Some technologies may look good on stage but do not work in the OR

Tuesday, July 9, 2024

Which technologies in the operating room have the greatest potential to improve surgeon and patient outcomes, and which are just hype? Interview with Professor Marlies P. Schijven, MD PhD, surgeon, Chair on Digital Health at the Amsterdam University Medical Centers (Netherlands).

How did your journey into the world of healthcare and digital technologies begin?

Well, I took a somewhat unconventional path: I started my training at the Design Academy.

Really? That's quite a detour from healthcare.

Yes, it is. I spent a year there, which expanded my perspective on creativity and solutions. After that, I studied Health Sciences and then Medicine. Though short, the Design Academy experience primed my brain uniquely and broadened my worldview.

How did this creative background influence your approach to medicine?

It definitely shaped my approach. In healthcare, especially in surgery, we are often challenged with problems for which there is no standard procedure or solution. My background helped me appreciate the value of creativity and interdisciplinary collaboration.

Gaming, for example, is one of the oldest forms of learning and exploration. Everyone plays—it's a natural way to stimulate learning and problem-solving.

Did you find it challenging to introduce these ideas to your peers in the surgical field?

Yes, initially. But things and times are changing. My chair was recently renamed from Simulation, Serious Gaming, and Applied Mobile Healthcare to Digital Health, which reflects the broader realm and use of technology in healthcare. In the surgical environment, though, it remains challenging. Surgeons need to focus intensely, and adding too much technology can be distracting. The key is to integrate technology in a way that supports us without adding clutter.

There's so much buzz around technologies like AI (Artificial Intelligence), VR (Virtual Reality), and AR (Augmented Reality) in healthcare. What's the most significant breakthrough you've seen?

AI is definitely generating a lot of excitement. The technology itself isn't the problem—it's about how we manage its limitations and potential errors.

We must accept that technology, like humans, can and will sometimes fail us. It's a matter of agreeing upon what failures we can afford and how to deal with them appropriately. The starting point for me is to classify technology as software as a medical device—healthcare professionals must get safe-to-use solutions.

For instance, well-built algorithms can outperform humans in pattern recognition but also can be wrong sometimes. Establishing acceptable margins for these errors is crucial to making the most of AI.

Among all these technologies, which one is currently the most beneficial for patients and healthcare professionals?

It's hard to choose just one, as multiple technologies are making significant strides in healthcare. Algorithms are already making a difference in radiology and Intensive Care Units (ICUs). For instance, the "PacMed Critical" decision support algorithm helps determine which ICU patients can be discharged sooner, which is invaluable in times of bed shortages. This not only optimizes bed usage but also ensures patients receive the right level of care at the right time, thereby improving overall patient outcomes.

In the Operating Room (OR), algorithms are now developed to optimize scheduling and predict operation durations, enhancing efficiency. We were the first hospital to install a black box in the OR back in 2016, and we're now working on installing a new version to improve processes through data-driven insights. This kind of technology allows for better analysis of surgical procedures, helping identify areas for improvement and reducing the likelihood of errors.

Photo by: Davy Rietbergen, dutchmedicalmedia

Are surgeons already using VR or AR goggles during operations?

Not really. You cannot operate with the VR system on your head. You have to see very clearly what you are doing, and it's for nothing that we have 4K screens or 3D cameras.

I don’t know any surgeons actually operating using VR glasses because—quite simply—you cannot see through them. Some surgeons are operating using AR glasses to overlay images onto their working field in neurosurgery or orthopedic surgery, where the head or limb is fixed so the subject for the surgeon cannot move. But these are still very much piloting efforts. That does not work for abdominal surgery, as the patient breathes and intestines move.

VR and AR are more useful for surgeons to train and simulate—including planning an operation—than for actual surgery. For instance, I've worked with Google Glass in the OR, live streaming and collaborating with another surgeon in real-time, but it was more about addressing latency and technical issues. In surgery, clarity and practicality are paramount. We use 4K screens and other supportive technologies that are more feasible for real-time operations.

