key: cord-0688773-4ydvjmr3 authors: Sekhar, Laligam N.; Juric-Sekhar, Gordana; Qazi, Zeeshan; Patel, Anoop; McGrath, Lynn B.; Pridgeon, James; Kalavakonda, Niveditha; Hannaford, Blake title: The Future of Skull Base Surgery: A View Through Tinted Glasses date: 2020-06-27 journal: World Neurosurg DOI: 10.1016/j.wneu.2020.06.172 sha: 5a0b72743c3bee0c9b81101d6d5aa5c8ab5bbf37 doc_id: 688773 cord_uid: 4ydvjmr3 ABSTRACT This article broadly outlines the potential advances in the field of skull base surgery, which may occur in the next 20 years based on many areas of current research in biology and technology. Many of these advances are also broadly applicable to other areas of neurosurgery. We ground our predictions for future developments in an exploration of what patients and surgeons most desire as outcomes for care. This leads to an examination of recent developments in the field and outlines several promising areas of future improvement in skull base surgery, per se, as well as identifying new hospital support systems needed to accommodate these changes. These include, but are not limited to advances in imaging, Raman Spectroscopy and Microscopy, 3-dimensional printing and rapid prototyping, master-slave and semi-autonomous robots, artificial intelligence applications in all areas of medicine, tele-medicine, and green technologies in hospitals. In addition, we review therapeutic approaches employing nanotechnology, genetic engineering and anti-tumoral antibodies, as well as stem cell technologies to repair damage caused by traumatic injuries, tumors, and iatrogenic injuries to the brain and cranial nerves. Additionally, we discuss the training requirements for future skull- base surgeons and stress the need for adaptability and change. However, the essential requirements for skull base surgeons remain unchanged, namely: knowledge, attention to details, technical skill, innovation, judgement, and compassion. Our conclusion is that active involvement in these rapidly evolving technologies will enable us to shape some of the future of our discipline to address the needs of both patients and our profession. and anti-tumoral antibodies, as well as stem cell technologies to repair damage 23 caused by traumatic injuries, tumors, and iatrogenic injuries to the brain and 24 cranial nerves. 25 26 Additionally, we discuss the training requirements for future skull-base 27 surgeons and stress the need for adaptability and change. However, the essential 28 requirements for skull base surgeons remain unchanged, namely: knowledge, 29 attention to details, technical skill, innovation, judgement, and compassion. Our 30 conclusion is that active involvement in these rapidly evolving technologies will 31 enable us to shape some of the future of our discipline to address the needs of 32 both patients and our profession. complex aneurysms and vascular lesions, and safely reconstruct the skull base 43 to promote healing and prevent cerebrospinal fluid leakage and infections. 44 45 More recent technological introductions have proceeded to revolutionize the 46 treatment of challenging skull base pathology including the introduction of 47 endoscopic surgery, advances in neuroimaging, radiosurgery and high energy 48 focused radiotherapy, the perfection of vascular bypasses for replacement of 49 major arteries and venous sinuses involved by tumors 1,2,3 , and the use of skull 50 base approaches to treat complex vascular lesions. 51 52 Through the establishment of organizations such as the North American Skull 53 Base Society, the World Federation of Skull Base Society, as well as clinical 54 institutions focused on the refinement and teaching of skull base surgery, the 55 knowledge and skillset necessary to properly practice this challenging 56 subspecialty have been effectively disseminated. 57 58 This long history of innovation has presently resulted in the safe and effective 59 practice of Skull Base surgery. However, the discipline remains on the cutting 60 edge of neurosurgery and many challenges have yet to be addressed. In this 61 paper, the authors survey the many emerging technologies that appear poised to 62 bring about the next revolution in the Skull Base surgery. Many of the advances 63 described in this article are generally applicable to many areas of Neurosurgery. Although the future is always difficult to predict, a specialist discussion of the 66 most promising advances may help young surgeons entering the field and in 67 turn help to shape the future. A number of techniques that may have an impact 68 on skull base surgery are shown in Table 1 . We will focus on some but not all of 69 these areas. Patients ultimately want their surgical team to cure, control, or ideally facilitate 78 the prevention of disease. They favor minimally invasive approaches. When 79 possible, they want illnesses to be treated by medicines only; if further 80 intervention is necessary, they prefer minimal