Richard M. Satava, MD FACSProfessor of Surgery

University of Washingtonand

Senior Science AdvisorUS Army Medical Research and Materiel Command

Richard M. Satava, MD FACSProfessor of Surgery

University of Washingtonand

Senior Science AdvisorUS Army Medical Research and Materiel Command

The Evolution of HospitalsThe Next 50 Years

The Evolution of HospitalsThe Next 50 Years

The Future of Healthcare – A.B. MedicaMilano, Italy11 June, 2009

The Future of Healthcare – A.B. MedicaMilano, Italy11 June, 2009

Greetings from MontereyCalifornia

Richard M. Satava, MD FACS

Financial Support: None (… but still hoping)

Consulting: Karl Storz

ISIS Support Stryker

SimuLab

US Surgical

Investment InTouch Technologies, Inc

* There will be no discussion of products from these companies

Presenter Financial Disclosure Slide

What does your patient want?What does your patient want?

Physician as

Super Her

Arrives in the office and expects:

Infinite amount of timeInstant diagnosisImmediate treatmentAbsolutely no painLeaves cured!

EXPECTATIONS

“The Future is not what it used to be”

….Yogi Berra

“The Future is not what it used to be”

….Yogi Berra

Disruptive Visions

The Change-makers

Robots (large and small)Imaging SystemsPhotonicsNano-(molecular-) systemsGeneticsTissue Engineering

Information (PHR – all bets are off – no hospitals?)

IntegrationInteroperabilityEnergyEducation

The Intangibles

The Technologies

“The Future is here …

. . . it’s the Information Age”

“The Future is here …

. . . it’s the Information Age”

Current Visions

New technologies that are emerging from Information Age discoveries are driving our basic approach in all areas of healthcare education

. . . EXAMPLES

New technologies that are emerging from Information Age discoveries are driving our basic approach in all areas of healthcare education

. . . EXAMPLES

Fundamental Concept

Why Robots?

The Touch Lab, MITMovie: Alien

SIMULATION

The Industry StandardCAD/CAM

Virtual Design

Virtual Prototyping

Virtual Testing & Evaluation

2015

It’s Time to Transition

Healthcare has yet to realize the potentialof high performance computing & simulation

Courtesy A. TsiarasAnatomic Travelogue

How we view the EMR - the InterfaceHow we view the EMR - the Interface

By 2015 a laptop will compute at 1 TeraHz - today’s supercomputer

Atari 1977 Mac 1984

HolomerTotal body-scan

for total knowledge

Satava March, 2004Virtual Soldier Program

Information Representation of a PatientInformation Representation of a PatientMedical equivalent of CAD/CAMMedical equivalent of CAD/CAM

Multi-modal total body scan on every trauma patient in 15 seconds

Virtual Autopsy . . .

Wound Tract

Less than 2% of hospital deaths have autopsy

Statistics from autopsy drive national policies

. . . is a SIMULATED Autopsy. . . is a SIMULATED Autopsy

Why modeling & simulation, imaging and robotics

• 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

Courtesy of Joel Jensen, SRI International, Menlo Park, CA

Minimally Invasive& Open Surgery

Pre-operative planningSurgical Rehearsal

Intra-operative navigation

Remote Surgery

Simulation & TrainingPre-operative Warmup

From tissue and instruments

to

Information and energy*

From tissue and instruments

to

Information and energy*

* “The Information Age is about changing from objects and atoms to bits & bytes”Nicholas Negroponte “Being Digital” - 1995

The Fundamental Change

Point-of-care Noninvasive Therapy

High Intensity Focused Ultrasound for

Non-invasive Acoustic hemostasis

HIFU

Courtesy Larry Crum, Univ Washington Applied Physics Lab

Mechanics to energy

Courtesy Larry Crum, Univ Washington Applied Physics Lab2003

Insure safety of other cells and tissues

Painless

Sterilization without supplies

100% effective30 sec, Continuous DBD, 8kHz

Power: 0.8 W/cm2

Treatment of Topical Wounds:Tissue Regeneration: Suppurated Burn Wound

Before treatment After 7 days of plasma therapy

(5 sessions)

The LSTATLife Support for Trauma and Transport

Courtesy of Integrated Medical Systems, Signal Hill, CA

“ . . . with a fully functional ICU ”

• 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

Total Patient Awareness

Bring the hospital to the casualty, not the casualty to the hospital . . .

212th MASH Deployed with LSTAT - Combat Support Hospital

LSTAT Deployment to Kosovo - March 2000

Courtesy of Integrated Medical Systems, Signal Hill, CA

LSTAT- liteLSTAT- lite

Why now?VTOL UAV technology is maturing rapidly enough to minimize risk.

