Nikolai Begg: A tool to fix one of the most dangerous moments in surgery

134,115 views ・ 2014-07-15

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Translator: Bob Prottas Reviewer: Ariana Bleau Lugo
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The first time I stood in the operating room
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and watched a real surgery,
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I had no idea what to expect.
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I was a college student in engineering.
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I thought it was going to be like on TV.
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Ominous music playing in the background,
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beads of sweat pouring down the surgeon's face.
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But it wasn't like that at all.
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There was music playing on this day,
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I think it was Madonna's greatest hits. (Laughter)
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And there was plenty of conversation,
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not just about the patient's heart rate,
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but about sports and weekend plans.
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And since then, the more surgeries I watched,
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the more I realized this is how it is.
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In some weird way, it's just another day at the office.
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But every so often
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the music gets turned down,
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everyone stops talking,
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and stares at exactly the same thing.
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And that's when you know that something absolutely critical
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and dangerous is happening.
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The first time I saw that
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I was watching a type of surgery
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called laparoscopic surgery
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And for those of you who are unfamiliar,
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laparoscopic surgery, instead of the large
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open incision you might be used to with surgery,
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a laparoscopic surgery is where the surgeon creates
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these three or more small incisions in the patient.
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And then inserts these long, thin instruments
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and a camera,
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and actually does the procedure inside the patient.
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This is great because there's much less risk of infection,
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much less pain, shorter recovery time.
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But there is a trade-off,
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because these incisions are created
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with a long, pointed device
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called a trocar.
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And the way the surgeon uses this device
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is that he takes it
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and he presses it into the abdomen
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until it punctures through.
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And now the reason why everyone in the operating room
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was staring at that device on that day
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was because he had to be absolutely careful
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not to plunge it through
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and puncture it into the organs and blood vessels below.
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But this problem should seem pretty familiar to all of you
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because I'm pretty sure you've seen it somewhere else.
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(Laughter)
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Remember this?
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(Applause)
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You knew that at any second
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that straw was going to plunge through,
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and you didn't know if it was going to go out the other side
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and straight into your hand,
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or if you were going to get juice everywhere,
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but you were terrified. Right?
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Every single time you did this,
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you experienced the same fundamental physics
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that I was watching in the operating room that day.
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And it turns out it really is a problem.
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In 2003, the FDA actually came out and said
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that trocar incisions might be the most dangerous step
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in minimally invasive surgery.
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Again in 2009, we see a paper that says
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that trocars account for over half
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of all major complications in laparoscopic surgery.
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And, oh by the way,
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this hasn't changed for 25 years.
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So when I got to graduate school,
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this is what I wanted to work on.
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I was trying to explain to a friend of mine
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what exactly I was spending my time doing,
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and I said,
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"It's like when you're drilling through a wall
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to hang something in your apartment.
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There's that moment when the drill first punctures through the wall
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and there's this plunge. Right?
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And he looked at me and he said,
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"You mean like when they drill into people's brains?"
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And I said, "Excuse me?" (Laughter)
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And then I looked it up and they do drill into people's brains.
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A lot of neurosurgical procedures
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actually start with a drill incision through the skull.
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And if the surgeon isn't careful,
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he can plunge directly into the brain.
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So this is the moment when I started thinking,
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okay, cranial drilling, laparoscopic surgery,
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why not other areas of medicine?
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Because think about it, when was the last time you went to the doctor
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and you didn't get stuck with something? Right?
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So the truth is
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in medicine puncture is everywhere.
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And here are just a couple of the procedures that I've found
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that involve some tissue puncture step.
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And if we take just three of them —
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laparoscopic surgery, epidurals, and cranial drilling —
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these procedures account for over 30,000 complications
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every year in this country alone.
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I call that a problem worth solving.
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So let's take a look at some of the devices
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that are used in these types of procedures.
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I mentioned epidurals. This is an epidural needle.
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It's used to puncture through the ligaments in the spine
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and deliver anesthesia during childbirth.
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Here's a set of bone marrow biopsy tools.
