The Future of Surgery
and the
Paradigm Change in Surgical Simulation
Richard M. Satava, MD FACS
Professor of Surgery
University of Washington
Program Manager, Advanced Biomedical Technologies
Defense Advanced Research Projects Agency (DARPA)
and
Special Assistant, Advance Medical Technologies
US Army Medical Research and Materiel Command
Simulation in Healthcare: Transforming Education
University of Minnesota Academic Health Center
Minneapolis, MN
November 28, 2005
Air Force 1 - refit
Unofficial Administration request
Disruptive Visions
“The Future is not what it used to be”
….Yogi Berra
Current Visions
“The Future is here …
. . . it’s the Information Age”
Fundamental Concept
New technologies that are emerging
from Information Age discoveries
are changing our basic approach
in all areas of medicine
...
EXAMPLES
Holomer
Total body-scan for total diagnosis
From visible human to Virtual
Soldier
Multi-modal total body scan on every trauma patient in 15 seconds
Satava
March, 2004
Virtual Autopsy
Wound Tract
Less than 2% of hospital deaths have autopsy
Statistics from autopsy drive national policies
Why robotics, imaging and
modeling & simulation
• Healthcare is the only industry without a
computer representation of its “product”
•A robot is not a machine . . .
it is an information system with arms . . .
• A CT scanner is not an imaging system
it is an information system with eyes . . .
thus
• An operating room is an information system with . . .
Total Integration of Surgical Care
Minimally Invasive
Surgery
Remote Surgery
Simulation & Training
Pre-operative planning
Intra-operative navigation
Joel Jensen,
SRI International, Menlo Park, CA
Remote telesurgery
“Operation Lindberg”
First remote and trans-Atlantic
Telesurgery procedure
Prof. Jacques Marescaux, MD
IRCAD, Strasbourg FRANCE
ROUTINE telesurgery from
Hamilton to North Bay
300 mile distant
Dr. Mehran Anvari, MD
McMaster Univ, Toronto CANADA
“TriCorder”
Point-of-care noninvasive therapy
HIFU
High Intensity
Focused Ultrasound
for
Courtesy Larry Crum, Univ Washinton Applied Physics Lab
Non-invasive
Acoustic hemostasis
“ . . .is aware of everything (patient) . . .”
Total Patient Awareness
The LSTAT
Courtesy of Integreated Medical Systems, Signal Hill, CA
• Defibrillator
• Ventilator
• Suction
• Monitoring
• Blood Chemistry
Analysis
• 3-Channel
Fluid/Drug Infusion
•Data Storage and
Transmission
• On-board Battery
• On-board Oxygen
• Accepts Off-Board
Power and Oxygen
LSTAT Deployment to Kosovo - March 2000
212th MASH Deployed with LSTAT - Combat Support Hospital
Courtesy of Integreated Medical Systems, Signal Hill, CA
LSTAT Lite
LSTAT – Back pack version
LSTAT for far-forward battlefield – less than 50 lbs
Nightingale UAV Goal
Or:
 Identify
“optimum” VTOL
UAV design
 Create a new
VTOL UAV
tailored to the
operational need
LSTAT
Why now?
VTOL UAV technology is maturing rapidly enough to minimize risk.
