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EDITORIAL |
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| Year : 2021 | Volume
: 26
| Issue : 5 | Page : 279-286 |
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The digital era and the future of pediatric surgery
Sumitra Kumar Biswas
Visiting Professor, Institute of Child Health, Kolkata, West Bengal, India
| Date of Submission | 24-Jun-2021 |
| Date of Acceptance | 09-Jul-2021 |
| Date of Web Publication | 16-Sep-2021 |
Correspondence Address:
Prof. Sumitra Kumar Biswas
Department of Pediatric Surgery, Institute of Child Health, Kolkata, West Bengal
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jiaps.jiaps_136_21
How to cite this article:
Biswas SK. The digital era and the future of pediatric surgery. J Indian Assoc Pediatr Surg 2021;26:279-86 |
The Cambridge English Dictionary defines DIGITAL ERA as “the present time in which many things are done by computers and a large number of information are available because of computer technology.”[1]
In fact, the digital technology has permeated into the very fabrics of our day-to-day lives, and with every function of present-day human civilization so imperceptibly, that we do not even recognize it, unless we think of it with a conscious effort. This computer/digital/information technology may be called the present-day industrial revolution, a second one, which is shaping and changing all kinds of other technologies toward an, yet unfathomable impact on the future of this planet itself and the mankind. This is noticed in the practice of medicine also, which is becoming more and more technology dependent. Pediatric surgery as a branch of medicine will be no exception to this.
In this article, I intend to summarize, how technology has already changed the practice of surgery and pediatric surgery; what lies ahead for us in the coming future, and the activities behind in the backyard of technological research which is going to revolutionize the practice of medicine, and the dream or vision ahead, in a stepwise manner.
I will discuss in succession: (1) MIS with special emphasis on robotics and what is going on in this field; (2) the available forms of computer technologies, which can be utilized in medicine; (3) three-dimensional (3D) printing of accurate physical models and 3D/4D bioprinting of tissues and organs; (4) briefly touch, the development of bioinformatics and computational biology – its application in genomics and other fields of medicine; (5) impact of digital technology on medical education as a whole including teaching, training, tele-mentoring and tele-surgery; (6) ethical, legal, technical, and financial issues involved to make surgical care digitalized; and (7) the vision of a future pediatric surgeon who may be aptly called “A DIGITAL PEDIATRIC SURGEON,” who will be not only knowledgeable in information management and decision-making, but at the same time will be a compassionate surgeon to give a “humane touch” to modern techno-dependent medical management.
The practice of surgery has itself undergone a paradigm shift. When we were students, the aphorism was “Big Surgeons give big incisions.” At that time, we never dreamt that the same task could be accomplished with key holes. Although history of endoscopy dates back over more than a century, it gained momentum only after the discovery of video computer chip, that allowed the magnified images projected on television screens around mid-eighties in the twentieth century.[2] Technology has made this possible and the practice of MIS (minimally invasive surgery) may aptly be called “a revolution in surgery” and this era of surgical practice as “MIS Era.”
Pediatric surgeons initially lagged behind their adult counterparts, particularly in neonates and infants, but with availability of miniature instruments, the scenario had changed. Most of the pediatric surgery teaching departments in India are now practicing laparoscopic surgery at different competency levels. However, laparoscopic proficiency needs a steep learning curve, and despite its magnified view, errors do occur due to its two-dimensional views, movement parallax, tremor, and blind spots. Furthermore, certain areas of abdominal cavity are difficult to access with it particularly in the depth of pelvis.
Robotics emerged to obviate these problems with more magnified 3D view, remote controlled instruments with hinge joints, and seven-degrees of freedom of movements; it is ergonomically comfortable for the surgeons and the learning curve is less. This has caused some to leapfrog. However, compared to hand-held laparoscopy, its progress is slow probably due to financial constraint[3] and <0.5% surgeries are done worldwide by the da Vinci platform.[4] At present, in our country, only seven centers are pursuing robot-assisted laparoscopy in children on da Vinci platforms. Present systems in market have no 3 mm instruments for smaller children, particularly neonates and infants though a recent publication points to its development by Intuitive Inc., and use in phantom cleft palate surgery.[5] Although use of robotic platform has many advantages over traditional laparoscopy, present-day robots are “master-slave systems” and errors may occur due to misjudgments from the master.
