1. Fig 1 How the Future of Surgery is Changing: Robotics, telesurgery, surgical simulators and other advanced technologies Richard M. Satava, MD FACS Professor of Surgery University of Washington Program Manager, Advanced Biomedical Technologies Defense Advanced Research Projects Agency (DARPA) and Special Assistant, Advance Medical Technologies US Army Medical Research and Materiel Command University of Washington, September, 2006

2. 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

3. Fig 3 Virtual Autopsy Wound Tract Less than 2% of hospital deaths have autopsy Statistics from autopsy drive national policies

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6. 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...

7. 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

8. Fig 8 Prof. Jacques Marescaux, IRCAD Remote telesurgery Dr. Mehran Anvari, MD McMaster Univ, Toronto CANADA “Operation Lindberg” First remote and trans-Atlantic Telesurgery procedure ROUTINE telesurgery from Hamilton to North Bay 300 mile distant

9. Fig 9 “TriCorder” Point-of-care noninvasive therapy High Intensity Focused Ultrasound for Non-invasive Acoustic hemostasis HIFU Courtesy Larry Crum, Univ Washinton Applied Physics Lab Mechanics to energy

10. 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

11. Fig 11 212th MASH Deployed with LSTAT - Combat Support Hospital LSTAT Deployment to Kosovo - March 2000 Courtesy of Integreated Medical Systems, Signal Hill, CA

12. Fig 12 LSTAT Lite LSTAT for far-forward battlefield – less than 50 lbs LSTAT – Back pack version

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

14. Fig 14 Nightingale UAV Goal  Identify “optimum” VTOL UAV design  Create a new VTOL UAV tailored to the operational need LSTAT Or:

15. Fig 15 Classic Education and Examination

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20. 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 Surgical Simulators Simulation and Objective Assessment

21. Fig 21 ENT Sinusoscopy Simulator Lockheed Martin 1999 Haptics Full System

22. Fig 22 “Red Dragon” “Blue Dragon” passive recording device Courtesy Blake Hannaford, PhD University of Washington, Seattle

23. Fig 23 Hand motion tracking patterns Ara Darzi, MD. Imperial College, London, 2000 Novice Intermediate Expert Objective Assessment

24. Fig 24 Modified Endoscope for Transgastric Surgery Courtesy of N Reddy, Hyperbad India 20005

25. Fig 25 Trans Oral Intra-peritoneal Surgery - Future Courtesy of N Reddy, Hyperbad India 20005

26. Fig 26 Peroral Transgastric Endoscopic Surgery Need for development of modified accessories and endoscopes Courtesy of N Reddy, Hyperbad India 20005

27. Fig 27 Suture Devices Eagle Claw Apollo Project Olympus, Tokyo. Courtesy of N Reddy, Hyperbad India 20005

28. Fig 28 So What Next?

29. Fig 29 “Ubiquitous lights” and “Sea of Cameras” Courtesy Eric LaPorte, MD Barcelona, Spain 2005 Courtesy Takeo Kanade, PhD Pittsburg, PA 1999 l Continuous training, assessment and maintenance of certification “Black Box”

30. Fig 30 “Penelope” – robotic scrub nurse Michael Treat MD, Columbia Univ, NYC. 2003

31. Fig 31 The Operating Room of the Future

32. Fig 32 SATAVA 7 July, 1999 DARPA Fighter Pilots – until 2002 Fighter Pilots – Beyond 2003 Predator 2003

33. Fig 33 Robotic Medical Assistant SATAVA 7 July, 1999 DARPA Nursing shortage crisis Applicable at all levels Hospitals Clinics Nursing Home Assisted living Courtesy Yulun Wang, InTouch Technologies, Inc, Goleta, CA

34. Fig 34 Scientific Method A Paradigm Change? Hypothesis Study DesignExperimentResults Reporting Hypothesis Study Design Modeling & Results Experiment Results Reporting Simulation (Preliminary) Modeling & Simulation Thousands of iterations on a computer

35. Fig 35 BIO INTELLIGENCE AGE TECHNOLOGY DEVELOPMENT CONSUMER ACCEPTANCE AGRICULTURAL AGE INDUSTRIAL AGE BIOINTELLIGENCE AGE INFORMATION AGE TIME (year) 2000 BC02000 AD190018001500 Satava 29 July 99

