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Around 2010, the concept of digital health was developed. Its definition is rather broad but can be thought of as: ‘Digital technologies using computing platforms, connectivity, software and sensors for health care. These technologies span a wide range of uses – from applications in general wellness to managing chronic disease or as applications as medical devices. They include technologies intended for use as a medical product, in a medical product, as companion diagnostics or as an adjunct to other medical products (devices, drugs, and biologics).’

Surgeons have taken a while to jump on this bandwagon to claim digital as their own.

The first surgical operation was carried out in Borneo around 31,000 years ago. It was an amputation involving the removal of the distal third of the left lower leg. The person survived the operation and lived for another six to nine years. For centuries, surgeons have practised analogue surgery. The term ‘digital surgery’ has recently become a concept and is increasingly accepted into the surgical fraternity. It has the real and exciting potential to revolutionise surgical practice.

My own definition, having been a recognised pioneer over the last decade in this field, is as follows: ‘Digital surgery are technologies that allow better visualisation and more precise surgery with real-time navigation and planning, use data to drive and improve surgical performance and patient outcomes and offer high fidelity simulation for training.’

CARED and connected

I consider digital surgery as essentially five pillars and remember these using the acronym CARED:

Connected surgery and remote collaboration.

Artificial intelligence and data analytics

Robotics

Extended Reality

3D printing.

We are now more connected than ever as a civilisation, with 95% of the world having at least a 3G connection. With the increasing availability of 5G and high-speed broadband, including Starlink, in many parts of the world, we are now hyperconnected.

Now, many platforms are available that allow surgeons to mentor from a distance using telemedicine.

As the global ambassador, I am pleased to share that Rods & Cones has connected 1,000-plus hospitals globally using their augmented reality smart glasses platform to allow remote training – a real milestone in mass adoption.

The mobile platform allows a surgeon to carry the set anywhere in a small case and set it up in a few minutes, truly helping to democratise surgical training.

I cannot believe that it has been nine years since I performed the world’s first Google Glass operation to a global audience and, in a small way, showcased what was possible. I think Google Glass was at least a decade ahead of its time, and it has been mooted that it is about to make a comeback of sorts.

With the introduction of robots and hyper-connectedness, remote robotic surgery is no longer the realm of science fiction. In 2000, Professor Jacques Marasceaux performed the first remote robotic transatlantic surgery, a laparoscopic cholecystectomy, with the patient in Strasbourg whilst, with his team, he operated from a robotic console in New York, some 4,000 miles away.

The operation was called the Lindberg Operation, named after Charles Lindbergh, who first flew across the Atlantic from Paris to New York. More recently, it was upgraded to version 5.0.

In 2017, at the Fujian Medical University Mengchao Hepatobiliary Hospital, 5G was used to perform a robotic operation on an animal that was devoid of its liver in China. This demonstrated the latency and fast speed to operate in real-time. The first cholecystectomy was carried out on a 30-year-old woman in Xinjiang, China, in only 30 minutes through remote surgery, in an operation orchestrated from more than 4,500km (2,800 miles) away.

The operation is part of broader national plans to advance 5G-based robotics in medical care as part of the country’s five-year plan. There are now reports of robotic hysterectomies being routinely performed remotely on patients in China.

There has been a welcome proliferation of surgical robots over the last few years, offering choice and healthy competition to the consumer. Still, Intuitive’s instantly recognisable Da Vinci robot completed much of the early groundwork and adoption into the surgical community.

Smaller and sleeker

As robots become smaller, sleeker, modular with open consoles, and increasingly more affordable, there should be rapid global adoption into emerging markets. The West has already reached its tipping point in adoption and will rapidly reach market saturation. For many countries, however, the robot remains an aspiration.

Undoubtedly, many surgeons will eye up the opportunity to be the first in their country to use the robot and count the column inches in the national press and media.

Virtual reality has finally found its place in surgery. We are seeing increasingly suitable content for surgical training, particularly in orthopaedic surgery, using computer-generated images built on platforms like Unity or Unreal Engine. Repetitive and systematic training improves surgical performance and helps surgeons understand the 3D perception and environment early in their careers.

Surgery is also now being augmented using smart glasses or mixed-reality headsets. The incredible ability to overlay DICOM images from an MRI or CT with 3D visualisations allows surgeons to plan surgery or, indeed, be guided during a surgical operation.

The analogue surgeon is rapidly replacing the Swann & Morton scalpel with a digital one. There has also been a digital to analogue transformation of surgical implants and prostheses created by the mesmerising technology of 3D printing – although the uptake and reimbursement models have been challenging.

Surgeons have always relied on two innate skills, accumulated over time, to improve their surgical and diagnostic prowess. One could argue that intuition and judgment are more important than surgical skills in the OR. Could AI replace a surgeon? Well, the answer, of course, is no, but certainly, a surgeon's practice could be augmented.

AI will become valuable to a surgeon, allowing more precision, and the data collected will undoubtedly improve surgical outcomes.

If we look at the automotive industry, with the introduction of smart cars that aim to be autonomous (although no car has officially reached level 5 of true autonomy yet), we get a sense of what may be possible in surgery.

Companies are using computer vision to train AI algorithms on thousands of surgical operations to allow real-time surgical navigation, which would be highly useful in video-assisted surgery like laparoscopy. Aiding a surgeon through a complex operation, perhaps to avoid important structures or indeed help define the margins of a cancer, will support precision surgery.

In 2017, we saw the world’s first ‘autonomous surgeon’, a rather grainy video of a robot performing a surgical anastomosis apparently as well as a trained surgeon. Interestingly, this has not been repeated or indeed reported widely, which obviously casts doubt as to the claimed outcome.

