MedTech Pioneers – The Future of Digital Surgery at the Mayo Clinic

Tell us about your roles at The Mayo Clinic.

(MW) I am chair of the Mayo Clinic Division of Engineering and have worked at Mayo Clinic my entire career. For over 30 years I have been developing custom devices to support our clinical and research practice. The Engineering team has over 65 engineers, software developers, and technologists on staff to work with and support our physicians developing new innovations within Mayo Clinic. I am also an Assistant Professor of Biomedical Engineering at the Mayo Clinic College of Medicine and Science. I work with Dr. Reisenauer and a host of other physician collaborators.  The Engineering team partners with our physician colleagues whether it is in surgical robots or instrumentation.

(JR) I am a surgeon in General Thoracic Surgery and Interventional Pulmonary Medicine. I have a special interest and focus in lung cancer treatment. I am also the Vice Chair of Innovation for the Department of Surgery.  My role involves collaboration with Mark and others internally as well as externally to Mayo Clinic to help enable our surgeons to innovate and transform the practice in keeping with the evolving needs of healthcare.

How is surgery evolving and what do you think are the key areas of opportunities in digital surgery?

Training

(JR) I think about the way that technology has advanced and is now such a key part of our lives. If you look at our cell phones or our cars and how it has impacted our daily lives in just the past ten years, it is tremendous. We have GPS in our cars, and on our phones, which is such a change from Mapquest, or even the old A to Z; our cell phones assist us with most everything. Yet to make these advancements in the Operating Room (OR), it is not there yet, but we are seeing progress and there are huge opportunities.

For me, I think there are big opportunities in surgeon training. When you ask a surgeon why they conduct a procedure in a specific way, it is often imprinted upon them by their mentors. We have good outcomes because we have great teachers. This way of learning is going to change rapidly and technology can facilitate training. There is now a generation of new surgeons learning via simulation. A critical component of digital surgery is in education and training. Many young surgeons are looking to build their practice early in their careers. With technology we can provide training tools to maintain if not accelerate that steep learning curve and allow surgeons to feel better connected to their patients.

Automation

(MW) In digital surgery I see this move to automation. The automaker, Honda, uses over 342 robots to make their new Accord. I think there are robotic procedures that are repeatable like suturing. These different automated procedures are segmented into steps and they can be parsed together to close a wound or even remove a gall bladder.

(JR) Yes, but there are things I would not trust a robot to do, such as an entire operation from start to finish – would I trust a robot to do it? No. There is just too much critical intraoperative thinking that goes into each surgery. For example, a lobectomy is an operation we do every day. We have a certain method we will follow, in terms of sequence of steps, or certain instruments based on tissue quality, but there can be subtle differences we note which cause us to adapt and we may use a different instrument or change the sequence for that particular patient. These differences are nuanced, each case is unique and these intraoperative decisions are critical. I see an area of opportunity real time assistance, however. If procedures could be automated and segmented and these individual steps or surgical segments could be conducted from afar or remotely, then this could be potentially very compelling.

Assistant Robots

(JR) At the Mayo Clinic we value the team approach. Trainees, operating room staff – all could potentially benefit from a robot to assist with and assess surgical steps. For instance, to have a robot that could provide autonomous-provided assistance would be very helpful e.g. discerning the appropriate retraction without tearing the tissue, or a robot monitoring the field and letting you know if there is an area of bleeding remote from where you are working at that time, or a sudden drop in blood pressure with a particular maneuver.  I am very curious to see how the definition of a “surgical robot” as we know it, will change in the next decade.

How do you view data and the impact it is having in digital surgery?

(JR) Collectively, we have all this data and we are still learning how best to utilize and interpret this information.   We gather so much detail about the patient before, during and after the procedure. The issue is distilling it down into useful segments that can deliver better outcomes overall. Historically, surgeons read textbooks to learn a technique, and mentally translated those 2D images in a book to a 3D picture in the mind of how that operation might be performed.  Again, in the digital era, there is ample access to surgical videos, images, and a transition to immersive learning.  This connected sharing is virtual and the experiences can be very engaging.

Telemedicine has also allowed Mayo Clinic, in particular, to maintain access to patients who cannot travel and provide the connectivity from afar.  This has been incredibly useful during the COVID era.

Another high priority is data connection in the operating room. Our world is connected through WiFi, will this eventually make its way into our operating rooms and allow machines to speak to each other?  Time will tell.

(MW) The data we need is usually tied to the simplest elements – clinical outcomes and cost. We want to see how robots are improving outcomes. Robots are amazing in that they are giving us the ability to do minimally invasive surgery – they do not have the limitations that a human hand does. The robot can snake into places a human hand could not access before and we will have better outcomes. A robotic platform would allow us greater access and potentially new treatments.

How do you view the value of surgical robotic platforms?

(JR) It depends on how you define a surgical robot.  Today, a laparoscopic surgeon might perform a procedure as well as one conducted with a robot. A robot is not the answer to everything as it stands in 2021. However, for the future it could be very different, if robots could provide the right assistance to deliver a shorter hospital stay, lowered cost or improved outcome.

(MW) We have an aging population and we are forecasting a shortage of surgeons. Robotic surgery could help extend the life of a surgeon. With age comes a wealth of experience yet a natural loss of dexterity. This skill is especially necessary for delicate procedures. Robotic assistance could help address this issue.

(JR) I see a lot of surgeons with neck and back issues from standing and performing procedures during very long stretches. There are ergonomic advantages to robotics; a surgeon can sit at a console and perform a surgery.

Another advantage of a robot or digital surgery platform is being able to provide real-time decision support. This data doesn’t need to come from a robot; it could come from a different surgical instrument that captures data in real time for every single case.

