The future is here — all you have to do is look inside a U.S. operating room. Robots can now mimic the hand movements of surgeons, glasses can project CT scans, and hybrid imaging systems can move robotically. “I think that any physician really is challenged today just keeping up with the technology,” says Rob Maliff, director of the applied solutions group at ECRI Institute.

These new, highly innovative technologies are entering into the operating room at a rapid fire pace and dramatically changing the practice of surgery. Today, surgeons can conduct procedures from a remote location and even live-stream them for educational and consulting purposes. This is key because these complex devices require extensive training.

Look, no hands!
Lately, one of the most buzzed-about technologies is a pair of glasses created by Google that works like a computer. Once the masses have access to Google Glass later this year, people will be able to take pictures, livestream videos and surf the Internet without having to lift a finger.

But it doesn’t stop there; Google is currently giving out early models of the glasses to various professions in order to find out what other capabilities it has. Surgery is one of them.

Dr. Selene Parekh, a surgeon at the North Carolina Orthopaedic Clinic, sent a proposal to Google about nine months ago discussing his interest in the technology and his plans for maximizing its potential. “When Google Glass was announced and was on limited availability I thought it would be a great way to potentially see exactly what I’m seeing in the OR and be able to archive surgeries and use them for teaching and education later on,” he says.

He recently brought Glass with him to the Indo-U.S. Foot and Ankle Surgery Conference and used it to live-stream surgery to about 120 orthopedic surgeons sitting in a conference room. Live-streaming surgery is not something new, but Glass enables a view that was previously only available to the surgeon.

Other than providing education, the live-stream capabilities enable surgeons to bring outside expertise into the operating room during surgery. It’s as if an expert surgeon is inside the room, except they could be thousands of miles away.

Parekh thinks that since it’s a generation one product, it still needs some fine-tuning, but it has enormous potential. “I think it goes obviously beyond health care, but in terms of surgery and health care, I think it will revolutionize educational training and improve global patient care,” he says.

In a step to bring Glass to health care, Philips Healthcare recently partnered with Accenture, a technology consulting firm, to investigate its usage. “We were excited by the prospect and agreed with them and thought it would be a good opportunity to, in fact, show the product within various use cases in a real clinical setting,” says Anthony Jones, chief marketing officer for the Philips Healthcare patient care and monitoring solutions business group.

They are currently in the development phase, but have made some strides. Philips created a tablet application for its eICU software that gives physicians access to all of the information from patient bedside monitors and recently began to work on creating a version for Glass.

The process to bring the application to Glass would normally have taken several months, but they managed to get it done in two weeks. There are some limitations because it’s a different platform and certain features that work on a tablet you can’t display on Glass, but they were able to make modifications and scale it down, says Jones.

“It’s not always practical for a nurse or doctor to take their hands off of what they’re doing and pick up a tablet or a smartphone, and so if I can call up information or see something out of the corner of my eye that is helping me without distracting me or requiring me to take my hands off of what I’m doing, that has value from a workflow standpoint for clinicians,” he says.

The product is coming along quickly, but it is nowhere near being commercially available. Philips has been showing it at a number of tradeshows to get feedback from clients, and going forward, they will continue to test it and identify its limitations.

Robots galore
In the past, it was inconceivable that a robot could assist a surgeon during a procedure, but today they are being used in almost every type of surgery. General, cardiothoracic, gastrointestinal, gynecological and neurological are only a few of the specialties that are being done with the aid of robots.

In 1999, Intuitive Surgical took the health care world by storm with the introduction of the da Vinci Surgical System. Using the system, surgeons no longer have to spend hours hunched over a surgical table performing the procedure because they now have the option to perform it remotely from a console. The surgeon can see a high-definition, 3-D video of inside the patient’s body as they control four robotic arms. By accessing the body through a few small incisions, the robot enables the surgeon to carry out precise, minimally invasive surgery that usually results in fewer complications and faster recovery times.

