Removing a suture: What the future may bring

The future of robotic surgery can be determined only by probing the possibilities. To ignore the potential for extending the boundaries and safety of surgical care with robotic technology seems unwise.
-“The Future of Robotics,” Bulletin of the American College of Surgeons (July) 2013; 98:9-15.

It is a spring morning in July 2047. Jenny, a nursing assistant, emerges from an exam room and gently closes the door. She is wearing scrubs tastefully covered with advertisements for a national chain of for-profit gastro-esophageal reflux treatment centers. Aiden Smith, MD strides down the corridor and greets her. Dr. Smith wears scrubs and a lab coat tastefully covered with advertisements for several medical devices and for the hospital by which he is employed.

“Everything is ready for you in room 2, Dr. Smith. You performed a thyroidectomy on the patient last week.”

“Thank you, Jenny. Ah! Is that Mrs. Morgan?”

Red lights flash on-and-off for several seconds.  Jenny looks around, alarmed. “Dr. Smith! You know it is a violation to mention a patient’s name out loud!”

“Sorry. I keep forgetting.” The lights stop flashing. “Remind me again which room is Mrs. — oops — umm — in?”

“She — I mean the patient — is in room 2. All of your equipment is set. Nurse Rebekah is already in there.”

Dr. Smith knocks on the door, pushes it open and enters. The walls, floor, and ceilings of the room are constructed entirely of electronic panels displaying a rotating array of anatomic charts, generic artwork, and tastefully created hospital marketing messages. The hospital system’s theme song plays quietly. Mrs. Morgan is sitting on the edge of the examination table in a disposable designer-label patient gown tastefully covered with advertisements for the hospital’s line of cosmetics and weight loss products.

Rebekah, the clinic’s nurse practitioner, is sitting at the room’s control panel wearing a uniform tastefully covered with certifications from the Joint Commission on Accreditation of Jointly Accrediting Commissions (JCAJAC). Dr. Smith greets her. “Good morning! Looks like our patient tolerated the surgery just fine. How has she been doing?”

Rebekah passes her palm over the control panel screen and the electronic walls now display Mrs. Morgan’s Electronic Medical Repository, Document Depot, and Revenue Optimizer (EMRDDRO) with graphic displays of her vital signs, everything she has eaten, her sleep patterns, the contents of her medication bottles, maps of her recent travels, insurance updates, and photos of the inside of her colon. Dr. Smith looks at the display thoughtfully for a few seconds.

“Well, let’s take a look at the thyroidectomy incision.” He turns to Rebekah and speaks under his breath. “We performed this robotic surgery through her belly button.”

Rebekah helps Mrs. Morgan lie back and exposes the incision. Dr. Smith dons a headset with the words “Clinic Room Operational Computerized Upload Synthesizer” emblazoned on the side. He speaks into the headset. “CROCUS, create a microscope.”

A wall panel opens and a 3-d printer appears. Within seconds, a fully-functional operating microscope custom fitted to Dr. Smith’s inter-pupillary distance and left-handedness emerges from the printer. A robotic arm grasps the microscope and brings it to eye level. Dr. Smith examines the umbilical wound carefully.

Still speaking clearly, Dr. Smith says, “Everything is healing well. The incision is clean and dry. Both stitches are intact. No evidence of any postoperative complications.”  As Dr. Smith speaks, his words appear on the screen and are transferred into Mrs. Morgan’s EMRDDRO. A running total of her bill updates on the screen.

Dr. Smith speaks again. “CROCUS, deploy the laryngoscope.” An endoscope emerges from the microscope and inserts itself into Mrs. Morgan’s right nostril and advances quickly into her throat. The examination table creates a vacuum between itself and Mrs. Morgan that prevents her from moving.  “Both vocal cords are mobile. There is a brisk gag reflex.”

“CROCUS, remove the microscope.” The endoscope retracts and the robotic arm drops the microscope down a chute in the wall. A whooshing sound is heard. The billing total updates.

Rebekah taps Dr. Smith on the shoulder. “Why did you close her incision with stitches? I haven’t seen you use suture since I started working with you! You use only bioengineered adhesives and genetically-compatible electronic closure devices.”

“Nice observation, Rebekah! I read about an improved suture removal technique in an advertisement and wanted to try it out. Her — I mean — this patient’s surgery offered the perfect opportunity. Watch this!” He speaks into the headset. “CROCUS, create a robotic suture removal device.”

The 3-d printer re-appears and begins working furiously. First, a standard robotic console emerges. Dr. Smith sits down at the console and looks through the eyepieces, his back to Mrs. Morgan. Next, a full-size surgical robot emerges. The arm yanks it over the exam table. As it does so, a puff of smoke emerges from the side of the robot. Mrs. Morgan frowns as she watches wisps of smoke continuing to appear.

Dr. Smith adjusts the controls. “See, Rebekah? In the past, I sometimes nicked the skin or pulled too hard when I removed sutures by hand. The company claims that this approach is more precise, causes less pain, and might possibly improve patient outcomes. Connect the attachments and we will get started.”

Rebekah loads the robot with two disposable arms, one with a diamond-tipped micro-dissecting scissor and the other with a laser-cut precision-matched jeweler’s forceps. The billing total updates. The articulated forceps grasp the first stitch and the scissors cut the suture just below the knot. The suture is removed. The billing total updates again.

Mrs. Morgan, who has been watching smoke pour steadily from the robot, now notices sparks. She passes out. Her EMRDDRO flashes warning messages as the robot is quickly engulfed in flames. The sprinkler system activates. Everyone is drenched.

“Dr. Smith!” Rebekah shouts over the deluge, “Mrs. Morgan has fainted! Move the robot so I can get to her!”

Dr. Smith turns and looks with surprise. “CROCUS, extinguish and discard the robot.”

Alarms sound and strobes flash. The flaming robot, now steaming from the sprinklers, is dumped down the chute. A whooshing sound is heard. The billing total updates.

“Wow, Dr. Smith, that was close! But, she still has one stitch left.”

“Well, let’s move her to another examination room and print another robot. I don’t think it would be safe in here with three inches of standing water.”

“Good thinking, Dr. Smith. Safety first! By the way, my control panel indicates that you failed to initiate the time out checklist before the suture removal.”

Dr. Smith looks at her in horror. “Oh, no! I forgot to initiate a time out? Not again! That’s the third time this year!”

The 3-d printer springs to life and the robotic arm grabs Dr. Smith, holding him in place as a jail cell emerges and encases him. He sits helplessly on the hard bench, pulls the rough wool blanket around his shoulders, and drops his head into his hands. “Now I’ll never get my charts finished!”

The power supply for the examination table shorts out, which releases Mrs. Morgan. As Rebekah contemplates Dr. Smith’s fate, Mrs. Morgan carefully steps down from the table and quietly sloshes her way out the door.

Bruce Campbell is an otolaryngologist who blogs at Reflections in a Head Mirror.

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