In all these MIS modus, the present-day instruments are no replacements for a well-trained surgeon's hands with innumerable nerve endings in open surgery, because of the absence of any haptic cues. A surgeon can assess the texture, turgor, temperature, and a multitude of other cues which help him to comprehend the anatomy, structural integrity, the pathological extent of the disease, for decision-making of a safe surgery. This is aided also by visual cues and previous learning.[6] Hence, active research is going on how to overcome this.
The ideal surgical robot may be defined as “a computer-assisted actuated device consisting of dexterity, perception, and intelligence functionalities for hard and soft tissue surgeries.”[7] Hence, the present-day surgical robots are merely tele-manipulators with only one dexterity of dimensions that is motion scaling and tremor nulling. The surgical robotics may be divided in two categories: (a) soft tissue robotics, where tissues are dynamic and deformable as in abdominal and thoracic cavities, and (b) hard tissue robotics, where tissues are relatively adynamic and somewhat nondeformable as for example bones and joints, the spinal and intracranial cavities. In the second category with straight forward simple tasks, automation has taken place such as ROBODOC in hip replacement surgeries and NEUROMATE for spine surgery.[8],[9] These may be called procedure-specific robotics.
The difficult task of combining dexterity, perception, and intelligence is now an active area of research, in soft tissue robotics. The use of computer vision with ultrahigh-definition resolution (CV, 8KUHD), augmented reality (AR), virtual reality (VR), machine learning (ML), artificial intelligence (AI) and improved networks (5G) enabling the internet of skills with standardized haptic codecs, so that in addition to audiovisual streaming, haptic cues are also streamed back to the operator (and streamed to any part of the globe). Microsensors based on different technologies may be attached to the tip of the instruments for this purpose.[10],[11],[12] Already there is a business report for the use of 3-mm robotic tools with haptic feedback and digital interface, in small children in Maastricht University Medical Centre, Netherlands, for complex abdominal procedure using Senhance® Surgical system by Transenterix on October 13, 2020.[13] It might be a vision for us that one day, robotic consoles empowered by AI and a big data incorporated by cloud or quantum computing may guide the future pediatric surgeon during complex operation with a system like traffic signaling (green light on when dissection is proceeding well; yellow light on when you are in a wrong plane; and red light on when you are about to injure nearby vital structures).[14]
Soft tissue robotics again can be classified into two categories: (a) linear robotics and (b) nonlinear robotics depending on the instruments used; the common da Vinci platform with all its variants including S, Si, and Xi is an example of linear robotics with straight instruments. All of them needs triangulation and unsuitable for surgeries where space is limited or where access is difficult.
However, over 70 companies in the world are now actively pursuing research for platforms for Natural Orifice Transluminal Endo-surgery (NOTES). Intuitive surgical has already come up with its da Vinci SP platform initially meant for SILS abdominal surgery, but it has been successful in transoral robotic surgeries (TORSs) in head and neck malignancies and transanal robotic surgeries (TARSs) in adults.[15],[16] It has three long slender flexible effector arms (6 mm) and a stereoscopic 0° camera all through a 2.5-cm port. With future miniaturization, it can be utilized in cleft palate surgery and repair of laryngeal and tracheoesophageal clefts through oral route, in pediatric age groups.
Another nonlinear semirobotic system for TARS is flex-robotic by Medrobotics. It has two 3.5-mm curvilinear instruments, a reusable metal access channel which can be docked to the operation table. Only the camera is driven by a robotic technology. There is no surgeon console. Gas leak is prevented by an effective seal (Airseal) with attachable insufflation mechanism. This relatively cheap system has been used in both TORS and TARS procedures in adults and for robotic vaginal access surgery (vNOTES/ VAMIS) for gynecological procedures.[17],[18],[19] There is no doubt that with miniaturization of accessories, this platform can be utilized for transanal pull-through (TAPT) procedures for Hirschsprung disease (HD) like Swenson procedure and TAPT even in long-segment HD, or removal of uncomplicated inflamed appendix or twisted ovary.
