Towards intraoperative measurements: reflections from SPOC-TRC Measure Twice Cut Once workshop

Reflections on the recent Surgery and Perioperative Care-Translational Research Collaboration (SPOC-TRC) workshop hosted by Tim Denison from the Oxford Biomedical Research Centre (BRC), Deena Harji from Manchester BRC and Jane Blazeby from the Bristol BRC.

The workshop brought together over 30 surgical innovators, from NIHR Biomedical Research Centres and beyond to explore how intraoperative measurements – taking measurements during surgery – are transforming surgical precision and outcomes.

The day began with a thought‑provoking look at how cardiac defibrillators have evolved since the 1980s to become the lifesaving devices they are known as today. We heard how with precise measurement, sensing and careful programming, the surgical team can observe the device response and test and tune in situ. The outcome is a device that demonstrates its lifesaving capacity before the patient even leaves the operating theatre. In cardiology, this has become everyday practice and implants are routinely used for patient benefit.

This paradigm of implant, measure, adjust and confirm has become the blueprint for how intraoperative measurements should be done to ensure that devices not only fit anatomically, but are evidenced to perform as intended.

Throughout the rest of the workshop, we explored how intraoperative measurements are already or could be applied to other surgical disciplines and how to involve patients and the public in the design and testing of new measures.

One such example is during brain surgery for Parkinson’s disease. We heard how by monitoring the electrical activity of the nervous system in real time, surgeons can make millimetre‑precise adjustments when placing electrodes deep into the brain. Combining this accuracy with stimulating electrodes at the right time and frequency, can suppresses tremors by up to 80% and mean patients often need fewer follow‑up procedures.

These approaches also hold promise for surgical procedures designed to restore continence. This is an area of urgent clinical need, given that over 60% of women will experience urinary incontinence in their lifetime. Yet with the right intraoperative measurements and right approaches, electrodes can target the nerves involved in restoring continence, enabling an optimal response, with the lowest levels of electrical stimulation.

For epilepsy, the solution is complex. It can be challenging to know where in the brain to cut or stimulate because of the uncertainty of where a seizure may originate.  Technology is in development that aims to determine the anatomy and physiology of seizure activity by detecting biomarkers (which are changes in cells or molecules associated with epilepsy) and probing the brain with electric stimulation and analysing its response. Currently, early phase studies are underway to use devices that send therapeutic stimulation to prevent seizures from starting.  These techniques present exciting prospects for the future.

Moving to other types of brain surgery, we heard how surgery for glioblastoma, one of the most aggressive types of brain tumour, is the only intervention to have improved survival rates over past decades. However, neurosurgeons must walk the tight rope between not taking enough tumour, so it progresses rapidly, or taking too much, damaging the brain and impacting on function and cognition. Use of intra-operative advanced imaging techniques holds real promise in guiding how much tumour should be removed, although using this technique within the operating theatre remains a challenge.

Looking to the future, we explored the growing role of intraoperative measurements in plastic surgery. With use cases including being able to demonstrate signs of life in skin and muscle, and visualising infection in wounds. These would help guide “reconstruction readiness” and novel ways to surgically manipulate tissue.

After a jam‑packed day, one thing was clear: whether it’s a defibrillator, a deep brain stimulator, or a device that helps control epilepsy, modern surgery is changing. Surgeons can now get real‑time feedback that gives early data about whether an approach might work. This needs more research and it is hoped that in due course it will lead to smarter surgery that is more responsive and personal.