Fig 1

How the Future of Surgery is Changing:Robotics, telesurgery, surgical simulators and other advanced technologies

Richard M. Satava, MD FACSProfessor of Surgery

University of Washington

Program Manager, Advanced Biomedical TechnologiesDefense Advanced Research Projects Agency (DARPA)

andSpecial 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

Satava March, 2004

From visible human to Virtual Soldier Multi-modal total body scan on every trauma patient in 15 seconds

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

Joel Jensen, SRI International, Menlo Park, CA

Minimally Invasive Surgery

Pre-operative planning

Intra-operative navigation

Remote Surgery

Simulation & Training

Fig 8

Prof. Jacques Marescaux, IRCAD

Remote telesurgery

Dr. Mehran Anvari, MDMcMaster Univ, Toronto CANADA

“Operation Lindberg”

First remote and trans-AtlanticTelesurgery procedure

ROUTINE telesurgery from Hamilton to North Bay

300 mile distant

Fig 9

“TriCorder” Point-of-care noninvasive therapy

High Intensity Focused Ultrasound for Non-invasiveAcoustic hemostasis

HIFU

Courtesy Larry Crum, Univ Washinton Applied Physics Lab

Mechanics to energy

Fig 10

The LSTAT

Courtesy of Integreated Medical Systems, Signal Hill, CA

“ . . .is aware of everything (patient) . . .”

• 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

Fig 11

212th MASH Deployed with LSTAT - Combat Support Hospital

LSTAT Deployment to Kosovo - March 2000

Courtesy of Integreated Medical Systems, Signal Hill, CA

Fig 12

LSTAT Lite

LSTAT for far-forward battlefield – less than 50 lbs

LSTAT – Back pack version

Fig 13Why now?VTOL UAV technology is maturing rapidly enough to minimize risk.

Fig 14Nightingale UAV Goal Identify “optimum” VTOL UAV design Create a new VTOL UAV tailored to the operational need

LSTAT

Or:

Fig 15

Classic Education and Examination

Fig 16

Fig 17

Fig 18

Fig 19

Fig 20

c. Laparoscopic Simulator with tactile feedback Courtesy Murielle Launay, Xitact, Lausanne Switzerland

b. Laparoscopic hysterectomy Courtesy Michael vanLent, ICT, Los Angeles, CA

a. LapSim simulator tasks - abstract & texture mapped Courtesy Andres Hytland, Sugical Science, Gothenburg, Sweden, 2000

SurgicalSimulators

Simulation and Objective Assessment

Fig 21

ENT Sinusoscopy Simulator Lockheed Martin 1999

HapticsFull System

Fig 22

“Red Dragon”“Blue Dragon” passive recording device

Courtesy Blake Hannaford, PhD University of Washington, Seattle

Fig 23

Hand motion tracking patterns Ara Darzi, MD. Imperial College, London, 2000

Novice

Intermediate

Expert

Objective Assessment

Fig 24

Modified Endoscope for Transgastric Surgery

Courtesy of N Reddy, Hyperbad India 20005

Fig 25Trans Oral Intra-peritoneal Surgery - 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 ClawApollo ProjectOlympus, Tokyo.

Courtesy of N Reddy, Hyperbad India 20005

Fig 28So What Next?

Fig 29

“Ubiquitous lights” and “Sea of Cameras”Courtesy Eric LaPorte, MD Barcelona, Spain 2005Courtesy Takeo Kanade, PhD Pittsburg, PA 1999

l

Continuous training, assessment and maintenance of certification

“Black Box”

Fig 30

“Penelope” – robotic scrub nurse

Michael Treat MD, Columbia Univ, NYC. 2003

Fig 31

The Operating Room of the Future

Fig 32

SATAVA 7 July, 1999DARPA

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

Fig 33

Robotic Medical Assistant

SATAVA 7 July, 1999DARPA

Nursing shortage crisis

Applicable at all levelsHospitalsClinicsNursing HomeAssisted living

Courtesy Yulun Wang, InTouch Technologies, Inc, Goleta, CA

Fig 34

Scientific MethodA Paradigm Change?