Like dedicated procedure-specific linear robotic system described earlier, robotics is being utilized in procedures like bronchoscopy,[20] minimally invasive cardiac procedures,[21] ureteroscopy,[22] and endoluminal lower GI procedures[23] dedicated to the systems, and obviously, these are examples of nonlinear robotics. For SILS also, there is a dedicated platform in trial.[24] Another emerging concept is dual-field robotics,[25] where the pathology is accessed from both say per anal and abdominal approach in cooperation by two surgeons with a dedicated platform. In pediatric surgery, this may be applied in any abdominoperineal operations like Duhamel procedure to reduce time, which has a direct bearing on infective complications.
The other fascinating area of research is Miniature Cooperative Medical Robotics. The idea is to place multiple small robots with different functionalities to complete any procedure cooperatively. After pneumoperitoneum, they are introduced into the peritoneal cavity through the umbilical port itself and positioned inside the cavity by remote manipulation and kept fixed there by a variety of anchoring mechanisms. After proper positioning, they are activated by external control to complete the operation. Mesoscale engineering will produce these robots. Already in Pigs, a cholecystectomy has been successfully done in preclinical trial.[26]
Till now, we have discussed on robotic platforms controlled by human operator without any autonomy of the robot. Active research is going on robotic autonomy with CVs, ML, and AI. Already two robotic semiautonomous system have evolved and used ex vivo. The AUTOLAP for intelligent endoscope holding,[27] and the STAR (Smart Tissue Autonomous Robot) for giving incisions on suspended intestine and suturing it or for performing, an end-to-end anastomosis.[28] Other areas of active research involves utilizing materials other than metals, on efficient energy source and many other things, which is beyond the scope of this discussion.[7] Edge and Fog Computing (Wikipedia) in future may help in robotic automation.
In the last decade, we have witness “A COGNITIVE REVOLUTION” in Computer Science in the form of CV. Cognition means “An act or faculty of Knowing” and Revolution “A Dramatic or Wide-reaching Change in Conditions.”[29] With the idea that a computer can be trained to see, came the idea of “AI” which may be called the Study of Computation that makes a Computer to perceive, reason and act autonomously, when it is fed with Big Data, a process called ML. The basic principles of CV came from the physiologic study of visions in experimental animals.[30] In living subjects, visual perception begins with an interpretation of the object's BORDERS and ORIENTED EDGES. CV evolved on these two tenets (starting in 1963 till 2012 when CONVNETS was developed simulating complex networking in human cortex).[31],[32],[33],[34],[35] This ML process can be (a) statistical (shallow) with predefined features and completely supervised: (1) natural language processing; an example, when we are typing in a smart phone with google English/Indic keyboard); (2) simple speech recognition, when we are using google ALEXA or Google voice typing keyboard and (b) deep learning when computer automatically learns the features of data fed and their weights with deep learning algorithms (unsupervised or reinforced learning). IBM's DEEP BLUE COMPUTER, which beat World Champion Garry Kasparov in a game of chess in 1997, is probably the most advertised example though it was still evolving at that time.[36] This AI revolution has been possible due to simultaneous development in other areas of computer science: (1) increased computing power due to availability of chips such as graphic processor unit or tensor processing unit;[37],[38] (2) the invention of CLOUD computing and the prospect of QUANTUM computing for very big data storage and its ready availability on demand;[39],[40] (3) the availability of 5G networking with its immense capability to achieve the dream of tactile internet;[41] (4) the discovery of deep learning algorithms with ConvNets;[42] and (5) phenomenal increase in investment from the entrepreneurs.[43] Application of AI is going to change the present health-care system radically. In pediatric surgery, it will influence all the phases of care, namely (1) preoperative; (2) intraoperative, and (3) postoperative. It is going to improve our preoperative diagnosis and risk assessment by incorporating all the available metrics; thus, it may change the preoperative decision and may recommend further prehabilitation of the patient for safe surgery.[44] In intraoperative, it can guide the surgeon for safe completion of the procedure.[14] Analysis of intraoperative videos may help to identify the metrics which can increase the chance of complications[45] in the postoperative period. With all the previous preoperative and intraoperative data, and longitudinal postoperative metrics monitoring AI may help predict an early complication and warn us even before its actual occurrence.[46]
