Dr Deborah Keller M.D. is a colorectal surgeon specialising in the diagnosis and treatment of diseases in the lower digestive tract, including colorectal cancer. An early proponent of telehealth technology and telesurgery, a significant portion of her time has been redirected to coverage of Covid-19 patients in light of the pandemic — during which she contracted and recovered from the virus herself. What follows is an interview that has been edited for clarity.
This is a virus that does not discriminate. Anyone, with any fitness level, without any pre-existing conditions can get so sick — and it’s just profound; the fact that it can become difficult to actually take a breath is terrifying. But even in isolation and recovery, telesurgery software on my phone and in the theatre enabled me to carry on working and proctoring without placing myself or others at risk.
In one instance, I was able to help a colleague in Texas correct a rectal prolapse — an operation that I perform routinely, but they had never done before — by implanting a mesh onto the rectum and pelvic floor that suspends it back inside the body; a ventral mesh rectopexy. Because it was a robotic procedure, I had the same field of view as my colleague from the live camera feed, I could show him how to situate the mesh, and I was ‘in the room’ when the nurse brought in multiple types of mesh so I could show him which was the right one for the procedure. I could explain what suture to use, and with overlay graphics I was able to show where exactly in the pelvis to place those sutures to best benefit the patient.
It’s like actually being with them in the operating theatre — only I’m sitting in my home, or my office.
But with elective surgery currently at a standstill, we know there will be a backlog once the curve has been flattened and we begin the first tentative steps back towards normalcy. It’s going to need us to be more efficient, to be able to turn over operating rooms, equipment, and staff faster to meet the surge in demand. This can present a particular problem here in the US, with concerns over adequate equipment supplies, support staff, and operating room and surgeon time to meet the demand.
Telesurgery helps surgeons ascend the learning curve — and therefore the time needed for a surgeon to learn and perform any given procedure — as well as providing real-time support so they are never alone while learning. The pandemic has created an unfortunate need for these technological solutions, and is pushing healthcare systems to actually put available technology into practice rather than hesitate over the adoption of new technologies. We are likely to see a major shift, because there will be no return to ‘normal’ for a long time; there will be a necessity for cases to be more efficient, with less unnecessary equipment and fewer people in the room. There will have to be a greater willingness to purchase and to implement the technological solutions that help simplify and streamline both individual cases and the whole surgical experience, including prehabilitation for patients and post-op recovery.
We’re seeing technology in motion, which makes it a very exciting time to be a surgeon. Innovation continues to help develop better equipment, better imaging modalities that can recognise specific cancer types, and even augmented reality that’s overlaid on our field of vision that we can see while we’re working. We’re also seeing fantastic opportunities for education and continued learning; once you’re a competent practising surgeon, it’s hard to get mentorship if you’re learning new skills in the operating room. Telesurgery technology is perfect for that, and actually a cut above having a mentor even in the room with you — here, they can share your field of vision, they can annotate and give real-time feedback on your work.
I do a lot of surgery for colorectal cancer, where there’s a focus on precision. I also teach in a teaching hospital, and when training residents and fellows it’s vital to be able to analyse their movements for efficiency and competency. Using software that can track and measure their motions, this analysis becomes more precise than it has ever been before. By pairing motion tracking with telesurgery, you gain the ability to follow and anticipate the movements of expert surgeons time and again, building up volumes of data that could be used to develop deep-learning models that hone in on best practice and efficiencies, and continue the drive towards better quality surgery.
The implications then, for robotic surgery, are huge — in terms of collecting a data bank of surgical procedures performed by expert surgeons, and applying this as both real-time guidance and as a training tool. But the immediate needs of the healthcare sector are both more humble and more urgent: to maximise efficiency in a way that doesn’t compromise the patient, the healthcare provider or the provision of consistently high quality medical procedures.