Rambodoc at large

Scientists have implanted computer chips in a pupa within a cocoon, leading to the creation of an intelligent moth that can be remote controlled. Stretching the imagination a bit, one can visualise these moths , fitted with cool, hi-res video cameras that transmit images wirelessly to the CIA, as spying on terrorist groups. This is yet another brainy project of DARPA, the US Army Division that plans research for the future. It may be worth remembering that DARPA is credited for the creation of the internet! For the full article on the cyborg moth, click here.
I have, in my article 'The Science of Bioterror', mentioned how the counterterror gurus have devised similar remote-controlled bees that are capable of detecting biological agents of terrorism, like anthrax, for example. I have been privileged to interact personally with Rick Satava, an authority on Disruptive Medicine, about which I have written previously.
While it remains to be seen how the fast evolving terrorists react to future technologies, we are likely to see commercially available advanced, miniature spying devices that will be used to violate individual privacy. I cannot but quote Peter Valery here: “The trouble with our times is that the future is not what it used to be.”

When it comes to the future of surgery, there are three kinds of surgeons: those who watch it happen, those who make it happen, and those who wondered what happened.
While most of the world’s surgical community would easily fall in the last category, Jacques Marescaux is one of the movers and shakers of surgical development. Marescaux wears too many laurels to enlist. An iconic surgical pioneer, he made history with ‘Operation Lindbergh’, an epochal event in 2001 when he, from New York, performed a laparoscopic gall bladder surgery on a patient 4000 miles away in Strasbourg, France. As an example of robotic telesurgery, this event opened up to the world a bewilderingly fast evolution of surgery. Surgery, as we know it today, is going to be archaic and laughable in the future. Or is it?

NO SCARS AFTER SURGERY?
Marescaux is now working on a surgical project on ‘no-scar surgery’ at the European Institute of Tele Surgery (EITS). Called NOTES (Natural Orifice Transluminal Endoscopic Surgery), this project involves research on removal of organs inside the abdomen, like gall bladder, appendix, adrenal, spleen and pancreas using endoscopes passed through the mouth, anus or vagina. In a typical procedure, a specially designed flexible endoscope is passed through the mouth and a small hole created in the stomach wall. Through this hole, the surgeon passes instruments to dissect out the target organ, eventually to extract it out through the stomach and then out the mouth. End result: no scars on the belly, no pain of cuts and wound infections! Is that really possible?
Nageshwar Reddy and GV Rao of the Asian Institute of Gastroenterology, Hyderabad, conducted the first human cases of removal of appendix through the stomach. Presenting his experience at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Conference at Dallas in June 2006, Rao said, “We put in a laparoscope in addition to doing the transgastric appendectomy just to be safe”. So, what is the safety issue here? Says Marescaux, “This approach is very difficult to use in humans because of the difficulty in closing the stomach hole. We are developing a method to close the hole that will be easier than stitches and clips, though we cannot reveal the method right now”. Why not? Companies like Karl Storz and Ethicon Endo-Surgery are pouring in millions of dollars to develop the first commercially available endoscopic NOTES device. Naturally, confidentiality is the keyword for researchers. With a spreading feeling that NOTES could change the face of surgery, work is on to be the first off the block to market the devices. Ethicon recently gave a one million dollar grant to SAGES for research on the new science.
At present frenetic work is on to develop and refine newer endoscopes that can accommodate multiple sturdy instruments through them as well as make stomach wall closure safer.

So, to repeat our question, is no-scar natural orifice surgery realistic?
Moshe Schein, author of multiple surgical books and Associate Editor of the World Journal of Surgery, is critical: “The idea is superficially appealing. But, to me, violating the integrity of the stomach wall to take out the gallbladder is against the basic rules of surgery, including the KISS principle (Keep It Simple, Stupid). Do you really want to produce a hole in the stomach, and then having to fix it—risking leaks—in order to take out an appendix or gallbladder? Not on me!” Marescaux, ever the visionary, is clearly optimistic, “ I believe NOTES is more minimally invasive than the laparoscopic approach, though I don’t know if this will replace laparoscopy in the future”. When will we see it in action, in the real world beyond animal labs? “One to two years ” is his stunning assertion.
Richard Satava, Professor of Surgery, University of Washington Medical Center, Seattle sums up: “The most important feature of this new approach will be if there is significant improvement for the patient over current laparoscopic procedures – success must be determined by patient outcomes.”


ROBOT: MASTER OR SLAVE?

