“Innovation is the ability to see change as an opportunity – not a threat.”
– Steve Jobs
Imagine having a hole drilled into your skull without adequate analgesia and anesthesia. The stakes intraoperatively are high, with the risk of dying from postoperative complications possibly even higher. This sounds horrifying, but this was the reality for patients during the infancy stages of surgery. Patients would often choose surgery as a last option, while others resorted to suicide rather than undergo a traumatizing procedure. On October 16, 1846, Dr. William T.G. Morton and Dr. John C. Warren forever changed the surgical landscape when they worked together to perform the first surgical procedure under anesthesia (J Invest Surg 2012;25:141-9). This moment showed the world that surgery could be performed under anesthesia safely and essentially free of pain. This historical event exemplifies the importance of the relationship and communication between the surgeon and anesthesiologist as leaders of the perioperative team.
Surgery has advanced significantly since its inception from archaic trepanation procedures to the current state-of-the-art technologies that utilize robotic systems for more refined movements of the previously handheld scalpel. The first documented robotic surgery occurred in the 1980s but didn't gain momentum until years later. Additional technological developments are under way that include digitally enhanced analysis of tissues with integrated immunofluorescence. This innovation seeks to improve outcomes in patients with benign and malignant disease by contributing to “reduced wound access trauma, shorter hospital stay, improved visualization, less postoperative wound complications and less disfigurement” (Br J Anaesth 2017;119(suppl_1):i72-i84). This – combined with the ability to use the robotic system across a wide variety of surgical subspecialties and the advantages of a robotic-assisted system compared to laparoscopic or open technique – has led to a dramatic increase in its use. An example is evidenced by the national robot-assisted radical prostatectomy (RARP) adoption rate in the U.S., increasing from 0.7% to 42% from 2003 to 2010 (Br J Anaesth 2017;119(suppl_1):i72-i84). At Duke, Drs. Muhammad Abd-El-Barr and Jeff Gadsden are great examples of the importance of evolving together to provide optimal patient care. With their collaboration, they were able to perform robotic-assisted spinal surgeries under sedation and advanced regional anesthesia techniques, thus avoiding the complications associated with a general anesthetic and opioids (asamonitor.pub/3dPfKlt).
As the complexity of surgeries increase, surgeons are faced with many potential problems, including the possibility of higher infection rates, inadequate pain control, and the potential for significant blood loss. Patient expectations for surgery have also shifted from the early-day mentality of caring mostly about mortality to thoughts of enhanced recovery. The Enhanced Recovery After Surgery (ERAS) movement was first introduced by a group of surgeons in the late 1990s with the focus on improving patient outcomes related to “hospital stay, complication rates, and reduction of economic burdens” (J Vis Surg 2018;4:40). As it continued to evolve, ERAS wasn't necessarily a set of protocols to follow but more “a new way of multidisciplinary teamwork with readiness to make changes as knowledge evolves” (J Vis Surg 2018;4:40). The goals are now to deliver excellence throughout the whole perioperative experience while minimizing repercussions of undergoing surgery.
Anesthesiologists play a pivotal role to help ensure this expectation to the patient. As perioperative specialists, anesthesiologists are tasked with ensuring adequate pain control during surgery and in the period immediately after. The shift to the Perioperative Surgical Home model has put a spotlight on the role we have in the postoperative outcomes of our patients. Although highly effective in treating severe surgical pain, high-dose opioids have long been associated with a number of adverse complications, including “respiratory depression, impaired gastrointestinal function, post-operative nausea and vomiting (PONV), pruritus, urinary retention, delirium and the potential for developing opioid addiction” (Transl Perioper Pain Med 2020;7:152-7). An aim with ERAS includes minimizing the adverse effects of opioids and focusing on the benefits of a multimodal approach to perioperative pain management. Although there are many highly effective non-opioid agents available to treat perioperative pain, many are still not widely used. These include agents such as dexmedetomidine, I.V. acetaminophen, I.V. NSAIDs, ketamine, I.V. lidocaine, magnesium, and neuraxial and peripheral nerve blocks (Transl Perioper Pain Med 2020;7:152-7). Obstacles may include lack of support with stocking medications in the operative theater, the additional work with setting up infusion pumps as compared to injecting an opioid, or confidence with the familiarity that opioids provide. But we must be willing to recognize the growing evidence highlighting the benefits of change and the value it brings to improved outcomes. Patient outcomes have improved dramatically when ERAS protocols are combined with minimally invasive surgical techniques. One study comparing intracorporeal robot-assisted radical cystectomy (iRARC) to open radical cystectomy (ORC) found that the marginal gains from robotic surgery combined with ERAS implementation significantly decreased hospital length of stay (7 days in the iRARC with ERAS compared to the iRARC without ERAS group at 11 days, and the ORC group 17 days). The study also demonstrated a reduction in 90-day all (P<0.001) and GI-related complications (P=0.001) (BJU Int 2018;121:632-9). Therefore, despite new innovations with surgery, the anesthesiologist needs to remain engaged in modifying their techniques to improving surgical outcomes and take more ownership of the entire journey for our patients (Anesthesiology 2018;129:1063-9).
Advances in surgery and anesthesia continue to occur but should not be done in parallel with each other. A continued shift toward more collaboration between both teams are needed in order to enhance the overall patient surgical experience and improve postoperative outcomes. Because patient expectations have changed, our quality outcomes measures must evolve as well. We must recognize the need to move forward as a team with our surgical colleagues to ensure better results for our patients. Finding more innovative ways to provide high-quality care to our patients should be the goal for everyone involved in the perioperative process. This process starts with the patient. Therefore, we – as the perioperative team – must align with our patients' goals to achieve better patient-centered outcomes.