FUTURE CHANGES IN SURGERY

by Stephen Clare

Introduction:

The field of surgery is, in many ways, on the cusp of a revolution. As with any revolution, the coming decade will bring great opportunity and unforeseen challenges to the art and its artisans. New technology carries with it the promise of sweeping change, while also allowing for incredible advancement and revisions to the practice of surgical medicine. 

The question of what the future may hold for surgery has been thoroughly debated in recent years. In 2018, the Royal College of Surgeons in England published their report on the Future of Surgery, in which they identified four major technologies that are predicted to deliver the greatest impact to the field.1 These include advancements in minimally invasive surgery; big data, genomics, and artificial intelligence; imaging, virtual reality, and augmented reality; and specialized interventions such as 3D bioprinting, artificial organs, and neural prosthetics.1

To interrogate the value of any of these technologies is to miss the forest for the trees; they are here now and carry pressing questions of who, when, where, and at what cost. A discussion of the next decade must pay close attention to the ramifications of these advancements, for each is a surgical instrument in and of itself, carrying a profound capacity to heal or to harm by virtue of its application. 

Who? The power of ‘Big Data’:

The term ‘Big Data’ refers to the collection of information on a large scale and its subsequent evaluation for insights and practical applications.2  Wearable devices, electronic health records, and genomic sequencing are but a few of the ways health data can be acquired.3-7 One of the most prescient uses of such data is prophylactic surgery, allowing for early detection, intervention, and prevention of serious health problems.8 Prophylactic surgery is not a new conceit. Already, female carriers of BRCA mutations may electively opt to undergo a prophylactic mastectomy to significantly reduce their risk of developing breast cancer.9-11 As far back as 28 years ago, discussion appeared in the literature on the merits of prophylactic foot removal for diabetic patients, while the efficacy of surgical prophylaxis has already been clearly demonstrated in connective tissue disorders, Lynch syndrome, and some cardiovascular pathologies.9- 16 Regardless, concern exists among patients for how such a radical intervention may subjectively impact on their quality of life, with one study finding that a majority of eligible women declined surgical prophylaxis when offered.13

The important question for surgery with regards to ‘Big Data’ lies in the promise of individual, personalized medical interventions. As advancements in the field lead to a reduction in complications, the potential of surgical interventions will only increase. Genetic testing allows for such myriad applications as screening for disease susceptibility and transforming the viability of organ transplantation through genetic matching and synthetic organ growth.1,17 Neural interfaced prosthetics will allow for previously unfathomable leaps forward in the quality of life for affected patients, and minimally invasive surgeries and nanomedicine will only serve to hasten these advancements.1, 18, 19 

Individual genetic sequencing has been identified as a major goal for healthcare systems, with the NHS outlining a plan to sequence five million genomes by 2023.1, 20, 21 The cost of genetic sequencing has dropped precipitously over the past twenty years, making large scale genomic screening now a viable part of routine care.22, 23 Within the next decade, the increased ability to discern survivability and outcomes of surgical procedures will lead to previously unparalleled choice for patients and surgeons in how to address health problems. Still, ethical questions exist as to whether such levels of data gathering are morally suspect, infringing upon individual privacy in the pursuit of improved results.7, 24 Encryption of data can only go far in systems rife with human error, and the economic viability of wholescale genomic sequencing remains poorly studied, with focus too often on the possibilities inherent, and little attention or transparency given to its cost or cost-effectiveness.25 This area should be a major focus of research within the next decade, alongside increased public education on what this data actually means for patients, practitioners, and society at large.26

When? A Duty to Teach:

Machine learning is a form of artificial intelligence which allows machines to learn from data and patterns that they analyse, rather than from prior programming.1 The application of machine learning to ‘Big Data’ will allow for extensive auditing and learning from otherwise neglected datasets.27 Of course, such data must be standardized and interpretable by the machines which hope to analyse it, which presents a significant barrier to widespread implementation. Health information currently exists as a combination of digital and paper records, in many different languages, and with varying levels of security.27, 28 The ethics of machine learning are also a fiercely debated topic in recent years, as machine learning is presently advancing at a shocking pace, and the potential results of such advancement are thoroughly unknown.29-32

Specific to the field of surgery is the application of machine learning to review existing surgical recordings, and subsequently to guide and train surgeons and surgical trainees in simulation and reality.1 Barriers specific to surgery include the inability to recognize what phase a surgery is in, or to recognize surgical instruments, gestures and errors, and anatomical landmarks.33 Standardization of format would help with these problems, but the pace at which machine learning has advanced has left medicine heretofore unable to even begin attempting such an initiative. 

The information age has brought with it increased access to surgical training, while also bringing increased demand on the limited resources available. Machine learning allows for every individual recorded surgery to act as a data point, from which training algorithms can be refined and improved upon iteratively. In this way, the coming decade presents a calling for each surgeon to contribute to these surgical video datasets, so that culmination of their life’s work and expertise will not be lost, but instead become a longstanding contribution to surgical progress.

Where? The Ethics of Access:

Virtual reality technology allows for profound and sweeping changes to surgical training and access to surgery for communities previously beyond the reach of top surgical professionals. Machine learning and ‘Big Data’ allow for trainees to try their hand in simulation against an amalgam of the best surgeons in the field today.1 This same technology allows for surgeons to guide or even perform complex surgeries remotely via human-robot interfaces, video link, and electronic platforms.34 Machine learning and 3D modelling will allow for significant progress in fields such as cosmetic surgical reconstruction, paediatric surgery, and complicated procedures where outcomes are often uncertain.35, 36

Over the past several years, the Royal College of Surgeons in Ireland has contributed significantly to improving surgical education and outcomes in sub-Saharan Africa.37-42 The implementation of e-learning platforms, local education initiatives, and modern technology has allowed for significant outreach to address an overwhelming need for surgical access in underserved regions where up to 94% of people do not have access to safe or affordable surgery.42 It is estimated that up to 85% of children in Africa will require surgical treatment before the age of 15.42 

Again, an ethical call is upon surgeons to help guide and contribute to these initiatives, as the outstanding success of the RCSI/SURG-Africa project only scratches the surface of what technologies such as virtual reality could achieve. Much as the field of surgery is transforming, so too may it transform medical education and community outreach in the years to come. 

At What Cost? A Professional Reformation:

Much as the field of surgery now possesses an unprecedented opportunity to change the face of the world, so too does it have the capacity to change itself and its working culture. Surgery remains the most male-dominated speciality in medicine, despite extremely promising strides forward over the past decade.43 As technology increasingly allows surgeons to work remotely, train virtually, and focus on clinical decision-making over physical dexterity, a window exists for individuals and minority communities to push for increased accessibility to training, practice, and healthcare. Proposals such as phased returns to work after maternity leave and the ability to hone skills outside of the operating theatre represent an opportunity for even greater leaps forward in diversity, equality, and access to speciality training.43-45 Though much work has already been done, there is ever more to do, and the field of surgery stands to benefit from solidarity between its professionals and trainees, now and in the years to come.

The coming decade should see surgeons welcoming all of these technological changes with open arms and cautious minds, as they represent new heights for medical practice as a whole. Though research is still sorely needed in areas such as the economic and ethical ramifications of ‘Big Data’, the feasibility of mass genomic sequencing, and the new limits of surgical practice, the future seems unabashedly positive and bright. The fledgling surgeons of tomorrow will doubtlessly benefit from the guiding hand of the surgical professionals of today, ushering the field toward new and exciting innovations, and taking bold strides into a promising unknown. 

References

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