Contrary to popular notion, robotic surgery does not mean the surgeon being replaced by a robot. The four- armed robot, wielding cameras and multiple instruments, is merely the slave by the patient’s side, obeying commands from its master, the surgeon, who sits outside on his console, moving his hands on joystick equivalents while looking at his own monitors. The interposition of machine between surgeon and patient eliminates the surgeon’s hand tremors. In addition, the three-dimensional ‘In-Site’ ten-fold magnified vision makes surgery easier and safer. The robot can maneuver its instruments like a human wrist, something that is impossible in laparoscopic surgery, making complex operative steps easier.
Ashok Hemal, Professor of Urology at the AIIMS in New Delhi and formerly at Vatikutti Urology Institute, Henry Ford Hospital, says, “Mani Menon and his team there have done around 2700 robotic radical prostatectomies, with excellent results”. Menon has standardized this traditionally bloody and complex operation for prostate cancer by using the da Vinci robot. The artist Leonardo, who conceived the world’s first robot, is now the flag bearer in name not only of a best selling book by Dan Brown but also of the fast evolving field of surgical robotics. This robot is a virtual monopoly product of Intuitive Surgical, a $260 million US company, with 509 installations around the globe. India has four of these, with AIIMS holding two, Escorts Heart Institute at New Delhi and The Cardiac Research and Education Foundation at Hyderabad accounting for the rest. So why are heart hospitals going in for the da Vinci?
Operations like coronary artery bypass and mitral valve reconstruction can now be done by the key-hole approach and are being touted as two of the most marketable robotic procedures, apart from radical prostatectomy, hysterectomy and weight loss (bariatric) surgery.
Thought by many to be the future of surgery, robotics does not come cheap. The da Vinci is priced at $1.7 million (nearly seven crore rupees), with an additional annual service contract of more than $100,000. Each procedure needs instruments that cost between $1000 and $1500, provoking people like Schein and Danny Rosin to scoff at the benefits. Rosin, Senior Surgeon at Sheba Medical Center, Tel Aviv University questions whether “it is a solution waiting for a problem”. Hemal is cautious, “This expensive technology needs a good surgeon. By itself, it cannot make for good results. Robotics only expands the horizons of laparoscopic surgery, it cannot replace it”. In the US and Europe, robotic procedures are increasing, with more than 8000 prostatic cancers coming under the da Vinci’s arms every year. In India, though, hospitals are doing very little work to justify the huge investment. At AIIMS, Hemal has done 50 robotic radical prostatectomies.
While rare and difficult to implement, robotic telesurgery is evolving. Like Operation Lindbergh, the surgeon operates from a distance, using a sophisticated telecommunications system using high output fiber optics that results in little transmission delay. Mehran Anvari of McMaster University in Hamilton, Ontario, Canada performs advanced robotic surgery in North Bay, 300 km away from where he sits at his hospital.
Mobile robots are also being used for simpler jobs, like seeing patients from home or office. The RP-6 mobile telemedicine robot made by a Californian company called In-Touch is a robotic platform with a flat-panel monitor supported by a telemedicine connection. The nurse can go with the robot on rounds, and the patient can see and converse with the doctor over the telemedicine link. Satava remarks, “There has been surprisingly good acceptance of this technology, especially where physicians do not have much time for rounds. Patients quickly become accustomed to seeing their doctor on the video monitor, and frequently prefer this method of communication because the surgeon takes more time and has better eye contact with the patient – rather surprising!”

NO SMALL MATTER:
The world’s first medical micro robot, invented by Dmitry Oleynikov, Associate Professor, Department of Surgery, University of Nebraska Medical Center looks like a lipstick case and can navigate inside the abdominal cavity on wheels and tracks, capturing pictures with its own inbuilt camera and lights, all the while being controlled by an external remote control. Though the device today can do little beyond biopsies and recording pH, temperature and pressure, it is of sufficient potential for NASA to be interested in exploring its possibilities in space.

An Israeli company, GI View Ltd., is developing a new technique for screening colonoscopy called ‘Aer-O-Scope’. This device propels and navigates itself up the colon when placed in the rectum. Moshe Schein, in spite of being known as a conservative surgeon, is enthusiastic about the tech: “Recent studies show that GI physicians miss polyps during screening colonoscopy. I think it is because they are doing too many of these procedures per day (often up to 30) to do a complete check. Now imagine a small robot with a video camera, traveling on minute tracks, like a Merkava Tank, inserted in the rectum, walking up through the colon, and photographing everything. The video is loaded into a computer and interpreted.”