Nightingale UAV Goal Identify “optimum” VTOL UAV design Create a new VTOL UAV tailored to the operational need

LSTAT

Aeromedical evacuation

Improved Patient Care

through

Advanced Medical Education

ManikinVirtual Reality

It’s all about . . .

The Revolutionis

. . . Now

Roughly 100 year cycles (1908 – Flexner Report)

MEDICAL EDUCATION

Classic Education and Examination

What is the REVOLUTION in Medical Education?

Training for New Technical Skills

Halstedian Model: See One, Do One, Teach One

Effective

1 July 2008 All residency programs must haveRRC* a skills training (simulation) center

1 July 2009 All surgical residents must pass FLS** ABS in order to apply for board certificate

The New Mandates

• Objective Training of Technical SkillsSimulators (technology)

Curriculum (training method)

• Assessment of Cognitive and Technical SkillsCriterion-based toolsObjective metrics

• Objective Training of Technical SkillsSimulators (technology)

Curriculum (training method)

• Assessment of Cognitive and Technical SkillsCriterion-based toolsObjective metrics

Two Components of the RevolutionUsing Modeling and Simulation

Standardized Curriculum

• Goals of the Simulation• Anatomy• Steps of the Procedures• Errors TEST• Skills Training• Outcomes

Suggested template

Technology Current areas of simulation

VirtualVirtualVirtualVirtual LiveLive ConstructiveConstructive

ManikinManikinVRVR

CAICAI

Models, tissue, animalsModels, tissue, animals

Methodology Objective StructuredAssessment of Technical Skills

Richard Reznick, Univ of Toronto - 1998Richard Reznick, Univ of Toronto - 1998

OSATS

Pre-operative Warm-up

Surgical Rehearsal

Courtesy Jacques Marescaux, IRCAD, Strasbourg France

Nurses Residents

OR

of

ER ICUHand-off Hand-off

Basic SkillsBasic Skills

Simple ProceduresSimple Procedures

Team TrainingTeam Training

Advanced ProceduresAdvanced Procedures

Continuity of CareContinuity of Care

Comprehensive CurriculumComprehensive Curriculum

Task Deconstruction

We need: New “tools” for the new procedures New simulators for education and training

We need: New “tools” for the new procedures New simulators for education and training

Disruptive Technology in SurgeryN.O.T.E.S.

Natural Orifice Transluminal Endoscopic SurgeryTrans-Gastric Surgery

New surgery for great new opportunities

Trans Oral Intra-peritoneal Surgery - Future

Courtesy of N Reddy, Hyperbad India 20005

Endo-luminal Malignancies

Robotic Endoscopic Mucosal Resection - EMR

Courtesy of N Reddy, Hyperbad India 20005

First Transgastric Appendectomy – N.O.T.E.S.

Courtesy of N Reddy, Hyberdad India 2005

What next?

NOTES - for Bariatric Surgery

Multifunctional Set-ups

Grasper and hook

Grasper and Laser tool additional suction tool

Suturing set up

Courtesy Karl Storz Endoscopy, Tutlingen, Germany 2009

ANUBISCOPE 2009

ANUBIS

Ancient Egyptian Godness„Magic surgery“ of mumification„Opening of the mouth“ ceremony

N.O.T.E.S. COBRA DEVICE

Courtesy of Olympus Endoscopy - 2007

Tele-endoscopy. Controlling micro-robot (which has been inserted into the rectum) from endoscope workstation

Conventional colonoscopy

Future EndoscopicWorkstation?

[ Courtesy R Satava, GI Clinics North America, 1983]

Endo-vascular work station – by Hansen Medical, Inc

URL http://hansenmedical.com Feb, 2007

The Future is MEMSBiopsy forceps, 2 & 3 French (0.7 & 1 mm)

Courtesy MicroFab Inc, 2005

10 mm

Hydraulic Scissors

Mechanical Scissors

The Future is MEMSScissors (0.5 & 1 mm)

Courtesy MicroFab Inc, 2005

Laparoscopic Sewing Machine

Courtesy of Karl Storz, Tutlingen, German 2008

Eric LaPorta, Barcelona, Spain 2005

New Concepts for OR of the Future“The OR Without Lights”

“Penelope” – robotic scrub nurseMichael Treat MD, Columbia Univ, NYC. 2003

ROBOT SURGICAL TECHNOLOGIES, INC

Currently in Clinical Trials

Integrating Surgical Systems for AutonomyThe Operating Room (personnel) of the Future

Surgeon Assistant Scrub Nurse Circulating nurse

100,000

Borrowing from the standard practices of other industries

Demonstration of Phase 1

Operating Room with no People

SRI International, Menlo Park, CA January, 2007

Demonstration of Phase 1

Operating Room with no People

SRI International, Menlo Park, CA January, 2007

SATAVA 7 July, 1999DARPA

Fighter Pilots – until 2002 Fighter Pilots – Beyond 2003Predator 2003

28 Training & Simulation Journal August/September 2006

“Remote Pilots”

