The dawn of the digital operating theatre and the rise of the digital surgeon.

Abstract

Let us begin by asking this seemingly simple question: What is minimally invasive surgery? While minimally invasive surgery (MIS) is typically defined as using smaller incisions to accomplish the same operative task as conventional surgery, it must also be appreciated that this methodology has been an important step towards the creation of the digital operating theatre. Why? Fundamentally, both laparoscopic and robotic MIS rely on a digitized video image sequences from a charge-coupled device (CCD) camera, which are then converted into digital signals and relayed at near-instant speed—approximately 0.7 times the speed of light. These signals are then typically processed and then projected onto a liquid crystal display (LCD) high-definition monitor. In the simplest sense, an MIS surgeon performs digital surgery, because the operation is carried out based on the surgeon’s interpretation of the real-time digitized cine displayed on LCD rather than direct visualization of the patient’s anatomy. This concept, essential to all forms of MIS, represents an important departure from conventional surgery, and a crucial segue towards the realm of true digital surgery. Thus, an MIS surgeon operates not by looking at a patient but rather by looking at digitized information that represents the patient—a sequential stream of 1 and 0 s converted into ‘picture elements’ (aka, pixels) via LCD and the image rendered visible by red–green–blue colour modelling. With robotic master–slave platforms, the surgeon is removed from the patient altogether. Nevertheless, despite the absence of haptic feedback, very precise surgical dissection is possible with robotic MIS and the prospect of telemedicine becomes real—because of the ability to convert human anatomy into digital data points that can be streamed to a remote site in real time. In the field of surgery, parallels are often drawn to the aviation industry due to the rigorous, safety-oriented protocols it mandates [1]. But another important aviation paradigm relates to navigation and includes the digitization of information and the processes used for data interpretation via advanced avionics. For instance, a pilot utilizes sophisticated navigational aides and fly-by-wire technology that allow an aircraft to travel safely in precise flight paths and at high velocity without reliance on visual references. In essence, a pilot can determine craft position and trajectory by using digital navigation inputs from various computer-centric instruments including the geostationary satellite global positioning system. For more complex vehicle navigation, system informatics and computing centres are necessary—such as those utilized for the manned space flight programme. The reason such systems are employed is because they are accurate and reliable and because a digital-based, augmented reality provides more meaningful information than visual cues alone. So then, if a pilot is able to navigate an aircraft by relying on digital information only, can a surgeon navigate though surgical planes in the same fashion, relying only on digital information? For select neurosurgical and orthopaedic procedures navigation-assisted surgery is already the norm, but other surgical specialties have been slow to adapt this modality. The modern digital OR remains in early evolution, but will likely mirror the advancements made in aviation. In addition to high-definition digital 2D and 3D stereoscopic video, the digital operating theatre will incorporate information from image-based systems, such as the Picture Archiving Communication System (PACS). It will & S. Atallah atallah@post.harvard.edu