Innovation in Surgery, Current and Future. A Review of the Literature

A literature review was conducted in the PubMed, Scielo, Google Scholar, and Cochrane databases, in both Spanish and English, using the search terms "authentic learning" and "problem-based learning," limiting the search to argumentative articles, resulting in 50 hits. A manual search was carried out without the support of any software, where 40 articles were included based on the review of the title, abstract, and keywords.

Inclusion Criteria: Studies in English and Spanish, comparative, descriptive, and analytical studies that evaluated current technological innovation, its implication in surgery, and provided a vision towards the next future advances were included.

Exclusion Criteria: Articles describing the early developments in surgery or those based solely on the experience of a single development center were excluded, as the aim is to present an analytical approach to innovation in surgery globally and its implications for the future.

Development of Minimally Invasive Surgical Techniques: Part of the revolution generated by laparoscopic surgery occurred thanks to a change in the treatment philosophy of conventional surgery, based on reducing trauma compared to open surgery. For this reason, laparoscopic surgery has also been called "minimally invasive surgery," which allows for the resolution of surgical problems while ensuring a faster postoperative recovery. The development of laparoscopic surgery has not been limited to performing routine procedures; it has also allowed for the use of changes in operating table position, which facilitates a better visualization of the anatomy compared to open surgery. This has served to design technical variations to improve performance. ^(4,5)

Despite its benefits, laparoscopic surgery, due to its greater complexity, presents challenges, such as technical difficulty, limited tissue manipulation, and the smaller number of cases to which a surgeon is exposed during training, all of which have a direct impact on the dissemination of these techniques. And proof of this is the emergence and consolidation of surgical research and development groups within and outside of academic settings. There is no doubt that new technologies must be integrated into the surgical arsenal of every general surgeon, who must undergo prior training, establishing a new alternative for physicians in training within medical schools and surgical specialty residencies. Simulation is an essential tool for acquiring basic and advanced skills in minimally invasive surgery; mastering it is essential before beginning the learning curve for a specific surgical procedure. This training can be enhanced by applying 3D printing designs that closely recreate human anatomy, as well as concepts of authentic learning, deliberate practice, and the ten thousand hours required to become "out of the ordinary," as author Gladwell Malcolm mentions in his book Outliers ^(5,6,7,8).

Development of Robotic Surgery: In the early 1990s, NASA, together with private entrepreneurs, established the company RAMS (Robot Assisted MicroSurgery) with the goal of developing a robot capable of performing microsurgical procedures remotely (telesurgery), with the intention of using it in the military field under the guidance of US Army surgeons. It was in 1999 that, based on military patents, the Californian company Intuitive Surgical Inc. developed the Da Vinci robot, which was the first robot to achieve FDA approval for use on patients. ⁽⁹⁾

Robotic systems are classified into two large groups: the first is a master-slave platform, and the second is called autonomous robots, the latter still in the experimental phase. The master-slave platform consists of three components:

• Control console: This is where the surgeon, who would be the master, controls the movements of three robotic working arms and a fourth, which holds the endocamera, from the comfort of a seat and maintains ergonomics.
• Efferent arm: This is the robot itself and acts as a slave. It consists of a base from which its arms emerge. The working arms hold the instruments that access the patient's abdominal cavity, while one arm is used solely to control the movements of the endocamera. The control console and the robot are connected by a cable system, although under suitable conditions, they can operate via satellite communication, allowing remote surgery.
• Laparoscopy tower: This must have a CO2 insufflator, which will be administered into the abdominal cavity (pneumoperitoneum). The surgical field is visualized using an endocamera with a cold light source, providing two-dimensional images. ⁽⁹⁾

Surgeons can experience burnouts and inaccuracies in technical proficiency, which impact their patients. Technological advances in robotic surgery provide substantial improvements in surgeon dexterity and precision, allowing complex procedures to be performed more easily and from a position that maintains harmonious ergonomics. The ability of robotic arms to replicate and extend the surgeon's range of motion from the comfort of the console with millimeter precision facilitates the execution of detailed procedures, significantly reducing complications. ^(3,9)

