Digital technology is being rapidly adopted in surgery. A variety of technologies ranging from robotics¹, advanced imaging systems², and artificial intelligence³ offer surgeons and their teams the promise of increased efficiency, improved performance and ultimately better patient outcomes^4,5. A significant driver behind this uptake in digital technology within the operating room has been the commercial opportunity it offers. Surgical robotics makes up only a proportion of these technologies yet is valued at $5 billion and estimated to continue growing⁶.  

The use of digital technology within surgery, however, is not unique to surgery; digital technology has been widely implemented across healthcare. However, we argue that this specific focus on digital surgery is necessary for a number of reasons. Firstly, digital surgery is a term that has been widely used within the specialty, despite the meaning of the term being unclear. Standardisation of this terminology is required for safe and effective translation of this technology into clinical practice; it is impossible to quality assure clinical interventions or trials without this. It is also essential that digital surgery can be explained to patients clearly and consistently especially in the context of data collection and processing. Secondly, this lack of clarity surrounding digital surgery impedes process. In rapidly emerging fields, such as digital surgery, there is a need for research priorities and areas for collaboration to be clearly identified. Finally, surgery is a high-risk clinical intervention when compared to other medical use cases with the potential to cause serious patient harm. 

Digital surgery may also pose unique challenges not found across wider digital health. For example, privacy concerns extend beyond the patient, normally the sole concern within digital health applications, to the surgeon and their team who may be scrutinised for their potential actions within the operating room. Furthermore, this concern may not only hinder deployment of digital surgery but also its development as surgical teams worry how donated data may potentially be used for other purposes such as litigation. The potential benefits of digital surgery may cause such challenges to be easily overlooked. We therefore aimed to define the term digital surgery, identify these key challenges and propose future research goals within this field. 

Given the limited evidence within this field and the need for knowledge to be drawn from multiple areas of expertise, we chose to implement Delphi methodology⁷. It has previously been successfully used to determine consensus in varying areas across healthcare^8,9. It consists of multiple iterative voting rounds where panelists are able to review the group’s votes, propose new items and ultimately converge towards consensus. In our Delphi, 38 international experts across the fields of surgery, technology, industry, law, ethics, and health policy undertook a 4 round Delphi (Figure 1). An initial scoping round, which was conducted in conjunction with a public panel, allowed issues to be generated which were subsequently voted upon in two subsequent voting rounds before all items were discussed in a final online consensus meeting. 

Consensus was obtained across 114 issues which were divided into 7 key areas: definition of digital surgery; data; privacy, confidentiality and public trust; consent; law; litigation and liability; and commercial partnerships. 38 barriers associated with the development, deployment and monitoring of digital surgery and 22 future research goals were identified and ranked with respect to their importance.  

Digital surgery was defined as the use of technology for the enhancement of preoperative planning, surgical performance, therapeutic support, or training, to improve outcomes and reduce harm.

Three main themes can be drawn upon from the issues highlighted. Firstly, the current lack of infrastructure within hospitals to support digital surgery. The majority of operating rooms lack the technical infrastructure to routinely record data hindering the development and adoption of digital surgery. Secondly, there is a need for patient and public engagement to ensure ethical and trustworthy digital surgery. Patients and the public must be aware of what they are consenting to when donating their data. Finally, appropriate education should be provided for all stakeholders within digital surgery. We argue that the future digital surgeon must not be a surgeon in isolation; they must understand the technical basis of the technology they are using and be aware of the legal, ethical and data governance issues concerning its use. 

Overall, this study achieves consensus definition of the term digital surgery. We highlight key issues concerning digital surgery and identify barriers and future research goals within the field which will act as a platform for future research. 

References

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