Emerging Technologies in Surgery PDF
Preview Emerging Technologies in Surgery
Richard M. Satava · Achille Gaspari · Nicola Di Lorenzo (Eds.) Emerging Technologies in Surgery Richard M. Satava · Achille Gaspari Nicola Di Lorenzo Emerging Technologies in Surgery With 90 Figures and 2 Tables 123 Richard M. Satava, MD Professor of Surgery Department of Surgery University of Washington Medical Center 1959 NE Pacific St Rm BB487 Seattle, WA 98195 USA Achille Gaspari, MD Tor Vergata University of Rome Department of General Surgery Viale Oxford, 81 00133 Rome, Italy Nicola Di Lorenzo, MD Tor Vergata University of Rome Department of General Surgery Viale Oxford, 81 00133 Rome, Italy Supported by: Library of Congress Control Number: 2006934463 ISBN 978-3-540-39599-7 Springer Berlin Heidelberg New York This work is subject to copyright. All rights are reserved, whether the whole or part of the material is con- cerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, repro- duction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer-Verlag. Violations are liable for prosecution under the German Copyright Law. Springer is a part of Springer Science+Business Media springer.com © Springer-Verlag Berlin Heidelberg 2007 The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Editor: Gabriele Schröder, Heidelberg, Germany Desk Editor: Stephanie Benko, Heidelberg, Germany Reproduction, typesetting and production: LE-TEX Jelonek, Schmidt & Vöckler GbR, Leipzig, Germany Cover design: Frido Steinen-Broo, EStudio, Calamar, Spain Printed on acid-free paper 24/3180/YL 5 4 3 2 1 0 Dedication To our devoted wives, Judith Satava, Franca Gaspari, and Fabiola di Lorenzo, without whose encouragement and patience this would not have been possible. During times of worry and frustration, you were there to console, advise, and help us. But most of all, you were our Muses, and gave us that unique inspiration that lifts the mundane to the sublime. For us, it was having you there to add that special sense of the aesthetic that has made this monograph a true labor of love. Foreword We live in a technological age, and the practice of sur- a shaky start, have in the last few years progressed to a gery is not exempt from this. Furthermore, predic- stage where no surgical training program can afford to tions are that the inevitable trend in surgical practice overlook their importance; the apprenticeship system is toward increasing dependence on high-technology of training is no longer sufficient, especially with the equipment. Thus, Emerging Technologies in Surgery ed- curtailment of the training period. The World Wide ited by Richard Satava, Achille Gaspari, and Nicola Di Web and progress in medical informatics in general Lorenzo, is timely and appropriate. My experience with (disruptive technologies in the extreme) have removed use of medical technologies together with my involve- all possible excuses for all healthcare providers—let ment in related research and development work over alone surgeons—to be misinformed or be lacking in many years has led me to classify these technologies in medical up-to-date information, because the technol- four categories all expertly covered in this book: (1) fa- ogy brings accurate information to the shop floor of cilitative—improve the efficiency of performance and medical practice. There is, however, one issue directly reduce the degree of difficulty of execution of specific related to the increasing dependence of surgical care tasks; (2) additive—bring technical sophistication and on high technology that I feel has been overlooked in accuracy to surgical manipulations/interventions that all training programs and which needs emphasis: Sur- are not considered essential to existing practice; (3) geons and other interventionalists increasingly use so- enabling—make possible certain surgical interventions phisticated energized equipment often and regrettably, or open new therapeutic approaches; and (4) disrup- without an adequate understanding of the physical and tive—technologies that, by breaking new ground, un- engineering principles involved. This cognitive deficit derpin real progress. The term “disruptive technologies” of current training program needs correction. was first coined by Clayton M. Christensen in 1997 in It seems to me that the approaches covered in the his book The Innovator’s Dilemma (Harvard Business various sections of Emerging Technologies in Surgery are School Press), to refer to technologies that, as they ma- breaking down turf barriers between disciplines, such ture, alter the way humans live and work. that patient management is slowly changing from iso- Wisely, the three editors of this book, rather than lated, single-discipline treatment to multidisciplinary pigeonholing the technologies covered in this