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

翻译人员: xiaomei he 校对人员: xiang fei

A talk about surgical robots

谈论手术机器人

is also a talk about surgery.

也就是谈论手术。

And while I've tried to make my images not too graphic,

我尽量使我的想象不是太生动的同时，

keep in mind that surgeons have a different relationship with blood

一直记着外科医生对血液的感觉

than normal people do,

与一般人不同。

because, after all, what a surgeon does to a patient,

因为毕竟，外科医生对病人做的

if it were done without consent,

如果没有得到患者同意

would be a felony.

将是严重违法的。

Surgeons are the tailors, the plumbers,

外科医生是裁缝，是管工

the carpenters -- some would say the butchers --

是木匠，也有人说是

of the medical world:

医疗界的屠夫。

cutting, reshaping, reforming,

切开，整形，重塑，

bypassing, fixing.

搭建旁路，固定。

But you need to talk about surgical instruments

但是谈论手术器械需要与

and the evolution of surgical technology together.

手术技术的进展一起来讨论。

So in order to give you some kind of a perspective

为了给大家一些全景的感觉

of where we are right now

对于我们目前

with surgical robots,

手术机器人的水平

and where we're going to be going in the future,

以及将来我们会向哪些方向发展，

I want to give you a little bit of perspective

我想给大家简要介绍一下

of how we got to this point,

我们是如何达到这一步的。

how we even came to believe

我们是如何相信

that surgery was OK,

手术是可行的，

that this was something that was possible to do,

是可以做到的事情，

that this kind of cutting and reforming was OK.

这种切开与整形是可行的。

So, a little bit of perspective --

即是一点点介绍

about 10,000 years of perspective.

关于手术一万年来的发展。

This is a trephinated skull.

这是一个做过环钻术的头颅骨，

And trephination is simply just cutting a hole in the skull.

环钻术简单说就是在头上凿个洞。

And many, many hundreds of skulls like this

而且有成百上千个像这样的头骨

have been found in archaeological sites

在考古时被发现，

all over the world,

在全世界，

dating back five to 10 thousand years.

时间退回五千至一万年。

Five to 10 thousand years! Now imagine this.

时间退回五千至一万年！想象一下。

You are a healer in a Stone Age village.

你是石器时代村落里的一个治疗师，

And you have some guy that you're not quite sure what's wrong with him --

有一些家伙,你不能十分确定他得了什么病，

Oliver Sacks is going to be born way in the future.

（Oliver Sacks(著名神经科医生)将在未来诞生）。

He's got some seizure disorder. And you don't understand this.

患者有些癫痫表现,你并不了解这种病，

But you think to yourself,

但是你自己想：

"I'm not quite sure what's wrong with this guy.

我不是很确定这家伙得了什么病，

But maybe if I cut a hole in his head I can fix it."

但是如果在他的头上切个洞,我可能就能治好它”。

(Laughter)

(观众笑)

Now that is surgical thinking.

现在看那就是手术想法。

Now we've got the dawn of interventional surgery here.

现在 我们看到了介入性手术的曙光。

What is astonishing about this is,

令人惊奇之处是

even though we don't know really how much of this

尽管我们不知道这其中有多少

was intended to be religious,

是出于宗教目的，

or how much of it was intended to be therapeutic,

有多少是出于治疗目的，

what we can tell is that these patients lived!

但我们在这里可以说的是 这些病人存活了！

Judging by the healing on the borders of these holes,

根据这些孔边缘的愈合情况判断

they lived days, months, years following trephination.

他们在钻孔术后活了几天，几个月，甚至很多年。

And so what we are seeing is evidence

因此，我们这里看到的是

of a refined technique

精湛技术的证据，

that was being handed down over thousands and thousands of years,

(该技术)已经传承了成千上万年

all over the world.

遍布全世界。

This arose independently at sites everywhere

在很多地方都有这个手术，

that had no communication to one another.

互相之间没有联系，

We really are seeing the dawn of interventional surgery.

我们的确看到了介入性手术的曙光。

Now we can fast forward many thousands of years

现在，我们快速推进几千年

into the Bronze Age and beyond.

进入到青铜时代，

And we see new refined tools coming out.

