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The Evolution of Hospitals
      The Next 50 Years


        Richard M. Satava, MD FACS
               Professor of Surgery
             University of Washington
                        and
              Senior Science Advisor
   US Army Medical Research and Materiel Command


      The Future of Healthcare – A.B. Medica
                   Milano, Italy
                  11 June, 2009
reetings from Monterey
                Californi
Presenter Financial Disclosure Slide

                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
Quarto evento dell'11/06/09 - Richard Satava
Quarto evento dell'11/06/09 - Richard Satava
E
X
P
    What does your patient want?
       Arrives in the office and expects:
E             Infinite amount of time
C             Instant diagnosis
T             Immediate treatment
              Absolutely no pain
A             Leaves cured!
T
I   Physician                      as
O
N      Super
S
Disruptive Visions

“The Future is not what it used to be”

                          ….Yogi Berra
The Change-makers
The Technologies
    Robots (large and small)
    Imaging Systems
    Photonics
    Nano-(molecular-) systems
    Genetics
    Tissue Engineering


The Intangibles
    Information (PHR – all bets are off – no hospitals?)
    Integration
    Interoperability
    Energy
    Education
Current Visions
  “The Future is here …

   . . . it’s the Information Age”
Fundamental Concept

New technologies that are emerging
from Information Age discoveries
are driving our basic approach
in all areas of healthcare education
                    ...   EXAMPLES
Why Robots?




Movie: Alien    The Touch Lab, MIT
SThe Industry Standard
I CAD/CAM
M
U                Virtual Design
L
A
T          Virtual Prototyping

I
O
N Virtual Testing & Evaluation
2
t’s Time to Transition
   How we view the EMR                    -    the Interface




                                                                                  0
    Atari 1977                                 Mac 1984
                                                                                  1
                                                                                  5
 Healthcare has yet to realize the potential
 of high performance computing & simulation

 By 2015 a laptop will compute at 1 TeraHz -   today’s supercomputer
                                                                       Courtesy A. Tsiaras
                                                                       Anatomic Travelogue
Information Representation of a Patient
Medical equivalent of CAD/CAM



                                 Holomer
                                 Total body-scan
                                 for total knowledge




                                 Multi-modal total body scan on

Virtual Soldier Program
                                every trauma patient in 15 seconds
                                                 Satava March, 2004
Virtual Autopsy . . .
                                     . . . is a SIMULATED Autopsy




                                                    Wound Tract



  Less than 2% of hospital deaths have autopsy

  Statistics from autopsy drive national policies
Quarto evento dell'11/06/09 - Richard Satava
Quarto evento dell'11/06/09 - Richard Satava
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




                                                        Minimally Invasive
  Remote Surgery                                        & Open Surgery




Pre-operative planning
                                                      Simulation & Training
Surgical Rehearsal
                                                      Pre-operative Warmup
                         Intra-operative navigation     Courtesy of Joel Jensen,
                                                        SRI International, Menlo Park, CA
The Fundamental Change


      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
Therapy
Mechanics to energy




                                          HIFU
                           High Intensity Focused Ultrasound
                                    for
                           Non-invasive Acoustic hemostasis
                         Courtesy Larry Crum, Univ Washington Applied Physics
Courtesy Larry Crum,
Univ Washington
Applied Physics Lab
2003
Sterilization without supplies




          Painless




                                                   10 % e c
                                                     0 ffe tive
                                             3 s c C ntinuo DBD, 8
                                              0 e, o       us      kHz
  Insure safety of other cells and tissues        Power: 0.8 W/cm2
Treatment of Topical Wounds:
Tissue Regeneration: Suppurated Burn Wound




   Before treatment     After 7 days of plasma
                                therapy
                              (5 sessions)
Bring the hospital to the casualty, not the casualty to the hospital . . .

                                                          “ . . . with a fully functional ICU ”

              The LSTAT                                             Total Patient Awareness
 Life Support for Trauma and Transport                                 • Defibrillator
                                                                       • Ventilator
                                                                       • Suction
                                                                       • Monitoring
                                                                       • Blood Chemistry
                                                                          Analysis
                                                                       • 3-Channel Fluid/Drug

                                                                          Infusion
                                                                       •Data Storage and
                                                                          Transmission
                                                                       • On-board Battery
                                                                       • On-board Oxygen
Courtesy of Integrated Medical Systems, Signal Hill, CA                • Accepts Off-Board
LSTAT Deployment to Kosovo - March
     212th MASH Deployed with2000 - Combat Support Hospital
                             LSTAT




LSTAT- lite




                              Courtesy of Integrated Medical Systems, Signal Hill, CA
Why now?
VTOL UAV technology is maturing rapidly enough to minimize risk.
Aeromedical evacuation

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




                         LSTAT
It’s all about . . .



