Welcome to the Future of Surgery

The Commission on the Future of Surgery gazed twenty years into the future to identify advances in medicine and technology that are likely to change surgical care. We analysed evidence and assessed the implications of such developments for patients, the surgical profession and the healthcare system.

This is an exciting time to be involved in surgery. The future of surgery will bring innovative technologies, enhanced understanding of disease and wider collaboration among experts and innovators to improve patient care. The partnership between patients and clinicians will remain at the centre of healthcare.

Technologies such as surgical robots, artificial intelligence, three-dimensional printing and new imaging methods are already changing and will continue to change the way surgical care is delivered. Developments in fields such as genomics, regenerative medicine and cell-based therapies could open new avenues for predicting and treating disease, which were unthinkable only a few years ago.

Explore what the future looks like, which technologies are likely to have the greatest impact, and what this means for patients and surgical professionals.

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WHICH TECHNOLOGIES WILL MAKE THE GREATEST IMPACT?

Surgery will be transformed over the next two decades. Four groups of technological developments are likely to make the greatest impact.

Minimally Invasive Surgery


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Imaging, VR and AR


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Big Data and Genomics


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Specialised Interventions


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Minimally Invasive Surgery

Surgery has moved towards ever less invasive interventions, with fewer but more-precise cuts and incisions to reduce the impact on patients. Surgery is shifting from seeing, feeling and manipulating organs and tissues through the surgeon’s own eyes and hands, to using an intelligent robotic medium to see and intervene inside the body.

Developments in laparoscopic and endoscopic surgery will enable less invasive diagnostic and therapeutic procedures. A new generation of surgical robots – planned to hit the market in 2019 – will be more slender, versatile and affordable. These attributes will improve the take-up of robot-assisted surgery, with the potential to reduce variation in outcomes. 

Developments in robotics and machine learning suggest that surgical tasks will increasingly be automated, with more guidance, support and information available to the surgical team. However, fully autonomous robot-surgeons remain unlikely to populate operating theatres in the next few decades.

The human touch of the clinician and their relationship with the patient will remain central to the delivery of excellent care. The ethical and regulatory framework must keep up with advances in technology to ensure patient safety.

Imaging, VR and AR

Imaging technology is key to the delivery of less invasive interventions, allowing the visualisation of internal structures and organs with reduced impact on the patient. In the next few years, advances in imaging technology will deliver better guidance during a surgical procedure and improve accuracy.

Better imaging is also likely to improve the speed and accuracy of diagnosis. If the direction of travel is one where imaging becomes better able to capture increasingly smaller structures and their functioning inside the body, surgery might move towards interventions at the micro level, such as the cellular level.

Simulation tools, such as augmented reality and virtual reality platforms, are already used by some surgeons to train and rehearse surgical procedures. The use of these technologies can improve surgical training and outcomes, while standardising procedures and democratising access to training.

Big Data and Genomics

The role of data collection and analysis will increase in future years. The potential for this resource to enable better prediction of disease and more personalised and effective treatments is huge. However, patients and the public must remain informed partners in every stage of this journey and standards on the use of their data must be enforced. Investment and leadership are also necessary to bring the healthcare system and its organisations into the future.

More patients will have access to a genomic medicine service. Genomic testing will improve our understanding of disease profiles, both at a patient-specific and population-based level. In the long-term, genomics will help the development of precision medicine. The choice of treatment will be based on their predicted success for each individual patient. 

Specialised Interventions

In the long-term, there will be more complex and specialised interventions. The delivery of cell-based therapies, bio-printed tissues and organs, ‘intelligent’ prosthetics or animal to human transplants will require specialised teams working together in multidisciplinary centres.

In ten to twenty years, organ bioengineering and 3D bio-printing might provide organs to patients waiting on the transplant list, and restore form and function in patients who have sustained trauma or burns.

3D printing and planning technologies are already widely used in surgery to prepare interventions and produce personalised implants. Further developments in 3D printing are likely to make surgery more precise, or open avenues for surgical procedures currently too complex or with outcomes that are too poor.

The use of robotic prosthetics has increased in recent years, with electrodes placed on muscles to control movement. For example, on the digits in a robotic hand. Research is ongoing on the development of ‘intelligent’ prosthetics, as the future of organically controlled prosthetic limbs is quite far away and is not likely to have an impact on surgery immediately in the NHS.

Over the next five years, it is likely that we will see more applications of stem cells across different conditions, such as chronic inflammatory conditions or neurodegenerative diseases.

Although developments in all these technologies hint at an exciting future for medicine and patient care, the complexity, cost, uncertainty and ethical implications of some of these interventions mean that their translation into routine medical practice might take a long time. 

WHAT DOES THE FUTURE
MEAN FOR PATIENTS?

Surgery is currently used to treat advanced disease and takes place after the display of symptoms. In the future, surgery will potentially prevent – and not just treat – illness.

Healthcare will continue to shift towards establishing and maintaining good health, prevention and prediction of disease, early intervention and co-ordinated management of chronic conditions.

