Following a pandemic-related hiatus, the workshop on “endoscopy and robotics in diagnostics and surgery” was finally able to return to the operating theatre of the Institute of Clinical Anatomy, where it provided exciting new insights and a glimpse into the future of surgery. The medtech engineers from numerous small and medium-sized medtech companies in the region watched live operations and practical exercises on the operating table. They also got a chance to discuss challenges – and solutions – with the medical directors and senior consultants directly. This time, the experts leading the workshop included Prof. Bernhard Krämer, Deputy Medical Director of Gynaecology, Prof. Hubert Löwenheim, Medical Director of the University Hospital Department of Otolaryngology, Prof. Arnulf Stenzl, Medical Director of the University Hospital Department of Urology and Director of the Stuttgart and Tübingen Inter-University Centre for Medical Technology (IZST), and Prof. Jürgen Honegger, Deputy Medical Director of the University Hospital Department of Neurosurgery. Prof. Tina Histing, Medical Director of the Clinic for Trauma and Reconstructive Surgery at BG Hospital in Tübingen, and Prof. Katja Schenke-Layland, Director of the NMI Natural and Medical Sciences Institute in Reutlingen, were also in attendance.

Cholangioscopy – single-use equipment versus cleaning

The first operation went deep into the abdominal cavity. It was a laparoscopy combined with a cholangioscopy, which makes it possible to perform endoscopic examination on the smallest passages in the gastrointestinal tract, such as the bile duct. This procedure sparked an initial discussion about the advantages and disadvantages of single-use endoscopes. In urology, where very long channels are required, cleaning endoscopes is often a difficult task. “Cleaning is no trivial matter,” says Prof. Stenzl. Roughly one in every eight devices is rendered defective after cleaning. This is a common problem with the fibre optics, for example. That is why the clinic is currently investigating the true environmental impact of opting for single-use devices, compared to cleaning reusable devices. The imaging provided by single-use endoscopes is considered to be inferior, and their size makes them more awkward to handle. That said, some argue that endoscopes should not be expected to do everything, for instance take care of diagnostics and treatment at the same time. Often, the doctor wants to “just take a look at things first”. To the astonishment of the medtech engineers, some users do not want one device with numerous functions, but rather highly specialised devices tailored to specific applications. It is believed that, if they were equipped with appropriate single-use elements, these devices would not be as expensive either. The doctors explained that performing an endoscopy with high-end equipment in tandem with a biopsy, for example, can be just as complex as open surgery. During the live operation, it became clear just how sensitive these devices are. The surgeons discovered a hole in the flexible part of the wafer-thin cholangioscopic endoscope and had to replace the wire. “It is precisely this level of authenticity that makes Incisions and Insights so extraordinary,” explains Prof. Hirt. “We don’t show perfection – we show what actually happens and what could be done better.”

Routine procedure with complications

The surgeons described the second procedure as “routine with complications”. This is because, during a nasal endoscopy, it is possible to access the base of the skull, even right through to the spinal column. During these procedures, it is very important to collaborate with neurosurgeons, because the base of the skull is so thin at the dome of the nasal cavity that there is a risk of causing damage. The surgeons demonstrated this on the anatomical specimen, while also illustrating why there is a desire for endoscopes to be even smaller for this application. In the discussion that followed, the participating medtech engineers noted that doctors’ wishes are not always easy to put into practice: “The devices should be small and long enough to go anywhere, but easy to use – ideally by just one person. They should be rigid enough to pass through narrow spaces more easily, but at the same time flexible enough to cope with bends. On top of that, these should be high-end devices that are only used once.” Another discussion arose on the subject of the material required to close lesions in the base of the skull, for example. This poses a particular challenge, as the lesion has to be sealed transnasally, which means dealing with secreted fluids. Identified as a medical need, a substance is required here that can be poured into the appropriate area and will bond to the edges. This was one of several discussions that left the doctors feeling hopeful, as Prof. Schenke-Layland was able report that research in this field was making great strides.

A nod to the future

Finally, the demonstration by Prof. Löwenheim attracted a great deal of attention. He used a head-mounted display (HDM), a type of video headset, to operate a robot arm with a camera head. This enabled him to control the 3D microscope just by moving his head, leaving his hands free to perform surgical procedures, such as placing fine electrodes for a cochlear implant. This glimpse into the future of surgery prompted further hopeful speculation. Some surgeons expressed a desire for the microscope display to also provide them with data on the nature of cells or to alert them to the presence of nerve pathways. As one participant explained, this field is ultimately undergoing a development similar to that of the automobile, but it is still a long way from fully autonomous driving or, rather, surgery.