Classic Education and Examination
Simulation and Objective Assessment
Laparoscopic hysterectomy
Surgical
Simulators
Courtesy Michael vanLent, ICT, Los Angeles, CA
LapSim simulator tasks - abstract & texture mapped
Courtesy Andres Hytland, Sugical Science,
Gothenburg, Sweden, 2000
Laparoscopic Simulator with tactile feedback
Courtesy Murielle Launay, Xitact, Lausanne Switzerland
Full System
ENT Sinusoscopy Simulator
Haptics
Lockheed Martin 1999
“Blue Dragon” passive recording device
Courtesy Blake Hannaford, University of Washington, Seattle
Novice
Objective Assessment
Intermediate
Expert
Hand motion tracking patterns
Ara Darzi, MD. Imperial College, London, 2000
Paradigm
Change
for
All Surgical Education & Training
•
Adhere to the 6 competencies (ACGME & ABMS)
• Curriculum, not the simulation
• Validation of the curriculum (and simulator)
• Criterion-based (proficiency level) training
Speculation on Future
Simulation will become part of surgical
procedures (eg surgical rehearsal/assessment)
Training will be continuously assessed
(Black box – Ara Darzi)
Training will be embedded in robotic surgery
Surgical rehearsal will join robotic surgery
The next steps
• Intelligent tutors
• Complex procedures
• Digital libraries
• Surgical Rehearsal
Pillars of Healthcare Education
Education
Curriculum
Research
Validation Studies
Assessment Efficacy
Train & Assess
Certification
Research
Simulators
Robotics
Virtual reality
Training
Center
Clinical
Knowledge
Base
Clinical Trials
and
Outcome studies
Clinical Practice
Patient care
Procedural skills
Professionalism
American College of Surgeons
Requirements for Endorsement*
Training
Competency
Criterion-based
Faculty commitment
Curricula
Assessment tools
Validation studies
Research
Curricula
Simulators
Comprehensive
Training
Center
RRC review
Scheduling
Protected time
Grants
Contracting
Graduate study
Administration
Resources (Personnel)
Space & simulators
Audit & Results reporting
Fiscal responsibility
*Comprehensive Training Center
Superhuman Robots!
Movie: Alien
The Touch Lab, MIT
“Penelope” – robotic scrub nurse
Michael Treat MD, Columbia Univ, NYC. 2003
Integrating Surgical Systems for Autonomy
The Operating Room (personnel) of the Future
100,000
Surgeon
Satava
March, 2000
Assistant
Scrub Nurse
Circulating nurse
The Operating Room of the Future
Fighter Pilots – until 2002
Predator 2003
Fighter Pilots – Beyond 2003
SATAVA 7 July, 1999
DARPA
Robotic Medical Assistant
Nursing shortage crisis
Applicable at all levels
Hospitals
Clinics
Nursing Home
Assisted living
Courtesy Yulun Wang, InTouch Technologies, Inc, Goleta, CA
SATAVA 7 July, 1999
DARPA
Disruptive Visions
“The Future is not what it used to be”
….Yogi Berra
Scientific Method
A Paradigm Change?
Hypothesis
Study Design
Experiment
Results
Reporting
Modeling & Simulation
Hypothesis
Study Design
Modeling &
Simulation
Results
(Preliminary)
Experiment
Results
Reporting
The Information Age is NOT the
Future
The Information Age is the
Present ...
There is something else out there
......
SATAVA 7 July, 1999
DARPA
Clayton M Christensen
TECHNOLOGY DEVELOPMENT
BIO INTELLIGENCE AGE
CONSUMER ACCEPTANCE
2000 BC
0
1500
1800
1900
2000 AD
TIME (year)
Satava 29 July 99
The BioIntelligence Age
BIOLOGIC
Biosensors
Biomaterials
Biomimetic
PHYSICAL
FUTURE
Genomics
Bioinformatics
Biocomputation
Robotics
HPCC/WWW
MEMS/Nano
INFORMATION
Satava 2 Feb 1999
The key to the future
is multi-disciplinary teams
University of Montana, 1999
University of Wisconson, 1999
Biomimetic Micro-robot
Courtesy Sandia National Labs
Capsule camera for gastrointestinal endoscopy
Courtesy Paul Swain, London, England
“BrainGate” John Donohue, Brown University, 2001
Richard Andersen, CalTech, 2003
Greg Kovacs. Stanford University, 1990
Brain Machine Interface – Controlling motion with thoughts
Recorded activity for intended movement to a briefly flashed target.
