THE FUTURE

THE FUTURE

Minimal access surgery has changed surgical practice; however, it has not changed the nature of disease. The basic principles of good surgery still apply , including appropriate case selection, excellent exposure, adequate retraction and a high level of technical expertise. Endoscopic and robotic surgery training is key to allow the specialty to progress. The pioneers of yesterday have to teach the surgeons of tomorrow not only the technical and dexterous skills required but also the decision-making and innovative skills necessary for the field to continue to evolve. Training is often perceived as di ffi cult, as trainers have less control over the trainees at the time of surgery and caseloads may be smaller, especially in centres where laparoscopic and robotic procedures are not common. However, trainees now rightly expect exposure to these procedures, and training systems should be adaptable for international exposure so that these techniques can be disseminated worldwide. The predominant video and digital component of these new techniques opens the door for simulation approaches for training in these modalities , which have demonstrated benefits in reducing learning curves and in tur n are aimed at improv - ing patient outcomes. The ultimate goal for this educational approach is to develop expert surgeons through the ‘totally safe’ and ‘risk-free’ environment of simulation before they

Figure 10.7 Robotic-assisted lung segmentectomy utilising indocyanine green administered endobronchially to highlight the segment for resec tion. (a) Robotic dissection of the superior (S6) segment. (b) Indocyanine green immuno /f_l uorescence of the marked segment, enabling clear identi /f_i cation of the area for resection. Figure 10.8 Navigational bronchoscopy. Split screen image demonstrating real-time endobronchial imaging adjacent to a virtual bronchoscope image and a three-dimensional map of the lesion and bronchial tree (courtesy of Mr Kelvin Lau, Barts Thorax Centre, London, UK).

actually have to operate on patients. Indeed, both videoscopic and robotic platforms now have established simulation pro grams that are a prerequisite for surgical trainees. Modern robotic simulation modules are able to create an environment that mirrors console use (face validity) and subsequently vide hierarchical training compatible with the user’s expertise. The combination of simulation with proficiency-based ‘mas tery’ training may be the key to optimising the impact that sim ulation may have on the sur gical learning curve and remains the subject of research in a range of surgical specialties. With widespread uptake of minimal access surgery , train ees are now facing a new pr oblem owing to lack of experience in open surgery . Surgeons must have su ffi cient open surgical experience to feel comfortable converting cases in the ev of di ffi culty or emergency . A minimal access approach to a particular procedure may di ff er significantly in the order of operative steps and dissection technique. It is therefore vital that the new generation of surgeons continues to receive train ing in open surgery so that they can apply either technique as appropriate. Advances in robotic surgery lend themselves to further AI integration, with potential advantages such as providing enhanced clinical decision support, warning of de from optimal workflow or detecting and over laying potentially at-risk structures. In this way , artificially intelligent systems may streamline procedural technique, reduce error and improve patient outcomes. Intelligent operating theatres may provide automated optimisation of a wide range of ergonomic features such as table positioning, lighting and temperature, further facilitating procedural e ffi ciency and e ff ectiveness. In turn, more advanced artificial systems may also develop a degree of supervised autonomy whereby basic surgical procedures can be independently performed by the robotic system. Indeed, Berkeley George Andrew Moynihan (Lord Moynihan) , 1865–1936, Professor of Clinical Surgery , Leeds, UK. Moynihan felt that English surgeons knew little about the work of their colleagues both at home and abroad. Therefore, in 1909, he established a small travelling club which in 1929 became the Moynihan Chirurgical Club. It still exists today . He took a leading part in founding the until his death. Robot) robotic system has demonstrated superiority over human surgeons in porcine bowel anastomosis. Translation of such laboratory-based e xperiments to real- world surgery is not simple. Application requires detailed understanding of surgical workflow and integra tion of com - plex data. To provide a fully comprehensive, annotated train - ing data set on which deep learning may be established, all devices and systems in the dynamic operating environment must be integrated, including operating room set-up, tool and camera usage and the variab le patient and procedural factors. In addition there are complex questions in terms of data pro - tection and confidentiality , not to mention the ethical consider - ations and accountability of autonomous or semi-autonomous robotic surgeons. The most promising elements of AI inte - gration into minimal access surgery remain enhanced object detection, speech recognition, video characterisation and integ ration with next-generation technologies. Real-time met - abolic pr ofiling and tissue-level diagnosis may di ff erentiate between cancerous and non-cancerous tissues on the basis of their metabolic signature. An example is the iKnife, w hich uses a rapid evaporative ionisation mass spectrometric (REIMS) technique to report tissue histology in real time by analysing - aerosolised tissue during electrosurgical dissection. Artificially intelligent systems also hold potential to dramat - ically improve the fidelity of simulation training in minimal pro - access surgery , through the creation of a ‘real-world’ training environment based on the vast data accrued in their develop - - ment. Such data may be used to create a dynamic simulation - environment for any procedure, much more akin to that of ‘real-life’ surgery . This holds potential f or a stepwise tutorial system similar to that of bedside teaching, with objective feed - - back provided against standardised proficiency benchmarks that can be easily integrated into national training programmes. One major obstacle for minimally invasive technology ent remains the cost e ffi ciency and device financing in an increas - ingly rationed global healthcare environment; this is an issue that will require surgical liaison with hospital management and national policy pro viders. Surgeons need to continue to have - a dialogue, discussing their experiences and ideas in order to e ff ectiv ely progress minimal access surgery and continue to adopt novel technology . As technological advancements are adopted, carefully designed outcomes research is required to provide a clear evidence base to support changes to clinical viations practice. In this way the comparative e ff ectiveness of novel minimal access technologies will be better understood in terms of both clinical outcomes and cost-e ff ectiveness, allowing selection of those with the greatest potential to provide lasting improvements in patient care. British Journal of Surgery in 1913 and became the first chairman of the editorial committee

