Fig 1
How the Future of Surgery is Changing:
Robotics, telesurgery, surgical simulators and other advanced technologies
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
University of Washington, September, 2006
Fig 2
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
Fig 3
Virtual Autopsy
Wound Tract
Less than 2% of hospital deaths have autopsy
Statistics from autopsy drive national policies
Fig 4
Fig 5
Fig 6
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 . . .
Fig 7
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
Fig 8
Remote telesurgery
“Operation Lindberg”
First remote and trans-Atlantic
Telesurgery procedure
Prof. Jacques Marescaux, IRCAD
ROUTINE telesurgery from
Hamilton to North Bay
300 mile distant
Dr. Mehran Anvari, MD
McMaster Univ, Toronto CANADA
Fig 9
“TriCorder”
Point-of-care noninvasive therapy
Mechanics to energy
HIFU
High Intensity
Focused Ultrasound
for
Courtesy Larry Crum, Univ Washinton Applied Physics Lab
Non-invasive
Acoustic hemostasis
Fig 10
“ . . .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
Fig 11
LSTAT Deployment to Kosovo - March 2000
212th MASH Deployed with LSTAT - Combat Support Hospital
Courtesy of Integreated Medical Systems, Signal Hill, CA
Fig 12
LSTAT Lite
LSTAT – Back pack version
LSTAT for far-forward battlefield – less than 50 lbs
Why now?
Fig 13
VTOL UAV technology is maturing rapidly enough to minimize risk.
Nightingale UAV Goal
Or:
Fig 14
 Identify
“optimum” VTOL
UAV design
 Create a new
VTOL UAV
tailored to the
operational need
LSTAT
Fig 15
Classic Education and Examination
Fig 16
Fig 17
Fig 18
Fig 19
Fig 20
Simulation and Objective Assessment
b. Laparoscopic hysterectomy
Surgical
Simulators
Courtesy Michael vanLent, ICT, Los Angeles, CA
a. LapSim simulator tasks - abstract & texture mapped
Courtesy Andres Hytland, Sugical Science,
Gothenburg, Sweden, 2000
c. Laparoscopic Simulator with tactile feedback
Courtesy Murielle Launay, Xitact, Lausanne Switzerland
Fig 21
Full System
ENT Sinusoscopy Simulator
Haptics
Lockheed Martin 1999
Fig 22
“Red Dragon”
“Blue Dragon”
passive recording device
Courtesy Blake Hannaford, PhD
University of Washington, Seattle
Fig 23
Novice
Objective Assessment
Intermediate
Expert
Hand motion tracking patterns
Ara Darzi, MD. Imperial College, London, 2000
Fig 24
Modified Endoscope for Transgastric Surgery
Courtesy of N Reddy, Hyperbad India 20005
Trans Oral Intra-peritoneal Surgery
-
Fig 25
Future
Courtesy of N Reddy, Hyperbad India 20005
Fig 26
Peroral Transgastric Endoscopic Surgery
Need for development of modified
accessories and endoscopes
Courtesy of N Reddy, Hyperbad India 20005
Fig 27
Suture Devices
Eagle Claw
Apollo Project
Olympus, Tokyo.
Courtesy of N Reddy, Hyperbad India 20005
Fig 28
So What Next?
Fig 29
Continuous training, assessment and maintenance of certification
l
“Black Box”
“Ubiquitous lights” and “Sea of Cameras”
Courtesy Eric LaPorte, MD Barcelona, Spain 2005
Courtesy Takeo Kanade, PhD Pittsburg, PA 1999
Fig 30
“Penelope” – robotic scrub nurse
Michael Treat MD, Columbia Univ, NYC. 2003
Fig 31
The Operating Room of the Future
Fig 32
Fighter Pilots – until 2002
Predator 2003
Fighter Pilots – Beyond 2003
SATAVA 7 July, 1999
DARPA
Fig 33
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
Fig 34
Scientific Method
A Paradigm Change?
Hypothesis
Study Design
Experiment
Results
Reporting
Modeling & Simulation
Hypothesis
Study Design
Modeling &
Simulation
Results
(Preliminary)
Thousands of iterations
on a computer
Experiment
Results
Reporting
Fig 35
TECHNOLOGY DEVELOPMENT
BIO INTELLIGENCE AGE
CONSUMER ACCEPTANCE
2000 BC
0
1500
1800
1900
2000 AD
TIME (year)
Satava 29 July 99
Fig 36
The BioIntelligence Age
BIOLOGIC
Biosensors
Biomaterials
Biomimetic
PHYSICAL
FUTURE
Genomics
Bioinformatics
Biocomputation
Robotics
HPCC/WWW
MEMS/Nano
INFORMATION
Satava 2 Feb 1999
Fig 37
¿And just what are these incredible new technologies?
