The OR of the Future


Reinvented spaces will be automated, collaborative and capable of generating endless data to analyze.

Imagine walking into the operating room of tomorrow and feeling out of place in unfamiliar surroundings. “ORs are going to look very different in the future,” says Michael P. Ast, MD, vice chair of the HSS Innovation Institute and chief medical innovation officer at Hospital for Special Surgery in New York City. “Nothing will be on the ground. Data and images will be displayed on floating screens or digitally projected into augmented reality (AR) glasses. Things like patient information, the consent form and the timeout checklist could be visible to everybody in the room at the same time.”

Dr. Ast says the increase of higher acuity outpatient surgery is combining with the emergence of advanced technology such as tracking and automation systems, computer-assisted surgery, robotics and AR. “I think the platforms will combine to automate the entire surgical experience,” he says. “Eventually, every surgeon could wear some type of AR headset, and when using robotic or computer-assistive technology, they’ll see everything right in front of them in the surgical field, and the information will be projected for everyone else in the room to see.”

The cables and wires that connect and power monitors and anesthesia equipment will be gone. “Everything will be wireless, making it simpler, easier and safer to use,” says Dr. Ast.

He believes patients will be tagged with wireless technology that identifies them throughout the perioperative process and connects to their relevant clinical information. “This will make patient care easier and more personalized,” says Dr. Ast. “The technology will perform its own safety checks and alert the surgical team if the wrong patient is in the wrong OR or about to undergo the wrong surgery. The more we implement technology, the safer surgery will become.”

Dr. Ast says video monitors on stands, booms and walls will disappear in a decade or so as more powerful and ethereal tech takes hold. “Imagine information being everywhere,” he says.
He likens surgical video of the future to mirrors in today’s upscale hotel rooms that turn into TVs. “Similarly, a window into the OR could become a projection screen,” he says, predicting these types of displays will convey information and video from a variety of sources — the computer at the nursing station, arthroscopy equipment, the procedure itself.

AR technology has the potential to be transformative, according to Dr. Ast. “Think about holographic design,” he says. “If you link video with an AR headset, it would project anywhere you looked.” He believes AR will allow OR personnel to work better, faster and more in tune. During time outs, for example, everyone’s video feeds could switch to whatever is collectively urgent, such as a surgical consent form.

Technology will also enable remote surgeries and collaboration. “A really big benefit would be live on-demand mentorship,” says Dr. Ast. “Through an AR headset, an expert surgeon offsite could watch the surgery. If you have a quick question, or it’s a complicated case, they’re right there to help walk you through it.”

Future ORs likely won’t need to be large, even though the current trend is toward building larger spaces for higher-acuity cases. “Technology doesn’t tend to get bigger,” says Dr. Ast. “When we started with computer navigation for knee replacement, it was a big line-of-sight console. Now the navigation technology we use is literally in a smartphone. As the technology improves, we’ll need less space.”

Another cool possibility: Checking out another surgery center without traveling to it. “Suppose a facility in Pennsylvania wants to start an ambulatory spine or joint replacement program,” says Dr. Ast. “They could virtually visit a center in Washington that’s already doing it and take a walk through their day. That surgery center could have a patient or surgeon wear AR glasses, and the remote team could see how they orchestrate the perfect patient experience and replicate it. It will enable sharing of best practices in a much logistically simpler way.”

Information overload

MOVING FORWARD In 2020, Hospital for Special Surgery’s Dr. Jonathan Vigdorchik became the first surgeon in the U.S. to complete an augmented reality-assisted knee replacement.  |  Hospital for Special Surgery

Gina Adrales, MD, MPH, FACS, director of the Johns Hopkins Medicine division of minimally invasive surgery in Baltimore, says tech will bolster the unique talents of surgeons, enhancing their performance to improve precision, safety and efficiency. She believes collection and analysis of OR data through “black box” systems, analogous to those found in airplanes, will be extremely valuable for process improvement and patient safety, particularly regarding near-miss events that may go unreported today.

“A number of things happen within ORs that never come to light because they don’t result in adverse consequences to patients and were caught, mitigated or didn’t make a difference intraoperatively,” she says. “We could learn a lot from those events to continue to improve patient safety. We need to do whatever we can to use automation in the OR to catch near misses that everyone can learn from, that could be shared non-punitively to change the system.”

