Professor the Lord Darzi of Denham, from Imperial College, London, UK, talks to Mr Robert Hinchliffe, BJS Associate Editor, about this Special Issue and the role of innovation in surgery. Click here to watch.
Leading article
Surgical innovation C. H. C. Dejong1 and J. J. Earnshaw2 1
Department of Surgery, Maastricht University Medical Centre, Euregional HepatoPancreatoBiliary Collaboration Aachen–Maastricht, NUTRIM School for Nutrition, Toxicology and Metabolism, and GROW School for Oncology and Developmental Biology, PO Box 5800, 6202AZ Maastricht, The Netherlands, and 2 Department of Vascular Surgery, Cheltenham General Hospital, Sandford Road, Cheltenham GL53 7AN, UK (e-mail: [email protected])
Click here to listen to co-Chief Editor, Mr Jonothan Earnshaw, discuss this Special Issue and the regular January issue. Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9727
‘If you are not prepared to be wrong, you will never come up with anything original.’1 This special issue of BJS covers some aspects of innovation in surgery. It is difficult, if not impossible, to pinpoint when innovation in surgery actually started. Although most surgeons would instinctively associate innovation in surgery with the introduction of novel techniques or new instruments, there is more to it than this. Innovation is intrinsically linked to curiosity and may therefore take many forms. It is the curiosity of the surgeon that leads to a question2 and a subsequent initiative, following which it is the creativity of the surgeon that determines whether this leads to innovation. There is always a certain level of risk in innovation. It is therefore not surprising that efforts have been made over time to identify and define surgical innovation, and control its inherent risks. A consensus definition of surgical innovation is currently lacking3 , but tools to help create formal processes for evaluation have been proposed4,5 . There is no agreement in the surgical community on the difference between research and innovation. Surgical curiosity may initiate a particular research project. Traditionally, such research was initially conducted in animals, or even in cell lines, in surgical research laboratories and then transferred to humans. © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
This classical translational research pathway has received considerable attention in recent years. There is now increasing awareness that true translation from animals to humans occurs infrequently2 , and so it seems justified to conclude that innovation presupposes some form of research, but not all research leads to innovation. From an economic point of view, the fact that few ideas tested in animal research trickle down into human research and innovation questions its value. Cost-efficiency is increasingly on the research agenda, and as a consequence more and more attention is being focused on public–private (university–industry) collaboration. As an example of a contemporary research theme addressed in this issue of BJS, an enormous amount of money has been invested in genomewide research. Technology has evolved rapidly in this area and many research groups have skewed their attention to this field. Often, the research conducted in this field is impolitely characterized as a fishing expedition, because the research question is frequently based on a broad search to identify something new. Questions remain concerning the translational value of this type of research6 . The ultimate challenge for many innovators has been the creation of another human being beyond procreation. The story of Frankenstein warns that this is not always
a successful concept, and there are myriad ethical issues surrounding this7 . Although creation of a complete human being may be too big a challenge, the notion of being able to create and transplant parts of human beings is intriguing. It is in the transplant setting that some of the most impressive innovations in medical history have taken place. Creating artificial organs, in terms of either function (bioartificial liver; Molecular Adsorbent Recirculating System (MARS®; Gambro, Lund, Sweden) renal dialysis) or whole organs has become a reality. Progress has been made in bone regeneration and also in the creation of intestinal organoids. Building livers is now on the verge of reality and, as highlighted in this issue, surgeons have created an artificial trachea for paediatric transplantation8 . It is highly likely that there will be rapid progress in this exciting field in the not too distant future. The emergence of the laparoscopic approach to cholecystectomy in the past two decades has been followed by rapid implementation of this technique in many areas of surgery. The laparoscopic revolution is a classic example of how an innovation by one person is popularized by another, who immediately recognizes the potential impact and then uses their academic network to disseminate the technique9 . Subsequently, surgeons used fewer trocars to improve the BJS 2015; 102: e8–e9
Surgical innovation