Surgery is often compared with aviation regarding ensuring safety with the introduction of checklists, but now we have a new analogy. We now have the ability to collect all of the data from the OR, including the laparoscopic video feed, patient biometrics from the intensive monitoring of the anaesthetised patient, and a bird’ s-eye view via cameras of the entire surgical team in action.

The data is collected in the so-called surgical black box, comparable to an aeroplane flight recorder. This data could be used to examine individual and team performance and provide documentation of a procedure allowing risk analysis when things do not go as planned.

The Silver Scalpel accolade is awarded yearly to the best national surgical trainer in the UK. I was most fortunate to be awarded this in 2016. I wonder what the best digital surgeon will be awarded in the future. Answers on a postcard.

Global surgical robotics business CMR Surgical (CMR) has launched partnerships with telementoring companies – Teladoc Health and SurgEase Innovations Ltd – to enhance its ongoing training support for surgical teams using the Versius® Surgical Robotic System.

Telementoring systems utilise specialised monitors, sound systems and cameras to allow trainers and surgical preceptors to provide real-time guidance and technical assistance during surgical procedures irrespective of geography, to provide expert clinical support for surgical team as they master the Versius technology.

This additional remote assistance is provided to surgical teams as part of CMR’s step-wise training programme, which utilises enhanced virtual reality technology, extensive supervised training and preceptor support.

CMR will utilise Teladoc Health’s Mini Tabletop device; initially launching at hospitals in Europe, South America, India and Australia.

CMR will use technology from SurgEase Innovation’s Connected Health intelligence Platform (CHiP) at hospitals in the UK.

Vanash Patel, Consultant Colorectal & General Surgeon, West Hertfordshire Teaching Hospitals NHS Trust, commented: “When developing your skills with Versius, it is crucial to be able to get technical advice from trainers and preceptors.

“As part of its Preceptor programme, CMR selects the right expert to support, firstly in-person at the hospital, then through telementoring meaning you can continue to get advice and support whenever you need it.

“It feels like the expert is in the room with you, seeing what you are seeing, advising you in real-time. Such technology will be of real benefit to the surgical team and their patients.”
Fiona Morrison, Global Head of Professional Education, CMR Surgical, commented: “We want to make sure that our training technology matches up to our next-generation surgical robot Versius.
“That’s why we are delighted to partner with both Teladoc Health and SurgEase Innovations to utilise their latest platforms.”
“These telementoring devices will allow surgeons and their teams to access on-demand virtual support from our expert technical skills trainers and surgical preceptors as they progress through their learning curve.
“It’s an efficient way to provide additional support as surgical teams perfect their performance with Versius which helps them to provide the best care for patients.”
Andy Puterbaugh, President, Hospital and Health Systems, Teladoc Health, commented: “We are pleased that CMR has chosen Teladoc to advance the skills and techniques of Versius robotic surgeons and teams around the globe.
“By securely connecting our telehealth devices with the Versius technology, surgeons, expert technical and clinical trainers as well as surgical preceptors can easily collaborate to advance patient care and help drive better outcomes.”

Fareed Iqbal, Founder and CEO, SurgEase Innovations Ltd, commented: “Partnering with CMR, a British-based company that shares values and ambitions aligned with ours, makes this commercial collaboration that much more meaningful.

“We look forward to merging our strengths within the digital surgery field to deliver high-quality technology to enhance patient outcomes.”

A company which specialises in surgical robotics and mixed reality closed a $5.2 million fundraising round earlier this year.

Zeta Surgical announced in the Spring, that it will use the capital to finalise the development of its neurosurgical navigation platform Zeta and its non-invasive focused-ultrasound system ZetaFUS.

The money will enable Zeta Surgical to finish its initial clinical studies, obtain FDA clearance and expand its technical and clinical teams.

“To date, the use of surgical guidance has been limited to long, operating room-based interventions, due to its invasiveness and complex deployment,” Zeta Surgical Co-Founder and CEO Jose Amich said.

“Our goal is to provide physicians with a robust, fast, and accurate guidance system deployable during any case, irrespective of where they are in the hospital or what hospital they are in. We’re thrilled to be partnering with such a strong group of investors who are aligned with our mission to improve access to safe and effective surgery.”

Innospark Ventures led Zeta Surgical’s fundraising effort with the participation of TSVC, Y Combinator, Trevor Fetter and others.

Titan Medical Inc has revealed that multiple disruptions have resulted in an updated Investigational Device Exemption (IDE) submission timeline for the Enos™ robotic single access surgery system. 

The medical device company, which is focused on the development and commercialization of innovative surgical technologies for single access robotic-assisted surgery, now expects the IDE submission to occur mid-year 2023 instead of in the first quarter of 2023. 

Pending successful regulatory review, and upon receipt of marketing authorization, the expected US product launch for the Enos system remains on schedule for early 2025.

By focusing on a single patient access point, Titan Medical expects that patient trauma and scarring can be reduced, and patients may be able to recover faster. 

Interim President and CEO Paul Cataford said: “We have been fortunate to have avoided and mitigated against many of the issues facing almost all other technology companies over the last few months. 

“However, we now expect our targeted IDE application date to be pushed out to the summer of 2023. Human clinical trials are still planned to start in 2023 and we expect to receive marketing authorization in the U.S. in early 2025.” 

The Enos project timeline has been impacted by several factors including:

“We continue to carefully monitor our project plan. With recent changes, we believe we have the right people, resources and partners in place to execute against our project delivery timeline. 

“This team is committed, engaged and accountable, and we’re excited to bring our vision of single access robotic assisted surgery to the market,” concluded Paul Cataford.

surgery
connecting surgeons. shaping the future
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