Patients can confidently expect surgery to become gradually less invasive, more accurate, have more predictable outcomes, faster recovery times and lower risk of harm.

The current unique relationship between the patient and the surgical team will become even more important, as technology allows greater access to information.

Surgery is likely to increasingly focus on improving quality of life and operating on well people and older patients with the aim of prevention.

 

New drugs and the development of other non-invasive treatments may make surgery obsolete for some conditions. Advances in radiotherapy and immunotherapy may drastically reduce the need for cancer surgery. Vaccination programmes are likely to affect the incidence of virally-driven diseases, such as the vaccination against human papillomavirus to prevent cervical, anal and oral cancer.

Less invasive technologies and advances in imaging will enable more patients, particularly frail and older people, and more diseases to be treated with surgery. For example, functional imaging of the brain is already enabling more radical but safer micro-surgery for some cerebral tumours.

The Commission does not anticipate any radical increases to life expectancy unless a significant breakthrough revolutionises prevention of the main causes of mortality. Societal attitudes to conditions like obesity might influence future longevity.

Patients will continue to experience an increasing burden of non-communicable chronic diseases and multiple morbidities, such as diabetes or dementia.

The ubiquity of healthcare information and personal data may help patients to become more informed about their own health, but may also lead to greater anxiety. For example, genomic information may inflate demand for risk-reducing surgery.

The speed and variety of innovations and information available will be such that patients may need specialist advice and support to make decisions about their care. For example, greater access to data and medical knowledge may generate inequalities due to different levels of health literacy.

HOW WILL THE DELIVERY
OF SURGERY CHANGE?

Operating theatres are likely to look different with greater integration of digital technologies. In the long-term, AI could be used to schedule procedures, request instruments and monitor the environment. Digital systems will also provide guidance to the operating team and show enhanced anatomical imaging.

Theatre space will become more flexible and dynamic, as equipment will be smaller and lighter. 

The recent history of complex surgery has been one of increasing centralisation to improve treatment results for patients by concentrating expertise and resources to make services more sustainable.

Specialised treatments – such as stem cell therapies or tissue engineering – will continue to be delivered by multidisciplinary teams with specialist expertise. Such care will only be available in a small number of locations, which need to be carefully planned. Other digital technologies, such as 3D printing and planning, will also benefit from multidisciplinary hubs.

Digital technologies and robotics could enable more types of routine surgery to be delivered locally if resources are available, thanks to platforms allowing for remote support and proctoring, and robotic platforms of smaller size and greater versatility.

As the ageing population is expected to live increasingly outside of metropolitan areas, demand for care in those areas will also grow. The current trend of an increasing amount of day-case and overnight stay surgery will continue. Preoperative and follow-up assessment will therefore acquire even greater importance, but they are likely to be undertaken in local settings through the use of telemedicine and digital platforms.

In contrast to drugs, many surgical innovations are introduced without clinical trial data or centrally held evidence. This is a risk to patient safety and public confidence.

Pathways need to be developed to assess digital devices, diagnostics and drugs, with compulsory registration of novel technologies and devices, using real-time data. A ‘one size fits all’ approach for randomised control trials or a national registry will not work for all innovations.

The surgical royal colleges could have a role in working with national regulators to support or oversee registries of innovations, and support the uptake of innovations that improve quality of life and patient safety.

Submission of follow-up information to central databases is crucial to ensure patient safety. A framework should be in place to oversee this, comprised of appropriate regulators who have access to databases.

THE FUTURE
SURGICAL TEAM

The future of surgery is exciting and full of change, and it will continue to need to attract talented, innovative and compassionate individuals.

The multi-disciplinary and multi-professional surgical care team will become increasingly important in developing and delivering care of the highest quality. They will be able to provide more aspects of care and may take over some areas of surgical care currently delivered by surgeons.

Specialised treatments will give rise to increased multi-disciplinary working. Surgical teams will work alongside bioengineers, geneticists, molecular biologists, data-analysts, transplantation experts and other expert disciplines.

The evolution of the role of the surgeon is likely to depend on the best treatment option for the patient. It could remain unchanged for areas little affected by developments in alternative treatment options or become increasingly blurred with the role of other clinicians for areas where other types of treatments may become preferable.

The surgeon’s role will become increasingly multifaceted and surgeons will need to become ‘multi-linguists’, understanding the language of medicine, genetics, surgery, radiotherapy and bioengineering.

The content of the surgical training curriculum will need to change and be flexible to reflect the likely future career of a surgeon and innovations as they evolve. With flexibility will come options to be a clinical surgeon, scientist, entrepreneur, educator, innovator or manager, with the ability to move across different roles throughout a career.

Training must incorporate knowledge of computing, engineering, molecular biology, data literacy, leadership, team building and communication. In an increasingly digitised health service, we must strive to ensure and enhance the humanity in surgery.

New technologies such as data analytics, AR and VR will enhance training, with high-fidelity patient-specific simulation, and remote mentoring and proctoring.

Entry requirements for medical school will need to reflect the diverse range of skills required and encourage students from other backgrounds, such as engineering or computing, to enter medicine.