surgery or radiosurgery without 81 any tissue damage; and when it cannot be avoided, more extensive surgery 82 without undue risk. Patients rightly put a premium on minimizing morbidity, 83 which means no damage to surrounding brain, cranial nerves or blood vessels and no cosmetic deformity. Regardless of the approach, they want to minimize 85 time away from work and family and to be treated for a reasonable cost. 86 87 Surgeons chose their profession to heal patients and to cure or control diseases 88 by performing elegant operations within their limits without major 89 complications. They want to balance this pursuit with their desire to live well 90 and to be healthy and happy with their families. Finally, they want the freedom 91 to operate with the professional autonomy they have earned through their 92 pursuit of highly specialized training without undue interference from the 93 hospital administration or the Government in their daily practice of medicine. The best way for surgeons to ensure that the needs of their future patients are 96 being met is to continue to drive the innovation necessary to deliver 97 transformative treatment options that are effective, economical and minimally 98 disruptive. for tissue preservation and augmented diagnostic utility 6, 8 . Examples are 152 shown in Figure 1 , wherein an ex-vivo skull base neoplasm has been examined 153 by a Raman fiber-optic touch probe device to determine a biochemical 154 "fingerprint" of the specimen ( Figure 1A and B), and by the stimulated Raman 155 scattering microscopy, in comparison with subsequent conventional tissue 156 section stained with H&E ( Figure 1C and D). In addition, such imaging modalities can be combined with immediate 159 treatment. For example, laser thermal ablation is already being used in the MRI 160 suite for epileptic lesions and some brain tumors with variable results 9,10 . Lasers 161 or ultrasonic removal may also be combined with rapid intraoperative pathology 162 for precise intraoperative tissue removal. Sporadic diseases exhibit multiple mutations, unlike syndromic diseases. They 206 require broader approaches than the treatment of syndromic diseases. 207 Immunotherapy is an approach that is being commonly used in other 208 malignancies 19 , using antibody-based drugs that target tumor-specific surface 209 antigens. An example is the use of bevacizumab, an antibody that targets the The most important step in bringing novel therapeutic approaches to skull base 237 pathology is the detailed molecular characterization of each of the pathologic 238 entities that collectively make up "skull base tumors". Such efforts are 239 underway and will to expand as investigational techniques become more widely 240 available and cost effective. For skull base tumors, we will need to tailor our 241 therapeutic interventions based on disease-specific, and even patient-specific, 242 mutational, transcriptional, or epigenetic profiles. This type of "precision 243 medicine" will offer hope to patients for which our current treatment paradigms 244 are inadequate. In the hospital, AI will become increasingly essential. Robotics and AI will 386 combine to influence every aspect of healthcare (see below). AI may be 387 employed in the ICU and general ward to monitor patient care in addition to 388 providing clinical decision-making support to doctors and nurses. For instance, Robotics will find increasing applications in all areas of surgery, including skull 457 base and neurosurgery. In order to be adopted widely, a medical robot should be 458 able to perform a task as well or better than a human, not cause any harm to the 459 patient or the human workers, be able to adjust to the human environment, and 460 able to be rapidly cleaned and sterilized. Tasks requiring great accuracy, It is widely expected that there will be increased use of AI combined with 542 robotics in the OR in the next 20 years. The great benefits will be for procedures 543 which will require great precision, procedures performed through a small space, In Japan, humanoid robots, specifically nurse robots and robotic assistants, are 551 being developed due to a lack of medical personnel and caregiver resources. In 552 the USA and other countries, such humanoid robots have also been developed 553 for other uses. Hansen Robotics (Hansen Robotics Co., Hong Kong, China) has created human looking and speaking humanoid robots, endowed with AI, 555 notably those named Jules and Sophia. These robots have been given speech 556 recognition skills, responses, and some other skills, but not all the elements of 557 intelligence that are displayed by humans. Humanoid robotic nursing assistants 558 will be developed and widely used in future due to health care worker shortages, 559 patients' desire to have 24x7 nursing assistance, and the needs created by 560 infectious diseases wherein human-human contact must be minimized. We expect