The other computer technologies which have profoundly affected the practice of medicine are (1) VR and (2) AR. Now what is reality? It is nothing more than experiences learned through our senses and interpreted by our brain in the physical world. What is then VR? Probably the closest example is when we remember a dream; the interactions in our dream was no less real than what we experience day to day. However, on awakening that world become nonexistent and we realize that it was an illusion or false perception of the real world. The definition of VR “is an artificial environment experienced through sensory stimuli, and provided by a computer, in which one's action partially determines what happens to the environment.”[47] The central theme of this technology is ILLUSION in different forms to form an immersive 3D environment. It started with computer games but soon academia is involved; the most influential adaptor is surgery as a branch of medicine. It is going to change the medical education scenario as a strong educational tool in the following ways: (1) teaching medical anatomy, normal or abnormal by virtual 3D models; (2) familiarization with surgical procedures; (3) developing technical skills in simulators, individually or as a member of a team; (4) managing crisis scenario; (5) experiencing very rare procedures; (6) utility in medical device industry; (7) realistic assessment and decision-making of competency of future surgeons; (8) training for situational and spatial awareness for future adverse events; (9) manipulation of medical image data; (10) surgical planning; (11) nonimmersive in Operation theatre as an assistance device to avert danger, for example, Captiview Operating Microscope in Neurosurgery by Leica; in addition to microscopic view a 3D VR image is synchronously projected side by side an example of mixed reality;[48] and (12) operating room planning. In spite of the above benefits, applications of VR are still in its infancy and only future will tell us its real role in medicine and its branches. Moreover, economic constraints will be a bar to its use in our situations.
Now what is AR? In medical practice, it can be defined as “a situation where the physical object is present in front you, but your vision is enhanced in some way delivered usually by technology that facilitates the safe and accurate accomplishment of the intended procedure.” The simplest examples are when we use LOUPES for surgery or use a vein finder for peripheral cannulation. In MIS, particularly in image-guided therapies (in which it has been maximally used), its primary goals are (1) to highlight specific feature of the real world; (2) to increase the understanding of those features; and (3) to derive accessible and smart insights that can be applied to real-world applications. AR uses the existing real-world environment and puts a virtual information on top of it to enhance the experience and ensure patient safety (giving an eye to the percutaneous blind procedures).[49],[50] The different methods utilized are (a) overlay, combines an earlier image with live intraoperative image; (b) intraoperative fusion guidance, integrates multiple live datasets into a single combined representation; (c) head mounted display, holograms, virtual screen, and 3D lens; and (d) preprocedural needle path tracking. The main problem is with smooth coregistration of the necessary dataset. AR application in laparoscopy is still an evolving science; the continuous deformation of abdominal organs makes coregistration of dataset very difficult. Active research is going on to minimize the error rate.[51]
Computer technology has also changed scenarios, in other areas of medicine. The most notable computer-assisted technology is what is called 3D printing or additive manufacturing. Using Digital Imaging and Communication in Medicine datasets, from existing 2D radiological images, a 3D virtual model is reconstructed and fed into the 3D printer as stereolithographic file with or without modification known as digital sculpting. The methods by which a 3D printer prints a 3D physical model are different and beyond the scope of discussion. However very accurate physical models for complex anatomy can be produced both for bones and organs for preoperative planning.
The other possible application of 3D printing is in tissue engineering to produce tissues or organs genetically matched and immunologically tolerant for transplantation from the recipient's own elements or decellularized autologous elements or synthetic materials. This will obviate the need for life long immune-suppressive medications and consequent complications. This is called 3D bioprinting to produce viable biomimetic tissues or organs. This is still in research stage and cinical applications are sporadic.
