Theatre of dreams – the future of surgical technology

Patients watching their own surgery like it's a video game. Doctors in New York operating on patients in France. Surgeons talking to computers in futuristic digital theatres. It all sounds a bit sci-fi, but as medical care joins the digital revolution, hospital operating rooms are evolving beyond recognition. However, there's a danger of this all sounding a bit abstract. What is life actually like in these new surgical environments? How is the surgeon's role changing as technology improves? And what are the actual benefits for patients?

In the Vale of Glamorgan, the most southerly part of Wales, lie two incredibly sophisticated operating rooms. Opened in 2010, Vale Hospital is considered one of the most technologically advanced hospitals in the world. In its two state-of-the-art operating rooms you can find high-definition image resolution on screens suspended from the ceiling; see integration broker technology giving surgeons instant access to patient information - from videos to X-ray images and other crucial documents that can be shared electronically between theatres; and find patient information stored digitally inside the hospital mainframe, for use whenever a problem arises.

There's plenty of justification for a complete overhaul of the present-day operating room; many just aren't designed with efficiency in mind. Multiple bottlenecks are created, lowering the turnover of patients, and even if high-tech new devices are added, they tend to be introduced haphazardly into an environment full of industrial-age tools. Improved and well-integrated technology could enhance patient safety and reduce the cost of care.

So are custom-designed suites the way forward? David Pemberton an orthopaedic surgeon at Nuffield Cardiff and Vale hospitals, certainly thinks so.

"This digital theatre system we've got now is such a leap forward from what was available previously," he says.

The kneed for clarity

Pemberton first qualified as a doctor in 1984 and has been a surgeon for the past 19 years, specialising in knee surgery. He was part of the first generation of surgeons to grow up with arthroscopic and endoscopic surgery, and has seen technology progress immensely over the years.

"As a junior trainee, I knew I could see inside the knee better with an arthroscope than some of my senior colleagues could do by opening it. That was a major shift in the way surgery was going. But of course, at the time, we were restricted by the technology," he says.

"In the 1980s, we used very primitive arthroscopes, which we would stick inside the knee and look down a little lens to get a visual idea of what was going on. What you could do then was relatively restricted. But new technology started to come in, and we began to have cameras at the end of the scopes and could observe what we were doing on a video monitor. We could record what was going on inside the knee with still photographs and then, later, in real time."

Not all of this technology was introduced in the most efficient way however. Changes in IT, invasive surgery and imaging technology were positive but often happened without much coordination or integration. When Vale hospital was opened five years ago as a joint venture with Nuffield Health, it was an opportunity to build something from scratch using new technology in a logical, efficient way.

"Around ten years ago, I and a group of other surgeons got together and started out on the road to build our own clinic and hospital," Pemberton says. "Because it was a brand new hospital, we had the opportunity to look at all the fittings and fixtures closely.

"One of the key things we wanted to do was have these digital theatres. We wanted to set up the entire theatre capacity digitally and then link it to the hospital computer system so it could be accessed from the outside. We were one of the first in Britain to do this."

Silver screens

The impact of these changes has been dramatic for Pemberton and the other practising surgeons, as well as for the patients being treated. Take high-definition imaging: the clarity of the images contained on the screens means the surgeons can see what's going on inside patients far better than they could in the past, and that makes their lives a lot easier. Procedures are quicker and more efficient, and it also makes the patient safer - the surgeons are no longer forced to work in that grey area where they can't clearly see what is going on.

"What I particularly like from an orthopaedic perspective is that I have two large screens on the wall that I can put whatever I like on," Pemberton says. "I tend to put the X-rays or images of the MRI scans on to it so that, when I'm operating, I can look up at the wall and see important information.

"On the second screen, I have a real-time image of what I'm looking at inside. That means I can be looking inside at a particular portion of the knee and see an image of it on the screen beside me. There's also a touch screen close to me so that I can scroll through images and pick out those I want to use," he explains.

As well as improving safety, the digital operating room offers information that can empower patients on their road to recovery.

It's well known that patients are becoming more aware of what goes on inside their bodies, demanding greater information about how procedures work and how they affect them.

"Patients increasingly want to watch their own procedure, and they can now do this on a video in real time," says Pemberton. "This is positive because it means they can understand much better why they should follow a particular post-operation regime.

"For example, they know not to put weight on a particular area because they've seen what I've done to it. I can then record what's happening in real time onto a disc or stick and give all my patients a copy of the operation.

"That is a unique opportunity that a digital theatre makes available that wasn't really there in a standard stack system where you only have one screen to look at."

Dr who?

Of course, technology moves fast, and the digital operating room is becoming even more radical and experimental. Hartford Hospital in Connecticut uses eight different surgical robots to help with procedures from heart surgery to urology, while at Mercy San Juan Medical Center in Carmichael, California, so-called 'doctors on wheels' have been introduced to allow surgeons to operate remotely using computers and mobile devices.

"Remote theatres are certainly where the industry seems to be going," Pemberton says. "This means surgeons won't need to be on site, and you won't need scrubs. You can just have a robotic attachment that you can operate from a separate room."

But Pemberton is not an advocate of experimental surgery and emphasises the importance of technology with proven results.

"We're not in any race to do this," he says. "As surgeons, we're relatively conservative people, and we want proof that something we use will help a patient before we use it," he says.

Nor do these changes in technology mean patients will necessarily see the benefits any time soon. Cutting-edge healthcare technology is expensive, and there is often a lag, particularly with national health services, between the technological developments that exist and what actually appears in theatres.

Still, as hospitals become more intelligent, the opportunities for patients, surgeons and everyone involved in healthcare remain hugely exciting.

What's trending?

An aging population and increasing need for chronic disease management are putting healthcare systems under mounting pressure, but technological solutions could help alleviate the strain and improve efficiency in our hospitals. So what are the key trends we can expect to see in operatings room in the future?

Augmented reality systems

Augmented reality systems, whereby the view of reality is modified, usually by some form of real-time overlay or information, will allow visualisation of volumetric information projected directly onto the patient's organ during the operation. Surgeons will be able to view the internal pathology of solid organs without having to cut into them, and remote wireless and overlaid virtual images will guide healthcare professionals.

Simulation

The necessary components of the image-guided surgery revolution will enable personalised simulation, pre-procedural planning and rehearsal of the intended surgical intervention within the specific anatomic environment of the individual patient. Surgical planning will be more specific and treatment will become more targeted.

Telesurgery

Telesurgery or remote surgery will enable doctors to perform surgery on a patient even though they are not physically in the same location. Surgical tasks are directly performed by a robotic system controlled by the surgeon at the remote site, enabling greater access to skilled practitioners, as well as having implications for improved hygiene and infection control.