John Mellinger, Chief of Gastrointestinal Surgery, Medical College of Georgia, who recently wrote an article on Endoluminal surgery in Surgical Endoscopy says, “The entire colonic status is seamlessly reconstructed from the images we get from this painless procedure”.

AN EYE FOR PERFECTION:

Every surgeon makes mistakes. Often human anatomy and disease create illusions in appearance that fool even the most expert eyes and hands. During a gall bladder surgery, the bile duct can be injured, as can the urinary tube (ureter) during removal of the uterus, each with devastating consequences. If the surgeon could see each structure clearly separate from the other, it could reduce or eliminate injury. Augmented Reality, initially a neurosurgeon’s guide map, is now a high priority at Marescaux’s European Institute of Tele Surgery (EITS). EITS have developed software to reconstruct laparoscopic images in 3D system. The patient first undergoes a CT scan that a computer reconstructs in 3D and in color. Therefore, veins are colored blue, arteries red, and so on. When the patient is on the table for surgery, the CT reconstructed images are superimposed on the monitor that is showing the actual operation in real time. Marescaux demonstrates this in the laparoscopic removal of an adrenal gland tumor, where he uses the technology at will to show the perfect location of the major veins that lurk beneath the fat. Injury to these veins could lead to massive bleeding and death. Now, here is a method for reducing surgical errors and improving patient safety! Danny Rosin thinks this concept is “a promising technology that is not that far from more widespread use. The success of stereotactic neurosurgery with navigation systems is a proof that this can be useful.”
Marescaux is convinced that the future of abdominal surgery lies in Augmented Reality combined with Robotics, in both laparoscopic surgery and NOTES ‘no-scar’ surgery. As the rest of the world looks on, Marescaux uses a Persian phrase: "The madman forces doors, the wise follow”. As one preparing for it today, tomorrow seems destined to be his.

We have all heard and read of the world's first transvaginal gall bladder operation (cholecystectomy), done at a premiere institute in Strasbourg, France. While the public may react with delight at the thought of surgeries of the future occurring without scars at all, there are troubling thoughts.
The most important question that surgeons are asking is: "after a transvaginal cholecystectomy, can the patient have sex before six weeks?"
Just jokin'!!
On a serious note, the issue here is simple: is the abdominal wall so sacrosanct an organ that we are risking injuries to internal organs? After a transgastric appendectomy, where the operation is done through the mouth, there is a risk of the stomach hole leaking fatally. Is the risk worth it? As always, the response of the surgical community to this new Natural Orifice Surgery (called NOTES or NOS) is predominantly negative. I will just quote John Cage, who said, “I can't understand why people are frightened of new ideas. I'm frightened of the old ones.” Well, here is another quote on this, by Pearl Buck: “You can judge your age by the amount of pain you feel when you come in contact with a new idea.” Since the majority of the surgical community must be old farts and getting-there-old- farts, it is clear that the quote strikes the truth.
Though the surgical community as a whole watches in a mixture of revulsion, fascination and admiration, many patients must be planning to postpone surgeries for a few years till the new no-scar surgery becomes established. Homeopaths are going to have more patients, I am sure!
If you ask me, I think NOS is the surgery of the future, as long as surgery HAS a future. I seriously doubt that it has one, once the nanobots are let loose inside the body. Maybe another 20 years? I have written on the natural orifice surgeries and other futuristic surgical developments in KnowHow, the Telegraph. You can get the original full article in the 'future' label when you check the 'labels' list on the right of this blog-page.
However, on a personal level, it has become important for me to learn this soon. The problem is that the equipment is still not available in the market, being under development, and I am sure will be only slightly cheaper than a nuclear bomb! This is why practising surgery in this age is so difficult: you spend your best years learning something, only to see it becoming obsolete or proven useless just when you have reached some level of competence in it! Is laparoscopic surgery doomed? Will the neo-endoscopist rule? My answer is YES.
And, by the way, we still don't know enough to answer the 'most important question' above, unless we can do a retrospective study on all the pigs who had previously undergone the operation in the last couple of years, and ask them how soon did it feel good and safe to have sex!!

