1. Radiology Grand Rounds University of Maryland Baltimore, MD February 1, 2006 Impact of Advanced Technologies Future of Medicine 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 on the

2. Conflict of Interest Truth in Advertising I have nothing to disclose and no conflict of interest with any corporation or institution

3. Air Force 1 - refit Unofficial Administration request UNCLASSIFIED

6. “The Future is not what it used to be” ….Yogi Berra Disruptive Visions

7. “The Future is here …... it’s the Information Age” Current Visions

8. New technologies that are emerging from Information Age discoveries are changing our basic approach in all areas of medicine... EXAMPLES Fundamental Concept

9. Information basis for surgery Borrow from Industry - CAD/CAM The Fundamental Changes

10. Why Robots? The Touch Lab, MIT Movie: Alien

11. 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

12. 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...

13. 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

14. 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

15. Mechanical to directed-energy Therapy to combined with Diagnosis Minimally invasive to non-invasive Macro to micro to intra-cellular Different instrumentation

16. “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

17. 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

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

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

20. 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

21. 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

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

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

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

25. Early Luminal Malignancies - Robotic EMR Courtesy of N Reddy, Hyperbad India 20005

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

27. Trans-gastric appendectomy Courtesy of N Reddy, Hyperbad India 20005

28. So What ?

29. 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

30. Operating Room without lights Operating Room without people Operating Room without anesthesia The “operating room” of the future

31. Eric LaPorta, Barcelona, Spain 2005 New Concepts for OR of the Future Lighting

32. “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”

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

34. Integrating Surgical Systems for Autonomy The Operating Room (personnel) of the Future Satava March, 2000 Surgeon Assistant Scrub Nurse Circulating nurse 100,000

37. The Operating Room of the Future

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

41. Wizard of Id by Brant Parker

42. 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

43. Biomimetic Micro-robot Courtesy Sandia National Labs Capsule camera for gastrointestinal endoscopy Courtesy Paul Swain, London, England

45. University of Wisconson, 1999

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

47. 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

48. Thoughts into Action Miguel Nicholai, Duke University, 2002 Satava March, 2000 Direct brain implant control of robot arm

51. Relative size of subjects Alaska Black Bear Artic Ground Squirrel Research in hibernation suspended animation hypometabolic states resuscitation reperfusion

52. Brian M. Barnes, Institute of Arctic Biology, University of Alaska Fairbanks 11/02 Suspended Animation Institute of Arctic Biology’s Toolik Field Station, Alaska's North Slope

53. 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)

54. Confidential

55. Classic Education and Examination How is technology changing the educational process?

56. 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 Surgical Simulators Simulation and Objective Assessment

57. “Blue Dragon” passive recording device Courtesy Blake Hannaford, University of Washington, Seattle

58. Hand motion tracking patterns Ara Darzi, MD. Imperial College, London, 2000 Novice Intermediate Expert Objective Assessment MEMS based tracking, RFID, etc

59. 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

60. 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

61. The next steps Intelligent tutors Complex procedures Digital libraries Surgical Rehearsal

62. “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

63. The Future is not what it used to be... Yogi Berra Wake up !! Reason there are no penguins at the North Pole