웨이브 테스트 1

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

http://www.ted.com/talks/lang/eng/catherine_mohr_surgery_s_past_present_and_robotic_future.html

A talk about surgical robots is also a talk about surgery.
수술에 사용하는 로봇에 관한 이야기는 수술 그 자체에 대한 이야기이기도 합니다.
And while I've tried to make my images not too graphic, keep in mind that surgeons have a different relationship with blood than normal people do.
그래서, 여러분들에게 보여드리는 이러한 이미지들을 너무 생생하게 보여주지 않기 위해 노력하겠지만, 외과의들이 ‘피, 혈액’에 대해 보통사람들과는 다르게 여긴다는 것은 기억하시기 바랍니다.
Because after all, what a surgeon does to a patient, if it were done without consent, would be a felony.
왜냐하면, 외과의들이 환자에게 충분한 설명을 하지 않는 것은 중죄이기 때문입니다.
Surgeons are the tailors, the plumbers, the carpenters, some would say the butchers of the medical world.
외과 의사들은 재단사이기도 하고, 배관공이기도 하고, 목수이기도 하며, 의학계의 몇몇 사람들은 외과 의사들을 도살자(푸줏간에서 일하는)라고 말하기도 합니다.
Cutting, reshaping, reforming, bypassing, fixing. But you need to talk about surgical instruments and the evolution of surgical technology together.
(그들은)자르기, 재단하기, 다시 만들기, 우회하기, 고치기 등등(을 합니다). 이에 오늘 당신과 함께 외과 수술 기구와 수술 기술의 진화(발전)에 대해 이야기하고자 합니다.

So in order to give you some kind of a perspective of where we are right now with surgical robots, and where we're going to be going in the future,
여러분들에게 현재 우리 외과적 로봇 기술의 위치와, 향후 미래에 어떻게 나아가야 할 지에 대한 몇몇 전망을 알려드리기 위해,
I want to give you a little bit of perspective of how we got to this point.
저는 여러분들에게 어떻게 외과가 지금까지 도달하게 되었는지에 대한 이야기를 간략히 하고자 합니다.
How we even came to believe that surgery was OK, that this was something that was possible to do, that this kind of cutting and reforming was OK.
어떻게 이러한 자르고, 다시 만들고 하는 것이 괜찮다고 될 수 있었는지, 어떻게 이것이 가능하게 되었는지, 수술이 이루어지게 되었는지에 대해서요.
(이 부분은 어렵습니다..T.T)

So, a little bit of perspective -- about 10,000 years of perspective.
긴 관점에서 말입니다..10,000년여 간의 긴 관점에서 보겠습니다.

This is a trephanated skull.
이것은 천두술이 시행된 두개골입니다.
And trephanation is simply just cutting a hole in the skull.
천두술이란 간단히 두개골을 잘라서 구멍을 내는 것입니다.
And many, many hundreds of skulls like this have been found in archaeological sites all over the world, dating back five to 10 thousand years.
그리고, 많은, 아주 많은 이와 같은 두개골들이 전 세계의 5000년에서 10000년 전의 고고학 유적지에서 발견되고 있습니다.
Five to 10 thousand years! Now imagine this.
5천년전에서 만년전이라니요! 상상해보세요.
You are a healer in a Stone Age village.
여러분이 신석기 시대의 의사라고 생각해봅시다.
And you have some guy that you're not quite sure what's wrong with him (Oliver Sacks is going to be born way in the future).
그리고, 질병의 원인이 무엇인지 알 수 없는 그런 환자가 왔다고 합시다.
He's got some seizure disorder.
그는 간질을 앓고 있습니다.
And you don't understand this.
그리고 당신은 이 질병에 대해 아는 것이 없습니다.
But you think to yourself, "I'm not quite sure what's wrong with this guy. But maybe if I cut a hole in his head I can fix it."
하지만, 당신은 아마 혼자 이렇게 생각할 겁니다. “도대체 뭐가 문젠지 알 수 없구만..하지만, 아마 내가 저 환자의 두개골에 구멍을 내면 아마 고칠 수 있을거야”
(Laughter)
(웃음)
Now that is surgical thinking.
자..이런 것이 외과적 사고방식입니다.

