The Future of Surgery: How Technology Is Transforming the Operating Room
By Michael Keller
It’s a decade from now, and you’re stable in the ICU after a recent heart attack.
Your doctor harvests some of your stem cells while a 3D printer outputs a drug-impregnated stent that has been designed specifically for the dimensions of your heart valves. Meanwhile, nurses prepare an injection of your cultivated stem cells and factors that trigger tissue regeneration.
As you go gently into light sedation, the surgeon dons augmented reality (AR) glasses that overlay your vitals and critical imaging data in her field of view. As the procedure unfolds, she guides a catheterization robot to your heart, deposits the stent to open a dangerously narrowed artery and continues on to inject the therapy in the damaged cardiac tissue.
Within days, your heart is almost repaired and your blood is flowing smoothly.
This minimally invasive surgery would have been unthinkable just a few years ago. But new technologies are already transforming modern surgery for physicians and patients. It’s the early stages of a revolution that will improve surgical training, procedure planning, health system efficiency and ultimately, patient health outcomes.
“Technologies like robotics, VR and 3D printing are making once complex, high-risk surgeries now commonplace and standard,” says Daniel Colling, HP’s global lead of clinical workflow and healthcare solutions. “The outcomes of this technology provides patients a lower risk of infection during and post-surgery, less time recovering and better health outcomes. These advances are about patient quality of life.”
Digital transformation sits at the heart of this new era. Smart sensors, instruments and machines can generate volumes of patient data, from advanced imaging to vitals monitoring. These are the raw materials that robots and cutting-edge tools like virtual reality and surgical navigation systems can use to speed procedures and make them more accurate
Also driving this new era forward: A global shift toward value-based healthcare that moves away from the old fee-for-service model to one that pays doctors and hospitals based on patient health outcomes.
Colling points to once complicated, time-consuming procedures like an appendectomy or coronary artery bypass graft surgery (CABG) to illustrate how far new technologies are pushing healthcare.
“Cardiothoracic surgeons used to have to perform large incisions and crack open the entire sternum to access the heart,” he says. “Now it can be done with minimal invasion. That’s huge.”
He sees a near future in which doctors 3D print anatomical models to plan procedures and educate patients about what will be done to them, then go into VR to simulate important steps of the operation and finally, use robots to perform the procedure with pinpoint accuracy.
Robots and AI become surgeons’ indispensable tools
About a dozen robots built for the OR already assist with hip and knee surgeries and specialized procedures like spinal, abdominal, or laparoscopic surgeries. Intuitive Surgical’s da Vinci robotic system has been in operation for almost two decades and has performed more than 6 million colorectal, thoracic and other minimally invasive operations where major surgeries used to be required.
While robots in the OR are not new, robots will soon help doctors reach patients who otherwise wouldn’t benefit from them, thanks to robust and hyperfast 5G cellular networks that are coming. As just one example, remote surgeons will be able to use robots as their eyes and hands in disaster zones and distant clinics.
And the field is about to explode with new models designed to operate on eyes, hearts and brains, according to Roger Smith, the CTO of Orlando, Florida's AdventHealth Nicholson Center, which trains more than 100 surgeons a year to use robotic systems.
“Some 40 companies are making robots that we expect to see on the market in the next five years,” Smith says. “More surgeons will be adopting robotic assistance because they’re recognizing this is the next generation of tools to help them do their job better.”
Smith also expects artificial intelligence to play a significant role in robotic and traditional surgeries. For example, AI systems could analyze thousands of hours of surgical videos to develop custom procedure planning. When combined with augmented reality, computer vision-equipped AI could detect anatomical structures such as major nerves and alert surgeons nearing them to keep their cutting instruments away.
Virtual reality training
These new technologies are also crucial for advancing education. VR visualizations are already helping train surgical teams for new procedures and instruments before they enter the operating room. They can also assist surgeons in planning complex operations and help doctors communicate with patients, who can view a pre-op simulation of the surgery through a VR headset.
Years ago, trainers started using VR to help teach doctors how to use robotic systems. Smith says his training center now holds 10 simulators that surgeons must practice on before they move to real da Vinci robots. The VR environment, he says, provides an unmatched training tool.
“The simulator measures your performance constantly and tells you if you’re wasting your movements so you can improve your work,” Smith says.
And VR systems are proving valuable to more than doctors. Perioperative nurses — who assist surgeons — are also being trained with them. One system, PeriopSim, which just came on the market in May, is already being used in a handful of hospitals.
PeriopSim counts on HP technology, including the HP Reverb headset, to create a vivid, immersive experience that mimics what nurses will see in the operating room, Angela Robert, Conquer Experience’s CEO and cofounder, says. The headset is paired with a handheld controller that trainees use to get a feel for picking up instruments and handing them to surgeons. This invaluable tool instills muscle memory in nurses using it so they’ll be ready for the real thing.
The system distills down surgeries that can take an hour or longer into 10-minute simulations. These help nurses anticipate what a surgeon will need, and gets them familiar with the names and handling procedures for complex and often dangerous instruments. It can also expose perioperative nurses to rare operations like emergency neurosurgery, which they may see only once or twice a year in real life.