Improved Patient Care


                       through

                                 Virtual Reality
    Manikin




dvanced Medical Education
MEDICAL
 EDUCATION
The Revolution
            is
                          . . .

           Now

Roughly 100 year cycles
Classic Education and Examination




What is the REVOLUTION in Medical Education?
Training     for   New Technical Skills
Halstedian Model:   See One, Do One, Teach One
The New Mandates
Effective
1 July 2008   All residency programs must have
    RRC*        a skills training (simulation) center
1 July 2009   All surgical residents must pass FLS**
   ABS           in order to apply for board certificate
Two Components of the Revolution
 Using Modeling and Simulation


• Objective Training of Technical Skills
           Simulators      (technology)
           Curriculum      (training method)

•   Assessment of Cognitive and Technical Skills
          Criterion-based tools
          Objective metrics
Standardized Curriculum
       Suggested template


• Goals of the Simulation
• Anatomy
• Steps of the Procedures
• Errors
        TEST
• Skills Training
• Outcomes
Technology
   Current areas of simulation
          Models, tissue, animals           Manikin
                                       VR




                                             CAI




Virtual
Virtual                             Live           Constructive
OSATS
             Methodology
Objective StructuredAssessment of Technical Skills




                                Richard Reznick, Univ of Toronto - 1998
Pre-operative Warm-up
Surgical Rehearsal




         Courtesy Jacques Marescaux, IRCAD, Strasbourg France
Nurses   Residents
of




ER   Hand-off   OR   Hand-off   ICU
Comprehensive Curriculum

Basic Skills

      Simple Procedures

              Advanced Procedures

                     Team Training
 Task
 Deconstruction          Continuity   of   Care
Disruptive Technology in Surgery
            N.O.T.E.S.

    N atural O rifice T ransluminal E ndoscopic S urgery
                   Trans-Gastric Surgery



      New surgery for great new opportunities


We need:

     New “tools” for the new procedures
     New simulators for education and training
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                        A      NUBISCOPE 2009




  Grasper and hook
                                Suturing set up




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


  Grasper and Laser tool   additional suction tool

                                Courtesy Karl Storz Endoscopy, Tutlingen, Germany 2009
N.O.T.E.S. COBRA DEVICE




                Courtesy of Olympus Endoscopy - 2007
Future EndoscopicWorkstation?



Conventional colonoscopy




                                          Tele-endoscopy. Controlling micro-robot
                                          (which has been inserted into the rectum)
                                          from endoscope workstation
                                                 [ 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 MEMS
Biopsy forceps, 2 & 3 French (0.7 & 1 mm)




                                  Courtesy MicroFab Inc, 2005
The Future is MEMS
                    Scissors (0.5 & 1 mm)




10 mm
                                    Mechanical Scissors




        Hydraulic Scissors                  Courtesy MicroFab Inc, 2005
Laparoscopic Sewing Machine




                Courtesy of Karl Storz, Tutlingen, German 2008
New Concepts for OR of the Future
         “The OR Without Lights”




                                   Eric LaPorta, Barcelona, Spain 2005
ROBOT SURGICAL TECHNOLOGIES, INC




          “Penelope” – robotic scrub nurse
Currently in Clinical Trials        Michael Treat MD, Columbia Univ, NYC. 2003
Integrating Surgical Systems for Autonomy
 The Operating Room (personnel) of the Future




                                                          100,000




  Surgeon     Assistant    Scrub Nurse     Circulating nurse


     Borrowing from the standard practices of other industries
Quarto evento dell'11/06/09 - Richard Satava
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
Quarto evento dell'11/06/09 - Richard Satava
Predator 2003
Fighter Pilots – until 2002                   Fighter Pilots – Beyond 2003
                                                                SATAVA 7 July, 1999
                                                                DARPA
“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
28 Training & Simulation Journal August/September 2006
Quarto evento dell'11/06/09 - Richard Satava
The Information Age is NOT the Future
The Information Age is the Present ...
                   There is something else out there . . . .




                                                   SATAVA 7 July, 1999
                                                   DARPA
D isruptive V isions

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

                               -    Yogi Berra




                       http://depts.washington.edu/biointel
What is radically new?
Quarto evento dell'11/06/09 - Richard Satava
University of Wisconson, 1999
Biomimetic Micro-robot

Courtesy   Sandia National Labs




Courtesy Danny Scott
Texas Southwestern
Dallas, TX




                                                                Capsule camera for gastrointestinal endoscopy

                                                                Courtesy Paul Swain, London, England
                          Courtesy D. Oleynkov, Univ Nebraska
lf-propelling Gastrointestinal Endoscop
                                        Core functions
                Locomotion                                  Modular functions


External magnetic guidance                                                         Core capsule
                                                                                  systems: optical
                                                                                 system, telemetry
                                                                                     and power
                                                                                      systems,
                                                                                   navigation etc.

