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Published Online 31 October 2023

Five years into the Future of Surgery

Publication: The Bulletin of the Royal College of Surgeons of England
Volume 105, Number 8

Abstract

Since the 2018 publication of the Future of Surgery report, how much progress has been made?
A robot whirrs quietly as it samples the margins of a tumour. It performs tissue analysis in real time and finds more excision is required. The team has prepared for this scenario; they’ve rehearsed it in the virtual theatre. The resection is completed with ease and a sensor is implanted to detect recurrence. This is surgery in 2035, according to predictions made by the Commission on the Future of Surgery in its 2018 Future of Surgery Report. The last 5 years has seen significant progress towards making this vision a reality. Today in 2023 we assess the state of play and revisit the forecasts made.

THE FUTURE OF SURGERY REPORT: AN OVERVIEW

The Royal College of Surgeons of England’s Commission on the Future of Surgery published the Future of Surgery Report in December 20181. An expansive look at the health technology landscape, the report identified key emerging technologies, and evaluated their potential impact on surgery and surgical training. It focused on four key areas:
1.
Minimally invasive surgery;
2.
Imaging, virtual reality and augmented reality;
3.
Big data, genomics and artificial intelligence;
4.
Specialised interventions.
In the report, the Commission made five, ten and twenty-year predictions in each domain as well as considering evolving frameworks and ethics of healthcare delivery.

THE VIEW FROM 2023

‘Unknown unknowns’, a phrase coined by the former US defence secretary Donald Rumsfeld, are events so unexpected that they defy consideration. The COVID-19 outbreak was exactly that, leading to seismic upheaval that few anticipated. Remarkably, many of the predictions in the Future of Surgery report have still come to pass.
As projected, futuristic surgical robots like Versius from CMR Surgical and Medtronic’s Hugo are now being deployed in UK hospitals.2, 3 In addition, a greater range of minimally invasive procedures are being undertaken, following advances in robotic thoracic, head and neck, and pancreatic surgery.46 The expectation that today’s robots would perform “a small number of more simple automated tasks” was premature but progress continues in animal models, with a world-first laparoscopic bowel anastomosis performed autonomously on pigs.7
Extended reality (XR), which includes augmented and virtual reality, has been in the spotlight since Facebook’s pivot to the metaverse in 2021. Implementation of XR in healthcare has been slow, but virtual reality is being trialled for patients with promising results (such as when used for patient education and patient distraction during procedures).8, 9 The Commission’s prediction that by 2028, “VR will become a standardised aspect of surgical training” seems optimistic but adoption is growing as companies such as FundamentalVR, CMR Surgical and Proximie develop increasingly high-fidelity surgical simulators.
The Future of Surgery Report, Published in 2018
There is a greater range of minimally invasive procedures being undertaken, following advances in robotic thoracic, head and neck, and pancreatic surgery
NHS meetings remain a long way from the metaverse. Nevertheless, the Future of Surgery report was prescient in its view that we would now “access expertise and conduct multidisciplinary team meetings through digital technology”. With the COVID-19 pandemic accelerating this transition, virtual meetings are now the norm. Although surgery is an unlikely candidate for ‘working from home’, the Commission estimated that by 2038, surgeons “will more frequently be able to conduct surgery from a remote console”. Innovations in robotics, virtual reality and digital telecoms are on track to make this prediction a reality, with the world's first 5G telesurgical operation performed in China in 2019.10
Artificial intelligence in the form of machine learning has seen an explosion in usage. Large language models such as OpenAI’s ChatGPT have had widespread adoption and machine learning is driving change in many of the areas cited in the Future of Surgery report. It suggested that “AI has the potential in the next five years to help improve the speed and accuracy of diagnoses”. Clear examples of this have emerged in medical imaging, with its diagnostic prowess demonstrated in breast cancer and ophthalmology trials.11, 12 This is opening the door to intraoperative image analysis, where ‘computer vision’ algorithms could be used to guide surgeons as they work.
As with machine learning, advances in genomics have far surpassed the projections in the Commission’s report. The prediction that by 2038 “gene editing could be in use, albeit limited” has already been achieved, with the first gene editing drug approved in the UK in 2020 to treat an inherited form of blindness.14 Furthermore, the Commission estimated that by 2028, treatments “will begin to be targeted at patients based on their genome types”. This too has occurred sooner than expected, with genotyping to guide chemotherapy choice now performed nationally by the NHS Genomic Medicine Service.15 Looking to the future, multiomics (which integrates genomic data with mRNA [transcriptomics], proteins [proteomics] and metabolites [metabolomics]) has the potential to personalise treatment in a way never seen before.
Looking to the future, could automated micro-robotics perform the same role, for example, inside a limb at risk of ischaemia?
Conversely, the Future of Surgery report was too optimistic in stating that we may be engineering tissues and organs for patients by 2028. Despite bioprinting innovations, the production of complex tissues faces major hurdles such as adequate tissue perfusion.16 Stem cell technology has seen greater progress, with several new trials in osteoarthritis, retinal disease and neurodegenerative disease, in line with predictions made.1719

NEW HORIZONS

Innovations outside the medical world are important to consider. Autonomous cars are already in use, with legal ‘hands-free’ models made available in Great Britain in April 2023.20 Similar systems could soon be used to drive ambulances or carry organs in retrievals. Strikingly, autonomous drones are now being used to deliver medications to remote UK locations21 and to detect machinery faults over large industrial sites. Looking to the future, could automated micro-robotics perform the same role, for example, inside a limb at risk of ischaemia?
Elsewhere, the rapid adoption of large language models like ChatGPT suggests a future where generative AI could play a pivotal role in healthcare. Current models are error prone, often producing misinformation or ‘hallucinations’. If refined, these models could be well suited to algorithmic tasks such as patient triaging. Coupled with advances in voice recognition, digital healthcare assistants could become a reality, an Alexa or Siri for NHS 111.
Quantum computing remains in the early stages of development. Nevertheless, over the coming decade, it has the potential to enter mainstream applications, driving drug discovery and in silico clinical modelling as well as drastically increasing the capabilities of machine learning models.