我们看到精良的手术器械出现了。

But surgeons in these eras are a little bit more conservative

但是这个时代的手术者

than their bold, trephinating ancestors.

比他们大胆的祖先变得保守了些。

These guys confined their surgery

这些人将手术限制在

to fairly superficial injuries.

相当表浅的创伤。

And surgeons were tradesmen,

而且手术者更像个商人，

rather than physicians.

而不象医生。

This persisted all the way into and through the Renaissance.

这种情况一直延续到文艺复兴时期。

That may have saved the writers,

文艺复兴可能拯救了作家，

but it didn't really save the surgeons terribly much.

但并没有太多地拯救外科医生。

They were still a mistrusted lot.

他们仍受到很多怀疑。

Surgeons still had a bit of a PR problem,

外科医生仍有很多公共关系问题。

because the landscape was dominated

因为当时主要是

by the itinerant barber surgeon.

流动理发医生控制着局面。

These were folks that traveled from village to village, town to town,

这些人穿行于村镇之间，

doing surgery sort of as a form of performance art.

做手术有点像艺术表演。

Because we were in the age before anesthesia,

因为我们这时还没发明麻醉技术，

the agony of the patient

病人的痛苦

is really as much of the public spectacle

象手术本身

as the surgery itself.

一样公开。

One of the most famous of these guys, Frere Jacques,

其中最著名的一位名叫Frere Jacques，

shown here doing a lithotomy --

这里展示的是他在做结石取出术，

which is the removal of the bladder stone,

取出膀胱里的结石

one of the most invasive surgeries they did at the time --

这是当时最具创伤的手术之一，

had to take less than two minutes.

需要在两分钟内结束。

You had to have quite a flair for the dramatic,

你会因这种戏剧性而感到惊奇，

and be really, really quick.

的确是非常迅速。

And so here you see him doing a lithotomy.

在这里你们看到他在做结石取出术了。

And he is credited with doing over 4,000 of these public surgeries,

他的纪录是做了超过4000例这样的公开手术，

wandering around in Europe,

遍布欧洲。

which is an astonishing number,

这是一个令人吃惊的数字，

when you think that surgery must have been a last resort.

尤其是当你认为手术是最后一招。

I mean who would put themselves through that?

我的意思是谁愿意经受那种手术？

Until anesthesia, the absence of sensation.

直到出现了麻醉，使意识丧失。

With the demonstration of the Morton Ether Inhaler

随着莫顿醚吸入的演示

at the Mass. General in 1847,

在马萨诸塞州，大约在1847年

a whole new era of surgery was ushered in.

开创了外科手术的新时代。

Anesthesia gave surgeons the freedom to operate.

麻醉使得外科医生可以自由操作，

Anesthesia gave them the freedom to experiment,

麻醉使他们可以自由尝试，

to start to delve deeper into the body.

开始深入到人体内。

This was truly a revolution in surgery.

这的确是手术的一场革命。

But there was a pretty big problem with this.

但还是有个非常大的问题。

After these very long, painstaking operations,

医生经过长时间辛勤的手术，

attempting to cure things they'd never been able to touch before,

企图去治愈他们过去从未接触到的病症，

the patients died.

但最后病人死了，

They died of massive infection.

他们死于严重感染。

Surgery didn't hurt anymore,

手术没有加重创伤，

but it killed you pretty quickly.

但是它能非常快地将你杀掉。

And infection would continue to claim a majority of surgical patients

而且感染还会继续发生在许多手术病人身上，

until the next big revolution in surgery,

直到外科手术的下一次革命。

which was aseptic technique.

那就是无菌技术。

Joseph Lister was aepsis's,

Joseph Lister是无菌

or sterility's, biggest advocate,

或灭菌的最大拥护者，

to a very very skeptical bunch of surgeons.

他努力说服一群持非常怀疑态度的医生，

But eventually they did come around.

但是最终，他们接受了。

The Mayo brothers came out to visit Lister in Europe.

Mayo兄弟去欧洲拜访了Lister。

And they came back to their American clinic and they said

他们回到美国的诊所后，说

they had learned it was as important to wash your hands

他们学到

before doing surgery

术前清洁双手

as it was to wash up afterwards. (Laughter)

与术后洗手同样重要，

Something so simple.

