Looking forward.

With the rapid acceleration of technology, fundamental changes in the science of surgery are emerging within the lifetime of a surgeon's practice. This review includes the technologies of information systems, robotics, virtual reality, simulation and training, directed-energy surgical instruments, photonics, and brain chips, as well as their impact on the practice of surgery. Also considered are those technologies that may replace surgery, such as genetic engineering, tissue engineering, suspended animation, and nanotechnology. The evidence for each of these technologies is presented as preliminary reports of their success in research laboratories.

The nature of surgical error: a cautionary tale and a call to reason.

Errors and "patient safety" have taken on monumental importance for surgery. Like all things new, there is an initial over-reaction before a return to a balanced perspective. The current response to the global interest in error has been to seize on the latest reports that are focusing on the "systemic nature" of errors, which is also being referred to as "the new look." There has been an unintentional ignoring of the actual error, referred to as the coface error, that the surgeon commits. It is time to put the approach to errors into perspective and redefine errors within the context of the surgical community, which can result in a balance of the surgeon's position in regard to systemic and personal responsibility.

Surgery in space. Phase I: Basic surgical principles in a simulated space environment.

The venturing forth of man into space confronts the surgeon with a new weightless environment with which he will inevitably have to contend. In this study operative procedures were performed on 20 rats in a simulated space environment with use of neutral buoyancy in order to identify those factors that could actually or potentially affect operative technique. There are three general areas of difference from normal conditions in simulated microgravity: physical adaptation to gravity deprivation tissue behavior, including bleeding; and the conduct of surgery. Without gravity, the tactile "feel" of objects is changed ("heavy" and "light" are meaningless terms) and proprioception is confused so that there is past pointing and overreaching of movements. Tissue planes tend to separate, and organs float and bob in the operative field, which makes clamping, cutting, and suturing different. Bleeding is a major consideration; surface tension tends to keep venous blood oozing along surfaces, whereas pulsatile arterial blood forms droplets, streamers, and clouds, depending on the force of the bleeding. These factors and others interfere with surgical technique in a number of ways: dispersion of blood obscures the surgeon's vision, sutures become entangled, organs are not stabilized, and instruments float into the operative field. The limitations of comparing neutral buoyancy to the true zero gravity of space are addressed. There is a definite need for further investigation for development of new surgical techniques in preparation for experimental and clinical surgery in space.

Emerging technologies for surgery in the 21st century.

Laparoscopic surgery is a transition technology that marked the beginning of the information age revolution for surgery. Telepresence surgery, robotics, tele-education, and telementoring are the next step in the revolution. Using computer-aided systems such as robotics and image-guided surgery, the next generation of surgical systems will be more sophisticated and will permit surgeons to perform surgical procedures beyond the current limitations of human performance, especially at the microscale or on moving organs. More fundamentally, there will be an increased reliance on 3-dimensional images of the patient, gathered by computed tomography, magnetic resonance imaging, ultrasound, or other scanning techniques, to integrate the entire spectrum of surgical care from diagnosis to preoperative planning to intraoperative navigation to education through simulation. By working through the computer-generated image, first with preoperative planning and then during telepresence or image-guided procedures, new approaches to surgery will be discovered. These technologies are complemented by new educational opportunities, such as tele-education, surgical simulation, and a Web-based curriculum. Telementoring will permit further extension of the educational process directly into the operating room.

Success rate of cervical exploration for hyperparathyroidism.

In a three-year experience with 361 patients who underwent exploratory surgery for hyperparathyroidism, the success rate for primary cervical operations was 95% and that for secondary operations (cervical and mediastinal) was 62%; for all operations, it was 94%. The three most important factors in determining successful cervical exploration of the parathyroid glands are correct preoperative diagnosis, meticulous surgical technique, and accurate determination of abnormal locations of pathologic conditions. Ancillary studies or techniques for preoperative localization of parathyroid tissue were utilized in only a few patients who had unusually complicated problems. The results of this study suggest that, because of cost, time involvement, and potential risk, selective venous sampling with radioimmunoassay of parathyroid hormone or arteriography or both should be reserved for complicated problems and for patients being considered for a second or third exploratory operation.

Telerobotic assisted laparoscopic surgery: initial laboratory and clinical experience.

OBJECTIVES: To assess the feasibility of telerobotic assisted surgery. METHODS: In a laboratory model, a cholecystectomy, splenectomy, and nephrectomy were performed by an inexperienced surgeon who was being mentored by an experienced surgeon stationed at a remote site. The remote surgeon controlled the laparoscopic camera by utilizing a telerobotic system. In patients, laparoscopic cholecystectomy, varix ligation, and bladder suspension were performed by an experienced team utilizing a robotic system controlled by an experienced surgeon from a remote site. RESULTS: In both the laboratory and clinical setting, all procedures were successfully completed without complications. CONCLUSIONS: Current technology is available to successfully allow for telerobotic assisted surgery.

Identifying and reducing errors with surgical simulation.

