Coming soon to an OR near you!
Multi-screen monitoring & more. Previews of coming attractions, starring 4 “OR of the Future” project leaders
What will the operating room of the future look like? Will it be a specialty-specific facility or a generic OR? Our Symposium panelists, each a primary investigator in an “OR of the Future” project at his own institution, share their ideas of what the future holds, from getting clutter off the floor and onto the ceiling, to integrating patient information, imaging, and robotic systems.
Panelists also share their visions of what the OR may look like in 25 years and what obstacles need to be overcome to make the futuristic vision a reality. Robotics, smart displays, information management and integration, and image-guided surgery may become as common as the stapler and the scalpel.
The making of the “OR of the Future”
PARK: It’s been said that the operating room of the future means that we take the clutter off the floor and put it on the ceiling, but we need to have a much broader view.
“OR of the Future” embodies a vision of improved patient safety and outcomes—from evaluating and assimilating existing technologies, to identifying technologies that need to be developed or brought in, to integrating the technologies that will get us there.
SANDBERG: The “OR of the Future” is also about therapeutic effectiveness for our patients and organizational effectiveness for the hospital.
The OR of the future is a concept through which a big organization such as an academic hospital can foster innovative projects. It can designate a place within its own organization that’s politically, financially, and physically separate from the main workflow and objectives, where the hospital can test processes and technologies.
“Wall of Knowledge”
A matrix of real-time screens
This operating room at Memorial Sloan-Kettering Cancer Center is one of 21 that employ the “Wall of Knowledge,” the matrix of screens in the background that show patient and OR data, high-resolution video of surgical and laboratory images, and two real-time monitors for viewing radiographs.
“Dashboard” data monitoring
One component of the “Wall of Knowledge” is the OR-Dashboard (LiveData, Inc, Cambridge, MA) that captures data from multiple information systems, physiological monitors, and medical devices and displays it to the OR team.
PHOTOGRAPH BY RICHARD DEWITT, COURTESY MEMORIAL SLOAN-KETTERING CANCER CENTER, COURTESY LIVEDATA, INCThe goal is to develop safer systems, evaluate technology, and accumulate evidence to prove these technological innovations are effective. This also involves developing new processes for information management and patient flow.
Will Gyns share their OR?
SATAVA: I think of two kinds of OR of the future: The near-term, in the next 20 years or so, will concentrate an information-based system, such as imaging, robots, computers, and just-in-time inventory.
Shared, yet specialty-specific OR
We will continue to have multiple ORs in the near future because we will still need specialization. Neurosurgeons, gynecologists, and pediatric surgeons will still find it difficult to share the same OR—no matter how flexible it is. What these multi-specialty ORs will have in common is the way they’ll leverage information technologies.
To the cell level and beyond
The second kind of OR of the future is longer term and harder to describe. Here, biotechnology and energy-directed systems will replace mechanical and, to an extent, information-based systems. For example, in 30–50 years we’ll be using lasers for intracellular operations. Rather than physicians injecting various drugs or immunochemistry, they will actually use lasers and optical tweezers and manipulate the various organs—the mitochondria, operate on the DNA directly, and change cell biology rather than remove organs.
Will your office be your OR?
SATAVA: A capital-intensive facility such as a hospital or dedicated outpatient surgery center for complicated procedures will always have its place, although we’ve seen more minimally invasive surgery move out of the hospital. Beyond minimally invasive procedures are noninvasive procedures. High-intensity focused ultrasound and terahertz energy are the types of technologies that can safely move out of an operating room.
A robot is not a machine. It’s an information system with arms
And a CT is not an imaging device, but an information system with eyes. Robotic machines and imaging devices can be integrated into “information space” in ways that are elusive in real space. “Information space” sees no difference between a process and an object.
Our product is our patient
Health care is the only industry that does not have an information representation of its product. Our product is our patient. We cannot use the hardware and software that all other industries use for virtual prototyping and testing.
Health care does not understand systems integration. We’ve spent a century dissecting the human into 26 different National Institutes of Health that don’t talk to each other.
We can reintegrate the human at the workstation and surgeon, where supply chain management, just-in-time inventory, robotics, and imaging for surgical rehearsal can come together.
The robot can capture a surgeon’s hand motions and play them back with 10–12 times the accuracy at 7–15 times the speed. In the long-term, the surgeon would get the image of the patient in the OR just before the operation, perform the motions of the operation, and edit out the mistakes until the procedure is perfect.
When the surgeon is finished, he or she sends the edited, perfected operation to the robot, which performs it accurately and with greater speed. Appendectomies and cholecystectomies would take 10 minutes; Whipple procedures 45 minutes.
Richard M. Satava, MD
Big hospitals believe in generic ORs. Do we have scientific proof of what is best?