VR has some value in instructing patients, although it's costly and more like a gimmick. You can also explain very well if you sit behind the monitor and take the patient through the image, translating and conveying what you're seeing to the patient. However, having a 3D vascular system on a VR display still confuses the patient. It's very costly to have such a system in the outpatient clinic; it needs to be securely stored, charged and maintained, and it's not feasible for all patients. It requires a lot of time, which we don't have.

What is most important for surgeons is to strive for seamless integration of all the tech around them. Technologies must support healthcare professionals without overwhelming them. This includes everything from improving surgical precision with better imaging to reducing administrative burdens for all healthcare workers with smarter systems. The goal is to enhance patient care while making the healthcare environment more efficient and less stressful for professionals.

What about surgery robotics? Are autonomous surgeries the future of operating rooms?

Of course not. The robot is the extended arm of what the surgeon does behind the console. A surgical robot does not operate independently. It merely allows the surgeon performing laparoscopic (key-hole) surgery to move around in narrow spaces and has no tremor. As a downside, when a surgeon operates with a robot, there is no ‘feeling’ for the surgeon of the tissue anymore, a quality which is preserved if you operate normally or laparoscopically. The use of the robot has shown some significance in the outcomes of urologic surgery when the surgeon has to operate on a small pelvic area. It's popular with patients because they believe the robot is better—but they do not really understand what a surgical robot does. For many hospitals, it's also a marketing tool. The neighboring hospitals have it, so hospitals feel they cannot stay behind, and more surgeons greatly value performing surgery supported by a robot.

Surgeons really like it. You sit comfortably behind a monitor in a console, with the robot performing the actions you direct. In terms of ergonomics, this is great. That is a definite plus, as training surgeons is very expensive, and we also need to protect our workforce. However, the use of a robot is incredibly costly for society. The robot itself costs millions. And the manufacturer requires the disposal of instruments after six uses, which adds up significantly. The costs of training surgeons and hospital staff, along with the use of disposables, easily amount to several million euros per year. So we must choose when being on a budget. For instance, doing gallbladder surgery with a robot has no value over standard laparoscopic surgery except maybe for training on the robot for the surgeon, and it is extremely expensive. You could do many more laparoscopic gallbladder surgeries for the same cost.

We have to balance everything. For now, we cannot solidly state that robotic surgery leads to better outcomes, even though research on it has been done for many years. It might be more beneficial if future studies can show significant advantages, especially for the surgeon. But with environmental concerns like CO2 impact and high disposable rates, it’s a complex issue.

If there is no substitute for surgeons' hands, then what? We face a massive shortage of healthcare professionals.

You can look at it differently. Surgeons of my generation operated without robots, and many of us happily did so until we were 65 or older. It's also about what we accept in terms of comfort for the surgeon. Of course, as a surgeon, I’d say give me a robot—it's easy and pleasant. But we must weigh everything carefully. There are areas where simulation, for instance, can help a lot. Training people for specific procedures using simulators is valuable, especially for repetitive tasks like dental surgery or cataract surgery.

Simulators can train people in procedures that need to be done frequently and can be valuable in regions with high demand for procedures like lens replacements for cataract surgery. You don’t need a highly trained eye surgeon for a relatively simple and straightforward procedure. It's about finding opportunities where technology meets the demand. It’s an ecosystem. People must understand the dilemmas involved, not just accept technology because it's there or it is hyped. It’s about making informed and calculated decisions.

…and carefully picking technologies that make sense, not just following market hype.

Exactly. Technology in itself doesn't have a value; it's the context and the questions it addresses that make it valuable. For example, training more surgeons using a dental simulator is perhaps useless in a place where there are already enough, and even unemployed, dental surgeons. We must consider the context for technology to thrive. In the end, human resource management is crucial. Technology should not be the primary focus. Start with the 'why.' Many think, "I have a robot. Now, what can I do with it?" That's not the right approach. It's about ensuring the technology serves a real purpose.