Integrated operating room

Minimally invasive surgery is at the centre of an integrated operating room. The traditional laparoscopic suites are limited by the arrangements of the ‘stack’, display monitors, access to instruments during the procedure, interaction with communication devices and poorly understood social dynamics to name a few. The arrangement of the environment has to be cognisant of its purpose if the execution of the task is to be safe and effective. Ergonomic factors influence the perceptual, cognitive and motor skills of a surgical team. A set of guidance is offered by van Det et al. on the optimal ergonomic arrangement of display units; this is based on high-quality evidence from both laboratory and clinical data.

Events (e.g. distractions) and conditions (e.g. fatigue) are important sources of adversity in this environment. One of the lessons learned from the aviation industry within the context of ‘crew resource management’ is the need for communication with clarity of content and its relevance to the task at hand. Non-technical skills are thought to contribute to better technical performance, and their absence may indeed lead to deterioration in technical performance.

The integrated operating room encompasses use of communication protocols. This is a crucial element in maximising the effectiveness of an ORF. Case-irrelevant communication is a recognised source of distraction. Communication failure can occur in 30% of cases; one-third of these may adversely affect patient safety. An increase in cognitive load can couple communication failure to clinical adverse effects. A strategy to improve the deficiencies in communication can be addressed by the concept of ‘sterile cockpit’ communication protocol. This tool is derived from careful qualitative assessment of the communication content so that irrelevant material can be eliminated and the relevant material can be coded using appropriate phraseology. The relevant content can then be synchronised with individual tasks of the procedure. Recently, such an approach has been studied in cardiovascular surgery with resultant reduction in the number of communication breakdowns. Similar strategies must be deployed across other high-risk, complex procedures where communication between key personnel has a bearing on workflow and safety. It is unlikely that such a strategy will lead to a significant reduction in mortality; it may be more appropriate to assess their efficacy in terms of procedural time and cognitive load as reported by the staff.

Stress adversely affects surgical performance and safety. Sources of stress include equipment, team factors, distractions and interruption. Incidence of physical fatigue is a common feature of laparoscopic surgery. An integrated operating theatre should minimise the occurrences of such events and bring about harmony to the team. In a prospective study, Klein et al. studied physical and psychological stress among surgeons operating in the traditional operating room and operating room 1 (an integrated operating suite [Karl Storz OR1™]). A significant reduction in physical complaint was reported when operating in the operating room 1. A recent survey among gynaecological oncologists revealed that, with increasing complexity of minimally invasive surgery, the prevalence of physical fatigue seems to be significant, with 88% of respondents reporting pain-related symptoms during minimally invasive surgery.

As the complexity of laparoscopic surgery has continued to grow, the supporting hardware has multiplied. Striking a balance between complexity and structuring is important to optimise work flow and efficiency. In a simulated study, Kenyon et al. have shown that a dedicated integrated operating room can significantly reduce the time taken for the ‘setup’ and ‘put-away’ of the equipment. Similar efficiency gains have been validated. In addition, patient preparation is also carried out with greater efficiency.

The integrated operating room is designed to overcome limitations of the traditional operating room set-up. A prospective study during laparoscopic cholecystectomy assessed the effect of the integrated operating room and an electronic checklist on the frequency of ‘risk-sensitive events’ (RSE). Compared with a traditional operating room, the number of RSEs in the integrated operating room using e-checklists, and the proportion of procedures with one or more RSEs, reduced from 87% to 47% in the 45 procedures analysed.

Sterility of the operating field is essential in minimising surgical infection. It is conceivable that, with ceiling-mounted equipment booms, more ergonomic arrangement of hardware, better surgical flow, improved sterility, and reduced infection rates may be a further benefit; clinical evidence for such a trend in the integrated operating room is awaited.

Process management

Perioperative care involves orderly flow of information. This ranges from consenting patients, organising equipment, arranging supportive medicinal products, channelling appropriate postoperative care, and operating room stock management. Co-ordination of such information flow is vital to ensure safety and productivity. Traditionally, this is achieved through face-to-face communication, bleeps, public address systems and phones. This is a fragmented, resource-heavy arrangement, which exposes patients to adverse events. In a root-cause analysis review of 3000 sentinel events, 70% of events related to the operating room resulted from ‘insufficient communication’.

A robust system to modulate the flow of information requires a centralised tool, a dashboard, permitting rapid real-time communication. Only an integrated dashboard can offer the ‘granularity’ necessary to understand the co-ordination of actions; this is essential in supporting a future operating room that will be a pervasive surgical suite. The integration is important in transforming the fragmented data into actionable knowledge. The retail industry best personifies this use of business intelligence to inform systems management.

