Catherine Mohr: Surgery's past, present and robotic future

53,748 views ・ 2009-06-18

TED


Please double-click on the English subtitles below to play the video.

00:18
A talk about surgical robots
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is also a talk about surgery.
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And while I've tried to make my images not too graphic,
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keep in mind that surgeons have a different relationship with blood
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than normal people do,
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because, after all, what a surgeon does to a patient,
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if it were done without consent,
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would be a felony.
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Surgeons are the tailors, the plumbers,
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the carpenters -- some would say the butchers --
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of the medical world:
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cutting, reshaping, reforming,
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bypassing, fixing.
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But you need to talk about surgical instruments
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and the evolution of surgical technology together.
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So in order to give you some kind of a perspective
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of where we are right now
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with surgical robots,
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and where we're going to be going in the future,
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I want to give you a little bit of perspective
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of how we got to this point,
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how we even came to believe
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that surgery was OK,
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that this was something that was possible to do,
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that this kind of cutting and reforming was OK.
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So, a little bit of perspective --
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about 10,000 years of perspective.
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This is a trephinated skull.
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And trephination is simply just cutting a hole in the skull.
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And many, many hundreds of skulls like this
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have been found in archaeological sites
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all over the world,
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dating back five to 10 thousand years.
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Five to 10 thousand years! Now imagine this.
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You are a healer in a Stone Age village.
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And you have some guy that you're not quite sure what's wrong with him --
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Oliver Sacks is going to be born way in the future.
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He's got some seizure disorder. And you don't understand this.
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But you think to yourself,
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"I'm not quite sure what's wrong with this guy.
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But maybe if I cut a hole in his head I can fix it."
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(Laughter)
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Now that is surgical thinking.
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Now we've got the dawn of interventional surgery here.
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What is astonishing about this is,
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even though we don't know really how much of this
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was intended to be religious,
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or how much of it was intended to be therapeutic,
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what we can tell is that these patients lived!
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Judging by the healing on the borders of these holes,
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they lived days, months, years following trephination.
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And so what we are seeing is evidence
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of a refined technique
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that was being handed down over thousands and thousands of years,
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all over the world.
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This arose independently at sites everywhere
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that had no communication to one another.
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We really are seeing the dawn of interventional surgery.
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Now we can fast forward many thousands of years
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into the Bronze Age and beyond.
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And we see new refined tools coming out.
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But surgeons in these eras are a little bit more conservative
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than their bold, trephinating ancestors.
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These guys confined their surgery
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to fairly superficial injuries.
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And surgeons were tradesmen,
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rather than physicians.
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This persisted all the way into and through the Renaissance.
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That may have saved the writers,
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but it didn't really save the surgeons terribly much.
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They were still a mistrusted lot.
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Surgeons still had a bit of a PR problem,
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because the landscape was dominated
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by the itinerant barber surgeon.
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These were folks that traveled from village to village, town to town,
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doing surgery sort of as a form of performance art.
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Because we were in the age before anesthesia,
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the agony of the patient
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is really as much of the public spectacle
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as the surgery itself.
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One of the most famous of these guys, Frere Jacques,
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shown here doing a lithotomy --
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which is the removal of the bladder stone,
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one of the most invasive surgeries they did at the time --
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had to take less than two minutes.
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You had to have quite a flair for the dramatic,
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and be really, really quick.
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And so here you see him doing a lithotomy.
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And he is credited with doing over 4,000 of these public surgeries,
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wandering around in Europe,
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which is an astonishing number,
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when you think that surgery must have been a last resort.
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I mean who would put themselves through that?
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Until anesthesia, the absence of sensation.
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With the demonstration of the Morton Ether Inhaler
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at the Mass. General in 1847,
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a whole new era of surgery was ushered in.
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Anesthesia gave surgeons the freedom to operate.
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Anesthesia gave them the freedom to experiment,
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to start to delve deeper into the body.
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This was truly a revolution in surgery.
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But there was a pretty big problem with this.
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After these very long, painstaking operations,
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attempting to cure things they'd never been able to touch before,
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the patients died.
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They died of massive infection.
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Surgery didn't hurt anymore,
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but it killed you pretty quickly.
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And infection would continue to claim a majority of surgical patients
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until the next big revolution in surgery,
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which was aseptic technique.
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Joseph Lister was aepsis's,
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or sterility's, biggest advocate,
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to a very very skeptical bunch of surgeons.
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But eventually they did come around.
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The Mayo brothers came out to visit Lister in Europe.
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And they came back to their American clinic and they said
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they had learned it was as important to wash your hands
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before doing surgery
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as it was to wash up afterwards. (Laughter)
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Something so simple.