that hospitals will also use robots to replace or supplement 580 employees such as internal delivery workers, cleaners, and other jobs inside the 581 hospital, which require regular or rapid maintenance such as with the hospital's 582 sewage, water, or electrical supply. Cleaning of operating rooms, or other 583 hospital rooms, which do not have patients, can be done efficiently and rapidly 584 with ultraviolet light or other techniques, using robots 63, 64 . Such robots will 585 need to be supervised by their human counterparts. But they will learn steadily 586 with use and such knowledge can be transmitted readily to other robots like 587 them. It is to be expected that, initially, there will be resistance to deployment of 588 these robots, but over time, people will gradually accept them, primarily 589 because of increased safety and lowered cost of health care. However, both of 590 these putative benefits will need to be demonstrated scientifically. Technology will transform the education of students, residents, and surgeons in 610 the future. Students will be able to study anatomy and physiology in 3-D, 4-D, 611 and 5-D. The fourth dimension reflects the time-related changes in 3-D images 612 (for example, carotid artery anatomy as the heart beats) along with physiology. 613 The fifth dimension indicates three dimensional images changing in time with 614 simulated pathology. Advanced virtual reality and surgical simulations and one 615 on one coaching by AI enabled robots will supplement traditional teacher-616 student learning. Flexibility in adapting to quickly evolving and increasingly 617 sophisticated systems of cognitive offloading will be critical to student success. 618 In the future, imagination, problem solving, and the ability to work in teams 619 with diverse members (including AI-enabled robots) will be more important 620 than accumulation of knowledge. This is because massive knowledge storage 621 will be available for quick recall. Master AI brains will assist all of our medical 622 work to varying degrees. This will reduce medical errors, increase work 623 efficiency, and improve on the job learning. The Educational Qualifications and training for trainee neurosurgeons will be 626 different in the next decade. Mathematics, biology, physics, chemistry, and 627 logical thinking will still form the building blocks of education in science. 628 However, residents will also need to learn computer science, software Hospitals of the next 20 years will be very different from the hospitals today. 646 We envision they will be smaller and closer to patients with only the most 647 difficult cases transferred to central hospitals. All hospitals will be 648 environmentally friendly and carbon neutral, deriving their entire energy 649 requirements from renewable energy. This will also apply to products used in 650 hospitals. They will be providing an enhanced and optimal healing environment 651 for patients. For example, the patient rooms may be optimized to each patient 652 with use of colors, plants, music, sunlight, etc. Better methods of medical waste 653 disposal will need to be developed, to avoid environmental contamination and 654 spread of infection into communities. The future of health care workers in the age of robotics and AI 657 658 In parallel with many other industries, fewer health care workers will perform 659 manual and highly repetitive jobs and AI-enabled robots will replace some such 660 workers. Health care workers in hospitals will require greater skills and 661 education. Hospital employees will be happier, work less, and supervise robotic 662 workers. There will be fewer Radiologists, Pathologists, Family Doctors, etc., 663 due to robotic assistants. Home visits may be made by Humanoid robot (AI 664 enhanced) exhibiting great knowledge, empathy, and no prejudice. Surgeons, 665 trainees, and other health care workers will also work collaboratively with such 666 robots and AI since they will become commonplace. Surgeons will be performing less invasive but more technically complex 669 procedures. There will be great emphasis on master-slave robots and 670 supervision of autonomous robots performing procedures. There will be a great 671 role for innovators and a constant retraining for the newer procedures. With increasing use of AI and robotics, will human beings still be involved in 674 patient care? Since the patients are humans, there will always a need for human 675 beings to care for them. However, we will see an evolutionary change in health 676 care professionals in the next 20 years. Adaptability, cooperation in the work 677 environment, compassion, and a special set of skills will be required of 678 surgeons. Some of these will not be obvious until the new reality emerges. The current Covid-19 epidemic has suddenly enhanced the use of many 681 technologies which had been developed, but not deployed on a large scale. 