The first remote robotic surgery was performed in 2001 by Dr. Marecaux. The surgeon operated on a patient in New York City using the ZEUS® Surgical System. In 2001, Dr. Jack Scott performed the first telerobotic operation (the surgeon sitting at the control console in a different location from the patient) using the ZEUS® Surgical System. It was a cholecystectomy performed by surgeons located in New York (USA) on a 62-year-old patient with cholelithiasis admitted in Strasbourg (France), being this complex and difficult due to the internet connection at the time. Currently, with the use of satellite internet and cybersecurity, robotic surgery has advanced to such an extent that it allowed remote surgery between continents, when in 2024 Dr. Alberto Breda, head of Urological Oncology and the kidney transplant surgical team at the Puigvert Foundation, operated through this innovative surgery on a 37-year-old man suffering from a kidney tumor, performing the first transcontinental robotic nephrectomy by telesurgery. Dr. Breda was in Bordeaux (France) and the patient was located in Beijing (China) more than 8,000 km away. ^(9,10,11)

The future of robotic surgery is shaping up to include continuous improvements in system ergonomics, the integration of artificial intelligence for real-time assistance, and the expansion of its application to new surgical fields. These advances promise not only to optimize the execution of existing procedures but also to open up new possibilities in even more specialized surgeries, including the development of autonomous robotic systems for the execution of surgical procedures. ^(3,9)

Augmented Reality: Augmented reality (AR) is a technology that combines the virtual world with the real one, superimposing digital information onto the view of reality. It is emerging as a useful tool in the field of surgery, allowing the real-time superimposition of virtual visual information onto the patient's anatomy, thereby improving spatial perception through navigation in three-dimensional environments. Virtual reality replaces the real environment with a completely virtual one, while augmented reality incorporates digital images within the real environment, complementing it with virtual three-dimensional elements. ^{(3, 12)}

The area of hepatobiliary surgery is one of the surgical fields that has benefited the most from this technology, due to the rigorous preoperative preparation required for these types of patients using computed tomography (CT) and magnetic resonance imaging (MRI). For complex cases, some groups utilize printed 3D models. These models can facilitate surgical planning as they provide a greater anatomical understanding of the case to be treated. In these instances, the available tests (CT, MRI, and 3D models) are evaluated using virtual holograms, and the anatomy and procedures are discussed based on them. Furthermore, this technology enables mixed-reality collaboration, making it possible to share a surgical procedure in real time with a consulting surgeon located at another site or hospital. This second surgeon can virtually see themselves in the operating room and can provide remote advice as if physically present. ⁽¹³⁾

An interesting modality is augmented reality superimposition, where holograms can be superimposed onto the patient's real anatomy during the surgical procedure. This represents a significant advancement, as it has the potential to serve as an intraoperative guide, reducing the error rate. ⁽¹³⁾

The impact of AR in the surgical field can also be seen in teaching, where the conventional method at the university level has varied little in recent decades. Explaining complex surgical procedures, for example, in hepatobiliary surgery, involves anatomical and technical knowledge that is difficult to teach and learn with conventional teaching resources. This technology, where the surgeon manipulates virtual instruments interacting with anatomical regions in real and 3D views, is proving useful. ^{(12, 13)}

Metaverse: The continuous advancement in the realm of virtual and augmented reality has enabled the development of the metaverse. This virtual world allows a user to create an avatar to experience an interactive and immersive expanded reality, implying an improvement in the experience for the surgeon in training, where they can participate and even be the protagonist in the execution of a specific procedure in the operating room. Thanks to its 360-degree vision technology and immersive sound, the metaverse offers unique training practices, which in turn can be related to robotic surgery training with remote supervision. Applied to the professional surgical field, the metaverse allows for the superimposition of instructional information from an expert directly onto the surgeon's view through augmented reality glasses, which facilitates intraoperative decision-making. As the metaverse expands, there will come a point where it will not be possible for a trainer to impart knowledge to many students, and it is here where artificial intelligence can be a fundamental basis in the development of this tool. ⁽¹⁴⁾

Artificial Intelligence: AI is the set of cognitive and intellectual capabilities expressed by computer systems through combinations of algorithms, whose purpose is the creation of machines that mimic human intelligence to perform specific tasks, and that can constantly improve as they gather information (machine learning). ⁽¹⁵⁾

The basis of AI is to use massive amounts of data found on the network and modify them to gain experience, that is, it establishes the patterns in which data is processed based on the information acquired. Therefore, using algorithms, computer software can learn substantially more experience in a much shorter period than humans can acquire in their lifetime. ^(15,16)

