Surgical innovation is a complex sociotechnical enterprise that couples human skill, team performance, organizational routines, and enabling technologies. This chapter synthesizes foundational concepts, historical lessons, and practical frameworks to guide responsible innovation from need identification through prototyping, evaluation, and scale-up. We distinguish invention, incremental improvement, and innovation; outline technical, procedural, and organizational modalities; and emphasize staged, risk-proportionate evaluation using IDEAL/IDEAL-D. Historical successes (e.g., minimally invasive surgery, enhanced recovery programs) and failures (e.g., poorly vetted implants) illuminate recurrent pitfalls and the necessity of transparent reporting, learning curve management, and postmarket surveillance. We detail processes for concept incubation, simulation and cadaveric rehearsal, feasibility and comparative assessment—including AI-enabled tools with SPIRIT-AI/CONSORT-AI/DECIDE-AI standards—and strategies for adoption, dissemination, and measurement of patient-centered outcomes and value. Ethical, legal, and professional duties are addressed, including informed consent for innovative procedures, conflict-of-interest transparency, equity, and de-adoption. The aim is a disciplined, patient-centered approach to cultivating surgical innovation that accelerates value while safeguarding trust and safety across diverse contexts.