NEXT STEPS

As the technologies cited by the Future of Surgery report mature, extraordinary advances in patient care are coming into view. We are entering a golden age for surgical technology and as computer scientist Alan Kay said: “The best way to predict the future is to invent it.” Surgeons are uniquely positioned to drive innovation but this requires integrating digital and technological literacy into surgical education, and providing opportunities for surgeons to collaborate and take on entrepreneurial roles. In 2022, the Royal College of Surgeons of England launched its Future of Surgery Innovation Hub, a new programme to collaborate with industry partners and support surgical innovators in the development and delivery of new products and tools.22 It is through initiatives such as these that surgeons and the NHS can lead the way.

References

1.
Royal College of Surgeons of England. Future of Surgery. London: RCS England; 2018.
2.
Digital Health. Versius robot used in minimal access surgery for the first time. https://www.digitalhealth.net/2020/02/versius-robot-minimal-access-surgery (cited October 2023).
3.
Medical Device Network. Medtronic’s Hugo robot debuts at Guy’s and St Thomas’ hospital. https://www.medicaldevice-network.com/news/medtronics-hugo-robot-debuts-at-guys-and-st-thomas-hospital (cited October 2023).
4.
Hardman JC, Holsinger FC, Brady GC et al. Transoral robotic surgery for recurrent tumors of the upper aerodigestive tract (RECUT): an international cohort study. J Natl Cancer Inst 2022; 114: 1,400–1,409.
5.
Lazar JF, Hwalek AE. A review of robotic thoracic surgery adoption and future innovations. Thorac Surg Clin 2023; 33: 1–10.
6.
Khachfe HH, Habib JR, Harthi SA et al. Robotic pancreas surgery: an overview of history and update on technique, outcomes, and financials. J Robot Surg 2022; 16: 483–494.
7.
Saeidi H, Opfermann JD, Kam M et al. Autonomous robotic laparoscopic surgery for intestinal anastomosis. Sci Robot 2022; 7: eabj2908.
8.
van der Kruk SR, Zielinski R, MacDougall H et al. Virtual reality as a patient education tool in healthcare: a scoping review. Patient Educ Couns 2022; 105: 1,928–1,942.
9.
Bernaerts S, Bonroy B, Daems J et al. Virtual reality for distraction and relaxation in a pediatric hospital setting: an interventional study with a mixed-methods design. Front Digit Health 2022; 4: 866119.
10.
China Daily. China performs first 5G-based remote surgery on human brain. https://www.chinadaily.com.cn/a/201903/18/WS5c8f0528a3106c65c34ef2b6.html (cited October 2023).
11.
Lång K, Josefsson V, Larsson AM et al. Artificial intelligence-supported screen reading versus standard double reading in the Mammography Screening with Artificial Intelligence trial (MASAI): a clinical safety analysis of a randomised, controlled, non-inferiority, single-blinded, screening accuracy study. Lancet Oncol 2023; 24: 936–944.
12.
Ting DS, Pasquale LR, Peng L et al. Artificial intelligence and deep learning in ophthalmology. Br J Ophthalmol 2019; 103: 167–175.
13.
Maktabi M, Köhler H, Ivanova M et al. Classification of hyperspectral endocrine tissue images using support vector machines. Int J Med Robot 2020; 16: e2121.
14.
National Institute for Health and Care Excellence. Voretigene Neparvovec for Treating Inherited Retinal Dystrophies Caused by RPE65 Gene Mutations (HST11). London: NICE; 2019.
15.
NHS England. Clinical commissioning urgent policy statement: pharmacogenomic testing for DPYD polymorphisms with fluoropyrimidine therapies [URN 1869] (200603P). https://www.england.nhs.uk/wp-content/uploads/2020/11/1869-dpyd-policy-statement.pdf (cited October 2023).
16.
Vajda J, Milojević M, Maver U, Vihar B. Microvascular tissue engineering – a review. Biomedicines 2021; 9: 589.
17.
Carneiro DC, Araújo LT, Santos GC et al. Clinical trials with mesenchymal stem cell therapies for osteoarthritis: challenges in the regeneration of articular cartilage. Int J Mol Sci 2023; 24: 9939.
18.
Hinkle JW, Mahmoudzadeh R, Kuriyan AE. Cell-based therapies for retinal diseases: a review of clinical trials and direct to consumer ‘cell therapy’ clinics. Stem Cell Res Ther 2021; 12: 538.
19.
Fan Y, Goh EL, Chan JK. Neural cells for neurodegenerative diseases in clinical trials. Stem Cells Transl Med 2023; 12: 510–526.
20.
Ford. Ford brings hands-free driving technology to motorways in Great Britain. https://media.ford.com/content/fordmedia/feu/en/news/2023/04/13/ford-brings-hands-free-driving-technology-to-motorways-in-great-.html (cited October 2023).
21.
Apian. Solent NHS drone trials. https://www.apian.aero/solent (cited October 2023).
22.
Kerstein R. The new Future of Surgery Innovation Hub needs your help. Bull R Coll Surg Engl 2023; 105: 2.

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Published In

cover image The Bulletin of the Royal College of Surgeons of England
The Bulletin of the Royal College of Surgeons of England
Volume 105Number 8November 2023
Pages: 392 - 395

History

Published online: 31 October 2023
Published in print: November 2023

Authors

Affiliations

MB Butler
Academic Foundation Doctor
Oxford University Hospitals NHS Foundation Trust, UK

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