A last bastion of guts-and-glory aviation is falling, as the U.S. Air Force prepares to unveil a new breed of unmanned aircraft pilots. Known as “remote pilots”, they’ll wear wings. They’ll fly aircraft. But chances are many will never climb into a cockpit. . Senior leaders have yet to approve the new Undergraduate Remote Pilot Training (URT), but Air Force officers familiar with the project expect approval by the end of the year. Instead of sticking reluctant manned aviators behind a console, the Air Force will groom remote pilots from the start to fly what the service now calls unmanned aerial systems

SATAVA 7 July, 1999DARPA

The Information Age is NOT the Future

The Information Age is the Present ...

There is something else out there . . . .

Disruptive Visions

http://depts.washington.edu/biointel

“The Future is not what it used to be !”

- Yogi Berra

What is radically new?

University of Wisconson, 1999

Biomimetic Micro-robot

Courtesy Sandia National Labs

Capsule camera for gastrointestinal endoscopy

Courtesy Paul Swain, London, England

Courtesy D. Oleynkov, Univ Nebraska

Courtesy Danny ScottTexas SouthwesternDallas, TX

Core capsule systems: optical system, telemetry

and power systems,

navigation etc.

Diagnostic system: sensors

for enhanced diagnosis

Therapeutic / biopsy system:

devices for tissue manipulation

Locomotion system: actuators

for mobility.

Supported by the European Union as an Integrated ProjectInformation Society Technologies - Contract Number 033970

www.vector-project.comCourtesy Marc O. Schurr &The VECTOR consortium - 2008

External magnetic guidance

Self-propelling Gastrointestinal EndoscopeCore functions

Locomotion Modular functions

Fluid environment

Vibratory locomotionWalking robot with legs

Internal Locomotion Actuators Currently Investigated

Source (both): A Menciassi et al., CRIM, Scuola Sant‘Anna, Pisa

Submarine

Source: M. Sfakiotakis et al., FORTH, Heraklion

Supported by the European Union as an Integrated ProjectInformation Society Technologies - Contract Number 033970

www.vector-project.comCourtesy Marc O. Schurr &The VECTOR consortium - 2008

Acrobat Document

Cold Spring Harbor Laboratory, Long Island, NY

Femtosecond Laser(1 x 10 –15 sec)

Time of Flight Spectroscopy

Cellular opto-poration

Los Alamos National Labs, Los Alamos NM

Surgical Console for Cellular Surgery

Courtesy Prof Jaydev Desai, Drexel Univ, Philadelphia, PA 2005

Courtesy Prof Jaydev Desai, Drexel Univ, Philadelphia, PA 2005

Motion Commands

Surgical Console for Cellular Surgery

Courtesy: Rahul G. Thakar, Ph.D. 2007

Molecular Imaging BioSurgery

Simulataneous multifunctional –6 different fluorophores in a cell

Roger Tsien, UC-San Diego, La Jolla, CA 2006

Monitoring

AFM of DU 145 cells after sonoporation IMSaT Dundee

Atomic Force Microscopy AFM Sonoporation of an ion channel

Surgical Cockpit

Simulated Tele-operation

Chrysalis directed by Julien Leclercq. October 2007

Greg Kovacs. Stanford University, 1990

“BrainGate” John Donohue, Brown University, 2001

Richard Andersen, CalTech, 2003

Recorded activity for intended movement to a briefly flashed target.

TARGET MOVEMENT

Time

PLAN

Courtesy Richard Andersen, Cal Tech, Pasadena, CA

Brain Machine Interface – Controlling motion with thoughts

Miguel Nicholai, Duke University, 2002

Direct brain implant control of robot arm

a) Rheo Bionic knee Ossur, Reyknavik, Iceland

b) C-leg Otto Bock, Minneapolis, MN

Intelligent Prostheses Tissue Engineering

Liver Scaffolding Artificial Blood Vessel

J. Vacanti, MD MGH March, 2000

Artificial Ear

Replacing Human Body Parts

Organs which have been grown synthetically

urothelial and smooth muscle cells that are capable of regeneration are isolated.

The isolated cells are cultured separately until there are a sufficient quantity.

The cultured cells are properly seeded onto a biodegradable scaffold shaped like a bladder.

Quality assurance that the cells attach and grow properly throughout the scaffold. After about 8 weeks, the neo-bladder construct is returned to the surgeon for implantation.

The neo-bladder construct is implanted by the surgeon using standard surgical techniques.

The body uses the neo-bladder construct to regenerate and integrate new tissue, restoring the bladder’s functionality.