(MW) We view the robot and the surrounding data and AI as serving to support the surgeon and their decision-making. It is an adjunct.

(JR) We are excited about collecting and leveraging real-time data to support our surgeon’s decision-making. There are quite a few companies that have equipped audio and visual feedback in the OR and the Mayo is testing some of these. We are interested in collaborating and testing them to understand their value for patient care.

How do advancements in imaging fit in with your vision for the evolved digital surgery OR?

(JR) Enhanced imaging systems represent one more tool to potentially make surgery safer. As a cancer surgeon focusing on the lung space, it is very important. When you resect a lung nodule in a minimally invasive fashion, we need to think in 3D to find it. Sometimes the nodule can’t be seen or felt and imaging is critical to know where the resection needs to be instead of taking out more than the surgeon intended to. Having technology to tell you where you are and decide on margins could be a gamechanger. I am currently investing some work with a CT scanner in the operating room and performing surgery under image guidance to better understand this workflow. Down the road, if we could leverage technology, and perhaps a new age surgical robot, we could perform the procedure with control from behind the wall to protect ourselves from exposure; this would be very impactful.

What are the unmet needs for digital assistance in the operating room?

(JR) We live in a world in which we want to protect what we hold dear. It can be hard to work together; we respect what is proprietary and what is not. This makes it difficult to collaborate. Physicians want to help and be at the forefront of innovation and better patient care. If we could broaden the role of physicians into the R&D world, we may have less silos of solutions and we will expedite innovation. We need to share in this development of the new digital surgical system.   There have been so many advances in augmented reality, virtual reality, and smartphones – it would be very interesting to be able to extrapolate these advances into the healthcare platform.

(MW) A key area involves simulation and training; there is a huge opportunity involving the training of new surgeons with reality-based systems which provide displays on headsets and haptic feedback.  Surgeons, that want to practice, often request a platform for creating 3D models e.g. for aortic aneurism so they can practice stenting on a similar anatomy to what they will see in the OR. This is incredibly helpful for complex cases.

What developments or trends are you seeing in surgical robotics?

(JR) In 2021 we live in a capitalistic society and competition breeds improvement. I think there has been immense discussion in terms of what it means when we say “surgical robotics”, and I think this definition will change in the next several years.

(MW) The Mayo Clinic wants to be device-agnostic; we want great outcomes, patient satisfaction, and to be at the forefront of innovation. We have our Bold Forward 2030 Mission; our focus is on looking at how we practice medicine in 2020 and determining what we will do to transform it by 2030. We want the Mayo Clinic to remain at the forefront of healthcare outcomes and innovation in 2030. We are mapping our plan across many pillars including data, device development, digital surgery with robotics, telemedicine, telehealth, telecare, web portals, connectivity and transformational Artificial Intelligence (AI).

We understand that healthcare is evolving; technology is a key driver and it is changing dramatically. We now have the computational power to run sophisticated algorithms. In the past we didn’t have the capabilities and it was not cost effective to harness the data. Now, we are getting to the point where it isn’t the same anymore. This has changed. For example, with AFib, we can get continuous real-time data; before there was no cloud, there was no easy way to transmit the data. Now it is trivial to get data to a cloud. We have the computational power to run intensive algorithms; there is a complete explosion in digital capabilities. There is a sea change in healthcare and the Mayo Clinic wants to continue to embrace it all and lead the way.

Tell us about some your digital surgery programs at the Mayo.

(JR) We have a lot going on. We have an agreement with Gentex, a car manufacturer that has expertise in lighting, and we are trying to create the optimal lighting in the operating room so that the team can see everything even around the shoulder of a surgeon.

Telemedicine is embraced. The pandemic has caused us to use telemedicine not only between patient and doctor but doctor-to-doctor too.

Remote telehealth multiple member participant visits are now a new offering.  We have a remote monitoring program; we discharge a patient with a daily diary and remote monitoring system so we can prevent and/or predict complications.

We are conducting research with multi-port and single port robotic systems.

Tell us about your focus on lung cancer.

(JR) I specialize in bronchoscopic treatment of lung cancer.  Lung cancer is a devastating disease and often is diagnosed late in stage.  There is ample data out there to suggest that although we have improved our screening processes, there are significant delays in the multiple steps and can result in over 6 weeks between diagnosis and treatment for a patient.  We are working very hard to change this to single stage diagnosis, staging and treatment, through natural orifices.  We are also looking at local therapy to help outcomes with stage 3 and 4 lung cancer to try and prolong life.  Our team is looking at many things – vaccines, immune therapy, stem cell treatment. It is something near and dear to my heart.

Please share what inspires you.

(MW) I partner with Dr. Reisenauer and other thought leader physicians at the Mayo; each is innovating and inventing in their own space. Each department has their own innovations and we work with all of these teams. We try to come up with new ways to solve problems. I am excited to see the momentum. We are not sitting back on our #1 status as the leading healthcare center of excellence. I love my work – we are discussing how we could perform a surgery on a Mars Mission – there could be up to a 20 min delay for communication, depending on the relative orbital positions in space. If we can do that, we can certainty care for patients anywhere on earth. I am also excited about building better home healthcare so as we get older this support allows us to have high quality care in our own homes. To me, that is amazing innovation and better patient care.

(JR) Similar to Mark, when I look around at the entire surgical team – physicians, nursing staff, ancillary staff – as well as the Mayo Clinic team – engineering, ventures, research centers – there is a singular goal to lead the way and transform health care.  It is so inspiring to be a very small part of a huge system that really cares and is so motivated.  Our multidisciplinary culture and collaboration at Mayo Clinic are very unique – we really understand the value of teamwork – I feel very privileged and inspired to be a part of that.

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