aesthetic outcome of the procedure, culminating in single-port laparoscopic procedures and natural-orifice transluminal surgery. There is certainly appeal in these approaches, but their exact role has still to be defined. Where tactile feedback is lost in purely minimally invasive surgery, methods have been developed to improve the visualization of crucial anatomical structures. Recent developments in the use of fluorochromes have made it possible to visualize the biliary tree during laparoscopic cholecystectomy, and the ureter during pelvic surgery. Fluorochromes may also be helpful in visualizing micrometastases in the liver, thus avoiding fruitless liver resection. There is still work to do before these tools can be implemented in everyday practice, but there is little doubt that fluorochromes will find their way into routine surgery10 . Robotic surgery is another potential breakthrough in minimally invasive surgery, and certainly has several appealing features. Working in confined spaces is much more accurate when a robot is used; undesirable movements (tremor) are filtered and, in theory, robotic surgery could be conducted over a long distance11 . Robotic surgery has a very real appeal to the public, and it may be attractive for a hospital to advertise that a robot is used for certain surgical procedures. However, robotic surgery is expensive, and in some parts of the world healthcare could become unaffordable if every hospital were to have a robot. A process is needed to identify procedures for which the robot has undeniable clinical and cost-effective advantage compared with standard laparoscopy or an open approach. Worldwide, there is growing awareness that more data are needed to assess the outcomes of various surgical procedures12 . Single centres can often not generate such data, or the results © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
e9
have limited external validity. Multicentre collaborations are frequently based on incidental initiatives, and are often heavily dependent on the role of, and interaction between, interested individuals. There are a number of initiatives to create nationwide audit databases to monitor the outcome of surgical procedures, for example in Sweden, the UK and the Netherlands. Such huge databases provide a very powerful instrument to monitor and improve the quality of specific, usually complex, surgical procedures. Clinical, nationwide databases provide insight into outcomes of individual centres or surgeons against the background of the national average, if necessary corrected for case mix. This provides transparency of outcomes and gives feedback to society as to whether healthcare budgets are spent adequately. Many of the articles in this Surgical Innovation issue come from highincome countries. Yet in areas where financial resources are scarce, creativity is of utmost importance. Innovation in income-poor environments is highly dependent on the explorative thoughts of out-of-the-box thinkers13 . There may be a tension between high-cost innovations in high-income countries and the potential for their delivery worldwide, which remains a challenge. There may be an opportunity in reverse, where innovations in low-income countries are more widely applicable and generalizable. This issue is dedicated to the future of surgery. The world needs innovators to challenge existing thoughts and BJS is more than happy to provide a forum for them to share their ideas with the surgical community.
Disclosure
The authors declare no conflict of interest. www.bjs.co.uk
References 1 Sir Ken Robinson. The Element: How Finding Your Passion Changes Everything. Penguin Books, 2009. http://www.goodreads.com/author/ quotes/43940.Ken_Robinson. 2 Basson MD. The role of the investigative surgeon: asking questions and questioning answers. JAMA Surg 2014; 149: 1188–1190. 3 Rogers WA, Lotz M, Hutchison K, Pourmoslemi A, Eyers A. Identifying surgical innovation: a qualitative study of surgeons’ views. Ann Surg 2014; 259: 273–278. 4 Barkun JS, Aronson JK, Feldman LS, Maddern GJ, Strasberg SM; Balliol Collaboration. Evaluation and stages of surgical innovations. Lancet 2009; 374: 1089–1096. 5 McCulloch P, Altman DG, Campbell WB, Flum DR, Glasziou P, Marshall JC et al.; Balliol Collaboration. No surgical innovation without evaluation: the IDEAL recommendations. Lancet 2009; 374: 1105–1112. 6 Beggs AD, Dilworth MP. Surgery in the era of the ’omics revolution. Br J Surg 2015: 102: e29–e40. 7 Harrison G, Gannon WL. Victor Frankenstein’s Institutional Review Board proposal, 1790. Sci Eng Ethics 2014; [Epub ahead of print]. 8 Teoh GZ, Crowley C, Birchall MA, Seifalian AM. Development of resorbable nanocomposite tracheal and bronchial scaffolds for paediatric applications. Br J Surg 2015: 102: e140–e150. 9 Riskin DJ, Longaker MT, Gertner M, Krummel TM. Innovation in surgery: a historical perspective. Ann Surg 2006; 244: 686–693. 10 de Boer E, Harlaar NJ, Taruttis A, Nagengast WB, Rosenthal EL, Ntziachristos V et al. Optical innovations in surgery. Br J Surg 2015: 102: e56–e72. 11 Diana M, Marescaux J. Robotic surgery. Br J Surg 2015: 102: e15–e28. 12 Cook JA, Collins GS. The rise of big clinical databases. Br J Surg 2015: 102: e93–e101. 13 Oppong FC. Innovation in income-poor environments. Br J Surg 2015: 102: e102–e107.
