The Coming Push For OR

Now is the time to start thinking about and preparing for what the future of OR technology might look like.

Technology changes at such a rapid pace that it can be hard to keep up with the latest developments. This is especially true when it comes to healthcare technology in general – and perioperative technology specifically. A wide range of new technologies is changing how many perioperative procedures are performed. Often, the results are improved surgical outcomes and higher levels of patient satisfaction.

Hospitals are investing in new devices, designs, and digital technologies that promise a new era of innovation for surgery. The moves are part of a growing shift away from traditional open procedures that involve big incisions, lots of blood loss, and long hospitalizations. They point toward a future where more patients can choose minimally invasive outpatient surgeries, with faster recoveries, fewer complications, and less pain and scarring.

These new technologies cover a range of advances. With some, surgeons can control robot cameras with eye movements as they move into patients’ bodies through tiny incisions. With others, doctors can create a GPS-like map projected onto a patient’s body to virtually see inside the anatomy before an operation, track their surgical tools, and help them operate more precisely.

Other advances aim to reshape the operating room (OR) itself, by adding more space for surgeons to work as well as imaging equipment that lets patients receive X-rays and other tests on the operating table instead of getting shuttled around the hospital. And Machine Learning and Artificial Intelligence (AI) technology is being developed to let surgeons tap into big data before, during and after they work, to get guidance from computer systems that have analyzed the procedures and learned to make recommendations.

If successful, these changes could have a profound effect on patients. Despite years of progress, surgery remains a risky field. Infections are a frequent complication and can cause death. Studies have shown that even in the same hospital there are large variations in outcomes among surgeons, related to differences in judgment, skills, and individual capabilities. Lower-skilled surgeons have higher rates of complications, readmissions to the hospital, and repeat operations. New technology could help level the playing field.

Of course, many technologies are still in development, and others have yet to be widely adopted or fully evaluated for safety and cost-effectiveness. And some in the healthcare industry warn about embracing new technologies too quickly.

Technology trends
Some of the new technologies promise to reshape ORs in the years to come.

Expanding OR. One of the most basic changes in store is the redesign of the OR. Some hospitals are creating hybrid facilities that combine conventional ORs with imaging equipment used in minimally invasive treatments that rely on tiny tubes inserted in a blood vessel or a body cavity. That way doctors can do both open surgery and minimally invasive procedures instead of scheduling them at different times. For patients, it means avoiding two separate procedures under anesthesia, and less time in the hospital and recovery.

For an idea of how this could improve treatment, consider cardiac catheterization, a so-called interventional procedure, where a tube is inserted through a blood vessel to reach coronary arteries. Doctors might use the catheter to insert a stent to improve blood flow to the arteries, but patients might also need open surgery to bypass the blocked artery. In a hybrid operating room, doctors can immediately shift from the less invasive interventional procedure to open surgery.

More responsive robots. No discussion of OR technology would be complete without mentioning surgical robotics and AI. Research is mixed on the benefit of robotic-assisted surgery, introduced nearly two decades ago as a more precise alternative to conventional minimally invasive surgeries, or keyhole surgeries, in which surgeons make small incisions and use a laparoscope—a thin telescope with light and a video camera—to insert special tools with long, thin instruments. Many studies suggest robotic surgery has fewer complications and shorter hospital stays, but others show lower success rates in some types of surgery and other negatives, including higher costs.

Developers are working to make such systems smarter, cheaper, and more autonomous. For example, researchers are working on programming robots to do such tasks as stitch up tissue after a surgeon is done, which could help prevent problems for patients such as leakage from sutures that are not consistently tight. The market is dominated by Intuitive Surgical Inc.’s da Vinci Surgical System, which has been used in more than five million surgeries worldwide. A number of new companies are also entering the market, including medical device giant, Medtronic PLC and TransEnterix Inc., which received approval from the Food and Drug Administration in 2017 for its Senhance Surgical System in some surgical procedures.

Artificial Intelligence. Achieving the scale of AI that will be necessary for healthcare applications will require tremendous computational power and the IT infrastructure necessary to support it. The computer power needed for this is now on the horizon and the medical software engineers who can create the matrix are out there.  In the short term, AI will be able to help improve scheduling and resource coordination and help make hospital HIS systems more user-friendly.