The biodegradable scaffold dissolves and is eliminated from the body, leaving a functioning bladder made only of the patient’s own newly regenerated tissue.

A surgeon takes a small, full-thickness biopsy from the patient’s bladder.

Courtesy of Tengion East Norrington, PA 2007.

Neo-bladder – a commercial synthetic bladder

Tegion,

Commercial Products

Spider silk protein as biomaterial -BioSteel

Nexia Biotechnologies, Montreal Canada

Cross section of synthetic fiber

Spinnerette of spider

Orb spider - web

Genetically Re-engineering the Body

Brian M. Barnes, Institute of Arctic Biology , University of Alaska Fairbanks 11/02

Institute of Arctic Biology’s

Toolik Field Station,

Alaska's North Slope

Suspended Animation (Auto-anesthesia – FRAMR)

metabolic rate 0.5 0.01 (2%)

active hibernating

body temp. 37oC -2oC

gene ongoing transcription function and translation suppressed

heart rate 300 3

resp. rate 150 <1 (breaths/min)

(beats/min)

(mlO2/g/h)

Confidential

HypothesisHypothesis

DesignDesign

ExperimentExperiment

ResultsResults

ReportReport

In Science and Discovery, there is always Risk . . .In Science and Discovery, there is always Risk . . .

The Scientific MethodThe Scientific Method… make evidence-based decisions… make evidence-based decisions

The only thing more dangerousthan trying too hard and failing … … is not trying hard enough

and succeeding ! Michelangelo 1503

Experience is the name everyone gives to their mistakes - Oscar Wilde

Be careful ofunintendedconsequences

• The rate of new discovery is accelerating exponentially

• The changes raise profound fundamental issues

• Moral and ethical solutions will take decades to resolve

Technologies Will Change the Future

Differing responses to scientific discovery by various sectors

TIME

Rat

e o

f C

han

ge

Society

Business

Sector

Technology

Healthcare

Technology is Neutral - it is neither good or evil

It is up to us to breathe the moral and ethical lifeinto these technologies

And then apply them with empathy and compassionfor each and every patient

The Moral Dilemma

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-hES-1. 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%).

Human embryos cloned

Chinese Cloning Control RequiredTuesday 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.

Genetically “designed” child1997

Jeffery Steinberg, MD Fertility Institutes of Los Angeles

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 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 '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

1. Verlinsky Y, Rechitsky S, Sharapova T, Morris R, Taranissi M and Kuliev A. Preimplantation HLA Testing. JAMA (2004) 29: 2079

Preimplantation Genetic ScreeningGeneral 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.

Gregory Stock

Science Vol 315: 1723-25, Mar 2007

Emergence of Novel Color Vision in Mice Engineered to Express Human Cone Photo-pigment

Changes in the genes encoding sensory recptor proteins are an essential step in

the evolution of new sensory capacities“new sensory capacities" . In primates, tri-chromatic color vision evolved aftre changes in x chromosome linked photopigment genes. Heterogous mouse females human L pigments showed enhanced long-wavelength sensitivity and chromatic discrimination. An inherent plasticity in the mammalian visual system thus permits emergence

whose retinas contained both mouse pigment andhuman L pigments

Extending Longevity

A strain of mice that have lived . . .

. . . more than three normal lifespans

Should humans live 200 years?

Life extension

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 anti-aging 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.

April 14, 2004

CAN I REPLACE MY

B O D Y ?

If I replace 95% of my body . . .

. . . Am I still “human”?

Artificial organs

Smart Prostheses

Genetic engineering

Regeneration

Should there be replacement “parts” for astronauts?

Moral and Ethical Issues

Raised by Technological Successwill take DECADES of debate

Summary of Examples

Should we do research in areas we may not be able to control? (eg, genetics, cloning, nanobots, intelligent machines?)

Will prolonging life 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 the technology, especially in 3rd WorldSATAVA 7 July, 1999DARPA

6

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?

The Ultimate Ethical Question?

CALL FOR ABSTRACTS

DEADLINE: August 14, 2009

Program Chair: Santiago Horgan, MD

Minimally Invasive Robotic Association (MIRA)

MISSION

To raise the level of robotic surgery care in the world.

As a multidisciplinary association, MIRA invites not only surgeons, but also internists, radiologist, engineers and computer scientists, interested in robotics, telerobotics, telepresence, teleconferencing and telementoring, to join the association and take part in the 2010 International Congress.

SMIT2009 MIRA2010

January 27-30, 2010San Diego, CA - Manchester Grand Hyatt

Sinaia, Romania, 7-9 October 2009

http://depts.washington.edu/biointelDo Robots Dream ?

The Fundamental Change

Well, maybe not all people understand the importance of visualization

The Visual Medical Record