ex- treatment by disease-related treatment groups, which cellent monograph, have adopted a different layout surgeons must buy into. The spate of integrations, wit- more suited—from a practical and educational stand- nessed on both sides of the Atlantic between vascular point—to the current and future practice of surgery; surgeons and interventional vascular radiologists over however, examples of all these categories are included the past 5 years, is a pertinent example. in the various sections. The contributions to all these The editors are to be congratulated for an immensely sections are by leading-edge experts in the respec- readable and informative monograph. It deserves to tive fields, and after reading all the chapters, I have no be read and will, I am sure, be well received. I suspect, doubts that the editors chose their contributors wisely. however, that we shall witness several future editions Emerging Technologies in Surgery should be of interest since one thing is sure: Medical technology does not to both the surgical trainees and their trainers, because stand still … for long. it contains a wealth of useful and practical informa- tion on the subject. It is appropriate in my view that Sir Alfred Cuschieri, FRS emphasis has been made on education and training, as Professor of Surgery they are axiomatic to quality care in surgical practice. Pisa The advances in virtual surgical simulation that, after Preface Tremendous acceleration and changes in our daily vices that seem to belong to the future but in reality are medical practice are occurring. Both as doctors and being implemented now. Because time and resources ordinary citizens, we are aware of living in a world are not infinite for the surgeon, both in everyday life more and more influenced by information technology. and in their busy practice, we hope this monograph In surgery, this revolution has brought about a dra- will contribute to their ability to select those innova- matic acceleration of the introduction of new devices, tions that will positively impact on his or her practice. techniques, and procedures that are changing patients’ To that end, we have invited eminent surgeons who treatment and destiny. In the last 30 years, innova- are experts on emerging procedures and significant tion has developed exponentially, forcing both current advances in their respective fields to participate. We and future generations to deal with new technologies have been fortunate to assemble authors who are ac- such as microsurgery or laparoscopy, and informatics. knowledged authorities in these areas, both in clinical Meanwhile, the old surgical approach still needs to be practice as well as in surgical education. We are grate- learned and mastered for patients’ safety. ful to them for their essential contributions, to bring Therefore, we decided to offer this book to illustrate together, outline, and illustrate the future trends. We to the practicing surgeon, who has precious little time are especially indebted to Dr. Manzelli for his invalu- to keep up with these rapid changes, what the impor- able support during the preparation of this work. We tant emerging technologies are that could affect his or are proud to have the privilege to stand on the shoul- her practice in the next 10–20 years. We approached ders of these giants. this effort with the expectation that this book will serve as a useful reference to introduce surgeons of every Richard M. Satava, Seattle generation to the principles of new technologies, and Achille L. Gaspari, Roma to familiarize them with those new procedures and de- Nicola Di Lorenzo, Roma Contents Part I Introduction 5.3 Metrics for Objective Assessment .... 29 5.4 Education and Training ............. 30 1 Overview of Emerging Technologies ....... 3 5.5 Simulation Fidelity: Are Graphics Enough? .............. 31 2 Economics of New Surgical Technologies ... 7 5.6 Simulation as Part 2.1 Technology: A Definition of Terms ... 7 of the Curriculum ................. 31 2.2 A Brief History 5.7 Training to Proficiency of Medical Technology .............. 7 on a VR Simulator ................. 32 2.3 The Economic Burden 5.8 Conclusion ........................ 32 of Health Care ...................... 8 2.4 A Technological Solution 6 Organizing Surgical Simulation Centers to Health Care Cost ................. 8 in Response to Disruptive Technologies ... 35 6.1 Making the Case for Simulation 3 The Scientific, Social, and Ethical for Medical Education .............. 35 Implications of Disruptive Technologies ... 11 6.2 Simulation and Simulators 3.1 Introduction ....................... 11 for Medical Education: 3.2 Intelligent Computers and Robots ... 13 Past, Present, and Future ............ 36 3.3 Human Cloning ................... 13 6.2.1 Bench Models ..................... 