TARGET
PLAN
MOVEMENT
Time
Courtesy Richard Andersen, Cal Tech, Pasadena, CA
Thoughts into Action
Direct brain implant control of robot arm
Miguel Nicholai, Duke University, 2002
Satava
March, 2000
Intelligent Prostheses
Rheo Bionic knee
Ossur, Reyknavik, Iceland
C-leg
Otto Bock, Minneapolis, MN
Artificial Retina
Multi-disciplinary team from USC Doheny Retinal Institute,
Oak Ridge National Labs, North Carolina State University and
Johns Hopkins University
Courtesy Jim Weiland,
USC Doheny Retina Institute,
Los Angeles, CA
Tissue Engineering
Artificial Ear
Liver Scaffolding
Artificial Blood Vessel
J. Vacanti, MD
MGH
March, 2000
Courtesy of J. Vacanti, MD
MGH
March, 2000
Femtosecond Laser
(1 x 10 –15 sec)
Los Alamos National Labs, Los Alamos NM
Time of Flight Spectroscopy
Cold Spring Harbor Laboratory, Long Island, NY
Cellular opto-poration
BioSurgery
Satava
September 2003
Orb spider - web
Spinnerette of spider
Spider silk protein as biomaterial -BioSteel
Cross section of synthetic fiber
Nexia Biotechnologies, Montreal Canada
Femtosecond Laser
(1 x 10 –15 sec)
Los Alamos National Labs, Los Alamos NM
Time of Flight Spectroscopy
Cold Spring Harbor Laboratory, Long Island, NY
Cellular opto-poration
BioSurgery
Satava
September 2003
Research in hibernation
Relative size of subjects
Alaska Black Bear
Artic Ground Squirrel
suspended animation
hypometabolic states
resuscitation
reperfusion
Suspended
Animation
Institute of Arctic Biology’s
Toolik Field Station,
Alaska's North Slope
Brian M. Barnes,
Institute of Arctic Biology , University of Alaska Fairbanks 11/02
active
heart rate
300
hibernating
3
(beats/min)
resp. rate
150
<1
(breaths/min)
body temp.
gene
function
metabolic rate
(mlO2/g/h)
37oC
ongoing
0.5
-2oC
transcription
and translation suppressed
0.01 (2%)
When this be accomplished
Technologies will change the Future
• The rate of new discovery is accelerating exponentially
• The changes raise profound fundamental issues
• Moral and ethical solutions will take decades to resolve
Sector
Rate of Change
Technology
Business
Society
Healthcare
TIME
Differing responses to scientific discovery by various sectors
Moral and Ethical Issues
Raised by Technological Success
Summary
Should we do research in areas we may not be able to control?
(eg, genetics, cloning, nanobots, intelligent machines?)
Will prolonging life through technology result in more disease in the
overall population
Can we change medicine from treatment to prevention of disease
In defeating diseases, will technology change a human into a
combination of man and machine - what does it mean to be “human”
How will we decide who gets the6 technology, especially in 3rd World
SATAVA 7 July, 1999
DARPA
And just what are these profound moral and ethical issues?
Saturday, 28 December, 2002, 14:28 GMT
.
Demands grow for human clone ban
Advocates argue cloning can help infertile couples
There are growing demands for a ban on human cloning
after claims that a girl born on Thursday is an exact
genetic replica of her mother.
“These
technologies . .
. are raising
new moral and
ethical
morasses for
us.”
Dr Ian Gibson
British legislator
Clonaid scientist Brigitte Boisselier said
four more clones will be born soon.
French President Chirac has called on all
countries to rally behind a Franco-German
proposal for a global ban on human
cloning which has been submitted to the
United Nations.
US President George W Bush says the
process is "deeply troubling".
Scientists remain sceptical of the success
claimed by the Clonaid company, which is
linked to a sect that believes aliens
created humans by cloning 25,000 years
ago.
But legislators in Britain and elsewhere
say there has to be discussion and
introduction of rules for the practice of
scientific methods which could produce a
cloned baby, even if Clonaid's claims are
untrue.
“The practice is contrary to
human dignity and is criminal”
French President Jacques Chirac
Clonaid scientist Brigitte Boisselier
said a baby girl - nicknamed Eve was born in the US after the
genetic material from a woman's
skin cell was fused with one of her
eggs.
Dr Boisselier said four other
women were due to give birth to
baby clones in the coming weeks one in Europe, another in North
America and two in Asia.
Human embryos
cloned
Chinese Cloning Control Required
Tuesday 16 April, 2002, 10:41 GMT 11:41 UK
Strict ethical guidelines are needed in China to
calm public fears about new cell technologies such
as cloning, the country's leading scientist said.
Professor Ching-Li Hu, the former deputy
director of the World Health Organization, was
speaking at the Seventh Human Genome Meeting
in Shanghai. His call follows recent reports that
Chinese scientists are making fast progress in
these research fields.
One group in the Central South University
in Changsa is said to be producing human
embryo clones, while another team from the Sun
Yat-sen University of Medical Sciences in
Guangzhou is reported to have fused human and
rabbit cells to make tissues for research.
