The Cutting Edge
Tomorrow´s Operating Room In the Year 2015
What passes as standard operating procedure today will soon look as primitive as Stone Age clubs and bone saws. By 2015, surgeons will use powerful visualization tools to navigate through the patient's anatomy on a millimeter level. They will repair tissues using minuscule robotic instruments in procedures minutely planned through simulation.
What surgeons will see and feel when looking into tomorrow's "Magnaviewer". Right: real time view from microbot instruments. This shows the actual operating field. Small box top left: road map anatomical view of patient's lungs showing microbot current and target locations; bottom left: real time tissue and image analysis from KnowlegeMan data base; top right: voice-activated access to the previous day's simulation; bottom right: additional information tools and measurements. Haptic gloves give surgeon a realistic "feel" when resecting tissues
UCLA Medical Center, September 18, 2015. Thoracic surgeon Janis J. Wan made medical history today when she used cellular techniques to eradicate the last vestiges of cancer from the lungs of a 47 year old unemployed carpenter and father of four. The man, Vincent Carlson Kowalski, had never been enrolled in a wellness plan and had never had a genetic test. The procedure marked the first time that remotely controlled "microbots"millimeter-sized tethered robotshad been used in conjunction with a new marker substance that makes cancer cells visible to their infrared sensors. "Mr. Kowalski is very lucky to be alive today," announced Dr. Wan at an Internet press conference following the three hour procedure. "Pre-operative diagnostic tests showed that his cancer had not spread beyond his lungs, which is very unusual in advanced cases. His prognosis is now excellent." As recently as the turn of the century, over 150,000 people per year died of lung cancer in North America alone and most patients diagnosed with the disease did not live to see their next birthday. Today, however, thanks to the widespread use of inexpensive and extremely accurate genetic tests and associated theranostic measures, only three or four thousand cases occur each year.
Dr. Wan explained that after being admitted to the hospital with what appeared to be chronic bronchitis, a routine protein test revealed the presence of Mr. Kowalski's cancer. The patient was injected with a recently approved contrast agent that is entirely non toxic. The agent glows at a unique wavelength when it comes into contact with the enzymes in cancer cells. A scanner then examines areas likely to be at risk and localizes any bright spots to within a few millimeters of their actual locations.
Following this step, Mr. Kowalski underwent a CT scan of the five areas where cancers had been detected. The resulting information was used to produce realistic and highly detailed three-dimensional images of the areas in question. A full-scale simulation of the operative procedures, including mapping of the routes to be taken by microbots, was then conducted to ensure they could be successfully implemented. "The cancers had invaded sections of the inner and outer walls of the bronchi, the principal air passages in the lungs," explained Dr. Wan. "Figuring out how to reach those spots with our endoscopic instruments would normally have been a real challenge. However, we were gratified, as always, to see how rapidly our KnowlegeMan expert system investigated possible routes and finallyafter about 15 secondssuggested several that were ideal in every way."
The operation began at 10:30 this morning after the patient had received a mild general anesthetic and the tethered microbots had been slipped down his trachea to a predetermined "launch" location. Working from within a glassed-in control pulpit adjacent to the OR, Dr. Wan rested her forehead on a "Magnaviewer" that gave her a vastly enlarged panoramic view from the tip of microbot A.
"When you're using the Magnaviewer, you may be looking into an area that's a millimeter in width, but you have the feeling of being in a vast cave. Microbotic lighting lets you see every detail. We call this immersion surgery," explained Dr. Wan. In addition to the views from microbots, the viewer gives physicians voice-activated access to the previous day's procedure simulation, a road map view of the patient's anatomy (in this case the lungs) that shows microbot and target locations, diagnostic evaluations based on real time image analysis from the KnowlegeMan data base, and a range of information tools and measurements.
When her finger tips touched the sensors on the Magnaviewer's joy sticks the system instantly recognized Dr. Wan and the operation began. In rapid succession the five microbotsone for each tumornavigated to their target locations using detailed image information from the previous day's simulation and comparing it with real time, high resolution images from their onboard cameras. Onboard ultrasound transducers were used to visualize the tumors on the outer bronchial walls. "The microbots know exactly where to go," said Wan. "Nevertheless, as an added safety measure, I never release them simultaneously. That gives me a chance to track their individual trajectories and compare them to the planned routes."
Once the microbots reached the tumors, Mr. Kowalski received a fresh injection of the marker substance. Several seconds later, the substance had been absorbed by the cancer cells, which in turn became clearly visible to the microbots' infrared sensorsand to Dr. Wan by means of augmented reality, the overlaying of otherwise invisible image information on actual structures. "This part of the procedure demands absolute concentration," said Wan. "At this point I put on a pair of haptic glovesthey look like standard, old-fashioned surgical glovesbut when connected to the feedback outputs from the microbots' instruments, they give me a realistic sense of the right amount of pressure to apply as I resect the cancer cells. The procedure then moves along fairly rapidly as I direct each microbot to cut out the tumor in its area on a cellular basis. You just have to be vigilant that no stray cancer cells are carried away down the alveoli and into the blood stream. We avoid this through a program that coordinates the movements of the microbots' cutting tools with the moments of respiratory relaxation between inhalation and exhalation, and by positioning the suction device which removes the cancer cells in a downstream position with regard to each cut," explained Wan. She added that, "Although what we've accomplished here today is a milestone in surgical management, UCLA Med and other centers are working on the next generation of microbots, which will essentially be sub-micron sized repair systems for cells. In other words, in a few years we expect to be able to reprogram cancer cells so that they will self-destruct."
Arthur F. Pease