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Professor Peter McCulloch has contributed evidence to the Royal College of Surgeons' independent Commission on the Future of Surgery.

The Commission predicts that surgery is about to be transformed for millions of patients by a new wave of technologies – driven by changes in digital technology and our understanding of human biology – which in some cases are only months away. Unlike many previous innovations, the forthcoming technologies are expected to affect every type of surgery, including the way it is provided and the way we train surgeons.

More diseases could be diagnosed by blood samples instead of invasive biopsies; ‘well’ patients will undergo earlier and, in some cases, preventive operations; and hundreds of thousands of patients may no longer need to undergo some cancer operations due to advances in genomics, vaccination, and non-surgical treatments. In the more distant future, surgeons may prevent, and not just treat, osteoarthritis through stem-cell therapies, and nano-surgery performed by micro-robots could allow surgeons to operate on individual cells in the body.

For the last year, The Commission on the Future of Surgery – established by the Royal College of Surgeons and made up of some of the country’s leading doctors, engineers, data experts, managers, and patient representatives – has been investigating the advances that will transform surgery over the next 20 years.

Professor McCulloch, who is head of the Quality, Reliability, Safety and Teamwork Unit at the Nuffield Department of Surgical Sciences, has been supporting this work throughout the last year and his contribution to the publication has helped to achieve this result.

Published today (7 December 2018), the report of the Commission says that patients can confidently expect surgery to become much less invasive and more personalised, with more predictable outcomes, faster recovery times and a lower risk of harm.

The report highlights four areas of technological development that are likely to have the greatest impact on how surgical care is delivered in the next two decades. These are robot-assisted surgery and minimally-invasive surgery; imaging (including virtual, mixed and augmented reality); big data, genomics and artificial intelligence; and specialised interventions like developments in transplants and stem-cell therapies.

Mr Richard Kerr, Chair of the Royal College of Surgeons’ Commission on the Future of Surgery, said:

“We’re standing on the verge of transformative changes in surgery that have the potential to dramatically improve patients’ care, helping them to live healthier lives for longer. We are now moving from the era of freehand surgery to the digitalisation of surgery – where surgeons are supported by data, genomic analysis and new tools such as robotics.

“From advances in minimally-invasive surgery and robotics, to genomics and virtual reality, this new wave of technologies will expand the surgeons’ toolkit exponentially. The changes are expected to affect every type of operation – this will be a watershed moment in surgery.

“Of course some of these technologies will remain science-fiction, with certain clinical challenges too big to overcome, and there may be other innovations we haven’t foreseen. Yet, with new surgical robots, for example those coming to the market in 2019, it seems reasonable to conclude that millions of patients will soon benefit from many of these new technologies.

“Collectively these technologies will make surgery faster to recover from, even more accurate and successful, with much less scarring for patients. Surgery may become redundant for some types of cancer treatment, while new forms of surgery might occur. For example, it will become easier to operate on older, frail patients given the reduced trauma involved. Surgery will also no longer just be about helping patients once they are ill, it will be about helping them avoid getting ill in the first place.

“It is an incredibly exciting time to be part of the surgical team, as technology is going to enable us to do so much more to keep our patients healthy. Better diagnosis and a more detailed understanding of how illnesses develop, thanks to advances in genomics and genetic testing, will give us the tools to tackle disease at an earlier stage. We will be able to act early and tailor surgery to the needs of individual patients, and therefore likely operating on patients who are otherwise well.

“Surgeons can look forward to spearheading these developments and tackling any challenges, leading patients on these exciting improvements in their care.”

Big data, genomics and artificial intelligence

Advances in big data, genomics and artificial intelligence will enable ‘precision surgery’ – where treatments can be tailored to patients according to their genetic profile. Genomics has the potential to revolutionise surgical care by making some types of surgery redundant and by allowing doctors to better understand cancerous tumours and target treatment accordingly. Liquid biopsies from a variety of bodily fluids may make it easier for disease to be diagnosed earlier. Evidence received from geneticists, clinical scientists and surgeons specialising in genomics suggests that in 20 years the population may be able to undergo annual testing for cancer through a blood sample, while similar tests are already being evaluated to monitor disease recurrence.

Robotics and minimally-invasive surgery

According to the Commission’s expert panel, alongside major developments in laparoscopic and endoscopic surgery, surgical robots will be smaller, lighter, and likely cheaper. The next generation of surgical robots are now expected to be launched in 2019 and are drastically smaller and lighter, meaning they could be moved between theatres or even hospitals. This is very likely to make robot-assisted surgery more widely available in local hospitals and will narrow the gap in performance between surgeons.

Over the next few years the Commission expects robots to start becoming more commonly used in gynaecological procedures, colorectal and cardiothoracic surgery.