SANDBERG: OR design is not a science. No peer-reviewed literature in OR architecture exists. Few if any studies have actually tested the effectiveness of a given OR design.
The OR is a gigantic medical device that encloses the patient and staff. It ought to be studied in a rigorous and, ideally, prospective way, although such studies would be very expensive.
SATAVA: Moving toward noninvasive surgery doesn’t mean that open and minimally invasive surgery are going away. However, I don’t see anything in the near term that will make computed tomography (CT), magnetic resonance imaging (MRI), and new terahertz technology small enough to share space in one room.
On the other hand, robotics are moving us toward an OR with no staff. Put the patient in, and the surgeon on the outside will operate robotically. We could see that in the next 4–5 years. Biosurgery may create a need for quarantine or isolation. We’ll still have these multiple ORs in the future.
PARK: Look at the last 15 years and how long it has taken certain minimally invasive techniques to become mainstream. Only now are we getting the OR suites to accommodate them.
It’s a challenge that such little scholarly study has been undertaken. We need to push industry and hospital administrators to bring modularity to the ORs now on the drawing board. It’s ambitious, but it’s a way to start.
What outcomes matter the most?
SANDBERG: The commonly discussed outcome variables are procedure time, and hospital cost and revenue—but they’re not necessarily the right metrics.
What we’re looking for is a metric that captures the patient benefits and risks. Then we need to determine if the surgeons, the nurses, the anesthesiologists, the technologists, and the informationists can use this near-term OR of the future effectively for the patient’s benefit.
PARK: Designing studies is one of the real challenges in trying to generate data in this field. These studies tend to start out looking at global principles but end up fixating on operational issues—for example, how to get a pair of sharp scissors to an OR on a regular basis.
This is going to bring new metrics to the operating room—concepts such as process mapping, and workflow and workspace assessments.
Robotics gives us the chance to rehearse an operation. How practical are rehearsals?
No warm-ups for surgeons
SATAVA: I don’t know of any other profession that immediately starts to work without warming up or practicing.
I’ve never seen a baseball player run from the dugout to the batter’s box.
I’ve never seen a symphony orchestra run right out and start playing.
Why don’t we do a little rehearsing and practice the hardest parts before we actually start the incision?
Still, this won’t become cost-effective in the near term.
PARK: You can rehearse selectively, based on the difficulty or complexity. We rehearse complex anti-reflux procedures and donor nephrectomies. Software models the patient’s data, and I will do a “fly-through” the afternoon before a laparoscopic donor nephrectomy.
Rehearsal at this stage has more to do with the cognitive processes than technical. So whether I need to practice taking that fat off the renal hilum is less of an issue than the position of lumbar veins or the relation of the renal vein to the aorta.
I feel immensely better prepared for the surgery when I’ve done that fly-through. I’m hard pressed to give you a good metric, to show the science to support it, but I believe there’s a role for it.
SANDBERG: This gets back to the question of metrics. Much of what we’re seeing as we look at ORs of the future actually improves the work experience for the surgeon, anesthesiologist, and nurses.
You can’t put a dollar value on that unless you’re talking about the cost of recruiting and training staff, but it does seem to improve outcomes for the people who work in the OR—and that must translate to patient outcomes. It’s difficult to justify to an administrator, but on a moral level it seems like the right thing to do.
The ideal would be a robotic anesthetist who would not be in the coffee lounge when you want to turn over your case.
SANDBERG: Making a business case for a robot for anesthesia is even harder. Functions such as vascular access and airway control are easy to an expert, but I don’t know yet of anyone who even attempted to make an IV-starting robot.
SATAVA: We have one.
SANDBERG: I’ve seen your prototypes. I don’t think you can program your “Robo-doc” to anesthetize the patient when you want, but the maintenance phase is one area in anesthesia ripe for automation.
Anesthesiology is actually in the driver’s seat for harvesting, controlling, and integrating information in the OR. Our project integrates data that anesthesiologists traditionally managed with that from surgical instruments and hospital information systems to create a total patient picture. That includes interventions and perturbations caused by surgery. Once that’s in place, you could imagine actually driving the anesthetic using closed-loop control.
SATAVA: Anesthesia is probably going to evolve more than surgery thanks to safer anesthetics and new nanotechnology. The new anesthetic autoregulators will make it almost impossible to overdose or under-dose a patient.
Are “smart” instruments equal to our own fingertips?
PARK: Today we can make a standard (open surgery) incision into which we insert one or both hands and have more than 20° of movement with the benefit of an innervated end effecter—our fingertips.
The OR of the future will put us in a situation where we’re disconnected in the tactile sense from the target anatomy and limit us to 4°–8° of movement. The stimulus is to get those degrees of movement back to compensate for the tactile feedback we’ve lost.