is also a talk about surgery.

這是關於外科手術機器的演講,

And while I've tried to make my images not too graphic,

也是關於手術的演講

keep in mind that surgeons have a different relationship with blood

在我試著不要讓畫面太血腥的同時

than normal people do,

請了解外科醫師對血有和一般人

because, after all, what a surgeon does to a patient,

不一樣的情感關係

if it were done without consent,

畢竟外科醫師對病人所做的事

would be a felony.

如果沒有得到同意

Surgeons are the tailors, the plumbers,

會是一項嚴重的罪行

the carpenters -- some would say the butchers --

外科醫師是裁縫、是水電工

of the medical world:

是木匠，有些人會說他們是

cutting, reshaping, reforming,

醫學界的屠夫

bypassing, fixing.

做切割、重建、改造

But you need to talk about surgical instruments

繞道、修補

and the evolution of surgical technology together.

但是你必須要把手術的器具

So in order to give you some kind of a perspective

和手術科技的發展放在一起來討論

of where we are right now

所以為了要讓你們稍稍了解

with surgical robots,

手術用機器,

and where we're going to be going in the future,

目前發展到哪裡

I want to give you a little bit of perspective

還有未來要往哪裡去

of how we got to this point,

我要讓你們有些概念

how we even came to believe

我們是怎麼走到這一步的

that surgery was OK,

我們到底是怎麼樣開始相信

that this was something that was possible to do,

動手術是可行的

that this kind of cutting and reforming was OK.

這件事是有可能做到的

So, a little bit of perspective --

這樣的切割和重建是好的

about 10,000 years of perspective.

所以，以下是一些觀點

This is a trephinated skull.

大約是一萬年以來的觀點

And trephination is simply just cutting a hole in the skull.

這是一個做了頭顱穿洞術的頭骨,

And many, many hundreds of skulls like this

頭顱穿洞術就是在頭骨上切開一個洞

have been found in archaeological sites

在世界各地的考古遺址

all over the world,

已經發現成千上百

dating back five to 10 thousand years.

像這樣的頭骨

Five to 10 thousand years! Now imagine this.

年代可以回溯到一萬年前

You are a healer in a Stone Age village.

五千到一萬年前! 現在想像

And you have some guy that you're not quite sure what's wrong with him --

你是石器時代村落裡的治療師

Oliver Sacks is going to be born way in the future.

有一個病人你不是很確定他到底怎麼了

He's got some seizure disorder. And you don't understand this.

(奧立佛薩克斯將在很久以後的未來才出生)

But you think to yourself,

他有癲癇的症狀。雖然你不知道是為什麼,

"I'm not quite sure what's wrong with this guy.

但是你的腦子裡就想

But maybe if I cut a hole in his head I can fix it."

“我不是很確定他怎麼了，

(Laughter)

但是如果我在他的頭上開個洞，我就可以把他治好”

Now that is surgical thinking.

(笑聲)

Now we've got the dawn of interventional surgery here.

這就是手術的想法

What is astonishing about this is,

現在我們已經知道侵入式手術的開端是什麼

even though we don't know really how much of this

真正讓我們驚奇的是

was intended to be religious,

即使我們不知道到底這樣的行為其中有多少是

or how much of it was intended to be therapeutic,

為了宗教的理由

what we can tell is that these patients lived!

或者這裡頭有多少的目的是為了治療,

Judging by the healing on the borders of these holes,

我們知道的是這些病人都存活下來!

they lived days, months, years following trephination.

從這些洞邊緣的瘉合狀況來看

And so what we are seeing is evidence

他們在環鋸手術後活了很多天、很多個月、甚至好幾年

of a refined technique

所以我們看到的是一種

that was being handed down over thousands and thousands of years,

精湛技術的證據

all over the world.

它在世界各地傳承了

This arose independently at sites everywhere

好幾千年

that had no communication to one another.

它在各個地點的崛起是個自獨立的

We really are seeing the dawn of interventional surgery.

彼此沒有交流

Now we can fast forward many thousands of years

我們真正見到了侵入式手術的起源

into the Bronze Age and beyond.

現在我們可以快轉幾千年

And we see new refined tools coming out.

到銅器時代以及之後

But surgeons in these eras are a little bit more conservative

我們看到新的更精良的工具出土

than their bold, trephinating ancestors.

但是這個時期的外科醫師比起他們那些

These guys confined their surgery

大膽、做環鋸手術的祖先要保守些

to fairly superficial injuries.

這些人做的手術只限於

And surgeons were tradesmen,

相當表面的損傷

rather than physicians.

而且外科醫師是工匠

This persisted all the way into and through the Renaissance.

而不是醫生

That may have saved the writers,

這狀況一直維持到文藝復興時代結束

but it didn't really save the surgeons terribly much.

那可能保全了作家

They were still a mistrusted lot.