                                                                                    Diagnostic
                                                                                  system: sensors
                                  Fluid environment                                for enhanced
                                                                                     diagnosis
                                                                                   Therapeutic /
                                                                                   biopsy system:
                                                                                  devices for tissue
                                                                                    manipulation

                                                                                   Locomotion
                                                                                 system: actuators
                                                                                   for mobility.




 Supported by the European Union as an Integrated Project
Information Society Technologies - Contract Number 033970             Courtesy Marc O. Schurr &
                 www.vector-project.com                               The VECTOR consortium - 2008
Internal Locomotion Actuators Currently
                     Investigated
       Walking robot with legs                                        Submarine     Vibratory locomotion




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




 Supported by the European Union as an Integrated Project
Information Society Technologies - Contract Number 033970                                       Courtesy Marc O. Schurr &
                 www.vector-project.com                                                         The VECTOR consortium - 2008
Acrobat Document
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
Surgical Console for Cellular Surgery




                  Courtesy Prof Jaydev Desai, Drexel Univ, Philadelphia, PA 2005
Surgical Console for Cellular Surgery




        Motion
       Commands




                  Courtesy Prof Jaydev Desai, Drexel Univ, Philadelphia, PA 2005
Molecular Imaging
       BioSurgery




    Courtesy: Rahul G. Thakar, Ph.D. 2007
Simulataneous multifunctional –      Monitoring
6 different fluorophores in a cell




                                     Roger Tsien, UC-San Diego, La Jolla, CA 2006
Atomic Force Microscopy AFM
    AFM of DU 145 cells after
   sonoporation of an ion channel
    Sonoporation        IMSaT Dundee
Surgical Cockpit
Quarto evento dell'11/06/09 - Richard Satava
Simulated Tele-operation




  Chrysalis directed by Julien Leclercq. October 2007
“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

                                                     Direct brain implant control of robot arm

                                                           Miguel Nicholai, Duke University, 2002
Quarto evento dell'11/06/09 - Richard Satava
Quarto evento dell'11/06/09 - Richard Satava
Replacing Human Body Parts
       Intelligent Prostheses                      Tissue Engineering




                                                        Artificial Ear




a) Rheo Bionic knee   b) C-leg
                                        Liver Scaffolding         Artificial Blood Vessel
Ossur,                Otto Bock,
Reyknavik, Iceland    Minneapolis, MN             J. Vacanti, MD MGH   March, 2000
Organs which have been grown synthetically
Commercial Products
   Neo-bladder – a commercial synthetic bladder



   A surgeon takes a        urothelial and smooth      The isolated cells are      The cultured cells are
   small, full-thickness    muscle cells that are      cultured separately until   properly seeded onto a
   biopsy from the          capable of regeneration    there are a sufficient      biodegradable scaffold
   patient’s bladder.       are isolated.              quantity.                   shaped like a bladder.




   The biodegradable
   scaffold dissolves       The body uses the          The neo-bladder              Quality assurance that the
   and is eliminated                                   construct is implanted      cells attach and grow
                            neo-bladder construct
   from the body,           to regenerate and          by the surgeon using        properly throughout the
   leaving a functioning    integrate new tissue,      standard surgical           scaffold. After about 8
   bladder made only of     restoring the bladder’s    techniques.                 weeks, the neo-bladder
   the patient’s own                                                               construct is returned to the
                            functionality.
   newly regenerated                                                               surgeon for implantation.
   tissue.
                           Courtesy of Tegion,
                                        Tengion       East Norrington, PA 2007.
Genetically Re-engineering the Body




      Orb spider - web




                                                      Spinnerette of spider



                                   Spider silk protein as biomaterial -BioSteel
Cross section of synthetic fiber
Suspended                         Animation                               (Auto-anesthesia – FRAMR)
Institute of Arctic Biology’s
Toolik Field Station,
Alaska's North Slope




                                                                     active                       hibernating
                                           heart rate                  300                                3
                                           (beats/min)


                                           resp. rate                 150                              <1
                                           (breaths/min)


                                           body temp.                 37oC                              -2oC

                                           gene                      ongoing                transcription
                                                                         function
                                           and translation suppressed
                                       metabolic rate                       0.5                             0.01 (2%)
                                           (mlO2/g/h)


                        Brian M. Barnes,                 Institute of Arctic Biology , University of Alaska Fairbanks 11/02
nti al
  n fi de
Co
Hypothesis    The Scientific Method
                                            … make evidence-based decisions

                           Design


                                    Experiment


                                                 Results

                                                                 Report




In Science and Discovery,
            there is always Risk . . .
Be careful of
 unintended
 consequences