The latest addition to the system is the da Vinci Single-Site Instrumentation, which involves inserting flexible instruments through the belly button to remove the gallbladder. It was manufactured in late 2011 and it received FDA-clearance last year.

This system is currently the only robotic system on the market used for soft tissue laparoscopy and according to Intuitive, it assists about 85 to 90 percent of prostatectomies. However, other robots are widely used in different surgeries including cardiovascular, head and neck, urological and partial knee replacement surgery.

When Corindus’s CorPath 200 System was cleared by the FDA and commercially sold through Philips Healthcare in late 2012, it became the world’s first robotic-assisted system to treat obstructed coronary arteries non-invasively. During surgery, an interventional cardiologist sits in a cockpit and uses a touch-screen and joystick to control a robotic arm that measures the movement of guide wires, balloons and stent catheters.

With the help of this technology, surgeons are able to open arteries and restore blood flow in patients with coronary artery disease. About 20 facilities in the U.S. have purchased it and several have ordered a second unit.

Other robots on the market include MAKO Surgical Corp.’s RIO, which aligns and places implants for partial knee and total hip arthroplasty, Mazor Robotic’s Renaissance, which is a guidance system for spine surgery, and Hansen Medical’s Sensei, which treats atrial fibrillation.

These robots allow for minimally invasive procedures and with a few small incisions, patients are able to get out of the hospital quicker with less scarring and fewer complications.

Minimally invasive surgical devices have infiltrated the market in the past few years because of the increasing demand to perform surgery that reduces complications and recovery time. According to a MarketsandMarkets report, the global minimally invasive surgical market was estimated at 23 billion dollars in 2011 and will have an annual growth rate of about 8 percent over the next five years.

“That’s an advantage for the patient but it’s also an advantage for the hospital in that when they’re using their facilities more efficiently they can put more patients through their post-operative bed and they can do more procedures,” says Catherine Mohr, director of medical research at Intuitive Surgical.

Imag(in)e this
Siemens Healthcare and GE Healthcare have new imaging systems on the market, which could have a huge impact in the hybrid operating room. Siemens’ system uses robotic technology that lets the physicians move the C-arm to almost any position around the patient and GE’s system is mobile so physicians can perform procedures with unrestricted access to patients.

A hybrid operating room has all of the aspects of a traditional operating room but it’s also equipped with imaging technologies including X-rays and CT and MRI scanners. Over the past few years, these rooms have become popular since having all of the technologies in one room allows surgeons to operate more efficiently.

According to a recent Millennium Research Group report, the operating room integration market will grow about 15 percent per year through 2015. As these rooms become more popular, the demand for hybridcompatible devices increases as well.

Siemens’ Artis zeego is the first multi-axis system that uses KUKA robotic technology, which is also used in factory automation. “What we did is added a C to this,” says Sudhir Kulkarni, segment director for hybrid ORs at Siemens Healthcare. “The robotic technology has been around for a while but we used it in imaging.”

The robot has six rotational axes that allow the surgeon to maneuver the C-shaped X-ray device around the patient. The surgeon can then get a 3-D map of the position of the blood vessels, the instruments used and the stents that are to be implanted during vascular surgery.

Using the device, the surgeon can examine internal organs from many different perspectives and view more anatomical details including the tiniest blood vessels.

With this system, surgeons have all of the benefits of the traditional floor and ceiling mounted systems with none of the disadvantages. For example, with a floor mounted system, lights can be positioned on the ceiling, but it’s only good for imaging above the diaphragm. A ceiling mounted system is great for full body imaging, but it’s hard to get the required air flow and requires longarmed lights since it’s above the table.

Since the Artis zeego’s introduction three years ago, its sales have dramatically surpassed ceiling mounted systems. Hospital installs currently ring in at 132 for the system, which is double the number of ceiling mounted systems ever installed,” says Kulkarni. GE’s Discovery IGS 730 doesn’t use the exact same technology as the zeego, but it still is its closest competitor. GE claims it’s the only system on the market that is completely mobile, which is enabled by a laser rotating guided technology that lets the system know where it is in the room.