The major determinant of a patient's safety and outcome is the skill and judgment of the surgeon. While knowledge base and decision processing are evaluated during residency, technical skills-which are at the core of the profession-are not evaluated. Innovative state of the art simulation devices that train both surgical tasks and skills, without risk to patients, should allow for the detection and analysis of errors and "near misses". Studies have validated the use of a sophisticated endoscopic sinus surgery simulator (ES3) for training residents on a procedural basis. Assessments are proceeding as to whether the integration of a comprehensive ES3 training programme into the residency curriculum will have long term effects on surgical performance and patient outcomes. Using various otolaryngology residencies, subjects are exposed to mentored training on the ES3 as well as to minimally invasive trainers such as the MIST-VR. Technical errors are identified and quantified on the simulator and intraoperatively. Through a web based database, individual performance can be compared against a national standard. An upgraded version of the ES3 will be developed which will support patient specific anatomical models. This advance will allow study of the effects of simulated rehearsal of patient specific procedures (mission rehearsal) on patient outcomes and surgical errors during the actual procedure. The information gained from these studies will help usher in the next generation of surgical simulators that are anticipated to have significant impact on patient safety.

Laparoscopic surgery. Transition to the future.

The twenty-first century will usher in a fundamentally new approach to the practice of medicine. It will be based heavily on information technologies, broadly defined as the devices that acquire information; those that process, transmit, and distribute information; and those that use information to provide therapy. Although conventional surgery will continue to have a presence, there will be radically different surgical approaches and technologies that may become the predominant form of surgery. The medical record may become a three-dimensional visual representation of the individual patient (like the Visible Human Project), which can be the vehicle that integrates the entire spectrum of health care. Examples of the technologies and infrastructures that support this new approach to medicine are discussed and illustrated, with emphasis on how technologies improve individual patient care.

Endoscopy for the year 2000.

With the rapid advancement in technology, there is a revolutionary paradigm shift in the delivery of health care: physicians are now interacting with their patients via an "electronic interface." This interface will make possible the future of endoscopy and endoscopic surgery by taking advantage of the emerging technologies in robotics, micro-robotics, telepresence, and virtual reality.

Establishing an endoscopy unit for surgical training.

Gastrointestinal endoscopy is slowly returning to the core of surgical resident training. The intent is to integrate endoscopy into the mainstream of surgical education such that it will be approached and used the same as any of the many diagnostic and therapeutic tools at the surgeon's disposal. The current feeling is that although endoscopy should be intimately incorporated into training, there is a level of technical expertise required such that a dedicated teaching experience must be provided. This education must be directed by a surgeon experienced in endoscopy; we should not abdicate this responsibility to others. The training program should be founded on education, clinical practice, and research, with technical skills to begin in PGY 2 or PGY 3 and be incorporated throughout the remainder of training. Quality assurance should be monitored closely but not separately from that of the surgical service. Certification of the resident should not depend on numbers, nor be specifically singled out from the body of surgery. There is adequate patient demand to establish the endoscopy unit under the supervision of a surgeon, either as a separate unit or as part of the surgical clinic. However, as the number of endoscopic procedures performed approaches 600 per year, a fully dedicated endoscopy room and full-time gastrointestinal assistant technician are required. The most efficient method of postsedation recovery is through coordination with an ambulatory surgery unit or postoperative recovery room. The current standard for equipment is video endoscopy in order to provide the most efficient method for surgical training.

Preparing surgeons for the 21st century. Implications of advanced technologies.

An entire spectrum of advanced technologies and concepts has been presented, from the new clinical applications to highly speculative possibilities. Not all of these technologies will survive the long process to clinical usefulness, but those that do may revolutionize surgery. With such change comes the ethical and moral responsibility to consider them not only in the light of improvement of patient care but also in their impact on society as a whole. If the remarkable rate of change of the past 2 decades continues, it is impossible to conceive of the role of future surgeons. Thus, to be prepared, surgeons must have an open mind, a willingness to consider and evaluate new directions, and the honesty and courage to change when a new approach is proven to be of value. A prepared mind is an open mind.

Disruptive visions: surgical education.

Technological change, decreased financial support for medical education, and social oversight (in the form of the "To Err Is Human" report, HIPPA, and reduced work hours) are forcing a rethinking of the traditional model of surgical education to improve patient safety. New approaches to evaluating surgical competence, such as objective assessment, in combination with new technologies, such as the Internet and surgical simulators, provide the tools to effect a revolution in surgical education and training. Competency based upon quantifiable criteria measures must replace the traditional subjective assessment. The implementation requires accurately defining the elements of training, establishing new quantifiable metrics, stringently measuring performance against criterion, and reporting outcomes throughout the career of a surgeon.

Disruptive visions: a robot is not a machine...systems integration for surgeons.

The discipline of surgery has become even more complex with the rapid introduction of revolutionary technologies. Laparoscopic surgery is just the simplest and first of these new directions. Robotic surgery and image-guided therapy are the next generation. As biosurgery and other modalities are introduced, the complexity will increase exponentially. In order to understand and utilize the new technologies, surgeons need to be grounded in the science of systems integration. The pervasive influence of this new requirement, as well as the skills, education, training, and assessment needs, are defined.