Developments in minimally-invasive surgery and advances in imaging will make more patients eligible for surgery, particularly the frail and elderly. For example, functional imaging of the brain is already enabling micro-surgery for some cerebral tumours.

Autonomous robots are not expected to replace surgeons due to the complexity and unpredictability of carrying out a surgical procedure, but nano-robotics to help diagnose patients and deliver drugs may become a reality longer-term, if enough of the current barriers are overcome.

Imaging, virtual reality and augmented reality

The report suggests that virtual, mixed and augmented reality platforms will allow surgical teams around the world to share advice during operations, and specialist surgeons to carry out or support complex procedures remotely. For example, a surgeon in one hospital might guide a team in another unit through an operation using augmented reality. The report also notes that advances in imaging and simulation, as well as 3D printing, are already being used to complement surgical training and planning. The Commission highlights the advantages of 3D imaging to support planning of personalised surgical interventions, and creating patient-tailored implants using 3D printing techniques.

Over the next 20 years, ultra-high definition stereo endoscopes and microscopes are anticipated to be in use, making further improvements to the accuracy of diagnosis and surgery.

Specialised interventions

The expert panel has also considered specialised interventions such as some stem-cell therapies, 3D-bioprinting of tissues and organs, artificial organs, developments in transplant, and neural prosthetics with adaptive control mechanisms. The report suggests that in the short-term advances in 3D printing will lead to more advanced prostheses, while in the longer-term more advanced imaging could enable ‘nano-surgery’, where surgeons could use miniaturised devices to operate on individual cell clusters – potentially with dramatic effects for cancer patients.

Research is also underway into manufacturing artificial organs which are easier to replicate such as bile ducts, although such advances are only likely over a much longer timescale.

Surgical training and the workforce

The role of some surgeons is likely to become increasingly wide-ranging, sometimes crossing boundaries with clinicians in other areas of medical intervention where a vast array of other treatments may become preferable, such as in cancer surgery.

Surgeons will need to become ‘multi-linguists’, understanding the language of medicine, genetics, surgery, radiotherapy and bioengineering. Leadership, managerial and entrepreneurial skills will become increasingly important attributes of the surgical profession. The surgeon will play a key role in genomics, acquiring and handling tissue samples and being the first healthcare professional to discuss genetic analysis with a patient.

The multi-disciplinary and multi-professional surgical care team, including surgical care practitioners and physician associates, will become increasingly important in developing and delivering care of the highest quality. They will provide more aspects of care and may take over some areas of surgical care currently delivered by surgeons. The Commission raises the possibility that highly skilled surgical technicians may undertake some further procedures – such as endoscopy and endoscopic biopsies, removing skin lesions and maybe even carrying out caesarean sections – under the supervision of a surgeon.

Recommendations

The report makes a number of recommendations to Government, healthcare regulators and medical royal colleges to ensure the surgical community is able to adapt to coming changes and enable patients to fully benefit from advances.

Some key recommendations from the Commission on the Future of Surgery include:

  • A UK-wide database or registry should be established to track all new devices and techniques. All new techniques and implantable devices should have long-term monitoring in such a register, akin to the breast implant registry.
  • There should be a review of the viability of creating a national database that encompasses a much wider range of procedures than currently covered by national clinical audits.
  • The location of surgical robots and centralised services needs to be much better planned in the future to balance equity of access across the country and cost effectiveness. NHS England should initially lead a robotics strategy to help the NHS plan and purchase new surgical robotics systems – this approach could extend to other innovations.
  • NHS Digital should carry out a review of how NHS websites, and digital and other communication from patient charities can support patients to understand the benefits and risks of new treatments and surgical procedures.
  • The NHS in England, Scotland, Wales and Northern Ireland, in conjunction with local trusts, should encourage investment in the creation of multidisciplinary hubs for the delivery of complex interventions. In the immediate term, they can enable the use of 3D printing and planning technologies. In future years, other specialised interventions, such as regenerative medicine, can benefit from centralised multidisciplinary expertise.
  • Surgical training needs to ensure surgeons are capable of evaluating and embracing change. It should also engage with the opportunities for distant and virtual learning.

RCS response

Responding to the Commission’s findings, Professor Derek Alderson, President of the Royal College of Surgeons, said:

“The Commission on the Future of Surgery has painted an awe-inspiring vision of how the surgical team will care for patients over the coming decades. It is a very exciting time to be embarking on a career in surgery.

“The Royal College of Surgeons will consider carefully all of the recommendations the Commission has made, particularly those relating to surgical training.

“It’s absolutely crucial that these exciting advances are introduced in ways that ensure the greatest possible patient benefit, and do not risk patient safety. The RCS is very supportive of the recommendations the Commission makes on compulsory registration of new technologies and devices.”

 

Download the full report on the Future of Surgery website.

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