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


 The only thing more dangerous
 than trying too hard and failing …
     … is not trying hard enough
         and succeeding ! Michelangelo   1503
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
                                                                 Technology
                         Rate of Change



                                                                 Business



                                                                 Society
                                                                 Healthcare




                                             TIME
                      Differing responses to scientific discovery by various sectors
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
Quarto evento dell'11/06/09 - Richard Satava
Human embryos
                                                                        cloned


                                                                              February 12, 2004
Chinese Cloning Control Required                      South Korean team demonstrates
Tuesday 16 April, 2002, 10:41 GMT 11:41 UK
                                                      cloning efficiency for humans similar
   Strict ethical guidelines are needed in China to   to pigs, cattle  | Thersa Tamkins
calm public fears about new cell technologies such
as cloning, the country's leading scientist said.     After outlandish claims, a few media circuses,
   Professor Ching-Li Hu, the former deputy           and some near misses by legitimate
                                                      researchers, a team of South Korean
director of the World Health Organization, was
                                                      researchers reports the production of
speaking at the Seventh Human Genome Meeting          cloned human embryos. The findings, were
in Shanghai. His call follows recent reports that     released Wednesday (Science,
Chinese scientists are making fast progress in        DOI:10.1126 /science.1094515, February 12,
these research fields.                                2004).Wook Suk Hwang and Shin Yong
    One group in the Central South University         Moon of Seoul National University used
in Changsa is said to be producing human              somatic cell nuclear transfer to produce 30
                                                      human blastocysts and a single embryonic
embryo clones, while another team from the Sun
                                                      stem cell line; SCNT-hES-1. Using 242
Yat-sen University of Medical Sciences in             oocytes and cumulus cells from 16 unpaid
Guangzhou is reported to have fused human and         donors, the group achieved a cloning
rabbit cells to make tissues for research.            efficiency of 19 to 29%, on par with that seen
                                                      in cattle (25%) and pigs (26%).
Jeffery Steinberg, MD
Fertility Institutes of Los Angeles
                                        Genetically “designed” child
                                                                                                               1997

                                                                                                             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,
 Preimplantation Genetic Screening                                                         says the medical team.The five babies were born after a
 General Science: May 13, 2006                                                             technique called preimplantation genetic diagnosis
                                                                                           (PGD) was used to test embryos for a tissue type match
 A British woman has become the first in the                                               to the ailing siblings, reports the team, led by Anver
 country to conceive a "designer baby" selected                                            Kuliev at the Reproductive Genetics Institute in
 specifically to avoid an inherited cancer,                                                Chicago, US.The aim in these cases was to provide
                                                                                           stem cells for transplantation to children who are
    The woman, who was not identified, used                        Gregory Stock           suffering from leukaemia 'Unlawful and
 controversial genetic screening technology to ensure                                      unethical' However, the use of this technology to
 she does not pass on to her child the condition                                           provide a "designer baby" to treat an ill sibling is
 retinoblastoma, an hereditary form of eye cancer                                                              Science Vol 315: 1723-25, Mar 2007
                                                                                           highly controversial.A UK couple involved in this
 from which she suffers.
    Doctors tested embryos created by the woman and                  Emergence of Novel Color Vision in Mice Engineered
 her partner using in-vitro fertilisation (IVF) methods              to Express Human Cone Photo-pigment
 for the cancer gene. Only unaffected embryos were
 implanted in her womb, the newspaper said.                        Changes in the genes encoding sensory recptor proteins are an essential step in
    It suggested the woman's pregnancy would
                                                 the evolution of new sensory capacities“new sensory capacities" . In primates, tri-
 increase controversy over the procedure -- pre-
 implantation genetic diagnosis (PGD) -- because chromatic color vision evolved aftre changes in x chromosome linked photopigment genes.
                                                 Heterogous mouse females
 critics say it involves destroying otherwise healthy                            whose retinas contained both mouse pigment
 embryos whose conditions are treatable.         human L pigments showed enhanced long-wavelength sensitivity and chromatic
                                                  human L pigments                                        and
                                                 discrimination. An inherent plasticity in the mammalian visual system thus permits emergence
  1.      Verlinsky Y, Rechitsky S, Sharapova T, Morris R, Taranissi M and Kuliev A. Preimplantation HLA Testing. JAMA (2004) 29: 2079
Extending Longevity
                                                                           April 14, 2004
                                          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
A strain of mice that have lived . . .    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
 . . . more than three normal lifespans   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
Should humans live 200 years?             extend their telomeres, because some stem cells in
                                          middle-aged humans had anomalously long
                                          telomeres.
CAN I REPLACE MY          Artificial organs

 BODY ?                   Smart Prostheses

                          Genetic engineering

                          Regeneration



                    If I replace 95%
                      of my body . . .


                    . . . Am I still “human”?



