The OR of the Future

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.

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