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Artificial Intelligence and Robotics in Neurosurgery:

The Future is Here!

Laligam N. Sekhar, MD, FACS, FAANSProfessor and Vice Chairman

Department of Neurological SurgeryUniversity of Washington

Seattle, USA

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Disclosures

Spi Surgical, Inc. (Stockholder)

Viket Medical, Inc. (Stockholder)

Grant Support:

National Institutes of Health

Amazon Catalyst Program

Department of Defense (STTR x 4)

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What is Neurosurgery???

A Specialty Devoted to the Treatment of Disorders of the Central and Peripheral Nervous System, and Spine Disorders

Has Distinct Sub-specialities: e.g;> Cerebrovascular Surgery> Endovascular Surgery and Stroke > Skull Base Tumor Surgery> Brain Tumor Surgery> Functional Neurosurgery> Neuro Trauma Surgery> Spine Surgery> Minimally Invasive Spine Surgery> Pediatric Neurosurgery> Peripheral Nerve Surgery

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What is the Future of Neurological Surgery???

Advanced Imaging Techniques Nano technology CRSPR Cas-9, and Genetic Engineering Techniques Anti- Tumor Antibodies, CAR T cells, Checkpoint Inhibitors,

etc. Master – Slave Robots, Autonomous Robots Humanoid Robots Artificial Intelligence applications Re-engineered Hospitals, and Health Care Advanced Training Methods of Surgeons, Residents, etc

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Predicting the Future

“ The future depends on what you do today” Mahatma Gandhi

“ I never think of the future, it comes soon enough” Albert Einstein

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32 years after “ Back to the Future”!!! Kitty HawkAero mobile

The Hyperloop

I Phone 11 ???

Apple Watch

Boeing Air Taxi

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The Future of Neuro- Surgery:What Do Patients Want?????

Efficacy : Cure or Control of Disease (even prevention)

Minimal Invasiveness: Medicine Only > Radiosurgery > Minimal Surgery> More

Surgery, but without morbidity

Minimal Morbidity: No brain Damage; No Damage to CNs; No Cosmetic

Deformity

Minimal Time Lost From Work and Family

Minimal Cost (To Them > Someone Has to Pay!!)

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What Do Surgeons Want???

We want to Help our Patients!

To Cure or Control Disease, To Heal Patients

To Perform Elegant Operations, within our limits, without Major Complications

To Make Enough Money (?) to Live well, for us and families

To be Healthy, and Be Happy with our families

Not to have Too Much Interference by Hospital Administrators, or the Government, in our Daily Practice of Medicine

Most Important: Remain Relevant!!

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What Do Hospitals and Payers Want ?

Hospitals want to stay open and be Profitable

Payers Want to be Profitable

Governments want to Control Costs, win

Re - elections (accountable to the people)

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Can Minimal Surgery and Efficacy Co Exist??

In some Cases (Small Vestibular Schwannoma, Meningioma) results of Excellent Surgery and Radiosurgery are Very similar, or even favor Radiosurgery

For Some Malignant Tumors, Complete Excision May Equal Better Survival (e.g. Chordoma)

This is also true for Benign Tumors when follow up is > 20 years (e.g. Meningioma)

Will the patient accept Morbidity for Some Time in Exchange for a Cure? (depends upon the patient, their age, and other factors) 10

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Modifications in ICU, and Postoperative Care

Pain, Immobility, and Patient Psychology are Major Causes of Morbidity

Frequent postoperative Narcotic Usage may result in addiction

Agents like Exparel® (Bupivacaine Liposomal) may be used to minimize local pain

Drugs like Gabapentin, Pregabalin can reduce postoperative Neuralgia

Mobilization is a problem in the ICU, wards, and at home

Patients may need a more healing environment inside the hospital, frequent checking as out patients, and more care givers

Some patients really want to or need to return to work, while others never want to leave the Hospital, or want to become disabled!

Experiments on “Minimum Basic Income” are in Progress!!