Hypothesis Study Design Experiment Results Reporting

Hypothesis Study Design Modeling & Results Experiment Results Reporting Simulation (Preliminary)

Modeling & Simulation

Thousands of iterationson a computer

Fig 35

BIO INTELLIGENCE AGETE

CH

NO

LOG

Y D

EV

ELO

PME

NT

CONSUMER ACCEPTANCE

AGRICULTURAL AGE

INDUSTRIAL AGE

BIOINTELLIGENCE AGE

INFORMATION AGE

TIME (year)

2000 BC 0 2000 AD190018001500

Satava 29 July 99

Fig 36

BIOLOGIC PHYSICAL

INFORMATION

FUTURE

RoboticsHPCC/WWWMEMS/Nano

GenomicsBioinformaticsBiocomputation

BiosensorsBiomaterialsBiomimetic

Satava 2 Feb 1999

The BioIntelligence Age

Fig 37

¿And just what are these incredible new technologies?

Fig 38

University of Montana, 1999

Fig 39

Fig 40Biomimetic Micro-robot

a. Courtesy Alan Morimoto,Sandia National Labs

b. Capsule camera for gastrointestinal endoscopy

Courtesy Paul Swain, London, England

Fig 41

Cold Spring Harbor Laboratory, Long Island, NY

Femtosecond Laser(1 x 10 –15 sec)

c.Time of Flight Spectroscopy

d. Cellular opto-poration

Los Alamos National Labs, Los Alamos NM

Fig 42

Surgical console for cellular surgery

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

Fig 43

Surgical console for cellular surgery

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

Motion Commands

Fig 44

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.

New Surgical Tools

Courtesy Prof Kit Parker, MD, Harvard Univ, Boston, MA 2005

Atomic Force Microscope ManipulatorFemtosecond Lasers

Fig 45

Greg Kovacs. Stanford University, 1990

“BrainGate” John Donohue, Brown University, 2001

Richard Andersen, CalTech, 2003

Fig 46

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

Fig 47

Thoughts into Action

Miguel Nicholai, Duke University, 2002

Direct brain implant control of robot arm

Fig 48

Fig 49

Fig 50

a) Rheo Bionic knee Ossur, Reyknavik, Iceland b) C-leg Otto Bock, Minneapolis, MN

Intelligent Prostheses

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

Liver Scaffolding

Artificial Blood VesselJ. Vacanti, MD MGH March, 2000

Artificial Ear

Fig 53

Courtesy of J. Vacanti, MD MGH March, 2000

Fig 54

Spider silk protein as biomaterial -BioSteel

Nexia Biotechnologies, Montreal Canada

Cross section of synthetic fiber

Spinnerette of spider

Orb spider - web

Fig 55

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

SuspendedAnimation

Fig 56

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)

Fig 57

Confidential

Fig 58

• 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 sectorsTIME

Rat

e of

Cha

nge

Society

Business

Sector

Technology

Healthcare

Fig 59

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

Fig 60

Reason there are no penguins at the North Pole

The Scientific Community must engage in their moral and ethical responsibilities . . .

. . . Or abdicate to those with political and selfish agendas.

ALERT !!

Fig 61

Fig 62

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.

Fig 63

Genetically “designed” child1997

Jeffery Steinberg, MD Fertility Institutes of Los Angeles (2003)

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 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 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

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

Fig 64

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

Fig 65Gaak

Courtesy Professor Noel Sharkey, Sheffield Unversity, London

"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.

TECHNOLOGY NEWS

Intelligent “Living Robot”Uses genetic algorithms to “learn”

Kismet

Courtesy Rosalind Picard, MIT Affective Computing Lab, Boston, MA

ESCAPED

Fig 66

Will Machines become “smarter than humans?

ROBOTHans Moravec

Ray Kurzweil

Humans vs Machine

Humans 4.0X10 19 cpsRed Storm 3.5X10 15 cps

Moore’ s Law “computer power doubles every 18 months”

Do the Math !!

Who is smarter now??

The Age of

Spiritual

Machines

WHEN COMPUTERS EXCEEDHUMAN INTELLIGENCE

Fig 67CAN 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

What does it mean to be human ?

Fig 68

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?

Fig 69

Do Robots Dream ?

http://depts.washington.edu/biointel