Figure 10.9 Image-guided video-assisted thoracoscopic surgery with the use of a navigationally placed /f_i ducial marker to guide tumour resection (courtesy of Mr Kelvin Lau, Barts Thorax Centre, London, UK). The cleaner and gentler the act of operation, the less the patient suffers, the smoother and quicker his convales

cence, the more exquisite his healed wound. Berkeley George Andrew Moynihan (1920)

Athanasiou T , Ashrafian H, Rao C et al . The tipping point of robotic surgery in healthcare: from master–slave to flexible access bio-inspired platforms. Surg T echnol Int 2011; 21 : 28–34. Bhandari M, Ze ffi ro T , Reddiboina M. Artificial intelligence and ro botic surgery: current perspective and future directions. Curr Opin Urol 2020; 30 (1): 48–54. Bodenstedt S, Wagner M, Müller-Stich BP et al . Artificial intelli gence-assisted surgery: potential and challenges. Visc Med 36 (6): 450–5. Brodie A, Vasdev N. The future of robotic surgery . Ann R Coll Surg Engl 2018; 100 (Suppl 7): 4–13. augmented reality in minimally invasive spine surgery . Global Spine J 2020; 10 (2 Suppl): 22S–33S. St John ER, Balog J, McKenzie JS et al . Rapid evaporative ionization mass spectrometry of electrosurgical vapours for the identification - of breast pathology: towards an intelligent knife for breast cancer surgery . Breast Cancer Res 2017; 19 (1): 59. Tan A, Ashrafian H, Scott AJ et al . Robotic surgery: disruptive innova - - tion or unfulfilled promise? A systematic review and meta-analysis 2020; of the first 30 years. Surg Endosc 2016; 30 (10): 4330–52. THE FUTURE

Minimal access surgery has changed surgical practice; however, it has not changed the nature of disease. The basic principles of good surgery still apply , including appropriate case selection, excellent exposure, adequate retraction and a high level of technical expertise. Endoscopic and robotic surgery training is key to allow the specialty to progress. The pioneers of yesterday have to teach the surgeons of tomorrow not only the technical and dexterous skills required but also the decision-making and innovative skills necessary for the field to continue to evolve. Training is often perceived as di ffi cult, as trainers have less control over the trainees at the time of surgery and caseloads may be smaller, especially in centres where laparoscopic and robotic procedures are not common. However, trainees now rightly expect exposure to these procedures, and training systems should be adaptable for international exposure so that these techniques can be disseminated worldwide. The predominant video and digital component of these new techniques opens the door for simulation approaches for training in these modalities , which have demonstrated benefits in reducing learning curves and in tur n are aimed at improv - ing patient outcomes. The ultimate goal for this educational approach is to develop expert surgeons through the ‘totally safe’ and ‘risk-free’ environment of simulation before they

Figure 10.7 Robotic-assisted lung segmentectomy utilising indocyanine green administered endobronchially to highlight the segment for resec tion. (a) Robotic dissection of the superior (S6) segment. (b) Indocyanine green immuno /f_l uorescence of the marked segment, enabling clear identi /f_i cation of the area for resection. Figure 10.8 Navigational bronchoscopy. Split screen image demonstrating real-time endobronchial imaging adjacent to a virtual bronchoscope image and a three-dimensional map of the lesion and bronchial tree (courtesy of Mr Kelvin Lau, Barts Thorax Centre, London, UK).