From 3D bioprinting, a new development has occurred in the tissue engineering branch of regenerative medicine. It is fascinatingly being called as 4D bioprinting as a fourth dimension is added to the 3D printing using sensitive biomaterials as inks or cell suspensions, which can respond to different forms of stimuli and change their character with time. This temporal change of character of the construct is the fourth dimension and so 4D bioprinting.[52],[53] It has been envisaged by some researchers that this printing technology one day may give rise to expandable functional prosthesis particularly for growing children.[54] The other emerging fields this technology might give births to are biorobotics, biosensors for physiologic systems, and bioactuators, all of which may help achieve a near normal prosthesis for lost parts.
3D printing is also now utilised for custom made prosthesis for lower limb prosthesis. The problem with upper limb amputees is to replace complete function. It can be predicted that one day in near future these prostheses will be robotically designed with biomaterials that will groww with the children; the fingers will be fitted with biosensors for transmission to and fro from the brain with AI powered Neural Interfaces to replace lost function.
The arrival of readily available big data, increased computer power, ML and AI, have given rise to, two inter-related fields in Biology et Medicine. They are (1)bioinformatics ie application of information science to understand complex biological data and (2)computational biology ie use of computational approaches to address theoretical and experimental questions in biology. However, there is considerable overlap at the interfaces of the two. In medicine, computational biology again has been extensively utilised in: anatomy;genomics; neuropsychiatry; neuroscience; cancer biology; pharmacology and evolutionary biology. It has helped us to sequence the human genome and might help us to understand the function of large segment of DNA, which do not replicate and “called JUNK,” in future. Computational anatomy predicted an accurate model of the human brain. In future, computational pharmacology will help us to deliver new personalized pharmaceuticals and computational oncology may predict us the likely course of a malignancy that too, patient specific(Wkipedia).
With all the background information in our mind, we can visualize that, the future Medical Colleges are going to be technology dependent in all aspects of its functioning. They can be termed as “DIGITAL MEDICAL COLLEGES.” What will be the educational system of such a medical college? The present system will be radically overhauled. It can be defined as “Medical Colleges empowered with digital technologies and effectively utilizing all such technologies to cater all the services including: Teaching, Training, Patient Care, Research and Innovations.”[44],[55],[56],[57] It should produce health professionals educated to mobilize and manage knowledge and to engage in critical reasoning and ethical conduct, so that they are competent to participate in patient- and population-centered health systems, as members of locally responsive and globally connected teams.[58] The educational technologies that will impact future education are numerous and utilises the digital platform. I will briefly discuss now about telemedicine which is possible with digital technology.
Telemedicine is the ability of a clinician to provide clinical healthcare or advice from a remote location using telecommunication technology. It is now, an established method, more so after COVID-19 pandemic. Then what is tele-mentoring? It is the ability for a clinician teacher to teach, demonstrate, and discuss matters pertaining to educate his pupils and peers, in specific areas of difficulties and interests in clinical medicine, critical care, pathology, radiology, and surgery. Expert mentors can disseminate their knowledge from a distance without the need to travel and decrease the learning curve and cost. Tele-mentoring in surgery has been possible due to robotics. Tele-mentoring starts with verbal instructions in its simplest form, With robotic MIS. Telestration (by a soft ware you can mark a distant video screen either in 2D OR 3D format) is the next armamentorium. The mentor can tele-assist also if needed. The dedicated platform for this is called the Socrates The latest mode is to guide with AR. Two dedicated platforms are there: Reacts® and Proximie® to superimpose video feeds, images, visual pointers, and other multimedia assets to live video feeds from the robotic system using day-to-day inexpensive hard wares. There is a report of tele-mentoring of open surgery also. We can increase care of our children by tele-mentoring the surgical community who are posted in subdivisional, rural, and district hospitals.[59],[60],[61],[62],[63],[64],[65]Finally, intercontinental robotic telesurgery in pediatric patients had been performed by Steven S Rothenberg and his group.[66]