                   Should there be replacement
                   “parts” for astronauts?
Moral and Ethical Issues
               Raised by Technological Success
                will 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 World
                                                                        SATAVA 7 July, 1999
                                   6                                    DARPA
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?
SMIT2009                                    MIRA2010

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


                                            C A LL F O R A B S TR A C TS
                                                          D E A D L IN E :
                                                   Au g u s t 14 , 2 0 0 9
                                                    Program Chair: Santiago Horgan, MD
                                    Minimally Invas ive Ro bo tic As s o c iatio n (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
Sinaia, Romania, 7-9 October 2009   International Congress.
Do Robots Dream ?
http://depts.washington.edu/biointel
The Fundamental Chang
   The Visual Medical Record




 Well, maybe not all people understand the importance of visualization

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Quarto evento dell'11/06/09 - Richard Satava

  • 1. The Evolution of Hospitals The Next 50 Years Richard M. Satava, MD FACS Professor of Surgery University of Washington and Senior Science Advisor US Army Medical Research and Materiel Command The Future of Healthcare – A.B. Medica Milano, Italy 11 June, 2009
  • 3. Presenter Financial Disclosure Slide 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
  • 6. E X P What does your patient want? Arrives in the office and expects: E Infinite amount of time C Instant diagnosis T Immediate treatment Absolutely no pain A Leaves cured! T I Physician as O N Super S
  • 7. Disruptive Visions “The Future is not what it used to be” ….Yogi Berra
  • 8. The Change-makers The Technologies Robots (large and small) Imaging Systems Photonics Nano-(molecular-) systems Genetics Tissue Engineering The Intangibles Information (PHR – all bets are off – no hospitals?) Integration Interoperability Energy Education
  • 9. Current Visions “The Future is here … . . . it’s the Information Age”
  • 10. Fundamental Concept New technologies that are emerging from Information Age discoveries are driving our basic approach in all areas of healthcare education ... EXAMPLES
  • 11. Why Robots? Movie: Alien The Touch Lab, MIT
  • 12. SThe Industry Standard I CAD/CAM M U Virtual Design L A T Virtual Prototyping I O N Virtual Testing & Evaluation
  • 13. 2 t’s Time to Transition How we view the EMR - the Interface 0 Atari 1977 Mac 1984 1 5 Healthcare has yet to realize the potential of high performance computing & simulation By 2015 a laptop will compute at 1 TeraHz - today’s supercomputer Courtesy A. Tsiaras Anatomic Travelogue
  • 14. Information Representation of a Patient Medical equivalent of CAD/CAM Holomer Total body-scan for total knowledge Multi-modal total body scan on Virtual Soldier Program every trauma patient in 15 seconds Satava March, 2004
  • 15. Virtual Autopsy . . . . . . is a SIMULATED Autopsy Wound Tract Less than 2% of hospital deaths have autopsy Statistics from autopsy drive national policies
  • 18. 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 . . .
  • 19. Total Integration of Surgical Care Minimally Invasive Remote Surgery & Open Surgery Pre-operative planning Simulation & Training Surgical Rehearsal Pre-operative Warmup Intra-operative navigation Courtesy of Joel Jensen, SRI International, Menlo Park, CA
  • 20. The Fundamental Change 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
  • 21. Therapy Mechanics to energy HIFU High Intensity Focused Ultrasound for Non-invasive Acoustic hemostasis Courtesy Larry Crum, Univ Washington Applied Physics
  • 22. Courtesy Larry Crum, Univ Washington Applied Physics Lab 2003
  • 23. Sterilization without supplies Painless 10 % e c 0 ffe tive 3 s c C ntinuo DBD, 8 0 e, o us kHz Insure safety of other cells and tissues Power: 0.8 W/cm2
  • 24. Treatment of Topical Wounds: Tissue Regeneration: Suppurated Burn Wound Before treatment After 7 days of plasma therapy (5 sessions)
  • 25. Bring the hospital to the casualty, not the casualty to the hospital . . . “ . . . with a fully functional ICU ” The LSTAT Total Patient Awareness Life Support for Trauma and Transport • Defibrillator • Ventilator • Suction • Monitoring • Blood Chemistry Analysis • 3-Channel Fluid/Drug Infusion •Data Storage and Transmission • On-board Battery • On-board Oxygen Courtesy of Integrated Medical Systems, Signal Hill, CA • Accepts Off-Board
