, our theoretical contributions reinforced the naturalistic approach while insisting on the important role of a team leader and the role of individual expertise in the development of new functional organizational routines.

Robotic surgery is at the forefront of surgical innovation and presents novel challenges for both postgraduate learners and seasoned specialists. Robotic teaching is underway, often without formalized robotic curricula. Research into robotic surgical steps and surgical decision-making that should be imparted to learners has been neglected. As such, I aimed to determine the knowledge gap of urology residents for a robotic prostatectomy. Further, I also aimed to determine the patterns and cognitive rules used by experienced surgeons to complete a robotic prostatectomy. This master’s thesis included a knowledge gap survey, completed by urology residents, and compared to urologic oncologists, of a robotic prostatectomy and contained both open-ended and rating scale questions. A cognitive task analysis (CTA) was then performed as a series of semi-structured interviews in which incident-probing questions were used to make urologic oncologists explain visual cues and decision-making processes. 42 surveys were administered to urology residents and urologists at The Ottawa Hospital over 10 weeks. There was disagreement between urology resident and urologist responses from the rating scale responses, from the following procedural steps: vesicourethral anastomosis, apical dissection, and seminal vesicle dissection. The open-ended responses found discrepancies between the residents’ and urologists’; understanding of anatomy and surgical decision-making, and of cause-and-consequence cognitive awareness. Subsequently, 16 CTA interviews of four urologic oncologists were completed. After data coding and thematic analysis was performed, CTA grids for each surgeon described a map of a robotic prostatectomy including the steps and goals of the procedure, procedural landmarks, key visual cues for each step, complications and/or error prevention, and management. Specific content not yet described in the literature also includes how the lack of haptic feedback is compensated by robotic surgeons. Additional findings included a gap in urology resident knowledge and understanding of a robotic prostatectomy. The CTA of a robotic prostatectomy documented the surgical decision-making rules, patterns and visual cues urologic oncologists use to avoid errors, and to manage intraoperative surgical complications. This information is key to expanding the understanding of robotic prostatectomy surgical decision-making and training and can be used to produce robust robotic educational curricula.

Robotic-assisted segmentectomy is a pulmonary resection procedure that is emerging as an alternative to lobectomy for the treatment of early-stage lung cancer tumours less than 2 cm in maximal diameter. Segmentectomy offers better lung function after surgery by only removing a few segments of the lobe that contain the tumour, and sparing remaining healthy lung tissue. As tumours are being more frequently detected in their early-stages, segmentectomy has gained considerable attention for its potential as a primary treatment option for suspected nodules less than 3 cm in maximal diameter. However, there is a reluctance in adopting segmentectomy due to technical challenges while performing the operation, and the lack of high-quality prospective data compared to lobectomy, which is the current standard of care. From a technical standpoint, segmentectomy is difficult to perform because the pulmonary lines that separate segments, or intersegmental planes, are invisible. This poses a challenge for the operating surgeon in determining where to resect the lung tissue to obtain adequate margin distance from the tumour. Near-infrared mapping (NIF) with indocyanine green dye (ICG) is a recent advancement in robotic-assisted segmentectomy that provides a complete delineation of the intersegmental plane. Previous work at our center has also shown that this technique was associated with an increase in the oncological margin distance compared to the surgeons’ initially estimated resection line. Given that segmentectomy is associated with a learning curve, we evaluated whether this was observed due to our early experience in robotic-assisted segmentectomy, and hypothesized that the added benefit of ICG would diminish as more cases were performed. In Chapter 2, we used a temporal analysis to monitor surgeon experience over time, and found that the clinical utility of NIF mapping diminished after approximately 42 cases with ICG, and the surgeon began to identify the location of the intersegmental plane more accurately and consistently without ICG injection since. The second barrier in the adoption of segmentectomy is the lack of high quality-prospective data. Current evidence pertaining to the effectiveness of segmentectomy in terms of cancer-related outcomes is inconclusive and difficult to generalize to the current lung cancer population. In Chapter 3, we performed a secondary analysis of a prospectively collected database of participants who underwent robotic-assisted segmentectomy or lobectomy for tumours less than 3 cm. The oncological efficacy of segmentectomy can be evaluated by the measuring the number of lymph node stations sampled intraoperatively and rates of nodal upstaging, and comparing these outcomes to pulmonary lobectomy. These are important surrogate outcomes that can be readily evaluated, and have been shown to predict overall survival after lung resection. We observed that these outcomes, including overall survival, were similar between patients who underwent segmentectomy and lobectomy for tumours less than 3 cm. While these findings were consistent for patients that underwent segmentectomy for tumours between 2 and 3 cm, recurrence-free survival was found to be significantly lower after segmentectomy compared to lobectomy. In conclusion, the clinical utility of near-infrared mapping diminishes over time, which is indicative of an improved ability to perform robotic-assisted segmentectomy as more cases were attempted. Second, adequate lymph node evaluation can be expected after segmentectomy, reducing the likelihood of missing positive lymph nodes. Although patients who underwent segmentectomy for tumours greater than 2 cm may be at a greater risk of experiencing recurrence compared to lobectomy, this population did not experience any reductions in overall survival. / Thesis / Master of Health Sciences (MSc)

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