We have discussed till now the impact of digital era on surgery. In general, there is a growing demand for MIS and the practice of pediatric surgery is also changing and moving steadily toward that goal. Robotics has very distinct and salient advantages over hand-held MIS and more and more centers will come up with this modality, particularly all the AIIMSs. Cloud Computing, ML, AI and global collaboration, will produce a vast repository of global Pediatric Surgical data available to us for perfecting ourselves through self-learning and proper mentoring giving a new heightened global standard. The vision for a UNIVERSAL STANDARD of CARE (USC) in pediatric surgery is only possible when manpower shortage, maldistribution of expertise, funds, and resource deficit and lack of consensus on best practices will be addressed to. Global initiative for children's surgery (GICS) & the World Federation of Associations of Pediatric Surgeons (WFOAPS) are two benchmark bodies working in this regard.[67],[68],[69]
DIGITAL SURGICAL PLATFORMS (though at present it may seem utopian) can effectively solve the maldistribution of expertise by tele-mentoring and tele-assist. UNIVERSAL STANDARD OF CARE can be achieved by establishing, a repository of standard care practices in the Cloud and open to all pediatric surgeons across the globe; it can be modified to local needs with cheaper options by the local stake holders. A library of videos, of best surgical open and MIS practices, can be made and shared to the cloud. Collaboration and cooperation of advanced and not so advanced centers will be necessary. With digital platform, the implementation will be much easier. International charities may play a role here. This ideal and most granular, platform with utmost concern for patient safety and increased cognizance of the total patient care environment aided by digitalizing A to Z of the pediatric surgical care metrics, may be called DIGITAL PEDIATRIC SURGERY powered by ML and AI. However, technology also brings its inherent drawbacks. A vast amount of data,imposes security issues. As the information are human centric, identity protection should be there. It should be easily available, but the security should be robust and pass ward protected.ML/AI needs feeding of large data in an appropriate manner and with proper algorithms. Data scientist should work in conjunction with clinician for ML. No bias, particularly racial and ethical, should be incorporated.[70],[71],[72] Moreover, ML needs consumption of computer power by 3 × 105 fold and may cause carbon emission as high as 80,000 lbs.[73],[74],[75],[76],[77] Preferably, the data should be in a third party cloud, so that there is zero probability of data loss. Logistic for implementation and maintenance should be properly evaluated with legal issues and country wise policy making.[78],[79],[80],[81],[82] As technology will modify our practice in not so very distant future, the future PAEDIATRIC SURGEON must be a techno savvy person and be knowledgeable about computational probabilities, statistics and logic, armed with bigdata, ML, AI, and equipped with AR/VR in the OR. He should also have a basic knowledge of different “OMIC” datas as personalised precision therapy will be the future goal of any particular pediatric patient, especially those with malignancies.[83] There is growing concern that this dependence on technology for precision medicine may abolish the humane touch of medicine and subjects may be treated as objects. Hence, the future pediatric surgeon should not forget the humane touch in treating the tiny tenders, bubbling toddlers, the dreaming preteens, and the demanding moody teens. He must be ready to give adequate time for a patient hearing to the troubled family. He should comfort the shocked parents with empathy. He should radiate confidence while counselling so that the family gains faith in him. He should always make a joint decision with the family on the future course of treatment, the disheartening possibilities of complications and future follow up in details. Sometimes he may have to tell the family, that the future may be uncertain and may need a lifetime surveillance. He should never forget to tell the family that in some, an alternative mode of treatment exists, and he may not be the fittest person to render that kind of treatment. He should tell the truth and nothing but the truth. It is his moral, at the same time legal and social responsibility, to do so. He should always remember that he is treating a growing future and not a decaying present and his treatment should never be detrimental to future growth and development; it should be as physiologic as possible. With this strong ethical/moral/humane background, he then may aptly be called a DIGITAL PAEDIATRIC SURGEON,[84],[85],[86],[87],[88],[89] who will be caring children in a facility, whose architecture will have a humanizing effect also.[90]
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