Driving the change as a doctor

Gabriela Bom Braga, August 2020

As doctors our task is to help people improve their health and their quality of life. This is why any technology in the OR needs to enhance patient outcomes. Otherwise, it's just an expensive toy. My experience shows that especially in ENT surgery, technologies that enable less traumatic interventions have a long tradition and are very useful.

I was seven years old when I got interested in surgery. As my father is a surgeon, I grew up around pathology, anatomy books and human skulls. These things and the science behind them always caught my attention. Being curious from the start, medicine intensified this yearning for knowledge of how the anatomy, the physiology and the pharmacology all interacted to make our body work and conquer diseases. In a sense, my current work at ARTORG as a Biomedical Engineering Research Center is an extension of this curiosity: It allows me to see what technology can do but also which flaws it might have in the operation room.

The thrill of having ideas about surgical technology and seeing those ideas translate into physical reality first hit me when I worked together with engineers at Vanderbilt University during my fellowship in Neurotology surgery that lead me to my PhD in robotics. Research is a great way of advancing medicine, and it fascinated me to develop the tools I could actually use in the OR, finetuning them until they did exactly what they should do for the patient. 

Before you implement costly technology into the operation room, ask: “Will it improve patient outcomes?”

This brings me to the most important aspect of medical technology for surgery: It must help the patient. So before implementing costly technology into the operation room, ask yourself: “Does it make the intervention less invasive? Will it increase safety? Will it decrease the surgical time? Will it improve patient outcomes?” if the answer to any of these is “Yes”, then let's go for it! Because doctors want patients to do well. If this isn't your maxim, then you are probably in the wrong profession. This is also why technology shouldn't be a walking stick for a surgeon: When it fails, the surgeon needs to be able to guarantee the safety of the patient.

My specialization is in otological surgery, with a focus in robotic techniques. As far as I know, I am the first ENT surgeon to consider robotic cochlea implantation for children. Exactly here it makes a lot of sense: Rather than having to open a large area of the mastoid bone to reach the child's cochlea, a robotic approach might be able to access the tiny hearing organ through only a 1.8-millimeter-wide hole behind the ear. This would greatly reduce infection risk and recovery time, allowing children to develop normal hearing and speech from an early age.

In the field of hearing there is no simple one-fits-all solution. Depending on the degree of the hearing impairment, very different options come to pass. These are always discussed in a board meeting with all involved specialists based on the individual patient characteristics, and the patient (or their parents) has the 

last say on what is done. It is also important not to destroy residual hearing by damaging healthy hearing cells through cochlear insertion. I currently focus on this problem, trying to find ways to preserve as much as possible of the natural hearing in patients that have only lost the ability to hear high frequencies.

When I first came across the research of ARTORG and met the engineers, we realized that this was a great opportunity for both sides: They were interested in my medical opinion and I was interested in how technology could be translated. Surgical navigation software, for example, can help a surgeon understand the 3D structures of the ear much better than 2D renderings in the medical books I once studied with. I believe that this will change medical education a lot. 

ENT surgery has a long tradition of driving medical technology innovation. Prof. Julius Lempert as one of the biggest ENT pioneers started using dentistry drills instead of hammer and chisels on patient heads and wore magnifying loops for improved visualization, massively reducing trauma-induced problems such as nerve paralysis. With more precise incisions and drillings came new surgical techniques for otosclerosis and mastoiditis and neuro-monitoring approaches to preserve the facial nerves during surgery. Now we have microsurgical techniques (the use of microscopes or endoscopes) for an even less traumatic and more precise access. These technologies have also found their way into other specialties such as neuro, vascular and pediatric surgery.

One especially interesting development is surgical robotics, as it allows for repeatable high-precision interventions and safe navigation into patient tissue. Studies at the ARTORG have shown that a robot-drilled 1.8mm tunnel in a precise angle can lead the ENT surgeon directly into a patient's cochlea. We achieve an accuracy to the facial nerve of 0.06 to 0.04mm and of 0.15 to 0.03mm on target with the robotic CI implantation procedure. These numbers are impossible to be consistently achieved with manual surgery, as the daily condition of a surgeon may vary. The robot fills that void and keeps the procedure safe for the patient.

Surgeons and engineers can together develop medical technologies that are realistic and work in real clinical contexts.

I am convinced that surgeons and engineers can together develop medical technologies that are realistic and work in real clinical contexts. When you work in an OR, you have a completely different view from that of a technician. The engineer would approach a problem from a rational analytical view (focusing on positions, angles and forces). The surgeon brings a practical view (taking anatomical structures and potential neurological or inflammatory responses into account). Joining the two mindsets to establish a common ground will create better solutions to clinical challenges and better outcomes for the patient.


Dr. Gabriela O'Toole Bom Braga is Postdoctoral Researcher at the ARTORG Image Guided Therapy group. She is an experienced otolaryngologic surgeon with a focus on cochlear implant surgery and hearing restoration. Her research foci are robotic ear surgery (focusing on pediatric CI implantation), inner ear access and surgical techniques for residual hearing preservation.