Remember Thomas Edison? Wrongly thought to be the inventor of the electric lamp, but actually the creator of the electric grid? Or Graham Bell, who rang in the first telephone? These men created products that changed civilisation. These, amongst some others, were disruptive technologies: technologies so outrageous that they are considered daring, provocative, and extraordinary. Today, we are on the threshold of possibilities so outlandish that science fiction sounds pretty ho-hum.
Nothing exemplifies this as fundamentally as the field of ‘disruptive’ medicine and, arguably, nobody in the field of medicine understands the future of this ‘outrageous’ medicine as well as Richard Satava. ‘Rick’ Satava is a Professor of Surgery at Washington University Medical Center, Seattle and has written several books and articles on futuristic ‘disruptive’ medicine. Apart from being a surgeon of world repute, Satava was part of the team that developed the first robotic and Virtual Reality systems, before joining DARPA (Defence Advanced Research Projects Agency), the brain bank of the US military. He is soon to take over as the Chief Scientist of theUS Army Medical Research and Command. It is here that he will be funding and overseeing more outrageous medical research. So, what earth shaking developments are afoot in the world of medicine?

A NEW AGE

Satava starts off, “A glimpse of what the future might become was given by Alvin Toffler in his 1976 book ‘The Third Wave’, in which he described the three different ‘ages’ – the Agriculture Age, the Industrial Age, and the Information Age. There appears to be a new age emerging – tentatively called the Biointelligence Age.” But one thought the Information Age is the future? He says, “The Information Era is here and is getting over. Over the past 20 years, there have been no new discoveries. The cell phone, computer, etc. are fundamentally the same as they were 20-30 years ago, the only difference being their level of sophistication and add-on features like small size, Internet access, cameras, etc."
The Biointelligence age features a slew of radical technologies that are set to change the entire way of treating health and disease issues. We examine some of the main issues here.

THE IMPOSSIBLE FUSION OF LIFE AND MACHINE

Scientists have implanted sensors and radio transmitters in bees and cockroaches to control them. The cockroach can be controlled with a joystick, allowing a possibility for cameras to be implanted in the creature for use in the detection of earthquakes and tsunamis. Bees fitted with sensors for biological weapons can transmit the information to the military. This is the beginning of the man-made fusion of living and non-living.
In man, brain implants are promising enormous hope for patients of paralysis, epilepsy and Parkinson’s disease. John Donoghue, a neuroscientist who also owns a biotech company called Cyberkinetics in California has begun implanting the Braingate device in the heads of patients that allow them to mechanically move an attached robotic arm with the power of electrical impulses generated by thought. The brain’s electrical impulses generated from thinking of an action go to a robot that then interprets these signals and performs an appropriate action.
How realistic is it to expect intelligent machines to perform radical functions in place of diseased body parts? Says Ray Kurtzweil, a global authority on science and future technology, “The latest generation of the implant for Parkinson’s disease (a slowly paralysing nerve disorder) is not an experiment, and it is an FDA approved therapy”. Rameez Naam says in his book ‘More Than Human’, “In Lisbon, Portugal, there is a group of blind men and women who can now see. In place of eyeglasses, they wear cameras connected to electrodes implanted in the visual parts of their brains. Some of them were blind for twenty years or more before the surgery. The same research that gives them sight could beam images from one person’s mind into another. “
Aubrey de Grey, a world-renowned scientist at the Department of Genetics, University of Cambridge, says, “There are non-biological organs such as cochlear implants already, and rapid progress is being made on more advanced things like artificial hearts. What will be more dramatic is when we start to be able to make machines that can replace some parts of the brain. For well-understood parts like the hippocampus (the part of the brain that stores memory), this may be only a couple of decades away. At that time we may wonder if ‘non-living’ is really the right word - non-biological, yes, but performing a living, cognitive function.”
de Grey looks even farther: “If we end up being able to replace the hippocampus with a machine that works just as well, there's no reason why we couldn't replace it with something that does more than the natural one. One additional function could be to use it as a knowledge base, an inbuilt Internet. In the more distant future we will probably understand the cerebral cortex well enough to start replacing parts of it too, and that is possible.”



