Dra. Isabel Vilaseca: “Surgery must be based on improvements in technology in order to enhance patients’ quality of life”

Many people think that the Surgical Area of a hospital like this is limited to a surgical block—where the operating theatres are—but it is in fact a crosscutting area that serves the different Institutes and Services.  We work to organize and plan the surgical process, which includes the patient’s preoperative and prehabilitation stages, the surgery and the postoperative period. At the Anaesthesiology Service, we also manage the surgical ICU, an Intermediate Care Unit and the Pain Unit.

There are around 120 of us in the medical field, we have a very large pool of nurses and technical healthcare assistants; we’re talking about 400 people, and about 50 in the administrative part.  Being a hospital with 3 centres means that there are Surgical Area professionals at the Villarroel Centre, the Plató Centre, and the Maternitat Centre.

We perform more than 28,000 operations every year. However the professionals in the Surgical Area, most of the anaesthetists and some nursing professionals, also serve many interventional areas of the hospital. Outside of the operating theatres, over 30,000 procedures with anaesthesia are performed in the hospital every year.  Between the 3 centres, we now have 41 working operating theatres, and different sterilization areas in each centre.

We have a chart listing the availability of all the operating theatres throughout the year, and a distribution of areas is assigned to each institute, so that they can programme their operations.  Then, a few days in advance, each institute sends us its surgery schedule, their duration and a list of the material that will be needed. If it is feasible, we include it in the definitive Surgical Programme. That way we know every day which surgeries will be performed and what the technical requirements will be.

There is fixed equipment in each operating theatre and other equipment that has to be shared, such as robots, scopes, exoscopes, neuromonitors, etc. So, we have to plan, in order to ensure maximum efficiency.

Some of the surgeries have to be performed within a certain timeframe, so as not to lengthen the time the patient is on the waiting list. Cancer surgery and serious cardiac surgery, as well as knee and hip replacements, for example, are guaranteed by the Catalan Health Service, and we have to perform them within an established maximum timeframe.  For example, the patient cannot be on the waiting list for more than 60 days from the diagnosis of prostate cancer, or 6 months for a hip replacement.

The rest of the surgeries are programmed in accordance with the severity of the patient’s condition and within one year at the most, following the "first in, first out" criterion.  The first person on the waiting list is the first to be operated on.

Together with the team, we have set ourselves four major challenges: space, internal organization, technology and personnel management

At the Hospital Clínic we have a problem with a lack of space, and everyone knows that. We’re in a hospital that has become too small and, despite the fact that in recent years we have made adjustments and improvements, there is still a lot to do, including the renovation of the ENT surgery area, as well as the major outpatient surgery and the sterilization areas.

We know that in a few years’ time we'll have a new location, the hospital will be enlarged, and that will be the opportunity to have pioneering and sustainable facilities. However, right now we have to manage the ‘meanwhile’ as efficiently as possible.  We need to renovate these areas, whilst ensuring we continue to provide a very high level of first-class surgical activity. That is a major challenge.  

We also need to adjust the size of the operating theatres, for example. We perform a great deal of conventional complex surgery that does not fit in conventional operating theatres, and we need larger operating theatres.  The required technology takes up a lot more space than it did a few years ago.  We need to adjust the size of the operating theatres to suit the type of technology we have today.

We manage a lot of staff and part of this management is still too manual.   We need to work on automating processes and making the areas and equipment we have more efficient.  For years now, we have been working with the Lean methodology to try to improve circuits. Although a great deal of good work has been carried out, there is still room for improvement regarding the global efficiency of the Surgical Area.

Medical technology, and especially the kind we need in the operating theatres, is extremely expensive.  A surgical robot costs around 2 million euros.  And we know that one of surgery’s greatest achievements in recent years is linked to technological development. Having tools that help you carry out processes in an increasingly safe, more automated and more precise way, and avoiding complications, is very important for the patient's well-being. Technological progress is what surgery is based on, in order to improve its results and to reduce the time spent in hospital, patient recovery time, and the number of complications.

It’s quite clear that we can’t have it all, and we need to know how to prioritize and, if possible, be the partners of technological development.  This often allows us to get the technology earlier, and even to reduce the final cost.  We need to provide the Hospital’s surgeons—who are excellent—with the best tools to work with, and to ensure they do so with the utmost safety. We need to prioritize in this area as well.

The surgeon must be very good, not just when operating, but also when prescribing the surgery, because a good prescription already represents half of the process.  For example, if you do something perfectly, but it was not the right thing to do, then it’s a disaster.  What is important is to do something when it is required, to do it well, with the best tools possible and, above all, to take the opportunity to teach it progressively to the new generations of surgeons. For example, the fact that most surgeries can now be followed through screens in the operating theatre is a fantastic training tool.

It has a great deal of potential, but we are still in the early stages. The robot is a highly precise instrument that can move in ways the human hand cannot—such as rotating in a 360º circle, for example—and it allows us to decrease hand tremor, work with excellent 3D vision, with magnifications, making it easier to see things that we cannot define well with the human eye, facilitating learning with simulation and double consoles, etc.  But robots don’t work on their own; you need an experienced surgeon behind them. 

I think that what is closest to boosting robot-assisted surgery is the application of certain automatisms based on artificial intelligence, and also the possibility of operating and tutoring surgeries remotely in real time, which is already possible thanks to 5G. Having support systems to better identify the borders of tumours while we operate, for example, could also be of great help. These are things that we are not yet able to do accurately enough at times, but which I am convinced we shall see in the near future.  

We know that technological development depends in part on robotic surgery, which is why robotics must be a priority strategic line of action at our centre.

It is very important for there to be complicity and trust between the doctor and patient when it comes to telling the patient that he or she is going to undergo surgery. It is very important to create a space where the patient feels comfortable to ask questions and resolve any doubts. Patients need to understand what is going to be done and why, and also to know the risks involved.

Patients also feel calmer when they see and feel that they are in an excellent centre, which is renowned for its procedures on a technical level... but also because if anything happens they know that the centre has the resources—ICUs, technology and professionals—required to cope with any possible complications.

However, it is true—especially if you are well—that if you are told, “we have to operate”, you need an environment of trust, which we do our utmost to generate.

It is a very rewarding task that requires planning and capacity for execution. We train for many years in order to have the required skills.   Seeing that everything goes well and knowing that you can help people who need it, is very rewarding. Although I am the head of the Surgical Area, I continue to operate each week and spend one day doing consultations, and I really enjoy it very much. Moreover, it is the best way to detect any problems, shortcomings, to see how certain procedures work, to talk to the teams, etc.

We surgeons love to operate, and operate whenever possible.  My specialty, Otorhinolaryngology, is medical and surgical and combines the two aspects.  I chose this specialty because it covers everything from the diagnosis to the treatment of the procedure, whether it be medical or surgical.