Radiology Grand Rounds University of Maryland Baltimore, MD February 1, 2006

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

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

3. UNCLASSIFIED Air Force 1 - refit Unofficial Administration request

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 From visible human to Virtual Soldier Multi-modal total body scan on every trauma patient in 15 seconds Satava March, 2004

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. Minimally Invasive Surgery Remote Surgery Pre-operative planning Simulation & Training Intra-operative navigation Total Integration of Surgical Care Joel Jensen, SRI International, Menlo Park, CA

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

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 Mechanics to energy HIFU High Intensity Focused Ultrasound for Non-invasive Acoustic hemostasis Courtesy Larry Crum, Univ Washinton Applied Physics Lab

17. Femtosecond Laser (1 x 10 –15 sec) Los Alamos National Labs, Los Alamos NM Time of Flight Spectroscopy Cellular opto-poration Cold Spring Harbor Laboratory, Long Island, NY

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

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

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. 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. Fig. 3. Schematic illustrating the technique for functionalizing AFM tips to identify specific molecules on the cell surface during raster scanning. New Surgical Tools Atomic Force Microscope Manipulator Femtosecond Lasers Courtesy Prof Kit Parker, MD, Harvard Univ, Boston, MA 2005

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 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 Figure 3. Micro-robotic endoscopy. Physician controling micro-robot (which has been inserted into the rectum) from endoscope workstation 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. New Concepts for OR of the Future Lighting Eric LaPorta, Barcelona, Spain 2005

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

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 100,000 Surgeon Assistant Scrub Nurse Circulating nurse Satava March, 2000

37. The Operating Room of the Future

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

41. Wizard of Id by Brant Parker   

42. Robotic Medical Assistant Nursing shortage crisis Applicable at all levels Hospitals Clinics Nursing Home Assisted living SATAVA 7 July, 1999 DARPA 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. “BrainGate” John Donohue, Brown University, 2001 Richard Andersen, CalTech, 2003 Greg Kovacs. Stanford University, 1990

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

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