但是對於拯救外科醫師的名聲卻沒有什麼貢獻

Surgeons still had a bit of a PR problem,

他們仍舊是不被信任的一群

because the landscape was dominated

外科醫師依然有些公關上的問題

by the itinerant barber surgeon.

因為當時這個領域中稱霸的

These were folks that traveled from village to village, town to town,

是四處巡迴的理髮師外科醫生

doing surgery sort of as a form of performance art.

這些人穿梭在城鎮之間

Because we were in the age before anesthesia,

動手術就好像是在種表演藝術,

the agony of the patient

因為當時仍是麻醉存在之前的年代

is really as much of the public spectacle

所以病人的強烈苦痛

as the surgery itself.

其實和手術本身同樣被大眾

One of the most famous of these guys, Frere Jacques,

視為奇觀

shown here doing a lithotomy --

其中最出名的，雅各修士

which is the removal of the bladder stone,

在這張圖上，正在進行截石術

one of the most invasive surgeries they did at the time --

就是取出膀胱的結石

had to take less than two minutes.

在當時是侵入性最高的手術之一

You had to have quite a flair for the dramatic,

他必須在兩分鐘內做完

and be really, really quick.

所以你一定要很戲劇化的炫技,

And so here you see him doing a lithotomy.

手法要非常地快

And he is credited with doing over 4,000 of these public surgeries,

在這張畫裡，你可以看到雅各修士在做截石術,

wandering around in Europe,

一般相信他在歐洲遊走

which is an astonishing number,

做過超過四千場大庭廣眾下的手術

when you think that surgery must have been a last resort.

當你的認知是手術一定是最後的手段時

I mean who would put themselves through that?

這個數字就十分驚人

Until anesthesia, the absence of sensation.

我的意思是有誰會願意經歷這過程？

With the demonstration of the Morton Ether Inhaler

一直到麻醉這種讓病人沒有知覺的手段出現──

at the Mass. General in 1847,

1847年，在麻省總醫院

a whole new era of surgery was ushered in.

莫爾頓示範乙醚吸入器後

Anesthesia gave surgeons the freedom to operate.

外科手術即被帶入一個全新的紀元

Anesthesia gave them the freedom to experiment,

麻醉給外科醫師開刀的自由

to start to delve deeper into the body.

麻醉給他們實驗的自由

This was truly a revolution in surgery.

讓他們開始對人體進行更深入的探索

But there was a pretty big problem with this.

這真的是手術的一大革新

After these very long, painstaking operations,

但是這也帶來了一個蠻大的問題

attempting to cure things they'd never been able to touch before,

病人接受這些冗長又辛苦的手術

the patients died.

目的就是為了要治癒他們以前根本無法碰觸的疾病

They died of massive infection.

但是完成後病人卻死了

Surgery didn't hurt anymore,

他們死於嚴重的感染

but it killed you pretty quickly.

手術雖然不再痛苦

And infection would continue to claim a majority of surgical patients

但是它可以迅速的致命

until the next big revolution in surgery,

且感染持續奪走大部份手術病人的生命

which was aseptic technique.

一直到手術的下一個重大革新出現

Joseph Lister was aepsis's,

就是消毒滅菌技術

or sterility's, biggest advocate,

約瑟夫李斯特是無菌處理

to a very very skeptical bunch of surgeons.

或消毒的最重要提倡者

But eventually they did come around.

他對一些對此非常懷疑的外科醫生做宣導

The Mayo brothers came out to visit Lister in Europe.

最後他們終於也改變立場

And they came back to their American clinic and they said

梅約兄弟到歐洲來拜訪李斯特

they had learned it was as important to wash your hands

在他們回到美國的診所後說到

before doing surgery

他們學習到手術前洗手

as it was to wash up afterwards. (Laughter)

和手術後的清洗

Something so simple.

是一樣重要的

And yet, operative mortality dropped profoundly.

這是多簡單的一件事

These surgeries were actually now being effective.

但是，手術的致死率就因此明顯降低

With the patient insensitive to pain,

這些手術事實上現在很有效

and a sterile operating field

在病人不感覺痛

all bets were off, the sky was the limit.

且在無菌手術室的狀況下

You could now start doing surgery everywhere,

一切都不一樣了，不再有限制

on the gut, on the liver,

現在你可以在任何地方動手術

on the heart, on the brain.

腸子、肝

Transplantation: you could take an organ out of one person,

心臟、腦

you could put it in another person, and it would work.

移植手術：你可以從一個人身上取出一個器官

Surgeons didn't have a problem with respectability anymore;

把它放到另一個人身上，仍可以運作

they had become gods.

外科醫生不再有聲望上的問題

The era of the "big surgeon, big incision" had arrived,

他們變成了神

but at quite a cost,

“大外科醫生開大刀"的時代來臨

because they are saving lives,

但這也付出一定的代價

but not necessarily quality of life,

因為他們雖然救了很多生命

because healthy people don't usually need surgery,

但卻不見得是有品質的生活

and unhealthy people have a very hard time recovering from a cut like that.