BJS 2015; 102: e8–e9
Copyright of British Journal of Surgery is the property of John Wiley & Sons, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Leading article
Surgical innovation C. H. C. Dejong1 and J. J. Earnshaw2 1
Department of Surgery, Maastricht University Medical Centre, Euregional HepatoPancreatoBiliary Collaboration Aachen–Maastricht, NUTRIM School for Nutrition, Toxicology and Metabolism, and GROW School for Oncology and Developmental Biology, PO Box 5800, 6202AZ Maastricht, The Netherlands, and 2 Department of Vascular Surgery, Cheltenham General Hospital, Sandford Road, Cheltenham GL53 7AN, UK (e-mail: [email protected])
Click here to listen to co-Chief Editor, Mr Jonothan Earnshaw, discuss this Special Issue and the regular January issue. Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9727
‘If you are not prepared to be wrong, you will never come up with anything original.’1 This special issue of BJS covers some aspects of innovation in surgery. It is difficult, if not impossible, to pinpoint when innovation in surgery actually started. Although most surgeons would instinctively associate innovation in surgery with the introduction of novel techniques or new instruments, there is more to it than this. Innovation is intrinsically linked to curiosity and may therefore take many forms. It is the curiosity of the surgeon that leads to a question2 and a subsequent initiative, following which it is the creativity of the surgeon that determines whether this leads to innovation. There is always a certain level of risk in innovation. It is therefore not surprising that efforts have been made over time to identify and define surgical innovation, and control its inherent risks. A consensus definition of surgical innovation is currently lacking3 , but tools to help create formal processes for evaluation have been proposed4,5 . There is no agreement in the surgical community on the difference between research and innovation. Surgical curiosity may initiate a particular research project. Traditionally, such research was initially conducted in animals, or even in cell lines, in surgical research laboratories and then transferred to humans. © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
This classical translational research pathway has received considerable attention in recent years. There is now increasing awareness that true translation from animals to humans occurs infrequently2 , and so it seems justified to conclude that innovation presupposes some form of research, but not all research leads to innovation. From an economic point of view, the fact that few ideas tested in animal research trickle down into human research and innovation questions its value. Cost-efficiency is increasingly on the research agenda, and as a consequence more and more attention is being focused on public–private (university–industry) collaboration. As an example of a contemporary research theme addressed in this issue of BJS, an enormous amount of money has been invested in genomewide research. Technology has evolved rapidly in this area and many research groups have skewed their attention to this field. Often, the research conducted in this field is impolitely characterized as a fishing expedition, because the research question is frequently based on a broad search to identify something new. Questions remain concerning the translational value of this type of research6 . The ultimate challenge for many innovators has been the creation of another human being beyond procreation. The story of Frankenstein warns that this is not always
a successful concept, and there are myriad ethical issues surrounding this7 . Although creation of a complete human being may be too big a challenge, the notion of being able to create and transplant parts of human beings is intriguing. It is in the transplant setting that some of the most impressive innovations in medical history have taken place. Creating artificial organs, in terms of either function (bioartificial liver; Molecular Adsorbent Recirculating System (MARS®; Gambro, Lund, Sweden) renal dialysis) or whole organs has become a reality. Progress has been made in bone regeneration and also in the creation of intestinal organoids. Building livers is now on the verge of reality and, as highlighted in this issue, surgeons have created an artificial trachea for paediatric transplantation8 . It is highly likely that there will be rapid progress in this exciting field in the not too distant future. The emergence of the laparoscopic approach to cholecystectomy in the past two decades has been followed by rapid implementation of this technique in many areas of surgery. The laparoscopic revolution is a classic example of how an innovation by one person is popularized by another, who immediately recognizes the potential impact and then uses their academic network to disseminate the technique9 . Subsequently, surgeons used fewer trocars to improve the BJS 2015; 102: e8–e9
Surgical innovation