Considered as an application of AI, machine learning algorithms include supervised, unsupervised, and reinforcement learning. Currently, there is a tool inspired by the architecture of the neural networks of the human brain, "deep learning (DL)." DL is an artificial neural network formed by multiple layers, through which data is processed, each evaluation occurs within a distinct layer, based on the result of the previous layer. This is what allows the machine to deepen its learning, identifying connections and altering the input data to achieve the best results. ⁽¹⁵⁾

AI has been implemented in clinical practice to support physicians. In certain clinical fields, the use of deep learning has been rapidly applied due to the conditions (digitization and high volume of data) that allow it, as occurs in radiology, where the AI called "Mia" used in the United Kingdom can analyze images at a much faster rate compared to a specialist physician. This tool analyzed more than 10,000 mammograms, most of which showed no signs of cancer, but the AI tool successfully identified those that did, including 11 patients who had not been diagnosed. ⁽¹⁷⁾

AI in surgery is developing more slowly than in medicine and radiology, which can be partly attributed to the high risks and complexity of surgical decision-making, dominated by hypothetical-deductive reasoning, based on unpredictable interaction with the patient, human intuition, and the environment, raising moral and ethical questions about the opening of this field and responsibility, opening a new area of study for the field of philosophy. ⁽¹⁶⁾

The integration of artificial intelligence in robotic surgery is a promising direction that deserves attention. Currently, the role of machine learning algorithms in preoperative planning and the visualization of patient anatomy with augmented reality has been explored, thus increasing surgical precision, safety, and training to improve decision-making during surgery, but the future seems to be oriented towards the development of autonomous robots that, guided by artificial intelligence and deep learning, are capable of effectively completing the entire surgical procedure. ^(16,17)

Supercomputers and Quantum Computers: A supercomputer is a computer with computational power superior to that of a standard computer. They are used to perform complex calculations and simulations in fields such as research, artificial intelligence, and Big Data. The TaihuLight is considered the fastest computer in the world, with a peak speed of 93 quadrillion calculations per second. Comparatively, a modern desktop computer equipped with an Intel Core i7 processor is millions of times slower. ⁽¹⁸⁾

However, the challenge at this scale isn't the speed of each individual processor but rather how they communicate with each other and the agility to transfer data to memory, the local network, and storage systems, which are typically much slower. Processors can move data to memory locally at around 136 gigabytes per second. Each processor carries 32 GB of memory, totaling 1.3 petabytes for the entire machine. That's approximately one million gigabytes of memory, like what's installed on conventional computers. The TaihuLight can hold as much data as the Large Hadron Collider at CERN (European Organization for Nuclear Research) generates in a year. ⁽¹⁸⁾

An increasingly important factor in the design of these super-machines is energy consumption. The TaihuLight requires 15 MW (megawatts) of power at full performance. Comparatively, a laptop needs about 50W and a desktop computer between 100 and 200W; therefore, the TaihuLight requires the same energy as a million home computers. Engineers are striving to reduce the energy consumption of these supercomputers to mitigate environmental damage. ⁽¹⁸⁾

Now we have a better understanding of the transformative impact of supercomputers compared to ordinary computers. However, as we are in an era of constant change, current development efforts are heavily focused on quantum computers. These computers are based on the use of qubits. To better understand this, the bits of classical computing can be in a state of 1 or 0, but only one state at a time, whereas a qubit can be in both states simultaneously. This superposition allows quantum computers to analyze more data and probabilities. Quantum supremacy is the potential ability of quantum computing devices to solve problems that classical computers practically cannot ¹ solve or would take supercomputers millions of years to resolve. To grasp the significance of quantum supremacy, it's worth noting that in December 2004, Google LLC unveiled a new quantum chip called Willow, which is still in the experimental phase with completion planned for the end of the decade. This small quantum chip was able to solve an algorithmic problem in 5 minutes that would take the most powerful supercomputers of today millions of years. ^(19,20)

This final section is to consider the future impact that the relationship between the use of quantum computers, capable of processing millions of data per second, in conjunction with artificial intelligence and specifically deep learning, may have in the surgical field. This will somehow enable the development of robots managed by artificial neural networks with an incalculable data processing capacity, comparable only to the human brain itself.