  • 26. LSTAT Deployment to Kosovo - March 212th MASH Deployed with2000 - Combat Support Hospital LSTAT LSTAT- lite Courtesy of Integrated Medical Systems, Signal Hill, CA
  • 27. Why now? VTOL UAV technology is maturing rapidly enough to minimize risk.
  • 28. Aeromedical evacuation Nightingale UAV Goal  Identify “optimum” VTOL UAV design  Create a new VTOL UAV tailored to the operational need LSTAT
  • 29. It’s all about . . . Improved Patient Care through Virtual Reality Manikin dvanced Medical Education
  • 30. MEDICAL EDUCATION The Revolution is . . . Now Roughly 100 year cycles
  • 31. Classic Education and Examination What is the REVOLUTION in Medical Education?
  • 32. Training for New Technical Skills Halstedian Model: See One, Do One, Teach One
  • 33. The New Mandates Effective 1 July 2008 All residency programs must have RRC* a skills training (simulation) center 1 July 2009 All surgical residents must pass FLS** ABS in order to apply for board certificate
  • 34. Two Components of the Revolution Using Modeling and Simulation • Objective Training of Technical Skills Simulators (technology) Curriculum (training method) • Assessment of Cognitive and Technical Skills Criterion-based tools Objective metrics
  • 35. Standardized Curriculum Suggested template • Goals of the Simulation • Anatomy • Steps of the Procedures • Errors TEST • Skills Training • Outcomes
  • 36. Technology Current areas of simulation Models, tissue, animals Manikin VR CAI Virtual Virtual Live Constructive
  • 37. OSATS Methodology Objective StructuredAssessment of Technical Skills Richard Reznick, Univ of Toronto - 1998
  • 39. Surgical Rehearsal Courtesy Jacques Marescaux, IRCAD, Strasbourg France
  • 40. Nurses Residents
  • 41. of ER Hand-off OR Hand-off ICU
  • 42. Comprehensive Curriculum Basic Skills Simple Procedures Advanced Procedures Team Training Task Deconstruction Continuity of Care
  • 43. Disruptive Technology in Surgery N.O.T.E.S. N atural O rifice T ransluminal E ndoscopic S urgery Trans-Gastric Surgery New surgery for great new opportunities We need: New “tools” for the new procedures New simulators for education and training
  • 44. Trans Oral Intra-peritoneal Surgery - Future Courtesy of N Reddy, Hyperbad India 20005
  • 45. Endo-luminal Malignancies Robotic Endoscopic Mucosal Resection - EMR Courtesy of N Reddy, Hyperbad India 20005
  • 46. First Transgastric Appendectomy – N.O.T.E.S. Courtesy of N Reddy, Hyberdad India 2005
  • 48. NOTES - for Bariatric Surgery
  • 49. Multifunctional Set-ups A NUBISCOPE 2009 Grasper and hook Suturing set up ANUBIS Ancient Egyptian Godness „Magic surgery“ of mumification „Opening of the mouth“ ceremony Grasper and Laser tool additional suction tool Courtesy Karl Storz Endoscopy, Tutlingen, Germany 2009
  • 50. N.O.T.E.S. COBRA DEVICE Courtesy of Olympus Endoscopy - 2007
  • 51. Future EndoscopicWorkstation? Conventional colonoscopy Tele-endoscopy. Controlling micro-robot (which has been inserted into the rectum) from endoscope workstation [ Courtesy R Satava, GI Clinics North America, 1983] Endo-vascular work station – by Hansen Medical, Inc URL http://hansenmedical.com Feb, 2007
  • 52. The Future is MEMS Biopsy forceps, 2 & 3 French (0.7 & 1 mm) Courtesy MicroFab Inc, 2005
  • 53. The Future is MEMS Scissors (0.5 & 1 mm) 10 mm Mechanical Scissors Hydraulic Scissors Courtesy MicroFab Inc, 2005
  • 54. Laparoscopic Sewing Machine Courtesy of Karl Storz, Tutlingen, German 2008
  • 55. New Concepts for OR of the Future “The OR Without Lights” Eric LaPorta, Barcelona, Spain 2005
  • 56. ROBOT SURGICAL TECHNOLOGIES, INC “Penelope” – robotic scrub nurse Currently in Clinical Trials Michael Treat MD, Columbia Univ, NYC. 2003
  • 57. Integrating Surgical Systems for Autonomy The Operating Room (personnel) of the Future 100,000 Surgeon Assistant Scrub Nurse Circulating nurse Borrowing from the standard practices of other industries
  • 59. Demonstration of Phase 1 Operating Room with no People SRI International, Menlo Park, CA January, 2007
  • 60. Demonstration of Phase 1 Operating Room with no People SRI International, Menlo Park, CA January, 2007
  • 62. Predator 2003 Fighter Pilots – until 2002 Fighter Pilots – Beyond 2003 SATAVA 7 July, 1999 DARPA
  • 63. “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 28 Training & Simulation Journal August/September 2006
  • 65. The Information Age is NOT the Future The Information Age is the Present ... There is something else out there . . . . SATAVA 7 July, 1999 DARPA
  • 66. D isruptive V isions “The Future is not what it used to be !” - Yogi Berra http://depts.washington.edu/biointel
  • 70. Biomimetic Micro-robot Courtesy Sandia National Labs Courtesy Danny Scott Texas Southwestern Dallas, TX Capsule camera for gastrointestinal endoscopy Courtesy Paul Swain, London, England Courtesy D. Oleynkov, Univ Nebraska