682 These include tele-consultations, tele-working, different requirements for sterilization of hospitals, and home based learning. The lead author's team has 684 also developed a low cost "home microsurgery lab" for resident trainees, and 685 proposed this as the seventh competency in resident training in the USA 65 . 686 Many of these changes will influence patient comfort, safety, costs of medical 687 care, and the need for particular types of health workers. Skull base surgeons and neurosurgeons of the future need to be nimble, 702 adopting newer technologies as they become available. However, essential 703 characteristics remain unchanged. These are knowledge, innovation, technical 704 skill, judgement, and compassion. Our active involvement in these technologies 705 will enable us to shape some of the future. 706 Innovation will be an important requirement of future and current doctors. 707 Innovations may not be major but may be found instead in the small things 708 impacting our day-to-day work. Or they may relate to clinical surgery, basic 709 neurosciences, workflow and efficiency, outpatient and hospital infrastructure, 710 patient satisfaction and quality improvements. Young surgeons must constantly 711 strive to leave things better than they find them. Surgeons need to be actively 712 involved in hospital, and health care administration to guide the changes. Tissue engineering to fabricate blood vessels, bone, facial tissues, etc. in conjunction with 3-D printing f) Nanotechnology to engineer diagnostic and therapeutic particles g) Rapid Molecular and Genetic Diagnosis of Tumours h) Anti-Tumoral antibodies, CAR-T cells, and Checkpoint inhibitors to treat malignant tumours i) CRISPR CAS-9 based genetic engineering techniques to eliminate inherited syndromes such as Neurofibromatosis, Von-Hippel Lindau's disease j) Stem Cell Technologies to Repair damage caused by traumatic injuries, tumours, and iatrogenic injuries to the brain, and cranial nerves k) Master-slave, and Semi-autonomous Robots for use in the operating room l) Humanoid Robots as helpers in the operating rooms, cleaning services, food services, and nursing services in hospitals m) Artificial Intelligence applications for diagnosis of disease, in the hospital, and outpatient care n) Re-engineered Hospitals which are Green, Energy self-sufficient, use proper waste disposal, and adapted to the patient's needs o) New Training methods for residents, and surgeons Saphenous vein graft bypass of the sigmoid sinus and 742 the jugular bulb during the removal of glomus jugulare 743 tumors Results of attempted radical Cerebral revascularization for difficult skull base 750 tumors. 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Application of Service Robots for Disinfection 971 in Medical Institutions Developing microsurgical milestones for psychomotor 977 skills in neurological surgery residents as an adjunct to 978 operative training: the home microsurgery lab LabelMe: a database and web-based tool for image 982 annotation The Roboscope™ is shown with the actuator mechanism The bendable sheath presently has 6 channels, the top two (SFE 1018 1.4mm)are for the two laser endoscopes, the middle two (2.0 mm) are 1019 for the instruments, and the bottom two (1.1 mm) are for suction 1020 devices. The channels can be modified to suit the surgical needs 1021 The Roboscope™ with two different dimensions (14mm and 8 mm The Roboscope™ is now bent, with the tow tools in close up 1023 The Karns Introducer device™ for the Roboscope™ is shown with a) the 1024 tulip closed, and b) the tulip open 1025 Cadaveric Use of Roboscope™. A) shows the introduction of the 1026 Roboscope™ through an opening in the skull base of a cadaver B)The remote manipulation of the controls c) The view of the structures 1028 through the laser fiber-optic endoscope (courtesy of Eric Seibel Concept of the Artificially Intelligent Robotic Assistant, showing a) the 1030 surgeon and robotic assistant , and b) the surgeon, a human, and a 1031 robotic assistant Ground Truth (GT) annotation for identifying instruments in a surgical 1033 field through the NeuroID 47 dataset generated by the UW team (a) Input 1034 frame (b) Annotations were created using the LabelMe annotation tool 1035 (c) GT for distinguishing Tool vs Background (Tissue, gauze, etc) (d) 1036 GT for locating each class of Conceptualization of the Android Robotic Nurse Helper (ARNH) for a 1038 patient in isolation due to an infection. The Physician and the Nurse are 1039 able to remotely view the patient, and all of his vitals, even sense 1040 palpation using haptic sensors, and instruct the Robotic Nurse Helper The ANRH is present with the patient continuously round the clock, and 1042 is able to sterilize itself using ultraviolet light or other methods Acknowledgements: 1048 We wish to thank Raja Sekhar, for his review of the manuscript and The authors report no conflict of interest in this paper.