How digital tools can advance surgical performance

Incision · · 11 min read

CSJ spoke to Charles Pallandt, chief commercial officer at Incision, to find out how digital tools for education and training could support operating theatre teams to improve performance, reduce delays and improve safety.

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Surgical training has been severely impacted by the pandemic. According to the 'COVID-19 impact on Surgical Training and Recovery' (COVID-STAR) survey, course cancellations were reported in 80% of cases, while a complete loss of training activity in elective operations (69.5%), outpatient clinics (67.3%), endoscopy (69.5%), specialty-specific accreditations (72%) and simulation training (68%) were also reported.1 This has led to calls for innovative approaches to support training, including the use of digital technologies - from simulation and VR solutions to digital Apps.

In August 2022, the Royal College of Surgeons published a set of recommendations, which stated that: " Technology-enhanced training solutions with evidence to demonstrate educational effectiveness should be considered for integration into surgical training. These should augment and not replace hands-on training.2

At the same time, there is an urgent need to improve efficiency and increase capacity in operating theatres, as the NHS battles to reduce waiting times and a backlog of over seven million. Digital technologies could have a vital role to play in:

  • Tackling the backlog by reducing pre- and intra-operative delays
  • Providing resources to support training for operating theatre teams
  • Tackling variation in performance
  • Standardising surgical approaches in line with best practice
  • Reducing complications

"There is limited time for in-service training, theatre teams are extremely busy, and the backlog has added to the pressures - yet healthcare has been slow to adopt digital technology that could help the NHS address operating theatres' key challenges. In other sectors, digital transformation has been much faster and more advanced," commented Charles Pallandt, chief commercial officer, Incision.

He points out that 59% of surgical complications in the operating theatre are avoidable3 and there is wide variation in performance between best-in-class centres and the not so well performing centres.

A digital educational platform

Against this backdrop, Incision has sought to develop a platform for surgical professionals to exchange knowledge and skills to improve surgical care. The technology, which is designed to convey information in a visual way - through animation, augmented reality, or illustration - aims to ensure that patients get the best possible outcome and care, in the most efficient way.

Pallandt explains that one of the key areas where digital technology could help to drive improvement is around operating theatre preparation: " Surgical teams are not always optimally prepared, and surgeons are trained to educate through the ' apprenticeship model', i.e. ' see one, do one, teach one'. This means that every surgeon may execute the procedure differently depending on how they have been taught by their predecessor. For the team preparing for surgery, this makes it very hard to standardise."

Pallandt points out that this can lead to delays, frustration, and complications. The patient may not be positioned correctly, or the right materials/instruments may not be present, for example, leading to a delayed start of the procedure. Incision's internal research shows that 2 out of 3 procedures do not start on time. Ultimately, this can have a significant impact on the bottom line. Furthermore, these avoidable delays do not help healthcare providers in their efforts to tackle the current backlog.

Another key issue experienced by the NHS relates to significant shortages of staff - this is proving to be an increasing challenge. A Freedom of Information request has suggested that the number of operations cancelled by the NHS in England due to staff shortages has doubled in three years. In fact, an estimated 30,000 operations did not proceed due to a lack of staff to perform them.4

"Speaking to Trusts and hospitals, we hear that rates of staff turnover can be up to 25%," commented Pallandt. "These gaps are being filled with locum staff - in some cases, this is up to 40%." Pallandt asserts that the key to productivity and safe care in the operating theatre starts with accessible and well-organised work instructions for operating theatre staff. He points out that new and 'transient' members of staff need to be 'onboarded' or better (i.e. trained during orientation or the induction period). They may not be used to working with the surgeon and this is where technology could have a significant impact.

E-learning and video-based training

Incision has developed a rapidly growing e-learning platform (Incision Academy) featuring around 700 accredited courses, aimed at providing education and training to prepare for the operating room. The technology includes video-based modules, interactive 3D anatomy, essential peri- and intra- operative information, test certification, and competence tracking, to support all levels of interdisciplinary training - helping to ensure the operating department is as safe and efficient as possible.

The platform can help theatre staff to better understand, identify and mitigate the potential hazard. Furthermore, the ability to project anatomy onto the procedure itself - using augmented reality and 3D modelling - can help staff fully understand the structures, medical devices that will be used, and steps of the procedure. Furthermore, the technology can also be used to optimise and standardise procedures. "If everyone works the same way, operating theatres can become much more efficient," Pallandt points out.

The technology provides a useful educational tool for a variety of professional roles within the theatre However, one area where it has been shown to have a particular impact is in supporting surgical trainees, scrub nurses and ODP students during their training.

Research by Selten et al (2022) investigated the effects of a video-based platform (in addition to the standard curriculum), on medical students' self-reported and tested surgical knowledge, for example.5 The study included fourth-year students undertaking training at the Erasmus University Medical Center (Erasmus MC), Rotterdam, The Netherlands, and across 11 affiliated general hospitals.

Ninety students followed the usual surgical curriculum (control group), followed by 88 students who were given voluntary access to a video-based surgical educational platform - i.e. Incision Academy (video group). Students in the video group indicated that they had better resources at their disposal than the control group for surgical procedures (p=0.001). Furthermore, students in the video group showed a greater increase in self-reported surgical knowledge (p=0.03) and more objectively tested surgical knowledge (p<0.001). The researchers concluded that the educational platform "improved test scores and self-reported surgical knowledge", while students felt "better prepared" and more able to find the information they required.