A prototype of a web-based information system was studied at the University of Maryland. This tool integrated clinically relevant data and presented the information in an easily accessible form, which projected operational trends and helped identify factors that lead to aggregate delays. An output of performance indicator further helped identify weaknesses in chains of activity. The study indicated that such a novel tool was viewed in a positive light by the staff, and its potential for delivering ready access to information outweighed the capital cost in personnel resources, hardware and management training. If such devices are to support decision-making processes, then certain attributes must be an intrinsic feature, including its alignment with the organisational goals, cultural acceptance, intuitive and real-time display and contextual accuracy. An immediate example of this application can be illustrated by incorporating safety checklists into a dashboard to monitor the individual patient’s progress. The compliance of operating room staff in applying checklist can fluctuate. In a recent prospective study, the compliance with pre-incision safety checklist improved significantly when this practice was incorporated within an electronic whiteboard. Similarly, tracking patients with infrared or radiofrequency identification systems can ensure that correct patients enter the correct operating room space for the correct procedure. Patients can be tagged with a smart wrist band, permitting remote monitoring. This can help identify delays and deficiencies in the perioperative journey. In its simplest form, such safety measures are already in place in many UK hospitals in the context of safety in blood-product transfusion; from obtaining the initial blood sample to administering transfusion, the activity is locked within an informatics loop.

Such mechanisation improves reliability and reduces cognitive work load, resulting in the reduction of clinical errors. In a broader context, this can be viewed as weaving clinical governance into mechanisms that drive the clinical process, although the final responsibility remains with clinical leaders.

Work flow modulation

Ergonomic work space design has the potential to confer permanent benefits to the system without the need for reinforcement or exposure to humans. Parallel design of non-operative processes and relocation of non-operative tasks from the operative space can significantly streamline the perioperative process. Such a redesign can improve the turnaround time, increase throughput and enhance cost-effectiveness. In a prospective study on reorganising the team activity to improve turnaround time, team-initiated measures were implemented with positive results. Although the investigators acknowledge the lack of metrics, they cite improvement in communication and anticipation of the turnaround phase as important contributors.

Visualisation

For the surgeon, minimally invasive surgery has intrinsic constrains in viewing the anatomy. The surgeon’s view is limited to the surface anatomy captured by the endoscope. Currently, the sensory system is tightly coupled to the display unit; this circuit being interrupted by an isolate processing unit. This is a balance between minimising latency, thus allowing surgeons to operate in ‘real-time’, and the desired bandwidth with the requisite processing capacity. Limitations to visualisation in laparoscopic surgery includes equipment, latency, colour and spatial fidelity, as well as calibration and registration. Innovations in improving the bandwidth of data acquisition and efficient display to the user requires an expansion of the algorithms (processing pathways) and architecture. Institutions such as modern hospitals feature powerful computational networks. Decoupling the sensor-display circuit and interposing a processing environment, such as a hospital computational network, can offer the digital space required without massive capital expenditure and space occupation. Such a change will expand the current limitations to image manipulation and surgical navigation.

Intraoperative imaging

In the development of imaging-guided surgery, three disciplines have converged to optimise visualisation. Innovations in smart instruments, robotisation, nanochemistry, and molecular biology have the great potential to realise the benefits of optical imaging. In the simplest form, blue-dye-guided imaging in surgery illustrates optical imaging. An example of a more specific imaging probe would be 5-amino levulinic acid (5 ALA). This imaging probe has been used in clinical ovarian cancer imaging with superior results compared with probe-free imaging. Sentinel-node imaging has also been demonstrated, using 5-ALA in breast cancer. The concept of multi-modal surgical navigation is illustrated by deploying three-dimensional magnetic resonance images and enhancing-lesion visualisation using 5 ALA in the management of malignant glioma. A further example of specific probe has been shown in ovarian-cancer imaging by targeting folate receptor over expression as the ligand for the imaging probe.

Within the past few years, interest in near infrared (NIR) optical imaging has increased. The advantage of NIR techniques includes real-time imaging, lack of tissue staining, tissue penetration, superimposition of infrared images on reflectance images, and reduced photobleaching. John Frangioni’s laboratory at Harvard is leading the development in instrumentation and chemistry. Near-infrared imaging has been used in delineating surgical anatomy, including sentinel-node mapping, ureteric and biliary imaging. Although indocyanine green and methylene blue are non-specific contrast agents, industry stake holders are actively developing cancer-specific NIR optical probes, with phase 1 trials completed for a probe in breast cancer.