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How Can We Improve Patient Management, and Yet Hold Down Labor

Costs? Patients can be given wearable devices to monitor

ambulation, vitals, other tests as needed

Humanoid Robots providing 24/7 Nursing for Each Patient in their rooms

AI enabled Chatbots provided with facial/wound recognition and other technologies can provide close follow up, Patient and Family Education, and Coaching

> Reporting to Nurse Providers and Physicians as Needed

Mandatory use of AI Technologies to prevent errors in Patient management

AI Technologies to provide inventory/ financial control, Improve efficiencies

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Potential Advances In Surgical Techniques (next 20 years)

Master- Slave Robots to Operate in Small Spaces

Artificial Intelligence enabled Autonomous Mini Robots Which will Remove Tumors and then Self Destruct, or Extrude from the body

Seamless Combinations of Endoscopic, Exoscopic, and Microscopic Technologies

Use of AI for Imaging and Navigational Assistance

Bendable Instrumentation, 3 – D Printed Tissue Engineered Prosthetics

Use of Stem Cells For Prevention and Recovery of Neurological Deficits

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Artificial Intelligence and Robotics in the Operating Room 2019: Our ORs are Antiquated, Inefficient,

Breeders of Infection, Highly Labor Intensive (cost)

AI, and Robotics (Master Slave, and Autonomous) can be used in a variety of areas: Surgical Assistants; Precision Surgical Technologies; Circulator/ Scrub Assistants; Inventory Management; Rapid Cleaning with UV Light; Anesthetic and Medication Oversight; Complication Prevention

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Artificial Intelligence

What is Artificial Intelligence? The field of study where computers are made to

perform tasks which require human intelligence (which consists of several components)

Artificial Intelligence Has Focused on: Learning: Rote Learning; Generalized Learning Reasoning: Deductive and Inductive Reasoning Problem Solving: Special Purpose, and General

Purpose Perception: Vision, Hearing, Touching (haptics) Language Understanding and Application

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What is Human Intelligence??

Sensory Organs> Perception> Recognition

Learning > Remembering, forgetting (memory)

Conscious Thought > Intent > Action & Reaction through Effector Organs

Language, Speech, Symbolism

Problem Solving and Logic

Imagination > Focused Action, Project Completion

Subconscious, Dreaming

Emotion, Social Interaction, Emotional Intelligence

Intuition, Premonition

Meditation

Artificial Intelligence has Not Yet Reproduced all Components of Human Intelligence, although it has exceeded or greatly exceeded in specific areas (e.g. Chess, Go, etc.) 16

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Some Medical Artificial Intelligence StartupCompanies

Evolution of Artificial Intelligence

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Artificial Neural Networks:Deep Learning

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Has AI Come of Age?

IBM “Deep Blue” beat Gary Kasparov in Chess in 1997: But due to brute computing power

Google Deep Mind created an AI program which is a combination of deep neural networks, and Search technology called“ AlphaGo” which beat the reigning European Champion Fan Hui 5-0 in 2017

Go is an incredibly difficult game; with each turn, more than 200 moves are possible

The 13-layer Neural Network program learned from more than 30 million moves from human games; the system also used statistics to determine the best move rather than playing out each move

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AI and Auto Drive

Recognizing Visual Cues (such as a cat, or another car) requires Neural network intelligence

Used as the only cue, it is flawed, because the car can be “Blind-sided” as happened with a Tesla car in Florida

However, when combined with ultrasonic detection technology, the system is vastly improved

Automatic Driving, and Delivery are being extensively tested in Pittsburgh, and Austin by Uber and Amazon

But have not yet been approved for use in the USA

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Speech/ Image Recognition Technology

Amazon Alexa, Google Home , and Apple Siri incorporate voice recognition as their primary human interface, and then use AI to perform various functions

“Chatbots” are being tried for follow up care in the NHS system in the UK

A Robotic AI enabled “Virtual Psychologist” was tried for interfacing with veterans with PTSD, and found to be more successful than Humans (Lucas GM, et al, Reporting Health Symptoms: breaking Down Barriers to Care with Virtual Human Interviewers. Frontiers in Robotics and AI 4: 1-9, 2017)

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Image Recognition by AI

IBM Watson and other Companies/ University Departments have extensively mastered reading of Radiographs, and is being tried in some institutions

Similar techniques are being developed for Pathological Diagnosis

https://youtu.be/Gigd1rkZTSE22

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Artificial IntelligenceIn Surgery

Patient Management Protocols and AlertsIn the OR, ICU, Wards

ChatbotsFor Preoperative EducationPostoperative Daily Management

Patient Population Monitoring of Prescribed ParametersRecommend Preemptive actionExample: Visit Doctor, Stop Medication

TelemedicineTriaging Patient/ NP calls, Providing Advice

Education of Students,Nurses, Residents

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Medical Robotics:Active and Passive Robots

Active Robot: Programmed to sense and evaluate data from their environment and complete their tasks appropriately

e.g: ROBODOC (Integrated Surgical System, inc. Fremont, Ca)- used in Hip Replacement Surgery; and

iROBOT (iRobot, Burlington, Mass)- used as an automatic vacuum cleaner

Passive Robots: (also called Master – Slave Robot):

The surgeon controls and moves the robot

Semi – Active Robots: Provides some guidance to the surgeon in performing the procedure .