AI algorithms are being used with ultrasound devices to do much of the work of calculating in the perioperative environment. For example, AI combined with ultrasound can help nurses easily and non-invasively identify how much urine is in a bladder. Ultrasound guidance for challenging peripheral IV placement has taken what was once nearly a mythical artform and made it routinely easy to perform. AI can help novice nurses identify correct structures and suggest the best approach and even catheter and needle size. AI-driven ultrasound applications can help even a near-novice OR nurse identify a pneumothorax causing hemodynamic instability or oxygenation problems in seconds. In the near future, an automated cardiac assessment with AI-driven ultrasound tools will be able to rapidly help identify hypovolemia, depressed systolic function, pericardial effusions and other pathology which could cause rapid patient deterioration at the most critical times.

Better decisions with Big Data. A new generation of digital surgery tools aims to combine robotics, big data, and other technologies to let surgeons make much better decisions when working on patients. The most closely watched new entrant in this field is startup Verb Surgical Inc., a partnership between Google parent Alphabet Inc.’s Verily Life Sciences unit and Johnson & Johnson’s Ethicon surgical equipment division. The partners are referring to their concept as surgery 4.0, the next step after traditional open procedures, minimally invasive surgery and the introduction of robotics. Verb is offering scant details on how the system will work. But the idea involves using a type of AI known as machine learning—computer programs that can crunch data from thousands of past surgical procedures to identify best practices and potential errors.

The system could let surgeons train before an operation, and then assess how they did after the operation, measuring things like procedure time, the economy of motion, and the number and type of instruments used. Eventually, the system will help surgeons make decisions in the midst of an operation, from suggesting the right technique in a particular surgery to warning of potential mistakes such as the severing of a blood vessel.

Verb plans to release its first product in 2020 and has already demonstrated a fully working system to its parent companies.

Speech control. Today, most high-tech systems in the OR are touch controlled. With new, touchless methods of software control being developed for everyday devices, the future of the OR will also offer the surgical team new ways of interacting with devices and software. The sterile field in the OR is essential for protecting the patient from potentially life-threatening pathogens. Offering the surgeon, the possibility to control devices and software without having to leave this field, keeping their hands free to operate on the patient, will have a huge impact on outcomes and patient safety. Existing touch based technologies to address software within the sterile field include draped ceiling-mounted and handheld displays. In the near future, however, touchless solutions, like gesture recognition, eye tracking and speech control, will enter the OR.

Gesture recognition can be inefficient and even counterproductive since it takes the surgeon’s hands away from the patient. Bright OR lights can interfere with the correct interpretation of hand movements. At this point, the variety of gestures as commands is limited and the technology as a whole still requires a lot of development. Addressing some of these potential issues is eye recognition, which quickly identifies the user’s field of view. While completely hands-free, this method is still fairly inaccurate and suffers from the Midas touch problem: Involuntarily triggering actions by accidentally looking at the controls.

While Apple Siri, Google Home, and Amazon Alexa have made speech control an everyday reality for many, experts believe that speech control will also play a significant role in the OR of the future.

Clearer views inside the patient. A variety of technologies aim to let surgeons better see what they are working on inside patients as they operate. A company is developing a method, which will let doctors visualize organs and tissues in real time, such as showing where a tumor ends and healthy tissue begins. Its technology, Molecular Chemical Imaging, or MCI, combines spectroscopy, the use of light to measure materials, and digital imaging. The technology is broadly applicable and will be designed in the future for use with endoscopy procedures, in which doctors insert a tube with a camera that allows them to view and operate on organs. It produces images in real time based on the evaluation of distinct colors in the visible light spectrum and beyond what the eye can see in the near-infrared light spectrum. MCI uses more colors overall than current cameras, which only use red, blue and green in the visible light spectrum.

Way forward
In the future, the integration of OR systems with various devices will also play an increasing role and present a challenge for manufacturers and users. At the moment, all manufacturers have their own operating philosophy the OR staff needs to understand. In the future, this should be different from  where the different technologies communicate with each other and equipment can be used effectively. Even though these ideas have already been initiated, they will continue to accompany the industry over the next few years and perhaps even over the next decade.