BOPA: digital innovation meets the operating theatre

Faced with the complexity of surgical procedures, what help can technologies such as artificial intelligence, Big Data and robotics provide? It was this question that prompted Professor Éric Vibert, a liver transplant surgeon at Paul-Brousse Hospital, to approach the Institut Mines-Télécom. These discussions led to the creation, by the AP-HP and the ITM, of the Bloc OPératoire Augmenté (BOPA) innovation chair, in January 2020. Its aim: to accelerate the development of technological solutions to facilitate the work of operating room staff and enhance patient safety.

Digital tools to assist and train practitioners

To this end, the BOPA Chair combines the expertise of its two founding partners, as well as that of players such as Université Paris-Saclay, Inria and several start-ups. Each is working to develop innovations, such as the surgical tele-expertise tool developed within the framework of the Chair, to which IMT Atlantique, another component of Carnot TSN, has contributed. This device, which can be used during an operation, should enable a young surgeon to receive advice from a more seasoned colleague following his or her procedure at a distance. Similarly, another project aims to develop a voice assistant, capable of providing information to practitioners in the performance of their duties, and facilitating surgical reporting.

BOPA is also interested in the training of healthcare professionals. To this end, the research teams want to develop digital twins, which would also help in the preparation of surgical procedures. This is a challenge, given the wide range of possible operations and target organs, which can be deformed by the surgeon's movements. In addition, the Chair is planning to develop a "black box" recording all data relating to an operation, to be used for post-operative analysis or training purposes.

The Chair provides an ideal "playground" for all these innovations. The Paul-Brousse hospital in Villejuif (94) provides researchers with an operating room simulator. This will enable them to experiment with solutions under conditions close to reality, to check their usefulness, to improve them, or even to quickly abandon those that do not provide real added value.

Combining technological research with human and social sciences

However, the work carried out by BOPA's teams is not limited to the development of technological tools. The Chair also aims to better understand the operating room environment, the people who work in it and the way they interact, with a view to proposing solutions that suit them and really help them - true "augmentations", in short. To achieve this, it relies, among other things, on the expertise of IMT-BS and its Languages and Human Sciences department.

"Gérard Dubey, Professor of Sociology at IMT-BS , explains: " In order to help operating room professionals, it is essential to understand what they do in real-life situations, and how they deal collectively with real-life contingencies . " For example, the "black box" project aroused opposition from some practitioners, who feared that they would be monitored and that their exchanges, particularly informal ones, would be exploited by outside players. The term "black box" was abandoned, as it was seen as too negative.

For his work, the researcher drew on his two decades of experience in the... aeronautics sector. " I studied the impact of digitization and automation of the work environment on the job culture and professional identity of aircrew, both civilian and military," he explains. " However, the two fields are comparable, in the sense that they are both highly-skilled professions, with high-risk activities and numerous procedures. The question was whether the methods used in aeronautics could be transposed to the world of the operating theatre. "

The heterogeneity of the operating theatre

Gérard Dubey therefore went out into the field to meet these healthcare professionals. He was thus able to come face to face with the reality of several operating theatres, starting, of course, with those at the Paul-Brousse hospital, but also within the Necker-Enfants malades, Cochin and even INO hospitals in Rabat (Morocco). These in situ observations, supplemented by qualitative interviews, have been the subject of several research reports and articles. They also contributed to the co-organization of a colloquium with the AP-HP, the Chair of Philosophy in Hospitals (CNAM) and the support of Carnot TSN, followed by a collective work, published in September 2024 and entitled Les coulisses de l'activité opératoire (Presses des Mines).

In particular, the researcher's work emphasizes the vital importance of preoperative work, which is crucial to the success of an operation. " Simply observing the actions in the operating room is like judging a play by analyzing only the acting , forgetting all the rehearsal work that goes into it," says Gérard Dubey. "In the same way, a surgeon's gestures are 'only' the implementation of a strategy prepared at length before the operation.

What's more, the operating theatre is characterized by its heterogeneity, which makes it difficult to transpose aeronautical methods, according to the researcher. " Even if there are a few points in common, there are many divergences between the two fields," he analyzes. " For example, operating theatres differ enormously from one another, for many reasons: their specific and local history , the specialty or sub-specialty practised (hard or soft surgery), the great individual variability of patients (biological and biographical), etc. Where aviation is rather standard, there are many differences. Where aviation is rather standardized, surgery contains a wide diversity, and therefore great complexity, which ultimately reflects that of human anatomy. "

Should we move towards total automation of the surgical gesture?

So, can technology adapt to such disparity and offer fully automated, and therefore standardized, solutions? In Gérard Dubey's view, this is neither feasible nor desirable. "Gérard Dubey warns: " It is not desirable tooppose 'artisanal' surgery to a practice that can be objectivized and standardized (based solely on Evidence Based Medicine). "On the contrary, the two should exist in tandem, without one replacing the other. It can, of course, be useful to bring a degree of automation to the performance of surgical procedures. But it must not become the alpha and omega: standardizing everything would prevent us from adapting to the singularity of each case. And yet, the extreme variability of situations calls for flexibility and responsiveness. Thus, the operating theatre can only be enhanced by intelligently combining in-house human know-how with the potential of new technologies, particularly algorithmic ones.

This observation is echoed in the issue of the surgeon's relationship with error, another major theme of the BOPA Chair. " An error is defined as a deviation from a standard," notes Gérard Dubey. " However, in an environment as changing as the operating theatre, it is sometimes necessary to deviate from the defined framework in order to perform the appropriate gesture. The desire to eliminate error could then lead to a rigidification of the profession, to the detriment of practitioners and, ultimately, patients. " What's more, even if such a development seemed desirable, it would be difficult to implement. Indeed, an error is rarely explained by a single bad human decision, but rather by a series of events that are difficult to read in context (in the open time of the action) and sometimes contradictory. So it's better to speak of "undesirable events" rather than errors, in order to understand in all their dimensions the conditions that make an action ultimately appropriate or inappropriate.

Today, Gérard Dubey's research focuses on the potential contributions and impacts of organic robotics. These new flexible, deformable, bio-inspired robots could be used in many fields, such as... surgery, thanks to their ability to move within a fluid, elastic and fragile environment, like the human body. A way, then, for the researcher to extend his contribution to the issues addressed by the BOPA Chair.