February 12, 2004
South Korean team demonstrates
cloning efficiency for humans similar
to pigs, cattle
| Thersa Tamkins
After outlandish claims, a few media circuses,
and some near misses by legitimate
researchers, a team of South Korean
researchers reports the production of
cloned human embryos. The findings, were
released Wednesday (Science, DOI:10.1126
/science.1094515, February 12, 2004).Wook
Suk Hwang and Shin Yong Moon of Seoul
National University used somatic cell nuclear
transfer to produce 30 human blastocysts and
a single embryonic stem cell line; SCNT-hES1. Using 242 oocytes and cumulus cells from
16 unpaid donors, the group achieved a
cloning efficiency of 19 to 29%, on par with
that seen in cattle (25%) and pigs (26%).
Jeffery Steinberg, MD
Fertility Institutes of Los Angeles
Five "designer babies"
created for stem cells
Five healthy babies have been born to provide stem cells for
siblings with serious non-heritable conditions. This is the first time
"savoir siblings" have been created to treat children whose
condition is not genetic, says the medical team.The five babies were
born after a technique called preimplantation genetic diagnosis (PGD)
was used to test embryos for a tissue type match to the ailing siblings,
reports the team, led by Anver Kuliev at the Reproductive Genetics
Institute in Chicago, US.The aim in these cases was to provide stem
cells for transplantation to children who are suffering from leukaemia
and a rare condition called Diamond-Blackfan anaemia (DBA)."It's a
big step, because it gives people another option," says Mohammed
Taranissi, at the Assisted Reproduction and Gynaecology Centre,
London, UK, one of the team. "Before that the only option was to look
in the siblings and immediate family to see if you had a match or
alternatively to just keep trying [to have a baby which matches]."He
told New Scientist that people trying to conceive a child naturally as a
tissue match for a sick sibling had only a one in five chance. This
method can also lead to terminations where the foetus is not a tissue
match for the sibling."If you do it this way, the chance of finding a
1997
match is 98 per cent."
'Unlawful and unethical' However, the use of this technology to
provide a "designer baby" to treat an ill sibling is highly
controversial.A UK couple involved in this study travelled to the US
for treatment after the UK's Human Fertilisation and Embryology
Authority (HFEA) ruled that they could not create a tissue-matched
sibling as a stem cell donor to their son.In-vitro fertilisation (IVF) and
tissue-typing was used in the US to give the Whitakers a perfectly
matched baby boy to help their son
Genetically “designed” child
Gregory Stock
1.
Verlinsky Y, Rechitsky S, Sharapova T, Morris R, Taranissi M and Kuliev A. Preimplantation HLA Testing. JAMA (2004) 29: 2079
Scientists create animals that are part-human
Stem cell experiments leading to genetic mixing of species
RENO, Nev. - On a farm about six miles
outside this
gambling town, Jason
Chamberlain looks over a flock of about 50
smelly sheep, many of them possessing
partially human livers, hearts, brains and
other organs. The University of Nevada-Reno
researcher talks matter-of-factly about his
plans to euthanize one of the pregnant sheep
in a nearby lab. He can’t wait to examine the
effects of the human cells he had injected into
the fetus’ brain about two months ago. “It’s
mice on a large scale,” Chamberlain says.
As strange as his work may sound, it falls
firmly within the new ethics guidelines the
influential National Academies issued this
past week for stem cell research. In fact, the
Academies’ report endorses research that comingles human and animal tissue as vital to
ensuring that experimental drugs and new
tissue replacement therapies are safe for
people. Doctors have transplanted pig valves
into human hearts for years, and scientists
have injected human cells into lab animals for
even longer.
Biological
mixing
of
species
But the biological co-mingling of animal and
human is now evolving into even more exotic
and unsettling mixes of species, evoking the
Greek myth of the monstrous chimera, which
was part lion, part goat and part serpent. In
the past two years, scientists have created pigs
with human blood, fused rabbit eggs with
human DNA and injected human stem cells to
make paralyzed mice walk.
Particularly worrisome to some scientists are
the nightmare scenarios that could arise from
the mixing of brain cells: What if a human
mind somehow got trapped inside a sheep’s
head? The “idea that human neuronal cells
might participate in 'higher order' brain
functions in a nonhuman animal, however
unlikely that may be, raises concerns that need
to be considered”.
