INTEGRATED THEATRES
training across disciplines can deliver efficiency and capacity today and in the future.
It is predicted that technologies that
provide less invasive approaches will continue to evolve. Intuitive recently received FDA approval for the da Vinci SP (single port) platform, developed to enable natural orifice and single-port surgical approaches. Three instruments and an endoscopic camera enter the body through a single orifice/port. This makes for easy positioning for the surgeon and increases access to MIS for a variety of patients. Undoubtedly, this is an area that will continue to evolve based on surgeon and patient need. We also believe that RAS technology has the ability to optimise “augmented reality” that enables surgeons to pull in information from other sources (eg: overlaying an MRI over the surgical screen/field). This could give surgeons access to valuable operative information both before and during the procedure. Advances in imaging also hold the potential to enhance the identification of tumours, blood vessels, nerves, and biomarkers beyond what the naked eye can see. This could allow surgeons to clearly identify the area to be operated, and even more precisely orient the instruments within the body without damaging surrounding structures. An example of this that already exists today is Firefly technology, which uses fluorescence imaging to identify vessels, blood flow and target anatomy. Another area that holds great potential for the future of surgery is data. Robotic surgical systems use anonymised data to optimise system function and continually improve existing minimally invasive approaches. Through a hospital’s collection and analysis of this information, surgeons could enhance their surgical skills and training programmes and hospitals could optimise efficiency in the OR. Training will be an important element both in the future of healthcare and surgery generally, and with RAS specifically. The value of virtual reality ‘surgical simulators’, which already exist, cannot be underestimated. These are useful for training purposes and for OR team preparation in advance of a complex surgery. Greater use of simulators has the potential to improve quality of surgery and patient safety.
20 l JULY 2018 l OPERATING THEATRE
As more companies produce new technologies and diagnostic imaging for use with RAS systems, the future promises to bring about some exciting advances.
The future may also see more of a standardised approach to training and learning techniques – standardised performance measures and/or other ways to track, assess and help enhance the skills of surgeons – not just for new surgeons, but for surgeons throughout the course of their professional lives.
A path to success While the patient, surgeon and healthcare system benefits that RAS can enable means it can play an important role in the future of surgery, over two decades of experience in developing and bringing to market robotic-assisted surgical systems has taught us that successful implementation of a RAS programme is about more than just the technology. There are a whole host of programmes, supports and solutions – including training and education, and customer service and support - that together form a supportive ‘ecosystem’ that contributes to a successful robotics programme. This is true today and will be a critical component of the future of RAS and surgery.
Furthermore, evaluation systems will need to evolve to be able to adopt innovation at a higher pace. The classic randomised clinical trial (RCT) - highly applicable and a key means of evaluating pharmaceuticals, may be less applicable as the sole or primary criteria for medical devices. This is because RCTs can take a very long time to complete and be cost- prohibitive to conduct. Furthermore, patients may not want to opt for a more invasive procedure when a minimally invasive alternative is available, making it a challenge to perform a comparative study. Greater use and inclusion of real world evidence (RWE), including patient registries and patient-reported outcomes and experience, is important when assessing technologies and medical devices like robotic-assisted surgical systems. RWE can be more reflective of whole patient population
results rather than just representing ‘ideal patients’ participating in RCTs and therefore may better reflect the real value that innovation can bring. Changes are afoot; according to the Lancet, there is increasing emphasis on long-term, RWE and ‘regulators are placing increasing reliance on real- world data in their decisions about market approval’. This could facilitate earlier patient access to new devices.21 Another key challenge in assessing the value of RAS is that the strongest value is often seen in hospital robotic programmes that are multi-disciplinary – ie: used across multiple surgical categories - and fully utilised, yet assessments for commissioning purposes are conducted indication by indication. Additionally, restricting the definition of cost effectiveness to the costs associated with operating time rather than the cost for the entire hospital stay (particularly important in an NHS where hospital beds are in demand) does not reflect the true value this technology has to offer. The economic value of innovation should take into account the cost savings that may be achieved through reduced complications, readmission rates and shorter hospital stays as well as wider quality of life measures.
An exciting future
The continual innovation and evolving technologies in minimally invasive, robotic-assisted surgery offer great potential for the future. Not only is RAS here to stay, it is forecast to grow and welcome new companies and technologies to the field. The advances in augmented reality, optimised learning and less invasive approaches are an exciting prospect for patient-centred outcomes and addressing the capacity and resource challenges of our healthcare system. It is a fascinating time to be involved in this field and I am excited about what the future holds.
References for this article can be sent upon request.
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