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And yet, operative mortality dropped profoundly.
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These surgeries were actually now being effective.
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With the patient insensitive to pain,
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and a sterile operating field
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all bets were off, the sky was the limit.
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You could now start doing surgery everywhere,
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on the gut, on the liver,
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on the heart, on the brain.
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Transplantation: you could take an organ out of one person,
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you could put it in another person, and it would work.
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Surgeons didn't have a problem with respectability anymore;
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they had become gods.
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The era of the "big surgeon, big incision" had arrived,
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but at quite a cost,
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because they are saving lives,
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but not necessarily quality of life,
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because healthy people don't usually need surgery,
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and unhealthy people have a very hard time recovering from a cut like that.
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The question had to be asked,
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"Well, can we do these same surgeries
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but through little incisions?"
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Laparoscopy is doing this kind of surgery:
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surgery with long instruments through small incisions.
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And it really changed the landscape of surgery.
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Some of the tools for this had been around for a hundred years,
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but it had only been used as a diagnostic technique
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until the 1980s,
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when there was changes in camera technologies and things like that,
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that allowed this to be done for real operations.
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So what you see -- this is now the first surgical image --
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as we're coming down the tube, this is a new entry into the body.
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It looks very different from what you're expecting surgery to look like.
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We bring instruments in,
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from two separate cuts in the side,
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and then you can start manipulating tissue.
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Within 10 years of the first gallbladder surgeries
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being done laparoscopically,
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a majority of gallbladder surgeries
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were being done laparoscopically --
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truly a pretty big revolution.
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But there were casualties of this revolution.
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These techniques were a lot harder to learn
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than people had anticipated.
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The learning curve was very long.
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And during that learning curve the complications went quite a bit higher.
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Surgeons had to give up their 3D vision.
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They had to give up their wrists.
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They had to give up intuitive motion in the instruments.
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This surgeon has over 3,000 hours of laparoscopic experience.
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Now this is a particularly frustrating placement of the needle.
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But this is hard.
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And one of the reasons why it is so hard
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is because the external ergonomics are terrible.
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You've got these long instruments, and you're working off your centerline.
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And the instruments are essentially working backwards.
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So what you need to do, to take the capability of your hand,
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and put it on the other side of that small incision,
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is you need to put a wrist on that instrument.
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And so -- I get to talk about robots --
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the da Vinci robot
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put just that wrist on the other side of that incision.
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And so here you're seeing the operation of this wrist.
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And now, in contrast to the laparoscopy,
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you can precisely place the needle in your instruments,
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and you can pass it all the way through
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and follow it in a trajectory.
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And the reason why this becomes so much easier
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is -- you can see on the bottom --
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the hands are making the motions,
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and the instruments are following those motions exactly.
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Now, what you put between those instruments and those hands,
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is a large, fairly complicated robot.
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The surgeon is sitting at a console,
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and controlling the robot with these controllers.
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And the robot is moving these instruments around,
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and powering them, down inside the body.
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You have a 3D camera, so you get a 3D view.
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And since this was introduced in 1999,
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a lot of these robots have been out
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and being used for surgical procedures like a prostatectomy,
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which is a prostate deep in the pelvis,
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and it requires fine dissection
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and delicate manipulation
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to be able to get a good surgical outcome.
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You can also sew bypass vessels directly onto a beating heart
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without cracking the chest.
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This is all done in between the ribs.
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And you can go inside the heart itself
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and repair the valves from the inside.
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You've got these technologies -- thank you --
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(Applause)
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And so you might say, "Wow this is really cool!
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So, smartypants, why isn't all surgery being done this way?"
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And there are some reasons, some good reasons.
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And cost is one of them.
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I talked about the large, complicated robot.
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With all its bells and whistles, one of those robots
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will cost you about as much as a solid gold surgeon.
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More useful than a solid gold surgeon,
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but, still, it's a fairly big capital investment.
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But once you've got it, your procedure costs do come down.
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But there are other barriers.
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So something like a prostatectomy --
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the prostate is small, and it's in one spot,
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and you can set your robot up very precisely
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to work in that one spot.
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And so it's perfect for something like that.
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And in fact if you, or anyone you know,
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had their prostate taken out in the last couple of years,
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chances are it was done with one of these systems.
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But if you need to reach more places than just one,
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you need to move the robot.
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And you need to put some new incisions in there.
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And you need to re-set it up.
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And then you need to add some more ports, and more.
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And the problem is it gets time-consuming, and cumbersome.
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And for that reason there are many surgeries
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that just aren't being done with the da Vinci.
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So we had to ask the question, "Well how do we fix that?"