CHANGING LIFE’S BUILDING BLOCKS

Conventional medicine looks at organ systems and deals with disease at the macro level. The dizzyingly fast developments in nanotechnology and genetic engineering are set to make this obsolete, if experts are to be believed.
Nanotechnology deals with molecules at the scale of a few nanometers, and banks heavily on the creation of an atomic ‘assembler device’ or molecular machine: a concept of scientist Eric Drexler that pertains to a group of molecules arranged to perform the functions of a machine or even a computer. Says Kurtzweil, “The golden era will be in about twenty years from now. The real Holy Grail of nanotechnology are nanobots, blood cell-size devices that can go inside the body and keep us healthy from inside.” Molecular machines can clear out clots in arteries, go into cells and correct abnormalities, and kill germs or cancer. Kurtzweil reiterates, “If that sounds very futuristic, let me point out that we’re doing sophisticated tasks already with blood cell-size devices in animal experiments.
One scientist cured Type 1 diabetes in rats with a nano-engineered capsule that has seven nanometer pores. It lets insulin out in a controlled fashion and blocks insulin antibodies. This is what is feasible today. MIT has a project of a sub-cellular nano-engineered device that is capable of detecting specifically the antigens that exist only on certain types of cancer cells. When it detects these antigens, it latches onto the cell, and burrows inside the cell, where it releases a toxin that destroys the cancer cell. This is a sophisticated nano-engineered device in that it is created at the molecular level. So that’s what is feasible already.”

CHANGING GENES OR SPECIES?

The era of transgenic animals is upon us already. Michael Crichton’s latest book 'Next’ deals with apes that speak Dutch and French, because of experiments in crossbreeding with humans.
Genetic engineering can prevent inherited disorders, but more radical is transgenic genetic engineering. Satava cites the example of rhodopsins (color detecting eye pigments). Man has four rhodopsins for vision of which he uses only two. The pit viper snake has one of the same rhodopsins that is unused by humans, and which gives the snake the ability to seek its prey in infrared. He asks, “ Should we genetically engineer our children to give them such abilities, so they can see in the dark? Should they have abilities that others do not have, giving them an enormous advantage? Moreover, who will decide which children can be ‘enhanced’? Are we on a threshold of designing our children to a point where there will be a whole class of enhanced individuals?”
Troubling questions, these! The ethical issues of genetic engineering are being debated fiercely in scientific and political circles, with more questions than answers.
With the establishment of ‘intelligent’ prostheses that function even better than a normal body part (as in amputees who can climb mountains or play), and with all possible organs (except the brain) being replaceable with biosynthetic ones, it is possible to conceive of an ‘enhanced’ man with 95% of his body replaced by artificial ones. “Would such a man be ‘humanoid’ or human?” asks Satava.
Talking of humanoids, a parallel development has been the creation of intelligent robots that help impaired patients. Satava remarks, “Advanced programs such as fuzzy logic can help the robot or computer to learn from tasks. This meets the definition of ‘thinking’. There are machines with life-like robotic faces which can answer verbal questions and attempt to make facial expressions that show six specific emotions”. Robotics is expected to be a $50 billion industry by 2025, with countries like South Korea set to become leaders in domestic multifunctional robots (with a target of one domestic droid for every home by 2013). Companies like Microsoft are working on the same lines. With such research, a thinking and emoting robot is not going to be mere science fiction. It is already reality in research!

WILL MAN HIBERNATE AND REJUVENATE?

American scientists have new insights into the phenomenon of hibernation, with stunning implications for medical care. Animals like the Arctic ground squirrel can turn their entire system off, effectively living with minimal heart rate, breathing, and circulation, owing to a molecule that blocks energy generation in the hypothalamus of the brain. Scientists have been able to create a block in mice such that they are put into a state of suspended animation for about 6 hours – no respiration, heart rate, blood pressure, ECG, EEG, and even no activity on functional MRI of the brain. After 6 hours, they are awakened and they behave normally. Satava points out “while this is an early experiment, it points to the possibility of using these molecules or drugs for anesthesia. If successful, in surgery a patient could be put to ‘sleep’ with no heartbeat, no bleeding when incised (bloodless surgery), unaware of pain and unable to move. When the surgery is over, he can be awakened.”
Drexler confirms, “It is possible to discover a drug that causes biostasis (putting life in pause). A method of producing reversible biostasis could help astronauts on long space voyages to save food and avoid boredom. In medicine, biostasis would provide a deep anesthesia giving physicians more time to work. When emergencies occur far from medical help, a good biostasis procedure would provide a sort of universal first-aid treatment: it would stabilize a patient's condition and prevent molecular machines from running amok and damaging tissues. 

But no one has found a drug able to stop the entire metabolism the way anesthetics stop consciousness - that is, in a way that can be reversed by simply washing the drug out of the patient's tissues. Nonetheless, reversible biostasis will be possible when repair machines become available.”
With much research involving other areas like human cloning, prolonging longevity of man, and tissue synthesis modern science is helping evolve a new breed of professional: the scientific ethicist.