Futuristic New World of Surgery Envisioned

BY BETSY BATES

LAS VEGAS -- Surgery in the future will look a lot like surgery today--that is, if you operate at a cockpitlike console, conduct rounds by robot, use smart scalpels that sense when you're close to a blood vessel, and conduct dress rehearsals of complex operations using virtual body images of your patients' anatomies.

"Star Trek, anyone?" Dr. Richard M. Satava asked an audience at the spring meeting of the American College of Surgeons.

It's almost here, explained Dr. Satava, professor of surgery at the University of Washington, Seattle, and Dr. C. Suzanne Cutter, of New York Hospital Queens, Flushing, N.Y., in two separate futuristic sessions at the meeting.

Dr. Satava opened his presentation with an animated video depicting a robotically controlled, armored "casualty evacuation vehicle" scooping up an injured soldier from a battlefield, scanning him for injuries, automatically starting an IV, and prepping him for surgery that is performed by a surgeon watching the scene from a remote, safe location. For the most part, lasers and other energy sources are used in the operation, but when a new tool is needed, a robotic scrub nurse replaces the one in the robotic arm controlled by the surgeon from his console. When the procedure is finished, the soldier is evacuated to safety on an unmanned air vehicle.

The system is based on a new paradigm of "bringing the operating room to the wounded soldier, not the soldier to the operating room," with the ultimate aim of reducing "the golden hour" to "the golden minute."

Such a scenario may seem far-fetched and years away, but there was nothing in the video that has not already been physically built, Dr. Satava noted.

He expects to see a transition "from tissues and instruments to information and energy." Virtual whole-body images, novel energy sources, and traditional surgical tools will be integrated into information systems controlled by the surgeon from a console.

"A robot is not a machine; it is an information system with arms," he said. "A CT scanner is not an imaging device; it is an information system with eyes."

Lifelike surgical rehearsals will be conducted, allowing surgeons to peer into organs and vessels as they navigate their way through superimposed real-time and stored body images, where mistakes can be made on patients' images rather than the patients themselves.

High-intensity focused ultrasound will be coupled with portable ultrasound during surgery, which means that diagnosis and treatment of traumatic bleeding can be accomplished with the same instrument.

Robotic scrub nurses will work from robotic tool-changer carousels capable of dispensing 210 supplies in an average of 7 seconds per instrument. Currently, it takes 17 seconds for a nurse to change a tool on the da Vinci robotic system.

Each time an instrument or supply is used, the patient will be billed, the item will be restocked, and a new one ordered, all in the span of about 50 milliseconds, said Dr. Satava.

Stem cell-based tissue engineering will also radically transform surgery, he predicted.

"I know 23 operations on the stomach, depending upon if you have cancer or an ulcer or bleeding. In the future, with tissue engineering and artificially grown organs, how many operations do you think I'm going to do on the stomach? One. No matter what's wrong with the stomach, I will take out your stomach and give you a brand new one," he declared.

Since immunosuppression will be irrelevant if patients receive stem cell-derived organs constructed according to their anatomy, Dr. Satava questioned whether transplant specialists will become obsolescent. But he said the future looks promising for cell surgery specialists, who may one day conduct microscopic biosurgery, removing individual genes and replacing them with healthy substitutes.

Dr. Cutter painted a picture of the future for today's young surgeons, who are riding "a tidal wave, almost a tsunami of change."

Residents will undergo simulation training using the virtual bone setter, the minimally invasive surgery trainer, and the virtual autopsy.

Bloodless surgery will give way to scarless natural orifice transluminal endoscopic surgery (NOTES). Patients will lie in suspended animation rather than being anesthetized, and operating rooms will have "active ceilings," featuring hundreds of lights interspersed with cameras and three-dimensional operating views, she said.

Doing rounds by robot will save time for surgeons and other physicians. Their images will be projected on a screen at the patient's bedside, ironically allowing more face-to-face communication than many patients now experience with their surgeons.

"We're entering the age of biointelligence," Dr. Cutter said.