37 3.4 Genetic Engineering ............... 13 6.2.2 Laparoscopic Skills ................. 37 3.5 Longevity ......................... 14 6.2.3 Gastrointestinal Endoscopy ......... 38 3.6 Human–Machine Communication .. 14 6.2.4 Endonasal Surgery ................. 38 3.7 Artificial Organs and Prostheses .... 14 6.2.5 Urology ........................... 38 3.8 Suspended Animation .............. 15 6.2.6 Bronchoscopy ..................... 38 3.9 Summary ......................... 15 6.2.7 Anesthesiology .................... 38 6.2.8 Case Study: The National Capital Area Medical Simulation Center ..... 39 Part II Education and Training 6.3 Conclusion ........................ 44 4 The World Virtual University and 7 Ideal VR systems: Is There a „Holy Grail“ the Internet: http://www.websurg.com ..... 19 in Simulation System Land? ............... 47 4.1 Surgical Operative Techniques ...... 21 7.1 Curriculum ........................ 50 4.2 Video Footage ..................... 21 4.3 The Voices and Opinions 8 The Medical Informatics Challenge of the Experts ...................... 22 in Surgery ................................ 57 4.4 New Improvements for Access 8.1 The Perioperative Environment ..... 57 to Surgical Education ............... 22 8.1.1 Why Adapt Solutions 4.5 Other Educational Services ......... 22 from Other Industries? ............. 58 8.2 Radical Improvement 5 Virtual Reality: Objective Assessment, in Quality of Patient Care is Possible 58 Education, and Training .................. 27 8.3 Toward a Solution: 5.1 Simulation Development: Adaptive Process Control ........... 59 Lessons Learned ................... 28 8.4 Context-Aware Workflow 5.2 Simulation Training: as Autopilot ....................... 60 Evidence-Based Adoption? .......... 28 XII Contents 8.5 Stealth Mode: 9.8 Adrenalectomy .................... 80 Automated Data Collection ......... 60 9.9 Donor Nephrectomy ............... 81 8.6 A RECIPE for Incremental Systems 9.10 Conclusion ........................ 82 Evolution and Process Improvement 61 8.7 Applying the RECIPE 10 Evolving Endoluminal Therapies .......... 85 to Perioperative Systems Design ..... 63 10.1 Endoluminal Surgery ............... 85 8.8 Perioperative Systems Acceleration 10.2 Transvisceral Surgery ............... 86 Tool in the Preoperative Period ...... 63 8.9 PSPAT in the Intraoperative Period .. 65 8.10 PSPAT in the Postoperative Period ... 65 Part IV Innovations in Surgical 8.11 PSPAT at the University of Instruments Maryland Medical Center ........... 65 8.12 PSPAT Components ................ 66 11 Microtechnology in Surgical Devices ...... 89 8.12.1 A Workflow Engine ................ 66 11.1 Introduction ....................... 89 8.12.2 Adapters to Gather Information 11.2 MST in Medical Devices: from any Human or Machine Source 67 Challenges and Opportunities ....... 89 8.12.3 MER: Virtual Information 11.3 Areas of MST Applications Repository in Medical Devices ................. 90 for the Workflow Engine Access ..... 67 11.3.1 Extracorporeal 8.12.4 A Rules Engine to Provide MST-Enhanced Devices ............ 92 Intelligent Agent Support 11.3.2 Intracorporeal for the Workflow Engine ............ 67 MST-Enhanced Devices ............ 92 8.12.5 An Alerting System to Ensure 11.3.3 Implantable MST Devices ........... 93 Timely Completion of Clinical Events 68 11.3.4 MST in Endoscopy ................. 95 8.12.6 A Reporting System to Access 11.4 Discussion ......................... 96 Outcomes Data in Real Time ........ 68 8.12.7 A Logistics Subsystem to Manage 12 Innovative Instruments Inventory ......................... 69 in Endoscopic Surgery .................... 99 8.12.8 Web-Based Telemedicine View ...... 69 12.1 Introduction ....................... 99 8.13 Research Directions ................ 69 12.2 Innovative Instruments 8.14 Web Services ...................... 69 for Laparoscopic Surgery ........... 99 8.15 Conclusion ........................ 70 12.2.1 Curved Instruments ................ 99 12.2.2 Instruments with All Degrees of Freedom for Suturing: Part III Robotics and Novel Surgical the Radius Surgical System ......... 101 Approaches 12.2.3 The Endofreeze System ............ 102 12.2.4 Combination Instruments 9 Robotics in General Surgery: for Endoscopic Surgery ............ 103 Today and Tomorrow .................... 75 12.3 Endoluminal Surgery 9.1 Introduction ....................... 75 of Rectum and Colon .............. 103 9.2 Cholecystectomy ................... 75 12.4 Full-Thickness Resection Device, 9.3 Bariatric Surgery ................... 75 the Concept of a New Device 9.3.1 Robotic-Assisted for Removal of Polyps from Roux-en-Y Gastric Bypass .......... 76 the Rectum and Descending Colon 105 9.3.2 Robotic-Assisted 12.5 Conclusion ....................... 