“It’s guided along trajectories and that really makes installation in the room much more flexible than other systems and it also basically removes all of the constraints that are attached with rails that are fixed on the ceiling,” says Emmanuel Abate, marketing manager of premium angiography at GE Healthcare.

With the use of minimally invasive procedures steadily growing, the equipment that contributes to it will continue to be the future of the operating room.

Not all sunshine and roses
While these high-tech devices are advancing the way procedures are done, there are many challenges ahead.

In November, the FDA published a survey that included 11 surgeons who performed 70 to 600 surgeries with the da Vinci Surgical System. All of the respondents reported that learning to use the system is the biggest challenge because of the device’s complex user-interface.

They all reported that they received training, but they still required time to learn how to use the foot pedals, attain successful hand-eye coordination and perform surgeries without the ability to use their hands to feel tissue and organs or use sutures.

The da Vinci system has recently been making headlines because of the lawsuits filed against it for allegedly causing serious and sometimes fatal complications during surgery. Wright & Schulte LLC, a personal injury law firm, claims that part of the problem is inadequate training methods.

Lack of adequate training has become a serious concern. This issue has made it to ECRI Institute’s Top Ten Technology Hazards for 2014. “The hospitals kind of run the gamut when it comes to structuring these programs,” says Chris Schabowsky, program manager of the applied solutions group at ECRI Institute. “Some of them made a brilliant decision to purchase the robot and throw their surgical staff into the fire without providing the proper training and they ran into patient complications pretty quickly.”

Intuitive provides the initial training and will issue a certificate saying that the surgeon understands the system and has practice performing surgical tasks. After that, it’s the hospital’s decision to give the surgeon operating privileges, says Intuitive’s Mohr.

Dr. Enrico Benedetti conducted over 400 operations with the system and says he is “very pleased” with it. However, he is not pleased with the way some hospitals train their surgeons on it.

He says that after the initial training, hospitals usually require a surgeon from another hospital to come and proctor five surgeries. “After that, many hospitals will actually grant you privileges and there is no further need for training, I don’t think it’s prudent,” he says.

In his hospital, he takes a more personalized approach that involves prolonged supervision under an experienced surgeon within their own hospital. “It’s very careful monitoring that allows us to control the surgeon and make sure that we let them fly on their own when we are confident that they acquired the proper skill,” he says.

Currently, there aren’t any national training requirements for the system, but professional societies are starting to work toward one. The American Urological Association is brainstorming and putting together a guideline for a standardized training and credentialing program for surgical staff, says ECRI’s Schabowsky.

But this doesn’t mean that the problem will disappear. “These are guidelines, they aren’t often incorporated into any requirement for a hospital to follow them, so it’s good practice to follow any professional society’s guidance, but again, there is often very little requirement to do so,” says ECRI’s Maliff.

Despite any challenges, experts believe that robots and other high-tech devices will continue to be the future of the operating room.

“I think the operating room is going through a lot of transformation and will continue to go through a lot of transformation in the next couple of years,” says GE Healthcare’s Abate. “We see more and more with new devices, new imaging technologies, we see that the number of procedures moving from open to minimally invasive is growing and so the equipment contributes to that, they’re really the transformation of the OR going forward.”

Click here to check out the DOTmed New Equipment Guide for OR equipment.

DOTmed Registered HCBN March 2014 O/R Suite Companies

Names in boldface are Premium Listings.
Domestic
Kristopher Derentz, Multi Imager Surgical, CA
Tom Tottleben, TSC, Inc, IL
Robert Harris, Imaging Associates Inc., NC
DOTmed Certified
DOTmed 100
Adam Rudinger, Lex-Tech, Inc., NY
DOTmed Certified
DOTmed 100
Robert Dewey, Siemens Healthcare, PA

International
Zaka Khaliq, Surtex Instruments, United Kingdom
Luis Campos, Inversiones CFM, El Salvador
Ashish Bhavsar, Wave Visions, India
Chaudhry Zahid Hussain, D.H. Enterprises, Pakistan