Augmented reality helps surgeons see inside
Where VR brings users into an immersive video game-like 3D world through a wearable screen, AR is meant to lay visual data over the real world when a user dons transparent glasses.
SentiAR is building that capability for surgeons. Berk Tas, the firm’s CEO and president, says AR is critical to give doctors access to all of the information being generated by monitoring, imaging and diagnostic systems during operations.
“All of these systems sit alone in the OR creating data,” Tas says. “Meanwhile, as humans, we have limitations to the amount of data that we can make sense of all at once. So we’re creating a connected environment, where data is contextualized through holograms and delivered to the surgeon at the time of need.”
Tas expects the FDA to clear SentiAR’s first offering by the end of 2019. It will offer catheter lab clinicians a model of a patient’s heart that floats before their eyes to help plan and execute procedures faster and more accurately. They will be able to navigate hands-free through this model based on anatomical mapping.
“In the future, entire procedures will be digitized, and doctors will be able to communicate with the instruments that surround them through voice, gesture and gaze,” Tas says.
Surgical procedures aren’t the only parts of the OR going digital. Rapid advances in 3D printing — where layers of metal or polymer materials are deposited on top of each other to create complex designs — could soon change how surgeons get tools in their hands.
Today, hospitals must order and stock surgical tools from distant manufacturers in a process that’s often wasteful and inefficient, because specialized tools come in kits that can contain instruments the surgeon doesn’t need. But researchers are pushing forward with ideas to 3D print instruments on-demand with no stockpiling, shipping or unwanted kit components.
One Army and Navy team found that a plastic surgical retractor they printed could do the job of much more expensive metal instruments. “Our estimates place the cost per unit of a 3D-printed retractor to be roughly a tenth of the cost of a stainless steel instrument,” they wrote in a paper published in the Journal of Surgical Research.
Engineers are also making significant progress 3D printing implants and prostheses that perfectly fit a patient’s dimensions. 3D printed implants from sugar-based vascular stents that hold blood vessels open during surgery and then quickly dissolve to polymer-based, biodegradable grafts of defective blood vessels themselves are on the way.
Colling says HP has been innovating on all fronts related to 3D printing for healthcare. Researchers have taken HP’s deep expertise in microfluidics printing technology and are now applying it to innovate therapeutic applications, including printing pharmaceutical samples to accelerate the testing of new antibiotics and 3D printing custom-built prosthetics.
“3D printing has been around for a while, but the technology for producing durable color anatomical and implantable parts didn't exist and wasn’t scalable, especially for healthcare settings,” Colling says. “HP has broken this barrier with its Jet Fusion 3D printing technology and we’re now partnering with others to bring it to scale.”
Bioprinting aids regeneration
Data is also helping scientists and surgeons better understand the basic biology underpinning our bodies. Armed with new insights, researchers are making biotechnology products that help patients heal.
In May, researchers revealed they had successfully used a 3D printing technique called projection stereolithography to engineer blood vessel networks. The news, which was big enough to land the cover of the journal Science, showed how far tissue engineering and 3D bioprinting has come.
Scientists have been working on bioprinting for decades with the promise that it will one day be a powerful tool for regenerative medicine. Burn patients could have compatible skin grafts printed in the OR and transplanted on the spot. Those with lung defects could have some of their stem cells harvested to grow a new, better pair.
Some of these ideas have already made it into clinics. In 2016, the U.S. Food and Drug Administration approved the first engineered tissue, lab-grown knee cartilage made from a patient’s own cells. Others have been approved to repair bone, skin and cardiac defects, and more are in the pipeline. Researchers also see huge potential in creating tissue and organs from a patient’s cells for personalized drug screening and disease modeling. Meanwhile, some are investigating using engineered tissue like mini-brains to test new therapies.
The promise of 3D printing a kidney or knee cartilage on a lab bench is only one of the sci-fi-like possibilities, says Ali Khademhosseini, a University of California, Los Angeles, chemical and biological engineer. Many scientists see an even more significant opportunity in so-called in-situ regeneration.
The idea is to deliver therapies that trigger the body’s own tissue engineering capabilities to a patient’s defective or injured part. Khademhosseini says research is underway to harvest heart cells, reprogram them and reintroduce them after a patient suffers a heart attack to heal and restart the organ. Another recent study healed skin ulcers by applying sheets of cells to turn on the body’s ability to regenerate.
“We have a lot of opportunities for bioprinting even outside of printing something like a whole heart for transplantation, which is still a long way off,” Khademhosseini says.“I’m confident we can make healing from injury or defect much better and faster.”
With advances like those being made in Khademhosseini’s lab, and in robotics, VR and AR, the future of surgery will usher in a revolution in human health. Using patient data, AI, biotechnology and highly trained healthcare professionals, “we believe we can make doctors superhuman,” says SentiAR’s Tas. “When they’re put at the center of all these digital tools and the contextualized data the instruments are creating, surgeons will have abilities they never had before.”