More of the same?

If you compared an operating theatre today, to one from 26 years ago, there wouldn’t be many differences on the surface, maybe a few more computers, maybe a robot, or fewer staff members. Some things certainly haven’t changed. There’s still a bed, a patient, lights, surgeons, nurses, anaesthetists, the trough-like sink, and shelves of equipment. Operating itself has seen a larger shift, laparoscopic and even robotic procedures now dominate, and advances in imaging play a much larger role than previously1. The world itself is rapidly changing. It is hard to go onto a news page without seeing the phase ‘AI,’ which every week, has achieved something new, and the fear we will be taken over by robots grows (very) marginally. But our world is struggling, overpopulated, and overheating. Future innovations will need to be sustainable as well as effective. 26 years from now, the operating theatre will undoubtedly have had to adapt.

You would expect operating theatre technology to become much more advanced. Studies describing the use of machine learning and AI in surgery are no longer just a scattering of the published literature. Intraoperative navigation tools have been shown to reduce the rates of complications in procedures where identification of anatomy is crucial to avoiding harmful complications2-4. Mascagni et al., and Madani et al., both reported on applications to identify the critical view of safety in laparoscopic cholecystectomy, seeing some reduction in incorrect identification of structures5,6. These may be integrated into practice and become a mainstay in the operating theatre, as laparoscopic surgery is now. Decision-support tools may similarly have a role, although perhaps greater outside the operating theatre, with a role in risk-stratification7. As impressive as these new tools are, it must be asked to whether they will be received with open arms by the surgical workforce. Will surgeons appreciate being challenged on their clinical decision making? Will they even have a choice? Introducing AI into the operating theatre does not only involve incorporating new technology, but a massive change in the mindset, culture, and training of surgical staff – a notoriously challenging task in the NHS8. AI has been around for a while too, but there are no applications currently in use in surgery – it has been slow to adopt. By 2050, AI may well be in our operating theatres, but one cannot see this being more than purely an adjunct for interested surgeons.

Robotic surgery is often cited as that with which AI will be most synergistic. In 2050, there will most likely be more operating theatres with robots in and those robots will look very different. Many new surgical robots are coming onto the market with advancing functions such as recording the procedure and ergonomic analysis. Some functions of the robot involve autonomy, such as suggesting port placement, but there is much discussion about whether this could go further. The power in robots is in the data. Think of similar high-pressure, high-performance fields like aviation or F1 driving, every single data point is scrutinised, and then acted upon to improve performance9,10. Channelling this data into deep learning models will give insights into surgical procedures that can be translated into adaptions to the surgical robot that will improve patient outcomes4,11. There is much scepticism as to whether an AI-powered robot can perform any part of an operation autonomously, but this is likely to have been achieved for repetitive tasks in surgery by 2050. However, human-in-the-loop will always be essential. This isn’t the only threat to surgeons, however. Medical therapies, like immunotherapy, are being integrated into care at a rapid rate and may reduce the need for surgeries, and therefore surgeons. Whilst surgeons won’t be out of a job by 2050, their job may look very different.

All this exciting new technology requires energy. Healthcare is already a major contributor to the world’s greenhouse gas emissions12,13. Many healthcare services have committed to achieving net zero, and the NHS aims to achieve this by 204514. The operating theatre is a major environmental burden, due to the high volumes of energy usage and waste production. The Intercollegiate Green Theatre checklist suggests changes that could be made to improve the sustainability of surgical practice15. Sensor-controlled taps in the scrub room will massively reduce water wastage when scrubbing in by stopping water flow between use but maintaining the sterility needed to scrub. Reusable drapes, hats and gowns would reduce the waste produced by surgery. Although the caveat here is the subsequent energy required to resterilise this volume of textiles, perhaps counteracting its initial sustainable benefit. We might see more reusable equipment too15. Surgical equipment tends to be sterilised and reused, but much is still disposable. Whether these interventions can be put in place in 26 years, seems unrealistic. Net zero goals are likely to be forced upon the health service and something will have to give. Steps will be taken to carbon emissions where they can, and essential resources must stay, limiting the capacity for innovation.

The operating theatre looks virtually identical to twenty six years ago, and twenty-six years into the future, there won’t be much difference. In 2050, there will be more studies describing AI applications, robotic surgery will dominate most specialties, and there will have been breakthrough technologies that no one could have predicted, but there is not much use in it if the environment is closed to change. Change is a concept so heavily resisted in the NHS. Most things are done the way they are in hospitals because that’s how they have always been done. In this digital age, where you can pay for a coffee with your watch, some trusts still use paper notes. Electronic hospital records are not linked. The technology used in the NHS currently is barely fit for purpose, and there is little reason to believe that will have changed in 26 years from now. If you compare the trajectory of the current global technological revolution, surgery is very far behind.