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These are actually used to burrow into the bone
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and collect bone marrow or sample bone lesions.
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Here's a bayonette from the Civil War.
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(Laughter)
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If I had told you it was a medical puncture device
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you probably would have believed me.
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Because what's the difference?
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So, the more I did this research
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the more I thought there has to be
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a better way to do this.
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And for me the key to this problem
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is that all these different puncture devices
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share a common set of fundamental physics.
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So what are those physics?
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Let's go back to drilling through a wall.
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So you're applying a force on a drill towards the wall.
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And Newton says the wall is going to apply force back,
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equal and opposite.
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So, as you drill through the wall,
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those forces balance.
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But then there's that moment
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when the drill first punctures through the other side of the wall,
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and right at that moment the wall can't push back anymore.
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But your brain hasn't reacted to that change in force.
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So for that millisecond,
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or however long it takes you to react, you're still pushing,
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and that unbalanced force causes an acceleration,
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and that is the plunge.
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But what if right at the moment of puncture
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you could pull that tip back,
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actually oppose the forward acceleration?
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That's what I set out to do.
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So imagine you have a device
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and it's got some kind of sharp tip to cut through tissue.
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What's the simplest way you could pull that tip back?
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I chose a spring.
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So when you extend that spring, you extend that tip out
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so it's ready to puncture tissue,
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the spring wants to pull the tip back.
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How do you keep the tip in place
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until the moment of puncture?
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I used this mechanism.
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When the tip of the device is pressed against tissue,
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the mechanism expands outwards and wedges in place against the wall.
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And the friction that's generated
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locks it in place and prevents the spring from retracting the tip.
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But right at the moment of puncture,
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the tissue can't push back on the tip anymore.
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So the mechanism unlocks and the spring retracts the tip.
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Let me show you that happening in slow motion.
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This is about 2,000 frames a second,
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and I'd like you to notice the tip
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that's right there on the bottom, about to puncture through tissue.
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And you'll see that right at the moment of puncture,
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right there, the mechanism unlocks and retracts that tip back.
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I want to show it to you again, a little closer up.
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You're going to see the sharp bladed tip,
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and right when it punctures that rubber membrane
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it's going to disappear into this white blunt sheath.
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Right there.
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That happens within four 100ths of a second after puncture.
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And because this device is designed to address the physics of puncture
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and not the specifics of cranial drilling
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or laparoscopic surgery, or another procedure,
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it's applicable across these different medical disciplines
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and across different length scales.
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But it didn't always look like this.
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This was my first prototype.
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Yes, those are popsicle sticks,
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and there's a rubber band at the top.
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It took about 30 minutes to do this, but it worked.
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And it proved to me that my idea worked
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and it justified the next couple years of work on this project.
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I worked on this because
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this problem really fascinated me.
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It kept me up at night.
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But I think it should fascinate you too,
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because I said puncture is everywhere.
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That means at some point it's going to be your problem too.
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That first day in the operating room
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I never expected to find myself on the other end of a trocar.
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But last year, I got appendicitis when I was visiting Greece.
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So I was in the hospital in Athens,
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and the surgeon was telling me
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he was going to perform a laparoscopic surgery.
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He was going to remove my appendix through these tiny incisions,
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and he was talking about what I could expect for the recovery,
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and what was going to happen.
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He said, "Do you have any questions?" And I said, "Just one, doc.
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What kind of trocar do you use?"
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So my favorite quote about laparoscopic surgery
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comes from a Doctor H. C. Jacobaeus:
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"It is puncture itself that causes risk."
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That's my favorite quote because H.C. Jacobaeus
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was the first person to ever perform laparoscopic surgery on humans,
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and he wrote that in 1912.
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This is a problem that's been injuring and even killing people for over 100 years.
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So it's easy to think that for every major problem out there
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there's some team of experts working around the clock to solve it.
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The truth is that's not always the case.
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We have to be better at finding those problems
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and finding ways to solve them.
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So if you come across a problem that grabs you,
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let it keep you up at night.
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Allow yourself to be fascinated,
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because there are so many lives to save.
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(Applause)
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