actually have to operate on patients. Indeed, both videoscopic and robotic platforms now have established simulation pro grams that are a prerequisite for surgical trainees. Modern robotic simulation modules are able to create an environment that mirrors console use (face validity) and subsequently vide hierarchical training compatible with the user’s expertise. The combination of simulation with proficiency-based ‘mas tery’ training may be the key to optimising the impact that sim ulation may have on the sur gical learning curve and remains the subject of research in a range of surgical specialties. With widespread uptake of minimal access surgery , train ees are now facing a new pr oblem owing to lack of experience in open surgery . Surgeons must have su ffi cient open surgical experience to feel comfortable converting cases in the ev of di ffi culty or emergency . A minimal access approach to a particular procedure may di ff er significantly in the order of operative steps and dissection technique. It is therefore vital that the new generation of surgeons continues to receive train ing in open surgery so that they can apply either technique as appropriate. Advances in robotic surgery lend themselves to further AI integration, with potential advantages such as providing enhanced clinical decision support, warning of de from optimal workflow or detecting and over laying potentially at-risk structures. In this way , artificially intelligent systems may streamline procedural technique, reduce error and improve patient outcomes. Intelligent operating theatres may provide automated optimisation of a wide range of ergonomic features such as table positioning, lighting and temperature, further facilitating procedural e ffi ciency and e ff ectiveness. In turn, more advanced artificial systems may also develop a degree of supervised autonomy whereby basic surgical procedures can be independently performed by the robotic system. Indeed, Berkeley George Andrew Moynihan (Lord Moynihan) , 1865–1936, Professor of Clinical Surgery , Leeds, UK. Moynihan felt that English surgeons knew little about the work of their colleagues both at home and abroad. Therefore, in 1909, he established a small travelling club which in 1929 became the Moynihan Chirurgical Club. It still exists today . He took a leading part in founding the until his death. Robot) robotic system has demonstrated superiority over human surgeons in porcine bowel anastomosis. Translation of such laboratory-based e xperiments to real- world surgery is not simple. Application requires detailed understanding of surgical workflow and integra tion of com - plex data. To provide a fully comprehensive, annotated train - ing data set on which deep learning may be established, all devices and systems in the dynamic operating environment must be integrated, including operating room set-up, tool and camera usage and the variab le patient and procedural factors. In addition there are complex questions in terms of data pro - tection and confidentiality , not to mention the ethical consider - ations and accountability of autonomous or semi-autonomous robotic surgeons. The most promising elements of AI inte - gration into minimal access surgery remain enhanced object detection, speech recognition, video characterisation and integ ration with next-generation technologies. Real-time met - abolic pr ofiling and tissue-level diagnosis may di ff erentiate between cancerous and non-cancerous tissues on the basis of their metabolic signature. An example is the iKnife, w hich uses a rapid evaporative ionisation mass spectrometric (REIMS) technique to report tissue histology in real time by analysing - aerosolised tissue during electrosurgical dissection. Artificially intelligent systems also hold potential to dramat - ically improve the fidelity of simulation training in minimal pro - access surgery , through the creation of a ‘real-world’ training environment based on the vast data accrued in their develop - - ment. Such data may be used to create a dynamic simulation - environment for any procedure, much more akin to that of ‘real-life’ surgery . This holds potential f or a stepwise tutorial system similar to that of bedside teaching, with objective feed - - back provided against standardised proficiency benchmarks that can be easily integrated into national training programmes. One major obstacle for minimally invasive technology ent remains the cost e ffi ciency and device financing in an increas - ingly rationed global healthcare environment; this is an issue that will require surgical liaison with hospital management and national policy pro viders. Surgeons need to continue to have - a dialogue, discussing their experiences and ideas in order to e ff ectiv ely progress minimal access surgery and continue to adopt novel technology . As technological advancements are adopted, carefully designed outcomes research is required to provide a clear evidence base to support changes to clinical viations practice. In this way the comparative e ff ectiveness of novel minimal access technologies will be better understood in terms of both clinical outcomes and cost-e ff ectiveness, allowing selection of those with the greatest potential to provide lasting improvements in patient care. British Journal of Surgery in 1913 and became the first chairman of the editorial committee

Figure 10.9 Image-guided video-assisted thoracoscopic surgery with the use of a navigationally placed /f_i ducial marker to guide tumour resection (courtesy of Mr Kelvin Lau, Barts Thorax Centre, London, UK). The cleaner and gentler the act of operation, the less the patient suffers, the smoother and quicker his convales

cence, the more exquisite his healed wound. Berkeley George Andrew Moynihan (1920)

