Using New Technology to Improve Surgical Outcomes

Here we feature Rafael J. Grossmann, MD, a surgeon and educator in Bangor, Maine, who performed the first-ever live surgery using Google Glass, in June 2013. This piece has been adapted from The Surgeons’ Lounge, a regular column in General Surgery News (column editor: Samuel Szomstein, MD, Cleveland Clinic Florida, Weston).

Questions from Isabel Elssner, a senior pre-med student at the University of North Carolina at Chapel Hill

How have you been using technology to improve your surgical outcomes?

There is plenty of evidence that surgical outcomes have improved significantly over the past several decades. We have to infer that the smart use of technology played a key role—from the use of anesthesia, analgesia and antisepsis, to minimally invasive, endoscopic and robotic surgery.

Today’s technology is advancing in a somewhat exponential way. I think that today’s challenge is how to use these technologies to improve education and diagnostics, and to achieve equity in global access to ethical, safe and compassionate care. I think that the current socioeconomic, political and environmental landscape is creating a “perfect storm” situation that will exacerbate an already stressed health care ecosystem. If we look at how the demand for health care services is increasing versus the rapidly decreasing availability, and especially access to safe and affordable health care services, we are confronting a grave problem.

How can technology help provide better access to surgical care?

Technology can help. I would argue that the smarter use of technology can paradoxically create a more empathetic and humane health care system. The proper use of these tools can get us closer to our patients, and, in some way, rescue the rapidly fading doctor–patient relationship.

One of the technologies that can enhance education, teaching and learning is immersive media. I’ve been involved in this field for close to a decade, sharing clinical expertise and futuristic insights to help shape its evolution.

Immersive technologies refer to platforms (Figures 1-3), such as: • virtual reality (VR), in which the user is immersed in a digital, computer-generated environment or a 360-degree video, completely isolated from the surrounding real world—think of gaming in an Oculus Quest device; • augmented reality (AR), in which the user experiences digital content superimposed on the real world, viewed through a mobile device or a head-mounted display—think of “Pokémon Go” or the NFL’s magic “first down” yellow line; and • mixed reality (MR), in which the digital content interacts with and responds to the physical world as if it were part of the real surroundings.

How have you been using technology to improve surgical education?

In the field of surgical education, there are several platforms that use VR as a way to train the next generation of surgeons. Platforms such as FundamentalSurgery, PrecisionOS, OssoVR and OramaVR are shaping the future of surgery learning.

Simulation in VR to learn and practice the different steps of a surgical procedure is not new. What is exciting and innovative is the use of haptic feedback to make that experience uniquely real. That’s what FundamentalSurgery has developed: the possibility of immersing yourself in the actual surgery and providing a safe, repeatable environment to learn. The offer of repetition and damage-free failures through simulation is a key benefit for

Figure 1. Google Glass.

New Technology

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learning and shows huge value in technology for surgical education. It is only with the addition of haptics and sophisticated high-fidelity simulation techniques, however, that you can truly understand the benefits of precise learning.

Precise learning is a combination of tracked data points to test a user’s submillimetric accuracy alongside the user’s interactions with the different tissue textures, all within a surgical environment. When combining the repetition with not just procedural steps but also individual complex steps, muscle memory is built, and skills transfer through “feeling” the virtual body, which is a huge step up from some of the current VR simulation platforms.

With this highly intuitive system, the platform allows surgeons to experience the same sights, sounds and accurate physical sensations of the human anatomy, enabling them to hone and rehearse skills in a safe and measurable environment, dovetailing perfectly with the cadaveric and assisted/observational learning in the OR, without putting patients at risk. The haptic interactions data also create a personal dashboard to highlight weaker and stronger areas within each step of the procedure.

Another example of using technology in education involves the live streaming of a surgical procedure. The design of some of the current headsets allows the audience to have a “preferred seat” in the surgical theater.

In June 2013, I performed the first-ever live operation using Google Glass. All I did was to securely livestream that surgery to facilitate the experience of the medical students—showing them my perspective, my focal point during an operation and enabling them to participate in a “virtual,” synchronous fashion, asking and answering questions as if they were physically present. I decided to use that new technology to enhance their educational experience. Obviously, this is not a substitute for being in the OR, but just an alternative, a complement to their surgical education, especially in times when the OR might be too crowded, or when, as in the current pandemic, one cannot be physically present.

Another example is the case of telehealth. According to a report, it is estimated that approximately 5 billion people do not have access to safe or affordable surgery (Lancet Glob Health 2015;3[6]:e31-e323). This is an unacceptable reality and a problem that can be mitigated by the use of these tools.

The COVID-19 global crisis has shown us the benefits of remote communications and connectivity in every aspect of human endeavor. Health care was no exception, and despite detractors and obstacles, it has made a tremendous difference. The way I see it, telehealth represents another tool to connect with patients and colleagues, just like email, phones, paper and even fax machines. It is a complement, not a substitution, to the physical interaction.

We are seeing more frequent reports of how head-mounted display (or HMD) like Vuzix, Realwear, Microsoft Hololens and others have been used to breach geographical and educational barriers, to enable remote surgical assistance (https://journals. sagepub.com/doi/full/10.1177/1553350619871787).

In the field of AR, the ability to perform teleconsultations with a platform like Proximie, which uses “telestration” to bring the “hand,” skill and knowledge of an expert surgeon to guide a remote colleague, represents a clear example of the smart use of technology to augment surgical care and provide more equitable and inclusive access to global health (bit.ly/3yPthly).

In the space of surgical navigation, platforms like MagicLeap and BrainLab have partnered to enable a “mixed reality viewer,” which allows the visualization of holographic, 3D imaging to facilitate and enhance the performance of a surgical procedure. The images are literally “released from the confines of flat screens and taken into your world.” A surgeon in the OR, wearing a MagicLeap headset powered with the BrainLab software, can have access to the patient’s diagnostic imaging in an unlimited number of axes, making the viewing much more intuitive and ergonomic (bit.ly/38KoqY8).

Another interesting field in which technology enhances learning is serious games for health. A platform like Level Ex brings the power and fun of gaming to empower medical learning. It creates video games for doctors that capture the challenges in practicing medicine. It has tapped the convergence of medicine and entertainment, bridging the gaps in the health care industry through state-of-the-art video game technology and design.

Are there any negative aspects to using new technologies in medicine?

There are certainly risks in the use of technology. Its improper use could make interactions impersonal, less empathetic and less emotional, more mechanical. There is a potential risk for violation of patients’ private health information. There are also legal, regulatory and cost barriers that must be addressed. These issues are real, but they should not be deterrents to the exploration of these tools to improve the way we practice and teach medicine. These issues are solvable as long as the developers, regulators and users take them into account. The problem is not the technology, but the use we make of it. ■

Left: Figure 2. In the OR with MagicLeap XR Smart Glass. Right: Figure 3. Varjo 2, the most advanced virtual reality headset.

Read Dr. Grossmann’s blog at www.RafaelGrossmann.Health.

Dr. Grossmann is a medical advisor to FundamentalVR, Level Ex and MagicLeap.