In his career, neurosurgeon and clinic director Andreas Raabe has seen major developments in medical technology that open unprecedented possibilities for interventions on the brain and spine. With a keen interest in physics, he develops new technologies for the operating room emerging from practice at Inselspital together with the ARTORG Center.
What is the most challenging, what is the most rewarding about being a neurosurgeon?
It’s both the intensity and the precision. Precision and very good knowledge of anatomy are necessary for the interventions. And intensity both characterizes our profession and marks the limits of our possibilities:
We experience unbelievable healings but on the other hand also tremendous setbacks in case of complications or certain tumors or accidents, where there is nothing left to be done. The emotionality is therefore very high in both directions.
We save lives, but unfortunately patients also die with us.
How has neurosurgery changed?
Decades ago, we started with a black box and had to use indirect signs to understand diseases and perform interventions – to a considerable extent palliative surgery. Today, neurosurgery has developed into a specialist discipline that can look inside people thanks to modern developments in medical technology, imaging, and navigation. We have been given eyes. We can see exactly where tumors and delicate structures are. That’s a world of difference from where I once started. Today we are smaller, better, gentler.
What is the driving force behind medical technology development?
Through my affinity for physics and engineering I have always tried to improve medical technology. After all, what could be better than feeling "What would I need right now?" when using it in the operating room? For me it’s important to think about potential improvements from a practical perspective at the current limits of possibilities.
One example of this is the Dynamic Mapping developed here at Inselspital, with which we can send something like a radar into the tissue through electronic impulses in surgical instruments. This creates additional safety because we know in advance where sensitive structures are. We developed this system here in Bern and today it is used worldwide.
The ideas for it arose during surgery and we were able to achieve this because technical know-how is available here and engineers and doctors can communicate.
You collaborate with the ARTORG Center of the University of Bern to develop medical technology solutions. What are your experiences?
The ARTORG is a dream come true for us, bringing together engineering, medicine and industry. We have collaborated with Stefan Weber in navigation and robotics (BRIDGE project). We want to continue our research in the field of robotics. This is also reflected in a new professorship, which we are about to establish with double affiliation Inselspital - ARTORG, University of Bern. The fact that we can implement this in this way makes me particularly happy about this collaboration.
Where do you use medical technology in your clinic?
In the OR from morning till night. Neurosurgery is the medical specialty that has been most influenced by medical technology. We practically perform no surgery without image guidance. Before we start, we mark the nerves and muscles with needles to monitor the pathways and the brain’s function. This takes a bit of time at the beginning, but afterwards the operation can be performed faster and more precisely. In general, we primarily use medical technology in navigation and neuromonitoring during surgery.
Neurosurgical interventions are highly precise and risky. Can residents be specifically trained for this?
Because of the structures we operate on good training is essential. Today, the anatomical knowledge and understanding of certain access points are easier to learn than before. Back then, you just had a picture in a book that you needed to memorize and then translate into 3D in your head. Today, with navigation, we can check our anatomical knowledge in real time. That helps residents plan the surgery better, even in the early stages. Also in areas with less navigation – such as clipping an aneurysm – we can now improve training. Aneurysms can be translated into realistic 3D models that even allow practice of the procedure. This is a big step forward, and since no one sets a clip exactly the same, even experienced surgeons can learn from this. I am very happy about this development and look forward to the first course with this technology.
What is the role of robotics in neurosurgical interventions?
Robotics in neurosurgery currently functions rather as a support arm for spinal surgery and does not yet exploit the new possibilities such as sensor technology. With its ability to be thousands of times more sensitive than human touch a robot can measure forces much more precisely than we can. We are not yet applying these advantages clinically, but this is the path that robotics must take for medicine: it must become intelligent.
Are you referring to artificial intelligence?
I currently understand artificial intelligence primarily as a type of information processing. Robotics in surgery would then be the highest form of AI, which integrates haptic feedback, can react to the unexpected and takes aspects such as hemostasis into account. An autonomous robot would therefore not automate procedures but could perform complex operations where no single movement is the same.
However, we are still missing a very big step between technology suggesting an action and technology performing this action itself. Therefore, I think that autonomous robots in neurosurgery will probably have to wait another 30 years.
What are the most exciting future innovation areas in neurosurgery?
I see innovation potential especially in the operating room, where we could visualize even more, see better inside the patient, or further increase the accuracy of navigation systems. A very important area will be intelligent robotics, perhaps with microsystems that can give us a third or fourth hand in the very small operating field. In addition, there will be new methods of hemostasis and electrophysiological monitoring.
If you could wish for a MedTech tool that does not yet exist, what would it be?
This question is extremely difficult. Predicting what we will need is the great art of innovation. If you knew that already, you would be the next Elon Musk, so to speak! It would be great, for example, if we could implant artificial neural pathways or processors. Unfortunately, that's utopian at the moment.
On the other hand, we are in the process of developing an intelligent robot for spinal surgery that recognizes bone boundaries and nerve pathways or, for example, notices when a screw is not holding well. We are currently devoting a lot of energy to this, because spinal surgery accounts for up to half of the interventions we perform at the clinic.
Prof. Andreas Raabe, MD, specializes in the surgery of brain tumors, aneurysms, and spinal diseases. To protect important motor functions during brain surgery, Andreas Raabe has developed a novel continuous monitoring method. He has also introduced microscope-integrated video angiography to neurosurgery during the operation of aneurysms and vascular malformations. In 2019, he received the prestigious "European Lecture" award from the European Society of Neurosurgery for developing these innovative surgical procedures.