Now we've got the dawn of interventional surgery here.
자..이제 우리는 중재적 수술의 시작기로 접어들었습니다.
What is astonishing about this is even though we don't know really how much of this was intended to be religious, or how much of it was intended to be theraputic, what we can tell is that these patients lived!
놀라운 사실은 이러한 행위가 종교적인 의미로, 혹은 치료적 행위로 이루어졌는지 알 수는 없지만, 확실한 것은 이 시술을 받은 환자들이 살아남았다는 것입니다!
Judging by the healing on the borders of these holes, they lived days, months, years following trephanation.
천두술 시행 후 구멍의 가장자리를 살펴보건데, 천두술을 받은 사람들은 수일, 수개월 심지어는 수년까지 천두술 후에 생존해있었습니다.
And so what we are seeing is evidence of a refined technique, that was being handed down over thousands and thousands of years, all over the world.
그리고 지금 보여드린 방법은 검증된 수술적 방법으로서 수천년전부터 전세계적으로 이루어진 것입니다.
This arose independently at sites everywhere, that had no communication to one another.
이 기술은 전 세계에서 교류가 없는 서로 다른 집단에서도 각각 확인되고 있습니다.
We really are seeing the dawn of interventional surgery.
중재적 외과학의 시초라 할 수 있지요.

Now we can fast forward many thousands of years into the Bronze Age and beyond.
자 이제 현대쪽으로 수천년 더 와서 청동기와 그 이후를 보겠습니다.
And we see new refined tools coming out.
보시는 것처럼 새로운 수술 기구들이 등장했습니다.
But surgeons in these eras are a little bit more conservative than their bold, trephanating ancestors.
하지만, 이때의 외과 의사들은 천두술을 시행하던 그들의 대담한 선배들보다는 보수적인 편에 속했습니다.
These guys confined their surgery to fairly superficial injuries.
그들은 그들의 수술 기술을 얕은 상처에만 국한해서 사용했습니다.
And surgeons were tradesmen, rather than physicians.
그리고 당시의 외과의사들은 의사라기 보다는 공상(잡상인)에 가까웠습니다.
This persisted all the way into and through the Renaissance.
이런 현상은 르네상스까지 이어집니다.
That may have saved the writers, But it didn't really save the surgeons terribly much.
르네상스에 작가들은 구원을 받았을지 모르지만, 외과의사들에게는 정말 힘든때였습니다.
They were still a mistrusted lot. Surgeons still had a bit of a PR problem.
그들은 여전히 불신받았습니다. 외과 의사들의 광고문제도 있었습니다.
Because the landscape was dominated by the itinerant barber surgeon.

These were folks that traveled from village to village, town to town, doing surgery sort of as a form of performance art.
외과 의사들은 마을에서 마을로, 도시에서 도시로 이동하는 사람들이었으며, 수술은 하나의 행위예술로 시행되었습니다.
Because we were in the age before anesthesia, the agony of the patient is really as much of the public spectacle as the surgery itself.
아직 마취가 가능하던 때가 아니었기 때문에 환자의 심한 고통은 수술 그 자체만큼이나 대중적인 관심거리였습니다.
One of the most famous of these guys, Frere Jacques, shown here doing a lithotomy, which is the removal of the bladder stone, one of the most invasive surgeries they did at the time, had to take less than two minutes.
(그림 보면서)여기 보이는 당시 가장 유명한 사람이던 Frere Jacques는 그 당시 가장 침습적인 수술인 방광의 돌을 제거하는방광결석제거술을 2분만에 시행하기도 했습니다.
You had to have quite a flare for the dramatic, and be really, really quick.
이는 정말 대단한 기술이고, 정말 정말 빠르게 수술을 한 것이랍니다.

And so here you see him doing a lithotomy.
여기 그가 방광결석 제거술을 하는 것을 볼 수 있습니다.
And he is credited with doing over 4,000 of these public surgeries, wandering around in Europe.
그는 전 유럽을 돌아다니면서 4000건 이상의 수술을 했습니다.
Which is an astonishing number, when you think that surgery must have been a last resort.
수술을 최후의 수단으로 생각할 때 정말 대단한 숫자입니다.
I mean who would put themselves through that?
제 말은 누가 그렇게 하겠느냐는 것 입니다.
Until anesthesia, the absence of sensation.
마취 없이 말입니다.

With the demonstration of the Morton Ether Inhaler at the Mass. General in 1847, a whole new era of surgery was ushered in.
Morton Ether 흡입기가 1847년 메사추세츠 종합병원에서 첫 시연을 하고 외과의 새로운 시대가 열립니다.
Anesthesia gave surgeons the freedom to operate.
마취는 외과 의사들이 자유로이 수술할 수 있도록 해 주었습니다..
Anesthesia gave them the freedom to experiment, to start to delve deeper into the body. This was truly a revolution in surgery.
마취는 외과의들이 자유로이 실험하고, 체내로 깊이 파고들 수 있게 해 주었습니다. 이는 진정 외과학의 혁명이라 할 수 있습니다.