  • 71. lf-propelling Gastrointestinal Endoscop Core functions Locomotion Modular functions External magnetic guidance Core capsule systems: optical system, telemetry and power systems, navigation etc. Diagnostic system: sensors Fluid environment for enhanced diagnosis Therapeutic / biopsy system: devices for tissue manipulation Locomotion system: actuators for mobility. Supported by the European Union as an Integrated Project Information Society Technologies - Contract Number 033970 Courtesy Marc O. Schurr & www.vector-project.com The VECTOR consortium - 2008
  • 72. Internal Locomotion Actuators Currently Investigated Walking robot with legs Submarine Vibratory locomotion Source (both): A Menciassi et al., CRIM, Scuola Sant‘Anna, Pisa Source: M. Sfakiotakis et al., FORTH, Heraklion Supported by the European Union as an Integrated Project Information Society Technologies - Contract Number 033970 Courtesy Marc O. Schurr & www.vector-project.com The VECTOR consortium - 2008
  • 74. 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
  • 75. Surgical Console for Cellular Surgery Courtesy Prof Jaydev Desai, Drexel Univ, Philadelphia, PA 2005
  • 76. Surgical Console for Cellular Surgery Motion Commands Courtesy Prof Jaydev Desai, Drexel Univ, Philadelphia, PA 2005
  • 77. Molecular Imaging BioSurgery Courtesy: Rahul G. Thakar, Ph.D. 2007
  • 78. Simulataneous multifunctional – Monitoring 6 different fluorophores in a cell Roger Tsien, UC-San Diego, La Jolla, CA 2006
  • 79. Atomic Force Microscopy AFM AFM of DU 145 cells after sonoporation of an ion channel Sonoporation IMSaT Dundee
  • 82. Simulated Tele-operation Chrysalis directed by Julien Leclercq. October 2007
  • 83. “BrainGate” John Donohue, Brown University, 2001 Richard Andersen, CalTech, 2003 Greg Kovacs. Stanford University, 1990
  • 84. 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 Direct brain implant control of robot arm Miguel Nicholai, Duke University, 2002
  • 87. Replacing Human Body Parts Intelligent Prostheses Tissue Engineering Artificial Ear a) Rheo Bionic knee b) C-leg Liver Scaffolding Artificial Blood Vessel Ossur, Otto Bock, Reyknavik, Iceland Minneapolis, MN J. Vacanti, MD MGH March, 2000
  • 88. Organs which have been grown synthetically
  • 89. Commercial Products Neo-bladder – a commercial synthetic bladder A surgeon takes a urothelial and smooth The isolated cells are The cultured cells are small, full-thickness muscle cells that are cultured separately until properly seeded onto a biopsy from the capable of regeneration there are a sufficient biodegradable scaffold patient’s bladder. are isolated. quantity. shaped like a bladder. The biodegradable scaffold dissolves The body uses the The neo-bladder Quality assurance that the and is eliminated construct is implanted cells attach and grow neo-bladder construct from the body, to regenerate and by the surgeon using properly throughout the leaving a functioning integrate new tissue, standard surgical scaffold. After about 8 bladder made only of restoring the bladder’s techniques. weeks, the neo-bladder the patient’s own construct is returned to the functionality. newly regenerated surgeon for implantation. tissue. Courtesy of Tegion, Tengion East Norrington, PA 2007.
  • 90. Genetically Re-engineering the Body Orb spider - web Spinnerette of spider Spider silk protein as biomaterial -BioSteel Cross section of synthetic fiber
  • 91. Suspended Animation (Auto-anesthesia – FRAMR) Institute of Arctic Biology’s Toolik Field Station, Alaska's North Slope active hibernating heart rate 300 3 (beats/min) resp. rate 150 <1 (breaths/min) body temp. 37oC -2oC gene ongoing transcription function and translation suppressed metabolic rate 0.5 0.01 (2%) (mlO2/g/h) Brian M. Barnes, Institute of Arctic Biology , University of Alaska Fairbanks 11/02
  • 92. nti al n fi de Co
  • 93. Hypothesis The Scientific Method … make evidence-based decisions Design Experiment Results Report In Science and Discovery, there is always Risk . . .
  • 94. Be careful of unintended consequences Experience is the name everyone gives to their mistakes - Oscar Wilde The only thing more dangerous than trying too hard and failing … … is not trying hard enough and succeeding ! Michelangelo 1503
  • 95. 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 Technology Rate of Change Business Society Healthcare TIME Differing responses to scientific discovery by various sectors
  • 96. 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