Accomplishments and challenges of surgical simulation.

For nearly a decade, advanced computer technologies have created extraordinary educational tools using three-dimensional (3D) visualization and virtual reality. Pioneering efforts in surgical simulation with these tools have resulted in a first generation of simulators for surgical technical skills. Accomplishments include simulations with 3D models of anatomy for practice of surgical tasks, initial assessment of student performance in technical skills, and awareness by professional societies of potential in surgical education and certification. However, enormous challenges remain, which include improvement of technical fidelity, standardization of accurate metrics for performance evaluation, integration of simulators into a robust educational curriculum, stringent evaluation of simulators for effectiveness and value added to surgical training, determination of simulation application to certification of surgical technical skills, and a business model to implement and disseminate simulation successfully throughout the medical education community. This review looks at the historical progress of surgical simulators, their accomplishments, and the challenges that remain.

Disruptive visions.

Numerous advanced technologies, both medical and nonmedical, are emerging faster than their social, behavioral, political, moral, and ethical implications can be understood. Some of these technologies will fundamentally challenge the practice of surgery: human cloning, genetic engineering, tissue engineering, intelligent robotics, nanotechnology, suspended animation, regeneration, and species prolongation. Because of the rapidity of change, the current status of these emerging technologies with their specific moral and ethical issues must be addressed at this time by the new generation of surgeons, or we must all face the consequences of an uncontrolled and unprepared future.

Disruptive visions.

A number of concepts have been advocated for the next generation operating room based on some inadequacies of the current systems. Most have focused on removing excess tubes and wiring, others on information systems or robotics. An analysis of other industries, a projected direction of current technologies, a focus on the importance of integrated information systems, and a serious consideration of emerging basic technologies suggest a significantly different approach.

Disruptive visions: predictive simulation--between scientific method and clinical trial is the role of modeling and simulation in scientific discovery and validation.

The foundations of surgery have rested upon the passing of knowledge from generation to generation by mentors and manuscripts. Until the 1900 s, the passage of knowledge was through tradition. Since then, it has changed from observation and experience to the scientific method to clinical trials. A new approach, derived from other scientific disciplines, is that of predicting results from modeling and simulation, which will allow for acceleration of the process of validation of discoveries and optimizing the implementation of clinical trials in order to more rapidly transfer trusted knowledge from generation to generation.

Virtual reality as a metric for the assessment of laparoscopic psychomotor skills. Learning curves and reliability measures.

BACKGROUND: The objective assessment of the psychomotor skills of surgeons is now a priority; however, this is a difficult task because of measurement difficulties associated with the assessment of surgery in vivo. In this study, virtual reality (VR) was used to overcome these problems. METHODS: Twelve experienced (>50 minimal-access procedures), 12 inexperienced laparoscopic surgeons (<10 minimal-access procedures), and 12 laparoscopic novices participated in the study. Each subject completed 10 trials on the Minimally Invasive Surgical Trainer; Virtual Reality (MIST VR). RESULTS: Experienced laparoscopic surgeons performed the tasks significantly (p < 0.01) faster, with less error, more economy in the movement of instruments and the use of diathermy, and with greater consistency in performance. The standardized coefficient alpha for performance measures ranged from a = 0.89 to 0.98, showing high internal measurement consistency. Test-retest reliability ranged from r = 0.96 to r = 0.5. CONCLUSION: VR is a useful tool for evaluating the psychomotor skills needed to perform laparoscopic surgery.

Disruptive visions: biosurgery.

There are a number of new therapeutic options generated by the biotechnology, bioengineering, and bioimaging revolutions in terms of organ-specific designer drugs, genetically engineered cells, cell-specific proteins and drugs, directed energy instruments, therapeutic microdevices, etc. Many of these new therapies need to be placed exactly on, within, or adjacent to an organ, and many others are delivered by endoluminal or endovascular approaches. The common requirements are (1) the accurate delivery of the modality and (2) the functional importance of targeting the biologic basis rather than the anatomic structure--hence the term biosurgery. As more of these therapies achieve clinical applicability and FDA approval, there will be the need for the precision of delivery to be at the micro- and nanoscale, which is well beyond human physical limitations. The surgeon of the future must be able to identify those therapeutic modalities that would benefit from such exact placement or implantation and acquire the skills, training, and equipment to use surgical expertise to deliver these new modalities. A review of some of the emerging opportunities is presented. Ignoring these challenges will relinquish these new procedures to other nonsurgical interventionalists, perhaps to the detriment of patient safety.

Metrics for objective Assessment.

As the need for improved methods of assessing surgical competence grows, it is imperative to establish the basic infrastructure to ensure the ability to communicate among educators, education researchers, responsible training bodies, and credentialing boards. A workshop was conducted to provide a foundation for communication and a standardization of definitions, measurements, and criteria. Future conferences and workshops will be needed to review and refine this initial framework.