But there was a pretty big problem with this.
하지만, 아주 중요한 문제가 발생합니다.
After these very long, painstaking operations, attempting to cure things they'd never been able to touch before, the patients died.
치료를 위해 그들이 일찍이 하지 못했던 고통 없는 수술법으로 긴 시간의 수술은 가능했지만, 환자가 죽기시작했습니다.
They died of massive infection.
감염때문이었습니다.
Surgery didn't hurt anymore, but it killed you pretty quickly.
이제 수술은 더 이상 아프지 않게 되었지만, 환자들은 매우 빠르게 죽어갔습니다.
And infection would continue to claim a majority of surgical patients until the next big revolution in surgery. Which was the aseptic technique.
그리고 이러한 감염은 ‘수술법의 무균술이’라는 큰 변화의 출현에 큰 요구로 작용합니다.
Joseph Lister was asepis's, or sterility's, biggest advocate, to a very very skeptical bunch of surgeons.
Joseph Lister는 대부분의 외과의들의 냉소에도 불구하고 무균술을 대단히 옹호했습니다.
But eventually they did come around.
결국 그들이 옳다는 것이 알려졌지요.
The Mayo brothers came out to visit Lister in Europe. And they came back to their American clinic and they said they had learned it was as important to wash your hands before doing surgery as it was to wash up afterwards.
Mayo형재는 Lister를 만나러 유럽으로 왔습니다. 그리고 미국으로 돌아가 그들의 병원에서 그들이 배운 ‘수술 후에 의사가 손을 씻는 것 만큼 수술 전에 의사의 손을 씻는 것이 중요하다’는 것을 전파합니다.
Something so simple. And yet, operative mortality dropped profoundly.
매우 간단한 것이지요. 그리고 수술사망률은 급격히 떨어졌습니다.
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여기까지 만두사랑님이 번역해 주셨습니다. 제가 느꼈던 발표자의 어조나 말투와 비슷하게 번역하셨군요^^ 조금 더 구어체에 가깝게 번역하시면 바로 검수받아도 되겠다능;;;

These surgeries were actually now being effective.With the patient insensitive to pain, and a sterile operating field all bets were off, the sky was the limit. You could now start doing surgery everywhere, on the gut, on the liver, on the heart, on the brain. Transplantation: you could take an organ out of one person, you could put it in another person, and it would work. Surgeons didn't have a problem with respectability anymore. They had become gods.

The era of the "big surgeon, big incision" had arrived. But at quite a cost. Because they are saving lives, but not necessarily quality of life.Because healthy people don't usually need surgery. And unhealthy people have a very hard time recovering from a cut like that. The question had to be asked, "Well, can we do these same surgeries but through little incisions?"Laparoscopy is doing this kind of surgery. Surgery with long instruments, through small incisions.And it really changed the landscape of surgery.Some of the tools for this had been around for a hundred years. But it had only been used as a diagnostic technique until the 1980s, when there was changes in camera technologies and things like that, that allowed this to be done for real operations.

So what you see -- this is now the first surgical image -- as we're coming down the tube, this is a new entry into the body. It looks very different from what you're expecting surgery to look like. We bring instruments in, from two separate cuts in the side,and then you can start manipulating tissue. Within 10 years of the first gallbladder surgeries being done laparoscopically, a majority of gallbladder surgeries were being done laparoscopically. Truly a pretty big revolution.

But there were casualties of this revolution. These techniques were a lot harder to learn than people had anticipated. The learning curve was very long.And during that learning curve the complications went quite a bit higher. Surgeons had to give up their 3D vision. They had to give up their wrists.They had to give up intuitive motion in the instruments. This surgeon has over 3,000 hours of laparoscopic experience. Now this is a particularly frustrating placement of the needle. But this is hard. And one of the reasons why it is so hard is because the external ergonomics are terrible.You've got these long instruments, and you're working off your center line. And the instruments are essentially working backwards.

So what you need to do, to take the capability of your hand, and put it on the other side of that small incision, is you need to put a wrist on that instrument. And so -- I get to talk about robots --the da Vinci robot put just that wrist on the other side of that incision. And so here you're seeing the operation of this wrist. And now, in contrast to the laparoscopy, you can precisely place the needle in your instruments, and you can pass it all the way through and follow it in a trajectory. And the reason why this becomes so much easier is, you can see on the bottom, the hands are making the motions,and the instruments are following those motions exactly. Now, what you put between those instruments and those hands, is a large, fairly complicated robot. The surgeon is sitting at a console, and controlling the robot with these controllers. And the robot is moving these instruments around, and powering them, down inside the body. You have a 3D camera, so you get a 3D view.

And since this was introduced in 1999 a lot of these robots have been out and being used for surgical procedures like a prostatectomy. Which is, a prostate deep in the pelvis, and it requires fine dissection and delicate manipulation to be able to get a good surgical outcome. You can also sew bypass vessels onto a beating heart without cracking the chest. This is all done in between the ribs. And you can go inside the heart itself and repair the valves from the inside. You've got these technologies -- thank you -- (Applause) And so you might say, "Wow this is really cool! So, smartypants, why isn't all surgery being done this way?" And there are some reasons, some good reasons. And cost is one of them.