36. Fig 36 BIOLOGIC PHYSICAL INFORMATION FUTURE Robotics HPCC/WWW MEMS/Nano Genomics Bioinformatics Biocomputation Biosensors Biomaterials Biomimetic Satava 2 Feb 1999 The BioIntelligence Age

37. Fig 37 ¿And just what are these incredible new technologies?

38. Fig 38 University of Montana, 1999

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40. Fig 40 Biomimetic Micro-robot a. Courtesy Alan Morimoto,Sandia National Labs b. Capsule camera for gastrointestinal endoscopy Courtesy Paul Swain, London, England

41. 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

42. Fig 42 Surgical console for cellular surgery Courtesy Prof Jaydev Desai, Drexel Univ, Philadelphia, PA 2005

43. Fig 43 Surgical console for cellular surgery Courtesy Prof Jaydev Desai, Drexel Univ, Philadelphia, PA 2005 Motion Commands

44. 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 Manipulator Femtosecond Lasers

45. Fig 45 Greg Kovacs. Stanford University, 1990 “BrainGate” John Donohue, Brown University, 2001 Richard Andersen, CalTech, 2003

46. Fig 46 Recorded activity for intended movement to a briefly flashed target. TARGETMOVEMENT Time PLAN Courtesy Richard Andersen, Cal Tech, Pasadena, CA Brain Machine Interface – Controlling motion with thoughts

47. Fig 47 Thoughts into Action Miguel Nicholai, Duke University, 2002 Direct brain implant control of robot arm

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50. Fig 50 a) Rheo Bionic knee Ossur, Reyknavik, Iceland b) C-leg Otto Bock, Minneapolis, MN Intelligent Prostheses

51. 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

52. Fig 52 Tissue Engineering Liver Scaffolding Artificial Blood Vessel J. Vacanti, MD MGH March, 2000 Artificial Ear

53. Fig 53 Courtesy of J. Vacanti, MD MGH March, 2000

54. Fig 54 Spider silk protein as biomaterial -BioSteel Nexia Biotechnologies, Montreal Canada Cross section of synthetic fiber Spinnerette of spider Orb spider - web

55. 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 Suspended Animation

56. Fig 56 metabolic rate 0.5 0.01 (2%) active hibernating body temp. 37 o C -2 o C gene ongoing transcription function and translation suppressed heart rate 300 3 resp. rate 150 <1 (breaths/min) (beats/min) (mlO 2 /g/h)

57. Fig 57 Confidential

58. 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 sectors TIME Rate of Change Society Business Sector Technology Healthcare

59. Fig 59 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 The Moral Dilemma

60. 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 !!

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62. 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 Required Tuesday 16 April, 2002, 10:41 GMT 11:41 UK Strict ethical guidelines are needed in China to calm public fears about new cell technologies such as cloning, the country's leading scientist said. Professor Ching-Li Hu, the former deputy director of the World Health Organization, was speaking at the Seventh Human Genome Meeting in Shanghai. His call follows recent reports that Chinese scientists are making fast progress in these research fields. One group in the Central South University in Changsa is said to be producing human embryo clones, while another team from the Sun Yat-sen University of Medical Sciences in Guangzhou is reported to have fused human and rabbit cells to make tissues for research.

63. Fig 63 Genetically “designed” child 1997 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 Screening General Science: May 13, 2006 A British woman has become the first in the country to conceive a "designer baby" selected specifically to avoid an inherited cancer, The woman, who was not identified, used controversial genetic screening technology to ensure she does not pass on to her child the condition retinoblastoma, an hereditary form of eye cancer from which she suffers. Doctors tested embryos created by the woman and her partner using in-vitro fertilisation (IVF) methods for the cancer gene. Only unaffected embryos were implanted in her womb, the newspaper said. It suggested the woman's pregnancy would increase controversy over the procedure -- pre-implantation genetic diagnosis (PGD) -- because critics say it involves destroying otherwise healthy embryos whose conditions are treatable.technology Gregory Stock

64. 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

65. Fig 65 Gaak 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

66. Fig 66 Will Machines become “smarter than humans? ROBOT Hans Moravec Ray Kurzweil Humans vs Machine Humans 4.0 X 10 19 cps Red Storm 3.5 X 10 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 EXCEED HUMAN INTELLIGENCE

67. Fig 67 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 What does it mean to be human ?

68. 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?

69. Fig 69 Do Robots Dream ? http://depts.washington.edu/biointel