Carla Pugh, MD, PhD, FACS, a professor of surgery at Stanford University School of Medicine and director of the Technology Enabled Clinical Improvement (T.E.C.I.) Center, is researching wearable technology for surgeons to improve their clinical skills and performance in the OR. It’s likely this kind of rich performance-based data collection and analysis will make its way to surgical facilities by decade’s end.

Her research centers around haptics — the science of touch — to understand more about perception and decision-making, and how it interplays with actions such as dissecting, cutting and suturing. “Surgeons make moment-to-moment adjustments and modifications, and bigger movements such as their reaction time when there is bleeding, and what they choose to do,” she says.

Dr. Pugh is studying the benefit of fitting surgeons with tiny magnetic motion-tracking sensors that provide detailed information about velocity, force and depth perception, with a focus on what she calls precision moments. “The motion sensors give a whole lot of information we are currently not tracking,” she says. “It tells a lot about what surgeons are thinking and seeing, when they’re moving quickly and when they move slowly. It turns out experienced surgeons move slowly during the most important part of the operation.”

Her work is focused on changing how information is exchanged about surgery and comparing processes versus outcomes. To establish a performance baseline, Dr. Pugh employs the sensors during procedures with animal tissue and cadavers rather than in live ORs where patient anatomy and other variables can differ greatly. One sensor is on the surgeon’s fingertip, while others track EKG and eye movement. “Eye tracking provides a whole other layer of information,” she says. “They can see where their eyes are moving, and we can synchronize that with video.”

That synchronization — enabled by wearable, overhead and endoscopic cameras — provides extremely valuable performance insight. “You can see the patterns in the data, and the video allows you to see what they’re actually doing in that moment,” says Dr. Pugh.

Down the road, this type of performance technology could be common at surgical facilities — but to what end? For Dr. Pugh, the focus should be on performance improvement, rather than “ranking” surgeons for marketing purposes. “The technology should be used for training — to shorten the learning curve from novice to competency, from competency to mastery,” she says.

Automated robots

PASSING GRADE Johns Hopkins’ Dr. Axel Krieger inspects the anastomosis formed by the Smart Tissue Autonomous Robot.  |  Max Aguilera Hellweg

Axel Krieger, PhD, an assistant professor in the Department of Mechanical Engineering and the Laboratory for Computational Sensing and Robotics at Johns Hopkins University in Baltimore, worked with colleagues for ten years to develop the Smart Tissue Autonomous Robot (STAR), which recently performed a robotic laparoscopic surgery in pig intestines without direct surgeon assistance.

“We spoke with surgeons to analyze where their biggest struggles are during soft tissue surgery — what creates a lot of complications,” says Dr. Krieger. “When performing an anastomosis, surgeons place close to 20 sutures, and one mistake will result in a leak and complications. The technique requires a lot of precision and repeatability, so it’s ideal for robotics. The robot doesn’t get tired or make mistakes.”

Dr. Krieger’s team of engineers set STAR up while a surgeon prepared the anastomosis site, positioned the robot and then supervised the procedure, with the ability to intervene if necessary. The robot automatically created a suturing plan, which the surgeon could confirm or modify.

“The robot simplified the suturing procedure, but the improvements really came in the quality of the anastomosis,” says Dr. Krieger. “We compared the outcomes against expert surgeons and demonstrated in a statistically significant experiment that the robot can increase the consistency of each suture placement.” He notes the robot eliminated unsuccessful or nonoptimal needle placements that cause tissue trauma.

Dr. Krieger hopes to broaden STAR’s application. “We’re excited to move from the preclinical stage to clinical experiments,” he says. “I see a lot of uses outside of suturing that are critical, such as precision tumor resection surgery or trauma surgery.”

Something Dr. Krieger doesn’t anticipate this decade is fully autonomous surgery on humans. “Maybe in the distant future that could be possible,” he says. “It’s more likely that surgeons would engage autonomous function for parts of a surgery, such as suturing. We haven’t gone from completely manual to fully autonomous cars — technologies such as parking assist have evolved over time. I think something similar will happen with robotics.”

Surgeon feedback about STAR has been very positive, according to Dr. Krieger, who says physicians he’s spoken to are excited about his team’s ideas, which could help them perform complex surgeries with better outcomes.

So perhaps one important aspect of futuristic surgery will look familiar. “Surgery requires so much more knowledge beyond physical skill to master,” says Dr. Krieger. “It’s really not our goal to replace the surgeon.” OSM

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