Riding the wave of transformative change in surgery

Source: NHE Jan/Feb 2019

Mr Richard Kerr, chair of the Royal College of Surgeons' (RCS) Commission on the Future of Surgery, argues that transformative changes in surgery will dramatically improve patient care.

Last year, the UK’s most prized public service, the NHS, celebrated 70 years of enabling patients from all over the UK to access treatment free at the point of delivery. It was a momentous year that allowed us to reflect on the heroic work of NHS staff past and present, and the enormous changes that have taken place since its inception in how we care for patients. It was also a moment to pause and consider what exciting developments might shape our beloved health service in the future.

The RCS’s Commission on the Future of Surgery aimed to do just that by setting out an inspiring and credible vision of surgery over the next 20 years, as well as the steps we need to take to make sure the reality is one that benefits patients. At the end of our year of evidence-gathering, one thing was abundantly clear: we are standing on the verge of transformative changes in surgery that have the potential to dramatically improve the care of millions of patients.

A wave of new technologies – ranging from minimally-invasive surgery and robotics, to genomics and virtual reality – will expand the surgeons’ toolkit exponentially. The commission expects these changes to potentially affect every type of procedure. We are moving from the era of freehand surgery to the digitalisation of surgery, where surgeons are supported by data, genomic analysis, and new robotic tools.

The commission believes there are four areas of technological development that will make the greatest impact: minimally-invasive surgery; big data, genomics and artificial intelligence; imaging, virtual reality and augmented reality; and specialised interventions.

Firstly, developments in minimally-invasive surgery and advances in imaging – such as functional imaging, which is already enabling micro-surgery for some brain tumours – will make more patients eligible for surgery, particularly the frail and elderly.

Robotic-assisted surgery is also hugely exciting. While the commission does not expect autonomous robots to replace surgeons, a new generation of smaller, lighter, and likely cheaper surgical robots is on the way and will impact how surgery is delivered. Robots that are easier to move between theatres and hospitals will allow robot-assisted surgery to become more widely available in local hospitals; it may also narrow the performance gap between surgeons. Over the next few years, the commission expects robots to start becoming more commonly used in gynaecological procedures, colorectal, and cardiothoracic surgery.

To balance equity of access across the country and ensure cost effectiveness, the location of surgical robots and centralised services needs to be much better planned in the future. Our experts suggested that NHS England should initially lead a robotics strategy to help the NHS plan and purchase new surgical robotics systems – and that this approach could eventually extend to other innovations.

The second area of development the commission identified is big data, genomics and artificial intelligence. These technologies may offer the greatest potential to revolutionise surgical care by making some types of surgery redundant and in allowing doctors to better understand cancerous tumours and target treatment. They will enable ‘precision surgery’, where treatments can be tailored to patients according to their genetic profile.

The commission also heard evidence from geneticists, clinical scientists, and surgeons specialising in genomics that suggests in 10-20 years, the population may be able to undergo annual testing for cancer through a blood sample, while similar tests are already being evaluated to monitor disease recurrence.

Thirdly, the evidence we gathered also suggests that virtual, mixed and augmented reality platforms will allow surgical teams around the world to share advice during operations, and specialist surgeons to support complex procedures remotely. For example, a surgeon in one hospital might guide a team in another unit through an operation using augmented reality. Advances in imaging and simulation, as well as 3D printing, are already being used to complement surgical training and planning.

Lastly, the commission also considered specialised interventions such as stem-cell therapies, 3D bioprinting of tissues and organs, artificial organs, developments in transplant surgery, and neural prosthetics with adaptive control mechanisms. In the short-term, advances in 3D printing will lead to more advanced prostheses; while in the longer-term, more advanced imaging could enable ‘nano-surgery,’ where surgeons could use miniaturised devices to operate on individual cell clusters – potentially with dramatic effects for cancer patients.

There is also exciting research underway into manufacturing artificial organs (for example, bile ducts), although it will be a while yet before patients actually benefit from developments in this area.

The commission calls on health services across the UK to work in conjunction with local trusts, and encourage investment in the creation of multidisciplinary hubs for the delivery of complex interventions. In the immediate-term, they can enable the use of 3D printing and planning technologies. In future years, other specialised interventions, such as regenerative medicine, could benefit from centralised multidisciplinary expertise.

Hospital managers will need to think carefully about what staff they need to enact this vision of the future of surgery. It’s clear that the role of some surgeons is likely to become increasingly wide-ranging, crossing boundaries with clinicians in other areas of medical intervention where a vast array of other treatments may become preferable, such as in cancer surgery. For example, surgeons will play a key role in genomics, acquiring and handling tissue samples and being the first healthcare professional to discuss genetic analysis with a patient. 

Surgery is already being delivered by a multi-disciplinary team, and this will be the case even more so in the future. Members of the surgical care team, including surgical care practitioners and physician assistants, will provide more aspects of care and may take over some areas of surgical care currently delivered by surgeons. Highly-skilled surgical technicians could in the future undertake procedures – such as endoscopy and endoscopic biopsies, removing skin lesions, and maybe even carrying out caesarean sections – under the supervision of a surgeon.

Collectively, all of these new technologies are going to make surgery less invasive and even more targeted. Surgery will no longer just be about helping patients once they are ill; it will be about helping them avoid becoming unwell in the first place. Predicting and preventing disease will play an ever increasingly important role. Of course, some of the technologies the commission considered may remain in the realm of science-fiction, with challenges too big to overcome. There may be other innovations we haven’t yet foreseen.

It is an incredibly exciting time to be working in surgery. The task now is to ensure that those innovations with the most potential are implemented effectively and safely to the ultimate benefit of all.


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