就是如此简单。

And yet, operative mortality dropped profoundly.

然而，手术死亡率却极大地降低了。

These surgeries were actually now being effective.

这些手术现今也很有效，

With the patient insensitive to pain,

由于病人对疼痛不敏感了，

and a sterile operating field

无菌手术领域

all bets were off, the sky was the limit.

不再有限制，天空才是极限。

You could now start doing surgery everywhere,

现在身体各部位都可以实施手术，

on the gut, on the liver,

肠道、肝脏、

on the heart, on the brain.

心脏，在大脑。

Transplantation: you could take an organ out of one person,

移植：器官从一个人身上取出

you could put it in another person, and it would work.

可以装到另一个人身上，仍然可以工作。

Surgeons didn't have a problem with respectability anymore;

外科医生不再有名声问题，

they had become gods.

他们变成了神。

The era of the "big surgeon, big incision" had arrived,

“大外科医生，大切口”的时代来临了。

but at quite a cost,

但是有很大的成本。

because they are saving lives,

因为医生虽然挽救生命，

but not necessarily quality of life,

但没有特别关注病人的生活质量。

because healthy people don't usually need surgery,

因为健康人通常不需要手术，

and unhealthy people have a very hard time recovering from a cut like that.

而不健康的人要从术后恢复有一段非常痛苦的时间。

The question had to be asked,

所以必须问这样一个问题：

"Well, can we do these same surgeries

“我们能否用小的切口

but through little incisions?"

做同样的手术？

Laparoscopy is doing this kind of surgery:

腹腔镜就是用于这类手术。

surgery with long instruments through small incisions.

手术用长器械，小切口，

And it really changed the landscape of surgery.

它真正改变了手术的景观。

Some of the tools for this had been around for a hundred years,

有些器械大约都有100年了，

but it had only been used as a diagnostic technique

但直到80年代

until the 1980s,

才被用于诊断技术，

when there was changes in camera technologies and things like that,

当时照相这类技术有所改进，

that allowed this to be done for real operations.

使它可以真正用于手术。

So what you see -- this is now the first surgical image --

所以你看到的——这是第一个手术影象——

as we're coming down the tube, this is a new entry into the body.

我们放入这个管子，这是进入身体的一个新入口。

It looks very different from what you're expecting surgery to look like.

它与你所想象的外科手术非常不同。

We bring instruments in,

我们从旁边两个分别的切口

from two separate cuts in the side,

把仪器放进去，

and then you can start manipulating tissue.

然后你可以开始操作了。

Within 10 years of the first gallbladder surgeries

在第一例腹腔镜胆囊手术后的

being done laparoscopically,

10年里，

a majority of gallbladder surgeries

又做了大量的

were being done laparoscopically --

腹腔镜胆囊手术。

truly a pretty big revolution.

这是一场真正的巨大革命。

But there were casualties of this revolution.

但是这场革命是有代价的。

These techniques were a lot harder to learn

这些技术

than people had anticipated.

比人们预料的更难掌握。

The learning curve was very long.

学习曲线很长，

And during that learning curve the complications went quite a bit higher.

在这期间并发症上升相当高。

Surgeons had to give up their 3D vision.

外科医生不得不放弃他们的3维视觉，

They had to give up their wrists.

不得不放弃他们的手腕，

They had to give up intuitive motion in the instruments.

不得不放弃对器械的直觉运动。

This surgeon has over 3,000 hours of laparoscopic experience.

这个医生有3000多小时的腹腔镜经验。

Now this is a particularly frustrating placement of the needle.

现在特别令人沮丧的是针的安置，

But this is hard.

这是很难的。

And one of the reasons why it is so hard

为什么这个很难呢，其中一个原因是

is because the external ergonomics are terrible.

外部工效太糟糕了。

You've got these long instruments, and you're working off your centerline.

你拿着这些长器械，你的操作会偏离中央线。

And the instruments are essentially working backwards.

这个器械基本上是逆向工作的。

So what you need to do, to take the capability of your hand,

所以你要做的，是利用你手的技能，

and put it on the other side of that small incision,

把它放在小切口的另一边，

is you need to put a wrist on that instrument.

