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Page 174 O’Reilly et al. Art Int Surg 2022;2:173-6 https://dx.doi.org/10.20517/ais.2022.26

The promise of AI lies in developing synergy between its subfields as well as with other computing
technology to analyse data and generate clinical support. Integration of multimodal data with AI can
augment surgical decision-making across all phases of care both at the individual patient and at the
population level. Hashimoto describes an integrated AI “collective surgical consciousness” serving as a
conduit to add individual patient data to a population dataset while drawing from population data to
[3]
provide clinical decision support during individual cases .
PROBLEMS IN HPB SURGERY AND POSSIBLE AI SOLUTIONS
The US philosopher Abraham Kaplan once wrote “Give a small boy a hammer, and he will find that
everything he encounters needs pounding”. AI is undoubtedly a powerful and exciting new tool. Its
application in medicine and specifically in HPB surgery, requires rigorous scientific evaluation. The end-
points must be clinically relevant too, for example safer surgery, fewer complications, better oncological
margins, cost-effectiveness and increased long-term survival, if AI is to avoid Kaplan’s trap. Artificial
Intelligence Surgery is the first journal to focus exclusively on the interface of computers and the art of
surgery and, fortunately for researchers in this field, no shortage of problems exist in HPB surgery that need
pounding.

Liver and pancreatic surgery is technically complex and requires careful preoperative planning and
intraoperative execution from highly-trained surgeons, anaesthetists and nursing staff. Despite recent
improvement in outcomes, achieved largely through specialisation and centralisation of services, the
postoperative morbidity remains high at 20%-30%, and mortality rates for some of the more complex
resections can be as high as 10% . Moreover, long-term survival for people with HPB malignancies are
[4-6]
among the lowest. Worse still, their position relative to other cancers has deteriorated, as more rapid
[7]
progress is being made in the treatment of e.g. breast, skin and prostate cancer . Can AI provide solutions
to this dismal situation?

One clear use of AI in HPB surgery involves the use of 3D visualisation, to delineate complex liver and
pancreatic anatomy and its relationship to the tumour. Opportunities exist to improve outcomes, such as
operative time, duration of liver inflow occlusion and complications, especially if the opportunity is taken to
perform virtual surgery before the real event. Intra-operative use of AI in HPB surgery involves associating
the 3D reconstructed images or physical models to the actual surgery. Augmented Reality can be used to
display virtual information based on real images of the patient to improve oncological surgery, delineating
the ideal dissection plane and anatomical landmarks in real-time to help achieve safe margins with
[8]
maximum functional preservation .

At present, robotic surgery seems like a form of minimally invasive surgery rather than AI. However, this is
an oversimplification because the true power of robotic surgery exists in its potential to create autonomous
actions . The concept of autonomy, or independent decision making, is central to AI in surgery and the
[1]
future of surgical robotics. Autonomy is not an “all-or-nothing” concept but a continuum. Initially, it may
be preferable for only parts of surgical procedures, such as an anastomosis, to become fully automated, if
safe and proven to provide patient benefit. Autonomous dissection may be the riskiest part of surgery to be
[2]
done autonomously and should be evaluated later . Full robotic surgical autonomy could eventually be
possible but will require convincing evidence of superiority before the control of a human surgeon, fully
capable of performing and completing the procedure, is relinquished.

Laparoscopic cholecystectomy (LC) is one of the most commonly performed operations worldwide, with
between 750,000-1,000,000 performed in the USA alone, every year. A recent Society of American