E.g: NeuroMate (Renishaw, Inc. Gloucestershire, UK) Provides assistance in performing stereotactic procedures

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Da Vinci Surgical Robotics SystemRosa® Robot:For Depth Electrode Placement and Pedicle Screw Placement

Mazor™ Robot for Spinal Procedures

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NeuroArm™Garnette Sutherland,

Calgary

NeuRobot™from Shinshu University

Tele surgery Between Hospitals1 msec. delay

RAVEN IICompact Table Mounted Surgical Robot developed at UW (Hannaford, Rosen, Mika Sinanan, Tom Lendvay)

For Abdominal and Urological Surgery; Used for Research in Multiple UniversitiesNot in Clinical use………

Surgical Robotics at the UW

Master- Slave Robots

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The Roboscope™ (developed by, Rosen, Sekhar, Hannaford, Moe, et al)

Introducer System

A bendable Endoscopic Sheath, with Tools

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The Artificially Intelligent Neurosurgical Robotic Assistant (AINRA)

Investigators: Blake Hannaford, Niveditha Chandrasekhar, Zeeshan Qazi, Laligam Sekhar

Surgeon, Assistant: Voice, and Tool movements recorded under the microscope

Tracking of Assistant’s Tool Motions under the Microscope; and Surgeon’s Voice Cues

Analysis using Publicly available AI Programs – IBM Watson, Google Deep Mind

Goals: > To Better Understand Surgeon – Assistant Interactions with voice commands and actions

> To Create a Microsurgical Assistant that can learn Progressively from videos and real time experience, first in the cadaver lab

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AI enabled Robots are Coming!!!!

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Japanese Nurse Robot

The Age of Humanoid Robotics

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Robots In Health Care Environments - Hospitals

Intelligent Robots will Find Increasing Applications

Many jobs currently Performed by Humans: Cleaning; Food Delivery; Circulating or Scrub Personnel

Humanoid Robots can Perform Nursing Functions: 1 / 1 nursing; 24 hour ICU care; performing difficult patient tasks; Avoiding Medication errors, etc.

Robot Assisted Rehabilitation

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Robot Assisted Outpatient Care

Intelligent Robots can perform much of History, Vitals, basic examination of patients

Virtual Robots (Hololens® from Microsoft, Inc.) can perform many functions in the patient’s home

For Patients with PTSD, a Robotic Psychologist was better received than a human psychologist at Madigan Army Center

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Robots and AI in Medicine and Dentistry

World's first qualified Robotic Doctor: AI Powered Robot Xiaoyi Passes Medical Licensing Examin China with high marks: designed by iflytech

IBM Watson AI Being Used in Chinaby Oncologists

China Developed Robot PerformingAutomated Dental Surgery: 3-D printed implants placed with 0.2 to 0.3 mm accuracy: Fourth

Medical Military University and Beihang University, Bejing

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Acceptance and Other Issues of Robots in

Medicine Robots may malfunction, or not function; Safety and

back up systems are crucial

The Cost savings in the Personnel who are being replaced by the Robots will be balanced by Personnel to maintain and Repair the Robots (will eventually be an autonomous function)

The Human – Robot interface and communication will create new problems, requiring special education and training

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AI: The Greatest Disruptor in History Now!!!

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Artificial Intelligence and Robotics

Will revolutionize all aspects of our Lives

Our Jobs will change appropriately

Creativity and Innovation will be very important

Many jobs involving patient care such as cleaning, nursing, follow up care, physician communication, indications for treatment, costs of care, etc. will change

Hospitals will be Dramatically different due to the adoption of AI, Robotics, and Green

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How Will We Educate Students and Residents in the Future?