你要把你的一个腕子放在那个器械上。

And so -- I get to talk about robots --

然后——我开始谈论机器人——

the da Vinci robot

达芬奇机器人

put just that wrist on the other side of that incision.

把你的腕子放在小切口的另一边。

And so here you're seeing the operation of this wrist.

在这里你可以看到这个腕子在操作。

And now, in contrast to the laparoscopy,

现在与腹腔镜相比，

you can precisely place the needle in your instruments,

你可以准确地把针放到你的器械上，

and you can pass it all the way through

你可以一直穿过它，

and follow it in a trajectory.

跟随它的轨迹。

And the reason why this becomes so much easier

它变得如此简单

is -- you can see on the bottom --

是因为你可以在下面看到，

the hands are making the motions,

手在做这些动作，

and the instruments are following those motions exactly.

器械准确地跟随那些动作。

Now, what you put between those instruments and those hands,

现在你放在器械和手之间的

is a large, fairly complicated robot.

是一个大的，相当复杂的机器人。

The surgeon is sitting at a console,

医生坐在一个控制台边，

and controlling the robot with these controllers.

用这些控制器控制机器人。

And the robot is moving these instruments around,

机器人在挪动这些器械，

and powering them, down inside the body.

推动它们，向下进入身体。

You have a 3D camera, so you get a 3D view.

你有3维相机，你就能得到3维视图。

And since this was introduced in 1999,

从1999年推出这个机器人后，

a lot of these robots have been out

许多机器人问世了，

and being used for surgical procedures like a prostatectomy,

并被用于外科手术，象前列腺切除术。

which is a prostate deep in the pelvis,

前列腺在骨盆深处，

and it requires fine dissection

它需要精细的解剖

and delicate manipulation

精确的操作

to be able to get a good surgical outcome.

才能得到良好的结果。

You can also sew bypass vessels directly onto a beating heart

你也可以给一个跳动的心脏做搭桥

without cracking the chest.

而无需打开心脏。

This is all done in between the ribs.

这都是在肋骨间做的。

And you can go inside the heart itself

你可以进入心脏里，

and repair the valves from the inside.

从内部修补瓣膜。

You've got these technologies -- thank you --

你们已经有了这些技术——谢谢——

(Applause)

（鼓掌）

And so you might say, "Wow this is really cool!

你可能会说，“喔，太酷了！

So, smartypants, why isn't all surgery being done this way?"

为什么不是所有的手术都这样做呢？”

And there are some reasons, some good reasons.

是有一些理由的，一些好的理由。

And cost is one of them.

费用是其中之一。

I talked about the large, complicated robot.

我谈论了大型的、复杂的机器人。

With all its bells and whistles, one of those robots

加上它所有的附属配件，一个机器人

will cost you about as much as a solid gold surgeon.

与你付给金牌外科医生的费用一样。

More useful than a solid gold surgeon,

但它比金牌外科医生更有用，

but, still, it's a fairly big capital investment.

它的确是一个相当大的投资。

But once you've got it, your procedure costs do come down.

但你一旦拥有它，你的费用就会下降。

But there are other barriers.

但还有一些其它障碍。

So something like a prostatectomy --

例如前列腺切除术，

the prostate is small, and it's in one spot,

前列腺很小，在一个位置。

and you can set your robot up very precisely

你安装你的机器人非常精确地在

to work in that one spot.

那一点工作。

And so it's perfect for something like that.

机器人用于这类手术非常好。

And in fact if you, or anyone you know,

实际上如果你或是你认识的人

had their prostate taken out in the last couple of years,

在过去几年里做了前列腺手术，

chances are it was done with one of these systems.

可能会有机会是这样做的。

But if you need to reach more places than just one,

但是如果你的手术不仅在一个位置上，

you need to move the robot.

你就需要挪动机器人。

And you need to put some new incisions in there.

你需要有新的切口，

And you need to re-set it up.

你需要重新设置，

And then you need to add some more ports, and more.

你需要增加一些接口，更多的接口。

And the problem is it gets time-consuming, and cumbersome.

这时的问题就是费时费力。

And for that reason there are many surgeries

因为这个原因，有许多手术

that just aren't being done with the da Vinci.