I talked about the large, complicated robot. With all its bells and whistles, one of those robots will cost you about as much as a solid gold surgeon. More useful than a solid gold surgeon, but, still, it's a fairly big capital investment. But once you've got it, your procedure costs do come down. But there are other barriers. So something like a prostatectomy,the prostate is small, and it's in one spot. And you can set your robot up very precisely to work in that one spot. And so it's perfect for something like that.And in fact if you, or anyone you know, had their prostate taken out in the last couple of years,chances are it was done with one of these systems. But if you need to reach more places than just one, you need to move the robot. And you need to put some new incisions in there. And you need to re-set it up. And you need to add some more ports, and more. And the problem is it gets time consuming, and cumbersome.

And for that reason there are many surgeries that just aren't being done with the da Vinci. So we had to ask the question, "Well how do we fix that?"What if we could change it so that we didn't have to re-set up each time we wanted to move somewhere different? What if we could bring all the instruments in together in one place? How would that change the capabilities of the surgeon?And how would that change the experience for the patient? Now, to do that, we need to be able to bring a camera, and instruments, in together through one small tube, like that tube you saw in the laparoscopy video. Or, not so coincidentally, like a tube like this.

So what's going to come out of that tube is the debut of this new technology, this new robot that is going to be able to reach anywhere. Ready? So here it comes. This is the camera, and three instruments. And as you see it come out, in order to actually be able to do anything useful, it can't all stay clustered up like this. It has to be able to come off of the center line and then be able to work back toward that center line. He's a cheeky little devil. But what this lets you do is gives you that all-important traction, and counter traction, so that you can dissect, so that you can sew, so that you can do all the things that you need to do, all the surgical tasks. But it's all coming in through one incision. It's not so simple. But it's worth it for the freedom that this gives us as we're going around.For the patient, however, it's transparent. This is all they're going to see.

It's very exciting to think where we get to go with this. We get to write the script of the next revolution in surgery. As we take these capabilities, and we get to go to the next places, we get to decide what our new surgeries are going to be. And I think to really get the rest of the way in that revolution, we need to not just take our hands in in new ways, we also need to take our eyes in in new ways. We need to see beyond the surface. We need to be able to guide what we're cutting in a much better way.

This is a cancer surgery. One of the problems with this, even for surgeons who've been looking at this a lot, is you can't see the cancer, especially when it's hidden below the surface. And so what we're starting to do is we're starting to inject specially designed markers into the bloodstream that will target the cancer. It will go, bind to the cancer. And we can make those markers glow. And we can take special cameras, and we can look at it. Now we know where we need to cut, even when it's below the surface. We can take these markers and we can inject them in a tumor site. And we can follow where they flow out from that tumor site, so we can see the first places where that cancer might travel. We can inject these dyes into the bloodstream, so that when we sew on a new vessel and we bypass a blockage on the heart, we can see if we actually made the connection, before we close that patient back up again. Something that we haven't been able to do, without radiation, before. We can light up tumors like this kidney tumor so that you can exactly see where the boundary is between the kidney tumor, and the kidney you want to leave behind. Or the liver tumor, and the liver you want to leave behind.

And we don't even need to confine ourselves to this macro vision. We have flexible microscopic probes that we can bring down into the body. And we can look at cells directly. I'm looking at nerves here. So these are nerves you see, down on the bottom, and the microscope probe that's being held by the robotic hand, up at the top. So this is all very prototypey at this point. But you care about nerves, if you are a surgical patient. Because they let you keep continence, bladder control, and sexual function after surgery. All of which is generally fairly important to the patient.

So, with the combination of these technologies we can reach it all, and we can see it all. We can heal the disease. And we can leave the patient whole and intact and functional afterwards. Now, I've talked about the patient as if the patient is, somehow, someone abstract outside this room.And that is not the case. Many of you, all of you maybe, will at some point, or have already, faced a diagnosis of cancer, or heart disease, or some organ disfuction that's going to buy you a date with a surgeon. And when you get to that point -- I mean, these maladies don't care how many books you've written, how many companies you've started, that Nobel Prize you have yet to win, how much time you planned to spend with your children. These maladies come for us all.

And the prospect I'm offering you, of an easier surgery ... is that going to make that diagnosis any less terrifying? I'm not sure I really even want it to.Because facing your own mortality causes a re-evaluation of priorities, and a realignment of what your goals are in life, unlike anything else. And I would never want to deprive you of that epiphany.What I want instead, is for you to be whole, intact,and functional enough to go out and save the world, after you've decided you need to do it. And that is my vision for your future. Thank you.(Applause)

동영상 및 글의 원본은 TED에 저작권이 있으며 CCL을 따릅니다.

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2009년 9월 13일 스크랩.

2009년 9월 15일 만두사랑님이 앞부분을 상당한 수준으로 초벌번역.