Athanasiou T , Ashrafian H, Rao C et al . The tipping point of robotic surgery in healthcare: from master–slave to flexible access bio-inspired platforms. Surg T echnol Int 2011; 21 : 28–34. Bhandari M, Ze ffi ro T , Reddiboina M. Artificial intelligence and ro botic surgery: current perspective and future directions. Curr Opin Urol 2020; 30 (1): 48–54. Bodenstedt S, Wagner M, Müller-Stich BP et al . Artificial intelli gence-assisted surgery: potential and challenges. Visc Med 36 (6): 450–5. Brodie A, Vasdev N. The future of robotic surgery . Ann R Coll Surg Engl 2018; 100 (Suppl 7): 4–13. augmented reality in minimally invasive spine surgery . Global Spine J 2020; 10 (2 Suppl): 22S–33S. St John ER, Balog J, McKenzie JS et al . Rapid evaporative ionization mass spectrometry of electrosurgical vapours for the identification - of breast pathology: towards an intelligent knife for breast cancer surgery . Breast Cancer Res 2017; 19 (1): 59. Tan A, Ashrafian H, Scott AJ et al . Robotic surgery: disruptive innova - - tion or unfulfilled promise? A systematic review and meta-analysis 2020; of the first 30 years. Surg Endosc 2016; 30 (10): 4330–52. THE FUTURE

Minimal access surgery has changed surgical practice; however, it has not changed the nature of disease. The basic principles of good surgery still apply , including appropriate case selection, excellent exposure, adequate retraction and a high level of technical expertise. Endoscopic and robotic surgery training is key to allow the specialty to progress. The pioneers of yesterday have to teach the surgeons of tomorrow not only the technical and dexterous skills required but also the decision-making and innovative skills necessary for the field to continue to evolve. Training is often perceived as di ffi cult, as trainers have less control over the trainees at the time of surgery and caseloads may be smaller, especially in centres where laparoscopic and robotic procedures are not common. However, trainees now rightly expect exposure to these procedures, and training systems should be adaptable for international exposure so that these techniques can be disseminated worldwide. The predominant video and digital component of these new techniques opens the door for simulation approaches for training in these modalities , which have demonstrated benefits in reducing learning curves and in tur n are aimed at improv - ing patient outcomes. The ultimate goal for this educational approach is to develop expert surgeons through the ‘totally safe’ and ‘risk-free’ environment of simulation before they

Figure 10.7 Robotic-assisted lung segmentectomy utilising indocyanine green administered endobronchially to highlight the segment for resec tion. (a) Robotic dissection of the superior (S6) segment. (b) Indocyanine green immuno /f_l uorescence of the marked segment, enabling clear identi /f_i cation of the area for resection. Figure 10.8 Navigational bronchoscopy. Split screen image demonstrating real-time endobronchial imaging adjacent to a virtual bronchoscope image and a three-dimensional map of the lesion and bronchial tree (courtesy of Mr Kelvin Lau, Barts Thorax Centre, London, UK).