  • 98. Human embryos cloned February 12, 2004 Chinese Cloning Control Required South Korean team demonstrates Tuesday 16 April, 2002, 10:41 GMT 11:41 UK cloning efficiency for humans similar Strict ethical guidelines are needed in China to to pigs, cattle | Thersa Tamkins calm public fears about new cell technologies such as cloning, the country's leading scientist said. After outlandish claims, a few media circuses, Professor Ching-Li Hu, the former deputy and some near misses by legitimate researchers, a team of South Korean director of the World Health Organization, was researchers reports the production of speaking at the Seventh Human Genome Meeting cloned human embryos. The findings, were in Shanghai. His call follows recent reports that released Wednesday (Science, Chinese scientists are making fast progress in DOI:10.1126 /science.1094515, February 12, these research fields. 2004).Wook Suk Hwang and Shin Yong One group in the Central South University Moon of Seoul National University used in Changsa is said to be producing human somatic cell nuclear transfer to produce 30 human blastocysts and a single embryonic embryo clones, while another team from the Sun stem cell line; SCNT-hES-1. Using 242 Yat-sen University of Medical Sciences in oocytes and cumulus cells from 16 unpaid Guangzhou is reported to have fused human and donors, the group achieved a cloning rabbit cells to make tissues for research. efficiency of 19 to 29%, on par with that seen in cattle (25%) and pigs (26%).
  • 99. Jeffery Steinberg, MD Fertility Institutes of Los Angeles Genetically “designed” child 1997 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, Preimplantation Genetic Screening says the medical team.The five babies were born after a General Science: May 13, 2006 technique called preimplantation genetic diagnosis (PGD) was used to test embryos for a tissue type match A British woman has become the first in the to the ailing siblings, reports the team, led by Anver country to conceive a "designer baby" selected Kuliev at the Reproductive Genetics Institute in specifically to avoid an inherited cancer, Chicago, US.The aim in these cases was to provide stem cells for transplantation to children who are The woman, who was not identified, used Gregory Stock suffering from leukaemia 'Unlawful and controversial genetic screening technology to ensure unethical' However, the use of this technology to she does not pass on to her child the condition provide a "designer baby" to treat an ill sibling is retinoblastoma, an hereditary form of eye cancer Science Vol 315: 1723-25, Mar 2007 highly controversial.A UK couple involved in this from which she suffers. Doctors tested embryos created by the woman and Emergence of Novel Color Vision in Mice Engineered her partner using in-vitro fertilisation (IVF) methods to Express Human Cone Photo-pigment for the cancer gene. Only unaffected embryos were implanted in her womb, the newspaper said. Changes in the genes encoding sensory recptor proteins are an essential step in It suggested the woman's pregnancy would the evolution of new sensory capacities“new sensory capacities" . In primates, tri- increase controversy over the procedure -- pre- implantation genetic diagnosis (PGD) -- because chromatic color vision evolved aftre changes in x chromosome linked photopigment genes. Heterogous mouse females critics say it involves destroying otherwise healthy whose retinas contained both mouse pigment embryos whose conditions are treatable. human L pigments showed enhanced long-wavelength sensitivity and chromatic human L pigments and discrimination. An inherent plasticity in the mammalian visual system thus permits emergence 1. Verlinsky Y, Rechitsky S, Sharapova T, Morris R, Taranissi M and Kuliev A. Preimplantation HLA Testing. JAMA (2004) 29: 2079
  • 100. Extending Longevity April 14, 2004 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 A strain of mice that have lived . . . 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 . . . more than three normal lifespans 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 Should humans live 200 years? extend their telomeres, because some stem cells in middle-aged humans had anomalously long telomeres.
  • 101. CAN I REPLACE MY Artificial organs BODY ? Smart Prostheses Genetic engineering Regeneration If I replace 95% of my body . . . . . . Am I still “human”? Should there be replacement “parts” for astronauts?
  • 102. Moral and Ethical Issues Raised by Technological Success will 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 World SATAVA 7 July, 1999 6 DARPA
  • 103. 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?
  • 104. SMIT2009 MIRA2010 January 27-30, 2010 San Diego, CA - Manchester Grand Hyatt C A LL F O R A B S TR A C TS D E A D L IN E : Au g u s t 14 , 2 0 0 9 Program Chair: Santiago Horgan, MD Minimally Invas ive Ro bo tic As s o c iatio n (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 Sinaia, Romania, 7-9 October 2009 International Congress.
  • 105. Do Robots Dream ? http://depts.washington.edu/biointel
  • 106. The Fundamental Chang The Visual Medical Record Well, maybe not all people understand the importance of visualization