Fig 38
University of Montana, 1999
Fig 39
Biomimetic Micro-robot
Fig 40
a. Courtesy Alan Morimoto,Sandia National Labs
b. Capsule camera for gastrointestinal endoscopy
Courtesy Paul Swain, London, England
Femtosecond Laser
Fig 41
(1 x 10 –15 sec)
Los Alamos National Labs, Los Alamos NM
c.Time of Flight Spectroscopy
Cold Spring Harbor Laboratory, Long Island, NY
d. Cellular opto-poration
Fig 42
Surgical console for cellular surgery
Courtesy Prof Jaydev Desai, Drexel Univ, Philadelphia, PA 2005
Fig 43
Surgical console for cellular surgery
Motion
Commands
Courtesy Prof Jaydev Desai, Drexel Univ, Philadelphia, PA 2005
New Surgical Tools
Fig 44
Atomic Force Microscope Manipulator
Femtosecond Lasers
Fig. 2. Top: Fluorescent micrograph of the actin cytoskeleton of an engineered
striated muscle cell. Bottom: AFM-acquired topographical map. Wrinkles and
lines along the diagonals of the 30 micron square are actin stress fibers under the
lipid membrane surface.
Fig. 3. Schematic illustrating the technique for functionalizing AFM
tips to identify specific molecules on the cell surface during raster
scanning.
Fig. 4. Nanoincision by electroporation.
(A) The AFM cantilever is positioned above a region of interest in the cell.
(B) Electrical current is injected through the cantilever tip, causing the
formation of a nanometer scale pore in the membrane, thru which the AFM
tip can be dropped, or other instrumentation attached to the tip, prior to the
membrane resealing.
Courtesy Prof Kit Parker, MD, Harvard Univ, Boston, MA 2005
Fig 45
“BrainGate” John Donohue, Brown University, 2001
Richard Andersen, CalTech, 2003
Greg Kovacs. Stanford University, 1990
Fig 46
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
Fig 47
Thoughts into Action
Direct brain implant control of robot arm
Miguel Nicholai, Duke University, 2002
Fig 48
Fig 49
Fig 50
Intelligent Prostheses
a) Rheo Bionic knee
Ossur, Reyknavik, Iceland
b) C-leg
Otto Bock, Minneapolis, MN
Fig 51
Artificial Retina
a) 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
Fig 52
Tissue Engineering
Artificial Ear
Liver Scaffolding
Artificial Blood Vessel
J. Vacanti, MD
MGH
March, 2000
Fig 53
Courtesy of J. Vacanti, MD
MGH
March, 2000
Fig 54
Orb spider - web
Spinnerette of spider
Spider silk protein as biomaterial -BioSteel
Cross section of synthetic fiber
Nexia Biotechnologies, Montreal Canada
Fig 55
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
Fig 56
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%)
Fig 57
Fig 58
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
Fig 59
The Moral Dilemma
Technology is Neutral - it is neither good or evil
It is up to us to breathe the moral and ethical life
into these technologies
And then apply them with empathy and compassion
for each and every patient
Fig 60
The Scientific Community must engage
in their moral and ethical responsibilities . . .
. . . Or abdicate to those with political and selfish agendas.
Reason there are no penguins at the North Pole
Fig 61
Fig 62
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 (2003)
Fig 63
Five "designer babies"
created for stem cell harvest
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
Preimplantation Genetic Screening
General Science: May 13, 2006
A British woman has become the first in the country to
conceive a "designer baby" selected specifically to avoid
an inherited cancer,
The woman, who was not identified, used controversial
genetic screening technology to ensure she does not pass on
to her child the condition retinoblastoma, an hereditary form
of eye cancer from which she suffers.
Doctors tested embryos created by the woman and her
partner using in-vitro fertilisation (IVF) methods for the
cancer gene. Only unaffected embryos were implanted in
her womb, the newspaper said.
It suggested the woman's pregnancy would increase
controversy over the procedure -- pre-implantation genetic
diagnosis (PGD) -- because critics say it involves destroying
otherwise healthy embryos whose conditions are treatable.
1.
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
Gregory
AuthorityStock
(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
Verlinsky Y, Rechitsky S, Sharapova T, Morris R, Taranissi M and Kuliev A. Preimplantation HLA Testing. JAMA (2004) 29: 2079
Fig 64
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
Fig 65
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
Fig 66
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
Fig 67
Smart Prostheses
Genetic engineering
Regeneration
If I replace 95%
of my body . . .
. . . Am I still “human”?
What does it mean to be human ?
Fig 68
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 of choosing …
… homo sapiens.
Who will be the next “created” species?
Fig 69
http://depts.washington.edu/biointel
Do Robots Dream ?