In imaging-guided surgery, fusion of pre-operative radiological data with real-time intra-operative imaging techniques will have the capability to identify the primary structure of interest and also guide the surgeons on neighbouring important anatomic features. The ultrasmall superparamagnetic iron oxide contrast-enhanced magnetic resonance imaging of lymph nodes in cancer has high sensitivity. Three-dimensional reconstruction of images and fusion with NIR sentinel-node mapping has the potential to enhance the efficacy of sentinel-node mapping and provide technical assistance during pelvic surgery in obese women. In addition, combining image reconstruction with computer-assisted surgical platforms can enable pre-operative planning and ‘mission rehearsal’ before undertaking surgery.

Telehealth for the operating room

Technical challenges of minimally invasive surgery means that many surgeons find that learning new procedures and using new technology is often faced with many obstacles. Traditionally, surgeons learn to perform new techniques through courses, videos, expert visitors, buddy systems and feedback. These have the attending problems of time, cost and a limited degree of guidance. As a result, skills and knowledge that might benefit both the patient and the healthcare system do not disseminate at a desirable pace.

Robotic surgery provides the perfect opportunity, whereby the expert located at a distance can assist or complete a procedure. Feasibility of robotic telesurgery has been proven in a number of studies. This option has high capital expenditure but, in the long term, it can provide a viable solution. Telementoring or teleproctoring can be an effective method of enhancing this learning phase as well as providing ongoing support without travelling to the site of activity. In Canada, telesurgery has offered advanced surgical care to patients in remote locations while training local surgeons in new procedures. This study also indicated unanimous patient acceptance of telesurgery.

Telesurgery can address two other unique scenarios, namely an outreach service in the developing world and battlefield surgery. The integrity of such a service will require training of a local team in surgical skills and provision of support services, such as radiology and pathology. This will require the application of cybercare at a global scale; the concept of cybercare is one of network-based distributed care. The feasibility of telementoring surgical skills training has been shown in a recent study using the Fundamental of Laparoscopic Surgery course. In the study, mentors from the USA were able to train surgeons in Botswana to a predefined level of proficiency. Although the exercise involves abstract tasks, the proof of principle here is encouraging. Provision of an expert pathological service will be essential to the success of remote care; centralising the expertise with efficient transportation of specimen can help overcome the initial inertia. Use of unmanned aerial vehicles can provide the answer for transporting specimen from remote locations to an expert; initial pilot results suggest that this is a practical solution. Subsequently, results could be transmitted via any number of electronic media to a local health advocate.

The versatility of unmanned aerial vehicles (UAVs) enables us to bridge the gap between a sophisticated safe medical environment and the perils of battlefield. Diagnostic services based on unmanned aerial vehicles will be a crucial element in appraising the battlefield casualty. Satava’s group have designed a multipurpose telerobotic unit capable of performing imaging and assisting in either an autonomous or telemanipulation mode. This Trauma Pod has the capability of performing tomographic x-ray and fluoroscopy in addition to performing scrub nurse’ function. Such advances will facilitate life-saving measures during the ‘golden hour’ of trauma care.

Telesurgery could particularly benefit surgical oncology. With increasing financial pressure and reconfiguration of the health service, one can envisage a national network for telesurgery where expertise could be concentrated and harnessed in selected centres, whereas patients could benefit from their expertise without travelling long distances. This may be an alternative to building super hospitals catering for particular sets of conditions.

Telesurgery can eliminate a number of logistical and geographical boundaries in the training of fellows in subspecialty surgery. At supra-regional level, training centres could synchronise teaching opportunities and improve trainee exposure. This has the potential to augment the ‘proximal learning space’ of the learning curve.

Further opportunities in robotic telesurgery include those relating to standardisation of practice and collaborative learning. These two factors are viewed as Achilles’ tendon in surgical trials. Thus, telesurgery as a quality-assurance strategy can address these factors.

Developments in robotics surgery

Transition from laparoscopic surgery to robotic surgery is significant in transforming surgery for the information age. Computer-assisted surgical platforms, such as robotic surgery, can enable integration of information from multiple sources such as computer axial tomography scan and three-dimensional reconstructed magnetic resonance imaging. Simultaneously, this may provide opportunities for pre-task rehearsal in patient-specific mode. Development of intelligent instruments, with sensors that engage with preoperative imaging data and positional information, can augment surgical navigation. Use of tissue and disease-specific optical probes can provide optical signatures enabling screening, optical biopsy and precision surgery.

Design of robotic architecture that specialises in specific subtasks, through the application of artificial intelligence, can result in a greater degree of precision beyond the limits of the surgeon. Such an application may enable more precise resection of rectovaginal endometriosis or more efficient retroperitoneal lymphadenectomy. Analogous to manufacturing industry, intelligent robotic systems in a pervasive environment could be remotely operated in an unmanned ORF.