An independent commission predicts that surgery is going to become much less invasive and more personalised with more predictable outcomes, faster recovery time and lower risk of harm.

A report undertaken by the Commission on the Future of Surgery – established by the Royal College of Surgeons (RCS) – predicts that a new wave of technology driven by changes in digital technology and understanding of human biology are expected to affect every type of surgery, including in the way surgeons are trained.

More diseases could be diagnosed by blood samples instead of invasive biopsies; ‘well’ patients will undergo earlier and, in some cases, preventive operations; and patients may no longer need to undergo some cancer operations due to advances in genomics, vaccination, and non-surgical treatments. In the more distant future, surgeons may prevent, and not just treat, osteoarthritis through stem-cell therapies, and nano-surgery performed by micro-robots could allow surgeons to operate on individual cells in the body.

The report highlights four areas of technological development that are likely to have the greatest impact on how surgical care is delivered in the next two decades. These are:

• Robot assisted surgery and minimally invasive surgery – with the next generation of surgical robots expected to be launched in 2019. Given they are smaller and lighter they can be moved between hospitals, making the surgery more readily available, while developments in minimally-invasive surgery and advances in imaging will make more patients eligible for surgery, particularly the frail and elderly;
• Imaging – including virtual, mixed and augmented reality platforms which may allow surgeons to carry out or support complex procedures remotely – meaning a surgeon in one hospital might guide a team in another unit through an operation using augmented reality;
• Big data, genomics and artificial intelligence – which can enable ‘precision surgery’, allowing treatments to be tailored to patients according to their genetic profile;
• Specialist interventions – such as developments in transplants and stem-cell therapies, with the report suggesting that the short-term advances in 3D printing will lead to more advanced prostheses, while in the longer-term more advanced imaging could enable ‘nano-surgery’.

The report also made a number of recommendations to Government, healthcare regulators and medical royal colleges to ensure the surgical community is able to adapt to coming changes and enable patients to fully benefit from advances.

Some key recommendations from the Commission include:

• A UK-wide database or registry should be established to track all new devices and techniques. All new techniques and implantable devices should have long-term monitoring in such a register, akin to the breast implant registry;
• There should be a review of the viability of creating a national database that encompasses a much wider range of procedures than currently covered by national clinical audits;
• The location of surgical robots and centralised services needs to be much better planned in the future to balance equity of access across the country and cost effectiveness. NHS England should initially lead a robotics strategy to help the NHS plan and purchase new surgical robotics systems – this approach could extend to other innovations.
• NHS Digital should carry out a review of how NHS websites, and digital and other communication from patient charities can support patients to understand the benefits and risks of new treatments and surgical procedures.
• The NHS in England, Scotland, Wales and Northern Ireland, in conjunction with local trusts, should encourage investment in the creation of multidisciplinary hubs for the delivery of complex interventions. In the immediate term, they can enable the use of 3D printing and planning technologies. In future years, other specialised interventions, such as regenerative medicine, can benefit from centralised multidisciplinary expertise.
• Surgical training needs to ensure surgeons are capable of evaluating and embracing change. It should also engage with the opportunities for distant and virtual learning.

Richard Kerr, chair of the Royal College of Surgeons’ Commission on the Future of Surgery, said: “We’re standing on the verge of transformative changes in surgery that have the potential to dramatically improve patients’ care, helping them to live healthier lives for longer. We are now moving from the era of freehand surgery to the digitalisation of surgery – where surgeons are supported by data, genomic analysis and new tools such as robotics.

“Collectively these technologies will make surgery faster to recover from, even more accurate and successful, with much less scarring for patients. Surgery may become redundant for some types of cancer treatment, while new forms of surgery might occur. For example, it will become easier to operate on older, frail patients given the reduced trauma involved. Surgery will also no longer just be about helping patients once they are ill, it will be about helping them avoid getting ill in the first place.

“It is an incredibly exciting time to be part of the surgical team, as technology is going to enable us to do so much more to keep our patients healthy. Better diagnosis and a more detailed understanding of how illnesses develop, thanks to advances in genomics and genetic testing, will give us the tools to tackle disease at an earlier stage. We will be able to act early and tailor surgery to the needs of individual patients, and therefore likely operating on patients who are otherwise well.”

The role of some surgeons is likely to become increasingly wide-ranging, sometimes crossing boundaries with clinicians in other areas of medical intervention where a vast array of other treatments may become preferable, such as in cancer surgery.

The Commission raises the possibility that highly skilled surgical technicians may undertake some further procedures – such as endoscopy and endoscopic biopsies, removing skin lesions and maybe even carrying out caesarean sections – under the supervision of a surgeon.

Professor Derek Alderson, president of the Royal College of Surgeons, responded to the findings saying: “The Royal College of Surgeons will consider carefully all of the recommendations the Commission has made, particularly those relating to surgical training.

“It’s absolutely crucial that these exciting advances are introduced in ways that ensure the greatest possible patient benefit, and do not risk patient safety. The RCS is very supportive of the recommendations the Commission makes on compulsory registration of new technologies and devices.”