Radiology Grand Rounds University of Maryland

Baltimore, MDFebruary 1, 2006

Radiology Grand Rounds University of Maryland

Baltimore, MDFebruary 1, 2006

Impact of Advanced TechnologiesFuture of Medicine

Impact of Advanced TechnologiesFuture of Medicine

Richard M. Satava, MD FACSProfessor of Surgery

University of Washington

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

and

Special Assistant, Advance Medical TechnologiesUS Army Medical Research and Materiel Command

Richard M. Satava, MD FACSProfessor of Surgery

University of Washington

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

and

Special Assistant, Advance Medical TechnologiesUS Army Medical Research and Materiel Command

on the

Conflict of

Interest

Truth in

Advertising

I have nothing to disclose

and no conflict of interest with any corporation

or institution

Air Force 1 - refit Unofficial Administration request

UNCLASSIFIED

“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 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 changing our basic approach in all areas of medicine

. . . EXAMPLES

New technologies that are emerging from Information Age discoveries are changing our basic approach in all areas of medicine

. . . EXAMPLES

Fundamental Concept

Information basis for surgery

Borrow from Industry - CAD/CAM

Information basis for surgery

Borrow from Industry - CAD/CAM

The Fundamental Changes

Why Robots?

The Touch Lab, MITMovie: Alien

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

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

Joel Jensen, SRI International, Menlo Park, CA

Minimally Invasive Surgery

Pre-operative planning

Intra-operative navigation

Remote Surgery

Simulation & Training

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

Mechanical to directed-energy

Therapy to combined with Diagnosis

Minimally invasive to non-invasive

Macro to micro to intra-cellular

Mechanical to directed-energy

Therapy to combined with Diagnosis

Minimally invasive to non-invasive

Macro to micro to intra-cellular

Different instrumentation

“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

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

Surgical console for cellular surgery

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

Motion Commands

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

Mechanical to directed-energy

Therapy to combined with Diagnosis

Minimally invasive to non-invasive

Macro to micro to intra-cellular

Mechanical to directed-energy

Therapy to combined with Diagnosis

Minimally invasive to non-invasive

Macro to micro to intra-cellular

Trans-gastric and Natural Orifice

Modified Endoscope for Transgastric Surgery

Courtesy of N Reddy, Hyperbad India 20005

Trans Oral Intra-peritoneal Surgery - Future

Courtesy of N Reddy, Hyperbad India 20005

Peroral Transgastric Endoscopic Surgery

Need for development of modified accessories and endoscopes

Courtesy of N Reddy, Hyperbad India 20005

Early Luminal Malignancies - Robotic EMR

Courtesy of N Reddy, Hyperbad India 20005

Suture Devices

Eagle ClawApollo ProjectOlympus, Tokyo.

Courtesy of N Reddy, Hyperbad India 20005

Trans-gastric appendectomy

Courtesy of N Reddy, Hyperbad India 20005

So What ?

Figure 3. Micro-robotic endoscopy. Physician controling micro-robot (which has been inserted into the rectum) from endoscope workstation

Figure 2. Translational endoscopy workstation. Physician advancing insertion tube of colonoscope by hand while controlling the tip and valves from endoscopic workstation.

Figure 1. Conventional colonoscopy

Satava RM Future of endoscopy. GI Clin NA, Oct, 1983

Operating Room without lights

Operating Room without people

Operating Room without anesthesia

Operating Room without lights

Operating Room without people

Operating Room without anesthesia

The “operating room” of the future

Eric LaPorta, Barcelona, Spain 2005

New Concepts for OR of the Future

Lighting

“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”

“Penelope” – robotic scrub nurse

Michael Treat MD, Columbia Univ, NYC. 2003

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

Satava March, 2000

Surgeon Assistant Scrub Nurse Circulating nurse

100,000

The Operating Room of the Future

SATAVA 7 July, 1999DARPA

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

Wizard of Id by Brant Parker   

Robotic Medical Assistant

SATAVA 7 July, 1999DARPA

Nursing shortage crisis

Applicable at all levelsHospitalsClinicsNursing HomeAssisted living

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

Biomimetic Micro-robot

Courtesy Sandia National Labs

Capsule camera for gastrointestinal endoscopy

Courtesy Paul Swain, London, England

University of Wisconson, 1999

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

Thoughts into Action

Miguel Nicholai, Duke University, 2002Satava March, 2000

Direct brain implant control of robot arm

Relative size of subjects

Alaska Black Bear

Artic Ground Squirrel

Research in hibernation suspended animation hypometabolic states

resuscitation reperfusion

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

SuspendedAnimation

Institute of Arctic Biology’s

Toolik Field Station,

Alaska's North Slope

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

Classic Education and Examination

How is technology changing the educational process?

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

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

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

SurgicalSimulators

Simulation and Objective Assessment

“Blue Dragon” passive recording device

Courtesy Blake Hannaford, University of Washington, Seattle

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

Novice

Intermediate

Expert

Objective Assessment

MEMS based tracking, RFID, etc

Paradigm Change 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

for

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

Team-training of set-up done on mannequins

The next steps

• Intelligent tutors

• Complex procedures

• Digital libraries

• Surgical Rehearsal

• “Information” is critical to surgical integration• Robotics is one of the key technologies• “Instruments” will change dramatically• Open, minimal, non-invasive will find their niche• The OR will take on a whole new meaning• Anesthesia will be revolutionized• Training with simulators and surgical rehearsal• Objective assessment/certification is continuous

• “Information” is critical to surgical integration• Robotics is one of the key technologies• “Instruments” will change dramatically• Open, minimal, non-invasive will find their niche• The OR will take on a whole new meaning• Anesthesia will be revolutionized• Training with simulators and surgical rehearsal• Objective assessment/certification is continuous

SUMMARY

The Future is not what it used to be . . . Yogi Berra

Wake

up !!

Reason there are no penguins at the North Pole