actually have to operate on patients. Indeed, both videoscopic and robotic platforms now have established simulation pro grams that are a prerequisite for surgical trainees. Modern robotic simulation modules are able to create an environment that mirrors console use (face validity) and subsequently vide hierarchical training compatible with the user’s expertise. The combination of simulation with proficiency-based ‘mas tery’ training may be the key to optimising the impact that sim ulation may have on the sur gical learning curve and remains the subject of research in a range of surgical specialties. With widespread uptake of minimal access surgery , train ees are now facing a new pr oblem owing to lack of experience in open surgery . Surgeons must have su ffi cient open surgical experience to feel comfortable converting cases in the ev of di ffi culty or emergency . A minimal access approach to a particular procedure may di ff er significantly in the order of operative steps and dissection technique. It is therefore vital that the new generation of surgeons continues to receive train ing in open surgery so that they can apply either technique as appropriate. Advances in robotic surgery lend themselves to further AI integration, with potential advantages such as providing enhanced clinical decision support, warning of de from optimal workflow or detecting and over laying potentially at-risk structures. In this way , artificially intelligent systems may streamline procedural technique, reduce error and improve patient outcomes. Intelligent operating theatres may provide automated optimisation of a wide range of ergonomic features such as table positioning, lighting and temperature, further facilitating procedural e ffi ciency and e ff ectiveness. In turn, more advanced artificial systems may also develop a degree of supervised autonomy whereby basic surgical procedures can be independently performed by the robotic system. Indeed, Berkeley George Andrew Moynihan (Lord Moynihan) , 1865–1936, Professor of Clinical Surgery , Leeds, UK. Moynihan felt that English surgeons knew little about the work of their colleagues both at home and abroad. Therefore, in 1909, he established a small travelling club which in 1929 became the Moynihan Chirurgical Club. It still exists today . He took a leading part in founding the until his death. Robot) robotic system has demonstrated superiority over human surgeons in porcine bowel anastomosis. Translation of such laboratory-based e xperiments to real- world surgery is not simple. Application requires detailed understanding of surgical workflow and integra tion of com - plex data. To provide a fully comprehensive, annotated train - ing data set on which deep learning may be established, all devices and systems in the dynamic operating environment must be integrated, including operating room set-up, tool and camera usage and the variab le patient and procedural factors. In addition there are complex questions in terms of data pro - tection and confidentiality , not to mention the ethical consider - ations and accountability of autonomous or semi-autonomous robotic surgeons. The most promising elements of AI inte - gration into minimal access surgery remain enhanced object detection, speech recognition, video characterisation and integ ration with next-generation technologies. Real-time met - abolic pr ofiling and tissue-level diagnosis may di ff erentiate between cancerous and non-cancerous tissues on the basis of their metabolic signature. An example is the iKnife, w hich uses a rapid evaporative ionisation mass spectrometric (REIMS) technique to report tissue histology in real time by analysing - aerosolised tissue during electrosurgical dissection. Artificially intelligent systems also hold potential to dramat - ically improve the fidelity of simulation training in minimal pro - access surgery , through the creation of a ‘real-world’ training environment based on the vast data accrued in their develop - - ment. Such data may be used to create a dynamic simulation - environment for any procedure, much more akin to that of ‘real-life’ surgery . This holds potential f or a stepwise tutorial system similar to that of bedside teaching, with objective feed - - back provided against standardised proficiency benchmarks that can be easily integrated into national training programmes. One major obstacle for minimally invasive technology ent remains the cost e ffi ciency and device financing in an increas - ingly rationed global healthcare environment; this is an issue that will require surgical liaison with hospital management and national policy pro viders. Surgeons need to continue to have - a dialogue, discussing their experiences and ideas in order to e ff ectiv ely progress minimal access surgery and continue to adopt novel technology . As technological advancements are adopted, carefully designed outcomes research is required to provide a clear evidence base to support changes to clinical viations practice. In this way the comparative e ff ectiveness of novel minimal access technologies will be better understood in terms of both clinical outcomes and cost-e ff ectiveness, allowing selection of those with the greatest potential to provide lasting improvements in patient care. British Journal of Surgery in 1913 and became the first chairman of the editorial committee

Figure 10.9 Image-guided video-assisted thoracoscopic surgery with the use of a navigationally placed /f_i ducial marker to guide tumour resection (courtesy of Mr Kelvin Lau, Barts Thorax Centre, London, UK). The cleaner and gentler the act of operation, the less the patient suffers, the smoother and quicker his convales

cence, the more exquisite his healed wound. Berkeley George Andrew Moynihan (1920)

Athanasiou T , Ashrafian H, Rao C et al . The tipping point of robotic surgery in healthcare: from master–slave to flexible access bio-inspired platforms. Surg T echnol Int 2011; 21 : 28–34. Bhandari M, Ze ffi ro T , Reddiboina M. Artificial intelligence and ro botic surgery: current perspective and future directions. Curr Opin Urol 2020; 30 (1): 48–54. Bodenstedt S, Wagner M, Müller-Stich BP et al . Artificial intelli gence-assisted surgery: potential and challenges. Visc Med 36 (6): 450–5. Brodie A, Vasdev N. The future of robotic surgery . Ann R Coll Surg Engl 2018; 100 (Suppl 7): 4–13. augmented reality in minimally invasive spine surgery . Global Spine J 2020; 10 (2 Suppl): 22S–33S. St John ER, Balog J, McKenzie JS et al . Rapid evaporative ionization mass spectrometry of electrosurgical vapours for the identification - of breast pathology: towards an intelligent knife for breast cancer surgery . Breast Cancer Res 2017; 19 (1): 59. Tan A, Ashrafian H, Scott AJ et al . Robotic surgery: disruptive innova - - tion or unfulfilled promise? A systematic review and meta-analysis 2020; of the first 30 years. Surg Endosc 2016; 30 (10): 4330–52.