106 Adjustable Gastric Banding ......... 77 9.3.3 Robotic-Assisted Biliary Pancreatic 13 New Hemostatic Dissecting Forceps Diversion with Duodenal Switch .... 77 with a Metal Membrane Heating Element 107 9.4 Esophageal Surgery ................ 78 13.1 Introduction ...................... 107 9.4.1 Heller Myotomy ................... 78 13.2 Materials and Methods ............ 107 9.4.2 Resection of Epiphrenic 13.3 Results ........................... 109 Diverticulum ...................... 79 13.4 Discussion ........................ 110 9.4.3 Total Esophagectomy ............... 79 Acknowledgment ................. 112 9.4.4 Esophageal Leiomyoma ............. 79 9.5 Pancreatic Surgery ................. 80 14 Radiofrequency and Hepatic Tumors ..... 113 9.6 Gastric Surgery .................... 80 14.1 Introduction ...................... 113 9.7 Colorectal Surgery ................. 80 14.2 Conclusions ...................... 119 Contents XIII 15 Technological Innovations in Kidney Part V Bioengineering and Liver Living-Donor–Related Transplantation ............................... 123 16 Tissue Engineering ...................... 133 15.1 Introduction ..................... 123 16.1 Introduction ...................... 133 15.2 Robotic Technology in Laparoscopic 16.2 Overview ......................... 135 Living-Donor Nephrectomy ....... 123 16.2.1 Skin .............................. 135 15.3 Surgical Technique ............... 125 16.2.2 Cartilage ......................... 136 15.4 Liver Transplantation .............. 126 16.2.3 Bone ............................. 137 15.4.1 Technological Innovations in 16.2.4 Intestine .......................... 139 Transplant Surgery: from “Crash 16.2.5 Cardiovascular Tissue ............. 140 Clamp Technique” to Modern 16.2.6 Liver ............................. 143 Instruments of “Intelligent” 16.3 Future Prospects .................. 144 Dissection, Hemostasis ............ 126 16.4 Relevance 15.5 Transection Systems .............. 127 for the Practicing Surgeon ......... 146 15.5.1 Ultrasonic Dissector ............... 127 15.5.2 Water-Jet Dissector ................ 127 15.6 Hemostasis Systems ............... 127 Part VI Beyond the Future 15.6.1 Staplers .......................... 127 15.6.2 Floating Ball ...................... 127 17 Adapting to Future Technologies ......... 155 15.7 Simultaneous Hemostasis and 17.1 Introduction ...................... 155 Transection ....................... 128 17.2 The Scientific Method ............. 155 15.7.1 Thermal Methods ................ 128 17.3 Interdisciplinary Medicine ......... 156 15.7.2 Harmonic Scalpel ................. 128 17.4 Multiaccess Surgery ............... 156 15.7.3 Laparoscopic Donor Hepatectomy 17.5 Information Technologies .......... 157 for Living-Related Transplantation 128 17.6 Surgical Education and Certification 157 17.7 Surgical Simulation ............... 158 17.8 Artificial Organs and Transplantation ............... 158 17.9 Surgical Systems and Robotics ..... 159 17.10 Unconventional Surgery ........... 159 17.11 Conclusion ....................... 160 Subject Index ............................ 163 List of Contributors Enrico Benedetti Timothy Ganous, MPA University of Illinois at Chicago University of Maryland School of Medicine College of Medicine 351 West Camden, CY-211 840 S. Wood Street Baltimore, MD 21201 Suite 402, CSB (M/C 958) USA Chicago, IL 60612 USA Achille Lucio Gaspari, MD Division of General Surgery Mark W. Bowyer MD, FACS Department of Surgery Uniformed Services University Tor Vergata University of Rome of the Health Sciences Viale Oxford, 81 4301 Jones Bridge Road 00133 Rome Bethesda, MD 20814-4799 Italy USA Santiago Horgan, MD Gerhard F. Bueß, MD Minimally Invasive Surgery Section for Minimally Invasive Surgery University of Illinois University of Tübingen 840 South Wood Street 72072 Tübingen Room 435 E Germany Chicago, Il 60612 USA Adriano De Majo Division of General Surgery Eiji Kanehira Department of Surgery Endosurgery Laboratory Kanehira (ELK) Tor Vergata University of Rome Kanazawa Viale Oxford, 81 Japan 00133 Rome Italy Michael S. Kavic, MD Director of Education, General Surgery Nicola Di Lorenzo, MD St. Elizabeth Health Center Division of General Surgery Professor of Clinical Surgery and Vice Chair, Department of Surgery Department of Surgery Tor Vergata University of Rome Northeastern Ohio Universities College of Medicine Viale Oxford, 81 1044 Belmont Avenue, P.O. Box 1790 00133 Rome Youngstown, OH 44501-1790 Italy USA Anthony G. Gallagher, PhD Antonio Manzelli, MD Department of Surgery Division of General Surgery Emory University Hospital Department of Surgery Room B206 Tor Vergata University of Rome 1364 Clifton Road, NE Viale Oxford, 81 Atlanta, GA 30322 00133 Rome USA Italy
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