都不是用达芬奇做的。

So we had to ask the question, "Well how do we fix that?"

因此我们不得不问这样一个问题，“我们如何解决呢”？

What if we could change it so that we didn't have to re-set up

我们能做什么改进使我们不必在每次挪动之后

each time we wanted to move somewhere different?

都要重新设置？

What if we could bring all the instruments

如果我们把所有的仪器

in together in one place?

放在一个地方集中起来会怎样？

How would that change the capabilities of the surgeon?

它会如何改变外科医生的技能？

And how would that change the experience for the patient?

它会如何改变病人的经历？

Now, to do that,

现在要那样做的话，

we need to be able to bring a camera

我们需要能带一个摄像头

and instruments in together through one small tube,

和一些器械，一起穿过小的管道，

like that tube you saw in the laparoscopy video.

就象你在电视腹腔镜手术看到的那个管子一样，

Or, not so coincidentally, like a tube like this.

或不完全一样，就象这个。

So what's going to come out of that tube

从那个管子里会出来什么呢？

is the debut of this new technology,

它是这个新技术的首次亮相，

this new robot that is going to be able to reach anywhere.

这个新机器人可以到达任何地方。

Ready? So here it comes.

准备好了吗？它来了。

This is the camera, and three instruments.

这是摄像头，还有三个器械。

And as you see it come out,

你看见它出来了，

in order to actually be able to do anything useful,

为了真正能够做任何有用的事，

it can't all stay clustered up like this.

它不可能老是以这种成簇的形式在一起。

It has to be able to come off of the centerline

它必须从中央线分出来，

and then be able to work back toward that centerline.

背对着中央线工作。

He's a cheeky little devil.

它是个冒失鬼。

But what this lets you do

但让你做的

is gives you that all-important traction,

是给你所有必要的牵引，

and counter-traction,

反向牵引，

so that you can dissect, so that you can sew,

这样你能够解剖、能够缝合，

so that you can do all the things that you need to do,

你可以做所有你需要做的事，

all the surgical tasks.

所有的手术工作。

But it's all coming in through one incision.

但所有都从一个小切口进去。

It's not so simple.

它并不是这样简单。

But it's worth it for the freedom that this gives us

但值得这样去做，因为它使我们能够

as we're going around.

自如地操作。

For the patient, however,

但对于病人来说

it's transparent. This is all they're going to see.

它是透明的。这是他们想要看到的。

It's very exciting to think where we get to go with this.

想到我们要开始做的事情我们非常兴奋。

We get to write the script of the next revolution in surgery.

我们开始撰写关于外科手术的下一次革命。

As we take these capabilities, and we get to go to the next places,

当我们使用这些技能的时候，我们又开始转向下一个地方，

we get to decide what our new surgeries are going to be.

我们开始考虑新的外科手术会是什么样子。

And I think to really get the rest of the way

我认为要走好这次手术革命

in that revolution,

下面的路，

we need to not just take our hands in in new ways,

我们不仅手要采取新的方式，

we also need to take our eyes in in new ways.

我们的眼睛也要采取新的方式。

We need to see beyond the surface.

我们要透过表面去看。

We need to be able to guide what we're cutting

我们要能够用更好的方法

in a much better way.

指导手术。

This is a cancer surgery.

这是个癌症手术。

One of the problems with this,

其中一个问题是，

even for surgeons who've been looking at this a lot,

即使对于外科医生，尽管他已经看过很多这样的病例，

is you can't see the cancer,

你看不到这个肿瘤，

especially when it's hidden below the surface.

特别是当它隐藏在深处的时候。

And so what we're starting to do

我们开始要做的

is we're starting to inject specially designed markers

就是向血管中注射特殊设计的标记物

into the bloodstream that will target the cancer.

瞄准肿瘤。

It will go, bind to the cancer.

它可以与肿瘤结合在一起。

And we can make those markers glow.

我们可以让那些标记物发光，

And we can take special cameras,

然后我们用特殊的摄像头

and we can look at it.

可以看到它。

Now we know where we need to cut,

现在我们知道我们需要切哪，

even when it's below the surface.

即使它不在表面。

We can take these markers and we can inject them in a tumor site.