Mice
with
human
brains
In January, an informal ethics committee at
Stanford University endorsed a proposal to
create mice with brains nearly completely
made of human brain cells. Stem cell scientist
Irving Weissman said his experiment could
provide unparalleled insight into how the
human brain develops and how degenerative
brain diseases like Parkinson’s progress.
Stanford law professor Hank Greely, who
chaired the ethics committee, said the board
was satisfied that the size and shape of the
mouse brain would prevent the human cells
from creating any traits of humanity. Just in
case, the committee recommended closely
Sheep that have partially human livers,
hearts, brains and other organs are shown
here at the University of Nevada, in Sparks,
Nev., on April 27.
The Associated Press April 29,2005
monitoring the mice’s behavior and
immediately killing any that display
human-like behavior.
Weissman, who has already created mice
with 1 percent human brain cells, said he
has no immediate plans to make mostly
human mouse brains, but wanted to get
ethical clearance in any case. A formal
Stanford committee that oversees research
at the university would also need to
authorize the experiment.
Extending Longevity
Life extension
A strain of mice that have lived . . .
. . . more than three normal lifespans
Should humans live 200 years?
April 14, 2004
Life extension consists of attempts to extend
human life beyond the natural lifespan. So far
none has been proven successful in humans.
Several aging mechanisms are known, and antiaging therapies aim to correct one or more of
these:
Dr. Leonard Hayflick discovered that mammalian
cells divide only a fixed number of times. This
"Hayflick limit" was later proven to be caused by
telomeres on the ends of chromosomes that
shorten with each cell-division. When the
telomeres are gone, the DNA can no longer be
copied, and cell division ceases. In 2001,
experimenters at Geron Corp. lengthened the
telomeres of senescent mammalian cells by
introducing telomerase to them. They then
became youthful cells. Sex and some stem cells
regenerate the telomeres by two mechanisms:
Telomerase, and ALT (alternative lengthening of
telomeres). At least one form of progeria (atypical
accelerated aging) is caused by premature
telomeric shortening. In 2001, research showed
that naturally occurring stem cells must
sometimes extend their telomeres, because some
stem cells in middle-aged humans had
anomalously long telomeres.
Gaak
Kismet
Intelligent “Living Robot”
Uses genetic algorithms to “learn”
TECHNOLOGY NEWS
"Thinking" robot in escape bid
Scientists running a pioneering experiment with
robots which think for themselves have caught one
trying to flee the centre where it "lives".
The small unit, called Gaak, is one of 12 taking
part in a "survival of the fittest" test at the Magna
science centre in Rotherham, South Yorkshire,
which has been running since March.
Gaak made its bid for freedom after it had been
taken out of the arena where hundreds of visitors
watch the machines learning how to repair
themselves after doing daily battle.
Professor Noel Sharkey said he turned his back
on the drone, but when he returned 15 minutes
later he found it had forced its way out of the
small make-shift paddock it was being kept in.
He later found it had travelled down an access
slope, through the front door of the centre and was
discovered at the main entrance to the car park
when a visitor nearly flattened it with his car.
Courtesy Rosalind Picard,
MIT Affective Computing Lab, Boston, MA
Courtesy Professor Noel Sharkey, Sheffield Unversity, London
Humans vs Machine
Humans
4.0X10 19 cps
Red Storm 3.5X10 15 cps
WHEN COMPUTERS EXCEED
HUMAN INTELLIGENCE
The Age of
Spiritual
Moore’ s Law
“computer power doubles
every 18 months”
Do the Math !!
Who is smarter now??
Machines
Ray Kurzweil
ROBOT
Hans Moravec
Will Machines become “smarter than humans?
CAN I REPLACE MY
BODY ?
Artificial organs
Smart Prostheses
Genetic engineering
Regeneration
If I replace 95%
of my body . . .
. . . Am I still “human”?
What does it mean to be human ?
Future interface for anthropomorhpic mobile robots
David Hanson, Hanson Robotics Inc, Dallas, TX
The Ultimate Ethical Question?
For the first time in history,
there walks upon this planet,
a species so powerful,
that it can CONTROL ITS OWN EVOLUTION,
at its own time and choosing …
… homo sapiens.
Who will be the next “created” species?
Do Robots Dream ?