Coming soon to an OR near you!

Rehearsal at this stage has more to do with the cognitive processes than technical. So whether I need to practice taking that fat off the renal hilum is less of an issue than the position of lumbar veins or the relation of the renal vein to the aorta.

I feel immensely better prepared for the surgery when I’ve done that fly-through. I’m hard pressed to give you a good metric, to show the science to support it, but I believe there’s a role for it.

SANDBERG: This gets back to the question of metrics. Much of what we’re seeing as we look at ORs of the future actually improves the work experience for the surgeon, anesthesiologist, and nurses.

You can’t put a dollar value on that unless you’re talking about the cost of recruiting and training staff, but it does seem to improve outcomes for the people who work in the OR—and that must translate to patient outcomes. It’s difficult to justify to an administrator, but on a moral level it seems like the right thing to do.

The ideal would be a robotic anesthetist who would not be in the coffee lounge when you want to turn over your case.

“Robo-doc” anesthetist

SANDBERG: Making a business case for a robot for anesthesia is even harder. Functions such as vascular access and airway control are easy to an expert, but I don’t know yet of anyone who even attempted to make an IV-starting robot.

SATAVA: We have one.

SANDBERG: I’ve seen your prototypes. I don’t think you can program your “Robo-doc” to anesthetize the patient when you want, but the maintenance phase is one area in anesthesia ripe for automation.

Anesthesiology is actually in the driver’s seat for harvesting, controlling, and integrating information in the OR. Our project integrates data that anesthesiologists traditionally managed with that from surgical instruments and hospital information systems to create a total patient picture. That includes interventions and perturbations caused by surgery. Once that’s in place, you could imagine actually driving the anesthetic using closed-loop control.

SATAVA: Anesthesia is probably going to evolve more than surgery thanks to safer anesthetics and new nanotechnology. The new anesthetic autoregulators will make it almost impossible to overdose or under-dose a patient.

Are “smart” instruments equal to our own fingertips?

PARK: Today we can make a standard (open surgery) incision into which we insert one or both hands and have more than 20° of movement with the benefit of an innervated end effecter—our fingertips.

The OR of the future will put us in a situation where we’re disconnected in the tactile sense from the target anatomy and limit us to 4°–8° of movement. The stimulus is to get those degrees of movement back to compensate for the tactile feedback we’ve lost.

Hand-assisted laparoscopy is a lowtech way for getting around that loss of movement. It’s nothing other than a transition step, but it’s a clever solution.

How did you discover “parallel processing” to save costs and time?

SANDBERG: We tried to deconstruct the perioperative process immediately upstream and downstream of the OR itself, then we tested the time savings and cost effectiveness of the new process.¹

ORs in America tend to do things sequentially via serial-processing work-flow: nurses and technologists set up the OR, the anesthesiologist brings in the patient and induces anesthetic, the surgery happens, the patient emerges from anesthesia, the anesthesiologist takes the patient to recovery.

We discovered that in any of these linear processes a team will be waiting for another team member to finish a task. That presented an opportunity to increase the effectiveness of the OR by finding a way for those team members to work in parallel rather than in sequence.

At Massachusetts General, we reduced the nonoperative time from when the surgeon steps back from the patient until the surgeon steps up to prep the next patient, from roughly 70 to 40 minutes by implementing a couple of parallel processing interventions. Other reports have verified this approach.^2,3

In the MGH project, however, the interface between that particular OR and the hospital became problematic when the OR sent patients to the floor faster than the hospital could accept them.

What happened when the conveyor belt speeded up?

This gets us to the notion of perioperative systems design, which is basically a fantastic accident at most hospitals. In our OR of the Future project at MGH, we isolated part of the perioperative process, optimized it, and in so doing we broke the recovery room and upstream admission process. It was like transplanting an elephant heart into a mouse.