我们可以用这些标记物，在肿瘤部位注射。

And we can follow where they flow out from that tumor site,

然后我们能够追溯它们从肿瘤的哪个部位流出来，

so we can see the first places where that cancer might travel.

这样我们能够看到肿瘤最初可能转移的地方。

We can inject these dyes into the bloodstream,

我们可以把这些染料注射到血流中，

so that when we do a new vessel

这样我们可以为心脏堵塞的病人

and we bypass a blockage on the heart,

搭建血管旁路。

we can see if we actually made the connection,

在我们最后为病人缝合之前，

before we close that patient back up again --

我们能够看到是否真正搭建了连接。

something that we haven't been able to do

以前由于没有放射技术，

without radiation before.

有些事我们还是做不到。

We can light up tumors

现在我们能使肿瘤发光，

like this kidney tumor,

就象这个肾肿瘤，

so that you can exactly see where the boundary is

你可以真实地看到肿瘤的边界，

between the kidney tumor and the kidney you want to leave behind,

这个肾你想留下。

or the liver tumor and the liver you want to leave behind.

或者肝脏肿瘤，这个肝脏你想留下。

And we don't even need to confine ourselves

我们甚至不需要限于

to this macro vision.

宏观视野。

We have flexible microscopic probes

我们有很灵活的显微探头

that we can bring down into the body.

可以直接下到身体里。

And we can look at cells directly.

我们可以直接观看细胞。

I'm looking at nerves here. So these are nerves you see, down on the bottom,

我正在这看神经。你看到的就是神经，在下面，

and the microscope probe that's being held by the robotic hand, up at the top.

这个显微探头由机械臂拿着，

So this is all very prototypey at this point.

实物就是这样。

But you care about nerves, if you are a surgical patient.

但如果你是个外科病人你就会关注神经，

Because they let you keep continence,

因为它使你在术后能保持节制、

bladder control, and sexual function after surgery,

排尿控制和性功能。

all of which is generally fairly important to the patient.

这些对病人来说都是非常重要的。

So, with the combination of these technologies

所以将这些技术结合起来

we can reach it all, and we can see it all.

我们就能够做到这一切，看到这一切。

We can heal the disease.

我们可以治愈疾病。

And we can leave the patient whole and intact

我们能保持病人术后

and functional afterwards.

各种功能完整无损。

Now, I've talked about the patient

我一直在谈论病人，

as if the patient is, somehow, someone abstract

好象病人是这个房间外面

outside this room.

某个抽象的人。

And that is not the case.

并不是这样。

Many of you, all of you maybe,

你们中的许多人，或者是全部，

will at some point, or have already, faced a diagnosis of cancer,

将会有这个问题或已经面临癌症

or heart disease, or some organ dysfunction

或心脏病的诊断，或一些器官功能失调，

that's going to buy you a date with a surgeon.

那就是你要花钱和医生约会了。

And when you get to that point --

当你出现这些问题的时候——

I mean, these maladies don't care

我是指，这些疾病可不管你

how many books you've written,

写了多少书，

how many companies you've started,

你拥有多少家公司，

that Nobel Prize you have yet to win,

也不管你获得了诺贝尔奖，

how much time you planned to spend with your children.

你打算与你的孩子在一起度过多少时间。

These maladies come for us all.

这些疾病我们都会有。

And the prospect I'm offering you, of an easier surgery ...

我提供给你的简单手术的前景

is that going to make that diagnosis any less terrifying?

能使诊断少一些恐怖吗？

I'm not sure I really even want it to.

我不能确定我是否真想让它这样。

Because facing your own mortality

因为当你面临死亡的时候

causes a re-evaluation of priorities,

你会重新评价你生活的重点，

and a realignment of what your goals are in life, unlike anything else.

重新排列你生活的目标，不象其它任何事情。

And I would never want to deprive you of that epiphany.

我从来不想剥夺你的顿悟，

What I want instead,

相反我想要的是

is for you to be whole, intact,

你完整无损、

and functional enough to go out and save the world,

功能齐全的去拯救世界，

after you've decided you need to do it.

在你一旦决定去这样做的时候。

And that is my vision for your future.

那就是我对你们未来的想象。

Thank you.

谢谢

(Applause)

（鼓掌）