There is a revolution taking place in the modern practice of medicine—particularly in the field of surgery. This surgical revolution has evolved out of the so-called “information age” of the late 20th century and early 21st century. We are witnessing an explosion in newer technologies that combine the biological, physical, and information sciences into systems that enhance technological performance well beyond previous limitations.
The essence of the information age was first proposed in 1995 by computer scientist Nicholas Negroponte, PhD, of the Massachusetts Institute of Technology in his book,
Being Digital.1 Using information science as a tool, Dr Negroponte developed the idea of “bits instead of atoms” as a driver of technological change. He suggested that these bits, or units of computer information, could be applied in medicine to improve the understanding of the human body and the healthcare of patients.
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One of the best-known applications of information science in medicine has been the National Library of Medicine's Visible Human Project,
2 a digital image library of volumetric data representing complete, normal male and female anatomy. In this project, high-resolution, three-dimensional (3D) representations of the bodies of a man and woman were created by combining computer-generated images derived from computed tomography (CT) scans and magnetic resonance imaging (MRI) scans.
2 These 3D digital representations can be manipulated on a computer screen to study aspects of internal anatomy from any angle at various levels of detail.
The current trend in surgery toward minimally invasive and noninvasive therapeutic procedures is another result of newer technologies generated by information science. This trend represents a switch from direct, hands-on surgical approaches to indirect, “hands-off” approaches (eg, laparoscopic, catheter-based, robot-aided, and computer-aided procedures). This switch coincides with moves by surgeons from unimodal therapy (eg, resection and reconstruction) to multimodal therapy (eg, biologically tagged, image-guided, and dexterity-enhanced procedures).
In the present article, we review a number of currently available technologies that are reshaping surgical procedures in the United States. Changes in the areas of preoperative diagnostics, preoperative planning of surgery (including surgical simulation), and intraoperative navigation (including augmented reality) are presented. We also look into the future of surgical care based on projected technological advancements, anticipated patient demands, and economic reality.
The revolutionary technological developments occurring today in surgical care provide hints at the even more amazing advancements that the future may hold. Framed by technology and directed by medical economics and patient demand, the operating room of the future will undoubtedly be dramatically different in both appearance and function from the operating room of today. A greater emphasis on integrated systems will provide for the streamlining of operating room personnel and materiels management (
Figure 2).
In a personal account in 2004 of the historic evolution of robotic surgery, Richard M. Satava, MD,
25,26 a professor at the University of Washington in Seattle who has conducted extensive research in robotic surgery, virtual reality, and computer simulation, shared the following vision of the operating room of the future: In the future, the patient will be brought to the preoperative holding area and placed upon a “smart stretcher”... that records the vital signs and all other physiologic and biochemical parameters about the patient, and will be anesthetized. A total body scan is performed, providing a complete “information-equivalent” image of the patient. The patient is then completely prepped for sterility, and brought into a sterile operating room (like the clean rooms used to manufacture computer chips)—there are no people in the operating room. In the operating room, instead of a scrub nurse, there is an automatic tool changer (as is customary in industry today), and instead of a circulating nurse there is an automatic parts dispenser (not unlike the automated medication dispensers in pharmacies or the parts dispenser on an assembly line).
The surgeon will be able to control numerous hands, the instruments are changed automatically, and the supplies (sutures, gauze, and so on) are automatically dispensed. Every time an instrument is changed or a supply is used, three actions occur: (1) the patient is billed, (2) the new instrument or supply is restocked for the operating room, and (3) a request for inventory re-supply is sent to the supply office to order a new instrument or supply—all within 50 milliseconds.
Since operating rooms are usually paired around a central scrub room (a cluster), there will be a reduction in personnel. By eliminating the scrub and circulating nurses from each of the rooms (as well as the “relief” nurse—robots do not take coffee breaks), it will be possible to safely run the two operating rooms with a single supervisory nurse/technician, reducing the number of people from six to one (an 85% reduction in personnel costs).
Many of the current and projected technological advancements in surgical care come with profound socioeconomic or ethical implications. Some of these implications may be perceived as beneficial, while the effects of others may be more open to debate.
With the use of remote robot-assisted surgery, geographic location no longer has to be an impediment to the type of surgical treatment available to a population. Telesurgery, should it become more common, would allow for the increased availability in remote areas of access to expert surgeons from the best institutions around the world. In developing countries, this increased and improved access could prove to be of great benefit, making it possible for people to recieve surgical care that would otherwise not be available to them. However, to take advantage of this possibility, these countries would need access to high-speed telecommunications technology—which is still lacking in many undeveloped regions of the world.
Telesurgery also holds great promise for medical education. With the ability that telesurgery provides of making the best training widely available, errors caused by surgeon inexperience could be reduced, resulting in an improvement in the nationwide standard of surgical care.
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Despite the many bright promises of new medical technology, the technology carries a serious risk—the risk of spreading faster than the medical profession can react to it, with surgeons facing the challenge of learning new skills but not having objective ways to assess competency in those skills. Therefore, with the projected growth in medical technology, new approaches to education, assessment, and training will be required. We are reminded of the accelerated development of laparoscopic surgery during the 1990s, when surgeons had little time to feel completely competent with the procedure before they felt compelled to incorporate it into their practices.
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Without proven efficacy for surgical procedures based on new technology, issues of billing and insurance reimbursement for those procedures can become a problem. Even after objective methods to measure competency have been developed, the need for surgeons to repeatedly practice the new techniques to reach the benchmark levels of performance could result in high quality, but very costly, surgical procedures. These costs could prohibit much of the population from using the new procedures.
The technological advancements in surgical care and other fields of medicine that have occurred since the late 20th century are forcing surgeons to re-evaluate the practice of surgery. Many of these advancements are related to technological breakthroughs in information science. We find ourselves in the middle of a transition period that will lead to fundamental changes in the practice of surgery. Despite these changes, however, surgery will not be replaced; rather, it will mature as new technologies are validated.
Several challenges face the surgeon during this transition period. As the rate of change in technology outpaces the ability of surgeons to respond in a timely manner, the need for stringent evaluation through evidence-based outcomes is essential. Surgeons must look at these emerging technologies with an open, yet critical, mind. They must be prepared to embrace change while remembering their responsibilities as stewards for their patients.
The surgeon of today must respond to ongoing technological changes through open discussion and debate on a national level. If not, the medical profession will relinquish far-reaching decisions on these important matters to lawyers, politicians, and others with limited understanding of science and humanistic needs, and rules and regulations will be established based on their personal, societal, or political agendas. As technological change happens and discussion and debate continue, the science will wait for no one. Surgeons must position themselves today to control the medical technologies that emerge tomorrow.
Ideas from this paper were presented at a forum during the Unified Osteopathic Convention in Orlando, Fla, on October 22, 2005.
The authors thank Shannon Fries for her assistance with the preparation of this manuscript.
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