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What if we could change it so that we didn't have to re-set up
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each time we wanted to move somewhere different?
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What if we could bring all the instruments
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in together in one place?
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How would that change the capabilities of the surgeon?
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And how would that change the experience for the patient?
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Now, to do that,
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we need to be able to bring a camera
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and instruments in together through one small tube,
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like that tube you saw in the laparoscopy video.
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Or, not so coincidentally, like a tube like this.
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So what's going to come out of that tube
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is the debut of this new technology,
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this new robot that is going to be able to reach anywhere.
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Ready? So here it comes.
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This is the camera, and three instruments.
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And as you see it come out,
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in order to actually be able to do anything useful,
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it can't all stay clustered up like this.
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It has to be able to come off of the centerline
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and then be able to work back toward that centerline.
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He's a cheeky little devil.
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But what this lets you do
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is gives you that all-important traction,
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and counter-traction,
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so that you can dissect, so that you can sew,
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so that you can do all the things that you need to do,
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all the surgical tasks.
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But it's all coming in through one incision.
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It's not so simple.
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But it's worth it for the freedom that this gives us
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as we're going around.
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For the patient, however,
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it's transparent. This is all they're going to see.
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It's very exciting to think where we get to go with this.
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We get to write the script of the next revolution in surgery.
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As we take these capabilities, and we get to go to the next places,
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we get to decide what our new surgeries are going to be.
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And I think to really get the rest of the way
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in that revolution,
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we need to not just take our hands in in new ways,
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we also need to take our eyes in in new ways.
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We need to see beyond the surface.
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We need to be able to guide what we're cutting
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in a much better way.
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This is a cancer surgery.
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One of the problems with this,
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even for surgeons who've been looking at this a lot,
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is you can't see the cancer,
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especially when it's hidden below the surface.
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And so what we're starting to do
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is we're starting to inject specially designed markers
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into the bloodstream that will target the cancer.
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It will go, bind to the cancer.
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And we can make those markers glow.
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And we can take special cameras,
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and we can look at it.
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Now we know where we need to cut,
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even when it's below the surface.
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We can take these markers and we can inject them in a tumor site.
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And we can follow where they flow out from that tumor site,
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so we can see the first places where that cancer might travel.
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We can inject these dyes into the bloodstream,
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so that when we do a new vessel
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and we bypass a blockage on the heart,
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we can see if we actually made the connection,
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before we close that patient back up again --
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something that we haven't been able to do
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without radiation before.
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We can light up tumors
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like this kidney tumor,
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so that you can exactly see where the boundary is
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between the kidney tumor and the kidney you want to leave behind,
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or the liver tumor and the liver you want to leave behind.
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And we don't even need to confine ourselves
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to this macro vision.
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We have flexible microscopic probes
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that we can bring down into the body.
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And we can look at cells directly.
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I'm looking at nerves here. So these are nerves you see, down on the bottom,
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and the microscope probe that's being held by the robotic hand, up at the top.
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So this is all very prototypey at this point.
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But you care about nerves, if you are a surgical patient.
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Because they let you keep continence,
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bladder control, and sexual function after surgery,
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all of which is generally fairly important to the patient.
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So, with the combination of these technologies
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we can reach it all, and we can see it all.
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We can heal the disease.
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And we can leave the patient whole and intact
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and functional afterwards.
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Now, I've talked about the patient
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as if the patient is, somehow, someone abstract
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outside this room.
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And that is not the case.
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Many of you, all of you maybe,
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will at some point, or have already, faced a diagnosis of cancer,
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or heart disease, or some organ dysfunction
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that's going to buy you a date with a surgeon.
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And when you get to that point --
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I mean, these maladies don't care
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how many books you've written,
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how many companies you've started,
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that Nobel Prize you have yet to win,
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how much time you planned to spend with your children.
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These maladies come for us all.
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And the prospect I'm offering you, of an easier surgery ...
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is that going to make that diagnosis any less terrifying?
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I'm not sure I really even want it to.
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Because facing your own mortality
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causes a re-evaluation of priorities,
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and a realignment of what your goals are in life, unlike anything else.
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And I would never want to deprive you of that epiphany.
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What I want instead,
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is for you to be whole, intact,
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and functional enough to go out and save the world,
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after you've decided you need to do it.
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And that is my vision for your future.
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Thank you.
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18:34
(Applause)
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About this website

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