OR of the future: technology benefits surgeons

Interview with Prof. Erwin Keeve, Department of Navigation and Robotics, Charité Berlin


When it comes to the future of medicine, we often ponder how we would like to be treated. On the other hand, there is the issue of how physicians would like to treat their patients. The surgical procedures are determined by the technology that doctors are surrounded by. That's why technology development also needs to be adapted to the needs of surgeons in the operating room of the future.
Image: Man with fair hair, black glasses and grey jacket is working at a computer - Prof. Erwin Keeve; Copyright: Erwin Keeve, Charité

Prof. Erwin Keeve; ©Erwin Keeve, Charité

In this interview with MEDICA-tradefair.com, Prof. Erwin Keeve talks about how imaging technology and robots can assist surgeons without impeding the surgical intervention and what still needs to happen before the OR of the future can become a reality.

Prof. Keeve, how do you envision the OR of the future?

Prof. Erwin Keeve: Right now, every medical discipline runs its own operating room in Germany. This results in ORs not being used optimally. Other countries feature surgery as a discipline that operating rooms are assigned to with subordinated specialty disciplines. ORs can be fully utilized when the surgical disciplines are being consolidated this way. That's why I believe that ORs of the future should be interdisciplinary operating rooms. Health care cost pressures will also force us to do this since we are not able to support every single medical specialty with its own high-tech equipment and set up individual specialty ORs. Instead, we can provide the rooms with standard equipment including specialty tools and adapt the logistics so various disciplines are able to utilize them.

If you take this concept further, in the future, major surgical centers will operate 20 to 40 rooms that are divided into different categories. This is already being done today to some extent. Some of these operating rooms will permit standard procedures, while others will feature high-tech equipment and support interventions with imaging techniques as hybrid operating rooms. We have witnessed this trend for several years: the large imaging systems that were originally designed for purely diagnostic purposes can be increasingly used in an intraoperative manner. They can be brought right to the patient during surgery and permit the staff to quickly intervene if needed.

Image: OR with modern equipment, patient chair, large screens and lamps; Copyright: Erwin Keeve, Charité

Is this what the OR of the future looks like?; ©Erwin Keeve, Charité

That suggests that future imaging systems will be smaller and more mobile.

Keeve: Yes, that is correct. C-arm imaging systems, for instance, use a source and a detector. These components need to be aligned as rigidly as possible and calibrated to facilitate great images. On the one hand, this can be achieved by the mass of the device. This makes the system more rigid but also heavy and hard to move. On the other hand, we are also able to calibrate today's imaging systems by using software. The source and detector are synchronized during the first images. This makes the systems smaller, lighter and more elegant.

We try to implement this with the ORBIT project where the source is built in under the ceiling and the detector is located in the surgical table. Source and detector of ORBIT move independently from each other and only minimally restrict patient access. This way, the patient does not need to be completely disengaged from the equipment before he is moved into the imaging system. Our approach varies from mainstream thinking: our system is designed to be transported to the patient. This saves valuable time in the case of emergency surgeries in critical care since the physician is able to receive images to reach a concrete diagnosis within a few short minutes.

What role will robotics play in the operating room?

Keeve: Many companies already utilize robotics to support intraoperative imaging. The surgical table is also a high-tech mechanical system that can be adjusted to move the patient for optimal access. Combined with imaging technology, this also makes it possible to position the patient for image recording. Mechanically controlled systems will increase. That said, this does not mean that robots will act autonomously. They are only intended to support the surgeons. However, it is not enough to transfer industrial robotics concepts into medicine. These types of robots are too powerful and are too heavy, despite them being called lightweight robots. A surgeon is not able to control them in an easy and manageable fashion. What’s more, these robots were originally designed for set, predictable tasks that do not exist like that when it comes to patients.

Over the past two years, we have built a truly lightweight endoscope surgery robot that can be mounted on the side of the surgical table. It only weighs 7.5 kilograms (16.5 pounds) and moves when the surgeon exerts a force of 0.5 kilograms (1 pound). This is approximately the force required to hold an endoscope. This way, the robot replaces the job of the surgical assistant who previously had to hold the instrument to ensure the surgeon has a full view of the surgical site.

Impressions from the OR of the future - photo gallery

Please click on the arrows on the right or on the left of each picture to browse through the pictures. For a bigger view please click the symbol below the lower right corner of each picture.
Image: OR with modern equipment; Coypright: Erwin Keeve, Charité
Surgeons need an unhindered access to the patient during surgery. Large imaging systems would only be in their way.
Image: Computer-generated image of a patient on an OR table, the patient's head is X-rayed; Copyright: Erwin Keeve, Charité
The ORBIT imaging system uses a radiation source that is mounted at the ceiling and a detector within the operating table.
Image: Surgical robot with many arms at a trade fair presentation; Copyright: Erwin Keeve, Charité
Robots have been established as an instrument of minimally-invasive surgery for a long time.
Image: Team of surgeons performs surgery with a robot with many arms; Copyright: Erwin Keeve, Rikshospitalet Oslo
Robots only support surgeons. They are not able to work independently.
Image: Team of surgeons in the OR; Copyright: Erwin Keeve, Charité
The OR of the future can be used interdisciplinary. It meets the requirements of different specialized surgical disciplines.

When it comes to imaging systems in the OR, do you also see opportunities to visualize data through augmented reality, virtual reality, and 3D images?

Keeve: Absolutely. Surgeons innately think three-dimensionally since they need to determine the best way to the surgical site based on image data. Software that generates three-dimensional sequences from two-dimensional image data and shows the surface or volume of specific structures is already available. In terms of technology, this is not an issue. The problem is more in presenting a reliable three-dimensional image that allows the surgeon to work safely.

During an endoscopy, augmented and virtual reality can show a surgeon for instance what lies deeper in the tissue, beneath the surface he is looking at. You can also show distance readings for example. This way, the surgeon is able to see how far away his instrument is from the surgical site. In a project, we show this for instance using a virtual extension of the endoscope that represents a centimeter scale.

Let’s get back to the initial header, the operating room of the future: what obstacles do you currently see to its implementation?

Keeve: It is technically very difficult to make the systems easy enough to use to where they do not overwhelm the surgeon. I believe the human machine interface is the biggest challenge. Engineers need to realize that tools need to be more intuitive and easier to use.

The other problem is the need for consolidation in hospitals. As I have mentioned earlier, we need to break through the structures between individual medical disciplines and build surgical interdisciplinary centers. Today, hospitals are only able to operate efficiently if they set up large structures and diversify their operations. This also includes the understanding that not every appendix needs to be surgically removed at a university hospital. This can also be handled by a regional community hospital located at the periphery of town that does not offer costly full-service acute care. Conversely, this technology-intensive neurosurgical intervention does not need to be available in every community hospital; these cases should be referred to a major hospital structure like a university hospital. Having said that, I am very optimistic that we can apply this knowledge together in the coming years.

Image: Man with glasses and beard - Timo Roth; Copyright: B. Frommann

© B. Frommann

The interview was conducted by Timo Roth and translated from German by Elena O'Meara.