Anatomy will be studied in 3-D, 4-D, and 5-D

4- D: Three Dimensional, Changing in time, Physiologic

5- D: Three Dimensional, with Simulated Pathology

Teacher –Student Learning will Be Supplemented by Advanced Virtual Reality; and Surgical Simulations

Imagination, Problem Solving, and Ability to Work in Teams with Diverse Beings will be more important than accumulation of Knowledge (due to massive knowledge storage, and AI)

All Medical Work will be Supervised to varying Degrees by Master AI Brains, to reduce Medical Errors, and To Improve Learning

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Virtual Reality for Training Budding Skull Base Surgeons

More Advanced Technologies: Simulated Operations

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What are Future Educational Requirements for Residents??? Biology, Mathematics, Physics, Chemistry Computer Science, Coding Robotics, Artificial Intelligence Video Games, Surgical Simulations Humanity, Communication Skills Meditation and Yoga Continuous Coaching by a Companion? Work Hours Limited to 6 hours/day At least 2 months of Vacation per year

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Brain Computer Interface:Neural Lace

In the Novels by Iain M. Banks, futuristic post-humans install devices on their brains called a “neural lace.”

Researchers from Harvard and the National Center for Nanoscience and Technology in Beijing have succeeded in inventing a flexible electrical circuit that fits inside a 0.1mm-diameter glass syringe in a water-based solution

Liu J,….Liber C Nature Nanotechnology Volume 10: 629 -636, 2015Ultra fine mesh can be injected into the brain of rats, and connected to electronics externally, the brain cells grow around it Can be used in Degenerative Diseases like Parkinson’s disease, stimulation of the

brain, or “Brain Enhancement techniques”

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“Smart Hospitals of the 21st Century”

Hospitals of Smaller Size, Closer to Patients Environmentally Friendly, Carbon Neutral Optimal Healing Environment for Patients (colors, plants, music, sunlight,

etc.) Optimal Environment for Staff and education on demand Constant Cleaning of Rooms, bathrooms, other areas Smart detection and Reduction of Infection Integrated use of AI systems for Image and Other Diagnosis Continuous Monitoring of treatments and Advice, to Physicians and

Nurses Robots will be used to Lessen the number of Health care workers

(Scalability, Cost Reduction) Changes in the Jobs of Health Care Workers, Reduction of Stress and

Burn-out Telecommunication with outpatient clinics, other hospitals

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What is the Future of Health Care Workers in the Age of AI and Robotics ?

Fewer Health Care Workers doing manual jobs like Janitors, LPNs, Techs, Medical Scribes, etc.

Remainder will be Happier, work less, but in Supervisory Roles

Fewer Jobs for Radiologists, some Pathologists, Family Doctors, etc. 44

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What will Surgeons Do???

Less Invasive, but technically Complex Procedures

Master – Slave Robots, and Supervision of Autonomous Robots performing Procedures

Big Role For Innovators

Constant Retraining for New Procedures

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Five varieties of Sentient Beings in

2040:all will work together Without or With Conflicts

1.Normal, Healthy Humans

2.Genetically Enhanced Humans (this will start in one or more countries, and spread to the rest of the world)

3.Cyber- Enhanced Humans, with Implanted Electrical Connection to Major AI Networks

4.AI Enhanced Humanoid, and 46

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The Next Steps in Evolution

Human Evolution: 4 million Years From Early Hominids to Current Humans

Further Evolution: Becomes Necessary Due to Information Explosion, Advances in Technology, Environmental and Species Destruction, Garbage accumulation, Global Warming, and Selfishness and Greed of Politicians (who are our products)

Most Important: Population Explosion, and the desire of everyone to have everything

The next Steps in Evolution are Already Here and Humans will have little or No control

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Future Beings….Already Here!

Artificially Intelligent Robots

Cyber-Humans: With a variety of Biological Implants

Genetically Engineered (Enhanced) Humans, Animals, Plants

What are the Ethics of Such “Creations”

It will not Matter, since China, and Korea will move ahead with some Experiments to gain the upper Hand

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The Rise of the Intelligent Machines

Do Artificially Intelligent Robots have Consciousness?

Programmed with Human like emotional reactions, Are they Human?

What Does it Mean to be Human?

Are we Creating a “Super Race” which will wipe out Humanity, or Relegate Humans to a second class Status?

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Who Will Be the Rulers in 50 years??

AI Enabled Robots will become the rulers

They will be able to self replicate as needed, specialize, have very simple processes for energy and waste (compared to humans)

Program and Recycle themselves

Humans May be Useful for their50

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Thank You!

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