How video content is presented is also important, however. Nazari et al (2020) conducted a study to compare the effects of cognitive load and surgical performance in medical students that performed open inguinal hernia repair, after preparation with a step-by-step video demonstration.6 In this prospective study, participants were randomly assigned to the step-by-step or continuous video demonstration. They completed questionnaires regarding perceived cognitive load during preparation and their surgical performance was assessed on a simulation hernia model. Forty-three students participated - 23 students in the step-by-step group and 20 in the continuous group. The step-by-step group perceived a lower extraneous cognitive load (2.92 +- 1.21) compared to the continuous group (3.91 +- 1.67, p = 0.030). The surgical performance was not statistically significantly different between both groups. However, in sub-analyses on a selection of students that prepared for 1 to 2 hours, the step-by-step group made fewer procedural errors (1.67 +- 1.11) compared to the continuous group (3.06 +- 1.91, p = 0.018). The researchers concluded that preparation using step-by-step video-based learning "results in lower extraneous cognitive load and subsequently fewer procedural errors during the surgical performance. For learning purposes, demonstration videos of surgical procedures should be presented in a segmented format."

A 'digital assistant'

While 'off-the-job' preparation is important, staff also need support while preparing for theatre lists on the day - including setting up the operating theatre, working with the surgeon and working as a member of the team. Incision Assist provides the surgical team with a unified view of the requirements and preferences to support staff through any procedure. The 'digital assistant' includes all the information required for a successful operating theatre performance, with access to an extensive library of different procedures. For each type of procedure, the App provides easy-to-follow information on operating theatre setup, patient preparation and positioning, disposables, instruments, implants, draping, surgical steps, and post-operative instructions. With all the people, setups and instructions related to a procedure in one place, efficiency can be improved. "Potential delays can be avoided by ensuring staff can quickly identify any medical device error codes; they know how to position the patient in the right way; and they understand how to apply the draping for a specific procedure. A 30-60 second animation or 3D image can solve issues very quickly," said Pallandt.

He added that the platform can replace reliance on printed preference cards or scribbled notes (which can lead to human error and misinterpretation); it can be updated easily to accommodate changes; and it avoids tensions arising within the team - caused by surgeon preferences not being adhered to. All of this information can be easily accessed and managed via the App.

The technology can also help with the implementation of unfamiliar technology and surgical approaches in the operating theatre. For example, the 3D animation can provide step-by-step instructions on how to set up a theatre for robotic surgery, including showing where trocars need to be placed. With an increasing number of Trusts adopting surgical robots, there is a significant learning curve that needs to be addressed across the whole operating theatre team.

Surgical teams can also learn from best-performing centres that have been shown to have more efficient or have better outcomes. The platform allows users to learn from - and benchmark against - these best-in-class examples, using video content, enabling standards to be continuously improved. " Digital support makes it easy to compare ways of working and to start a discussion about why you do things differently - to learn from each other. We see teams working together in a more synchronised way, which is a step towards increased efficiency," commented Pallandt. He suggested that theatre teams may even be able to increase their capacity "from 5-6 surgeries to 7-8 surgeries".

In fact, a recent study conducted at IJsselland Hospital in the Netherlands, found that the majority of users (95%) felt better prepared for their work, operating theatre staff were able to complete their training on average three months earlier compared with non-app users, while changeover times between surgical cases also reduced.7 Ultimately, feeling "better prepared" leads to increased confidence in the operating theatre, as Pallandt points out: "The more informed teams are, the more confident they are. If the team feel more empowered this can have an impact on retention."

Adoption by UK Trusts

Pallandt reports that the digital technology is increasingly being rolled across the surgical sector. Incision is no longer a start-up - the company is serving over 250 hospitals and its goal is to support 10,000 clinics by the end of 2030. In the UK, there is increasing interest from Health Education England, as it seeks to modernise education and tackle capacity challenges. As part of this strategy, it is being rolled out at more than 10 Trusts in England. The technology has been accredited by the Royal College of Surgeons for over five years and, more recently, endorsed by the Association of Surgeons of Great Britain and Ireland.

Ultimately, the digitisation of education and more training has the potential to make it much more efficient and effective," Pallandt concluded. "Digital training tools can help develop more productive teams, lower costs and ensure safer care.

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  1. COVID-STAR Collaborative Study Group. COVID-19 impact on Surgical Training and Recovery Planning (COVID-STAR) - A cross-sectional observational study. Int J Surg. 2021 Apr;88:105903. doi: 10.1016/j.ijsu.2021.105903. Epub 2021 Feb 27. PMID: 33652133: MPCID: PMC7912362.




  5. Selten JW, Nazari T, Andriessen EH, Konings S, Wiggers T, de Jonge J. Standardized videos in addition to the surgical curriculum in Medical Education for surgical clerkships: a cohort study. BMC Med Educ. 2022 May 19;22(1):384. doi:10.1186/s12909-022-03314-w. PMID: 35590406; PMCID: PMC9121575.

  6. Lange JF, van Merrienboer JJG, Wiggers T. One Step at a Time: Step by Step Versus Continuous Video-Based Learning to Prepare Medical Students for Performing Surgical Procedures. J Surg Educ. 2020 Jul-Aug;77(4):779-787. doi:10.1016/j.surg.2020.02.020. Epub 2020 Mar 11. PMID: 32171749

  7. Data reported for feasibility study, by Thomas Needs (Incision BV), Marian Scheer (Incision BV) and Reinier Feitz (Department of Plastic and Reconstructive and Hand Surgery, Rotterdam Erasmus MC, Netherlands)

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