Exponential Surgery

Welcome to my first newsletter on Xponential Health. I will cover many of the technologies that will impact health.

Around 2010, the concept of digital health was developed. Its definition is rather broad but can be thought of as: "digital technologies using computing platforms, connectivity, software, and sensors for health care. These technologies span a wide range of uses, from applications in general wellness to managing chronic disease or as applications in medical devices. They include technologies intended for use as a medical product, in a medical product, as companion diagnostics, or as an adjunct to other medical products (devices, drugs, and biologics)."

Surgeons have taken a while to jump on this bandwagon and claim digital as their own.

The first surgical operation was carried out in Borneo around 30,000 years ago. It was an amputation, involving the removal of the distal third of the left lower leg. The person survived the operation and lived for another 6 to 9 years. For centuries, surgeons have practised analogue surgery.

Recently, the term Digital Surgery has slowly become a concept and is increasingly accepted into the surgical fraternity. It has the real and exciting potential to revolutionise surgical practice. My own definition, having been a recognised pioneer over the last decade in this field, is as follows.

“Digital surgery are technologies that allow better visualisation and more precise surgery with real-time navigation and planning, uses data to drive and improve surgical performance and patient outcomes and offers high-fidelity simulation for training”

I consider digital surgery to have essentially five pillars, and remember these using the acronym

CARED

1. Connected surgery and remote collaboration.

2. Artificial intelligence and data analytics

3. Robotics 

4. Extended Reality

5. 3D printing 

We are now more connected than ever as a civilisation, with 95% of the world having at least a 3G connection. With the increasing availability of 5G and high-speed broadband, including Starlink, in many parts of the world, we are now hyperconnected.

Now, many platforms are available that allow surgeons to mentor from a distance using telemedicine. As the global ambassador, it is with pleasure to share that Rods&Cones have connected 1000+ hospitals globally using their augmented reality smart glasses platform to allow remote training. A real milestone on mass adoption. The mobile platform allows a surgeon to carry the set anywhere in a small case and set up in a few minutes, truly helping to democratise surgical training.

I can’t believe it has been 10 years since I performed the world’s first Google Glass operation to a global audience and, in a small way, showcased what was possible. In my opinion, Google Glass was at least a decade ahead of its time, and it has been muted that it is about to make a comeback of sorts. 

With the introduction of robots and hyper-connectedness, remote robotic surgery is no longer the realm of science fiction. In 2000, Professor Jacques Marasceaux performed the first remote robotic transatlantic surgery, a laparoscopic cholecystectomy with the patient in Strasbourg whilst with his team, he operated from a robotic console in New York, some 4000 miles away. The operation was called the Lindberg operation, named after Charles Lindbergh, who first flew across the Atlantic from Paris to New York. More recently, this was upgraded to version 5.0. 

In 2017, at the Fujian Medical University Mengchao Hepatobiliary Hospital, 5G was used to perform a robotic operation in China on an animal that was devoid of its liver. This demonstrated the latency and fast speed of operation in real time. The first cholecystectomy was carried out on a 30-year-old woman in Xinjiang, China, in only 30 minutes through remote surgery, in an operation orchestrated from more than 4,500km (2,800 miles) away. The operation is part of broader national plans to advance the use of 5 G-based robotics in medical care as part of the country’s five-year plan. There are now reports of robotic hysterectomies being performed remotely on patients in China routinely.

There has been a welcome proliferation of surgical robots over the last few years, offering choice and healthy competition to the consumer, but Intuitive's instantly recognisable Da Vinci robot completed much of the early groundwork and adoption into the surgical community.

As robots become smaller, sleeker, modular, with open consoles and increasingly more affordable, there should be rapid global adoption in emerging markets. The West has already reached its tipping point in adoption and will rapidly reach market saturation. For many countries, however, the robot remains an aspiration. Undoubtedly, many surgeons will be the first in their country to use the robot and counting the column inches in the national press and media.

Virtual Reality has finally found its place in surgery. We are now seeing more and more suitable content for surgical training, particularly in orthopaedic surgery, using computer-generated images built on platforms like Unity or Unreal Engine. The repetitive and systematic training improves surgical performance and helps surgeons understand the 3D perception and environment early in their careers.

Surgery is now also being augmented using smart glasses or mixed reality headsets. The incredible ability to overlay DICOM images from an MRI or CT with 3d visualisations allows surgeons to plan surgery or be guided during a surgical operation. The analogue surgeon is rapidly replacing the Swann & Morton scalpel with a digital one. There is also a digital-to-analogue transformation of surgical implants and prostheses created by the mesmerising technology of 3d printing, although the uptake and reimbursement models have been challenging.

Surgeons have always relied on two innate skills, developed over some time, to improve their surgical skill and diagnostic prowess. One could argue that intuition and judgment are more important than surgical OR skills. Could AI replace a surgeon? – Well, the answer, of course, is no, but certainly a surgeon's practice could be augmented. AI will become valuable to a surgeon, allowing more precise data collection, and the data collected will undoubtedly improve surgical outcomes.

If we look at the automotive industry, with the introduction of smart cars that aim to be autonomous (although no car has yet officially reached level 5 of true autonomy), we get a sense of what may be possible in surgery.

Companies use computer vision to train AI algorithms on thousands of surgical operations to allow real-time surgical navigation, which would be highly useful in video-assisted surgery like laparoscopy. Aiding a surgeon through a complex operation, perhaps to avoid essential structures or help define a cancer's margins, will support precision surgery. In 2017, we saw the world’s first “autonomous surgeon”, a somewhat grainy video of a robot performing a surgical anastomosis and a trained surgeon. This has not been repeated, interestingly, or reported widely, which casts doubt on the claimed outcome.

Surgery is often compared with aviation regarding ensuring safety with the introduction of checklists, but now we have a new analogy. We can now collect all of the data from the OR, including the laparoscopic video feed, patient biometrics from the intensive monitoring of the anaesthetised patient, and a birds-eye view via cameras of the entire surgical team in action. The data is collected in the so-called surgical black box, comparable to an aeroplane flight recorder. This data could be used to examine individual and team performance and provides documentation of a procedure allowing risk analysis when things do not go as planned.

The silver scalpel accolade is awarded yearly in the UK to the best national surgical trainer. I was most fortunate to be awarded this in 2016. I wonder what the best digital surgeon will be awarded in the future. Answers on a postcard?

To follow the latest news on the world of surgery, visit https://surgery.international/