aesthetic outcome of the procedure, culminating in single-port laparoscopic procedures and natural-orifice transluminal surgery. There is certainly appeal in these approaches, but their exact role has still to be defined. Where tactile feedback is lost in purely minimally invasive surgery, methods have been developed to improve the visualization of crucial anatomical structures. Recent developments in the use of fluorochromes have made it possible to visualize the biliary tree during laparoscopic cholecystectomy, and the ureter during pelvic surgery. Fluorochromes may also be helpful in visualizing micrometastases in the liver, thus avoiding fruitless liver resection. There is still work to do before these tools can be implemented in everyday practice, but there is little doubt that fluorochromes will find their way into routine surgery10 . Robotic surgery is another potential breakthrough in minimally invasive surgery, and certainly has several appealing features. Working in confined spaces is much more accurate when a robot is used; undesirable movements (tremor) are filtered and, in theory, robotic surgery could be conducted over a long distance11 . Robotic surgery has a very real appeal to the public, and it may be attractive for a hospital to advertise that a robot is used for certain surgical procedures. However, robotic surgery is expensive, and in some parts of the world healthcare could become unaffordable if every hospital were to have a robot. A process is needed to identify procedures for which the robot has undeniable clinical and cost-effective advantage compared with standard laparoscopy or an open approach. Worldwide, there is growing awareness that more data are needed to assess the outcomes of various surgical procedures12 . Single centres can often not generate such data, or the results © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd
e9
have limited external validity. Multicentre collaborations are frequently based on incidental initiatives, and are often heavily dependent on the role of, and interaction between, interested individuals. There are a number of initiatives to create nationwide audit databases to monitor the outcome of surgical procedures, for example in Sweden, the UK and the Netherlands. Such huge databases provide a very powerful instrument to monitor and improve the quality of specific, usually complex, surgical procedures. Clinical, nationwide databases provide insight into outcomes of individual centres or surgeons against the background of the national average, if necessary corrected for case mix. This provides transparency of outcomes and gives feedback to society as to whether healthcare budgets are spent adequately. Many of the articles in this Surgical Innovation issue come from highincome countries. Yet in areas where financial resources are scarce, creativity is of utmost importance. Innovation in income-poor environments is highly dependent on the explorative thoughts of out-of-the-box thinkers13 . There may be a tension between high-cost innovations in high-income countries and the potential for their delivery worldwide, which remains a challenge. There may be an opportunity in reverse, where innovations in low-income countries are more widely applicable and generalizable. This issue is dedicated to the future of surgery. The world needs innovators to challenge existing thoughts and BJS is more than happy to provide a forum for them to share their ideas with the surgical community.
Disclosure
The authors declare no conflict of interest. www.bjs.co.uk
References 1 Sir Ken Robinson. The Element: How Finding Your Passion Changes Everything. Penguin Books, 2009. http://www.goodreads.com/author/ quotes/43940.Ken_Robinson. 2 Basson MD. The role of the investigative surgeon: asking questions and questioning answers. JAMA Surg 2014; 149: 1188–1190. 3 Rogers WA, Lotz M, Hutchison K, Pourmoslemi A, Eyers A. Identifying surgical innovation: a qualitative study of surgeons’ views. Ann Surg 2014; 259: 273–278. 4 Barkun JS, Aronson JK, Feldman LS, Maddern GJ, Strasberg SM; Balliol Collaboration. Evaluation and stages of surgical innovations. Lancet 2009; 374: 1089–1096. 5 McCulloch P, Altman DG, Campbell WB, Flum DR, Glasziou P, Marshall JC et al.; Balliol Collaboration. No surgical innovation without evaluation: the IDEAL recommendations. Lancet 2009; 374: 1105–1112. 6 Beggs AD, Dilworth MP. Surgery in the era of the ’omics revolution. Br J Surg 2015: 102: e29–e40. 7 Harrison G, Gannon WL. Victor Frankenstein’s Institutional Review Board proposal, 1790. Sci Eng Ethics 2014; [Epub ahead of print]. 8 Teoh GZ, Crowley C, Birchall MA, Seifalian AM. Development of resorbable nanocomposite tracheal and bronchial scaffolds for paediatric applications. Br J Surg 2015: 102: e140–e150. 9 Riskin DJ, Longaker MT, Gertner M, Krummel TM. Innovation in surgery: a historical perspective. Ann Surg 2006; 244: 686–693. 10 de Boer E, Harlaar NJ, Taruttis A, Nagengast WB, Rosenthal EL, Ntziachristos V et al. Optical innovations in surgery. Br J Surg 2015: 102: e56–e72. 11 Diana M, Marescaux J. Robotic surgery. Br J Surg 2015: 102: e15–e28. 12 Cook JA, Collins GS. The rise of big clinical databases. Br J Surg 2015: 102: e93–e101. 13 Oppong FC. Innovation in income-poor environments. Br J Surg 2015: 102: e102–e107.
BJS 2015; 102: e8–e9
Copyright of British Journal of Surgery is the property of John Wiley & Sons, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