這是因為健康的人通常不需開刀

The question had to be asked,

而不健康的人卻很難從這麼大的傷勢中復元

"Well, can we do these same surgeries

這時我們就會問

but through little incisions?"

“嗯，我們是不是可進行同樣的手術

Laparoscopy is doing this kind of surgery:

但是不用這麼大的切口呢？”

surgery with long instruments through small incisions.

內視鏡檢查就是這類的手術

And it really changed the landscape of surgery.

醫師以一根很長的器械穿過很小的切口來進行手術,

Some of the tools for this had been around for a hundred years,

這真的改變了外科手術的視野

but it had only been used as a diagnostic technique

其實有些內視鏡的器械已經存在約一百年了,

until the 1980s,

但是它只被用來當作診斷的技術

when there was changes in camera technologies and things like that,

一直到 1980 年代

that allowed this to be done for real operations.

當照相機及相關技術有重大突破後

So what you see -- this is now the first surgical image --

這些器械才得以實際應用於手術上,

as we're coming down the tube, this is a new entry into the body.

你在這裡看到 ─ 這是第一張手術照片 ─

It looks very different from what you're expecting surgery to look like.

我們沿著管子往下走，這是一個進入身體的新入口

We bring instruments in,

這和你期待的手術的樣子很不一樣

from two separate cuts in the side,

我們分別從側面兩個切口

and then you can start manipulating tissue.

把器械帶入,

Within 10 years of the first gallbladder surgeries

現在你就可以開始處理組織

being done laparoscopically,

自從第一次膽囊手術使用內視鏡

a majority of gallbladder surgeries

開始的十年內

were being done laparoscopically --

大部分的膽囊手術

truly a pretty big revolution.

都是經由內視鏡手術完成

But there were casualties of this revolution.

這真的是一項很大的改革

These techniques were a lot harder to learn

但是這項改革也造成一些傷亡,

than people had anticipated.

內視鏡這項技術比一般人預期的,

The learning curve was very long.

要難學習

And during that learning curve the complications went quite a bit higher.

學習的時間很長

Surgeons had to give up their 3D vision.

且在學習期間併發症產生的機率偏高

They had to give up their wrists.

外科醫生要放棄原本 3D 的視覺

They had to give up intuitive motion in the instruments.

他們要放棄它們的手腕

This surgeon has over 3,000 hours of laparoscopic experience.

他們要放棄使用工具的直覺式動作

Now this is a particularly frustrating placement of the needle.

這位外科醫生有超過 3000 小時的內視鏡手術經驗

But this is hard.

從這段可以看到要把針放對很不容易

And one of the reasons why it is so hard

這真的很困難

is because the external ergonomics are terrible.

為什麼這麼困難的原因之一

You've got these long instruments, and you're working off your centerline.

是因為在體外器械操作的人體工學很糟糕,

And the instruments are essentially working backwards.

工具很長，你得偏離身體中線操作，

So what you need to do, to take the capability of your hand,

而這些器械又主要是以反向操作,

and put it on the other side of that small incision,

所以你要做的，是在器械上置入類似手腕的關節，

is you need to put a wrist on that instrument.

這樣就在小切口的另一側，

And so -- I get to talk about robots --

利用手的靈巧度。

the da Vinci robot

所以在這 我有機會來聊聊手術用機器,

put just that wrist on the other side of that incision.

達文西機器的設計,

And so here you're seeing the operation of this wrist.

讓類似手腕的關節得以放到切口的另一邊,

And now, in contrast to the laparoscopy,

你在這可以看到這個關節的操作,

you can precisely place the needle in your instruments,

現在，相對於內視鏡手術

and you can pass it all the way through

你可以準確的把針放到工具上

and follow it in a trajectory.

而且讓針穿過整個組織，

And the reason why this becomes so much easier

並讓針延著切口的軌跡縫合。

is -- you can see on the bottom --

為什麼會變得這麼容易是因為

the hands are making the motions,

你可以在畫面下方看到,

and the instruments are following those motions exactly.

當手在移動時，

Now, what you put between those instruments and those hands,

工具可以精確的描摹手部的動作,

is a large, fairly complicated robot.

你放在那些工具和那些手之間的

The surgeon is sitting at a console,

是一台很大且相當複雜的機器,

and controlling the robot with these controllers.

外科醫生坐在操縱臺

And the robot is moving these instruments around,

用這些控制器來控制機器,

and powering them, down inside the body.

在病人身體裡面，藉著操作機器,

You have a 3D camera, so you get a 3D view.

醫生得以移動手術器械，並給予動力,

And since this was introduced in 1999,

你會有個 3D 相機，所以你可以看到 3D 畫面

a lot of these robots have been out

自從 1999 年問世以來

and being used for surgical procedures like a prostatectomy,

生產了很多這類的機器,

which is a prostate deep in the pelvis,

且用在外科手術上，像是攝護腺切除術

and it requires fine dissection

就是說，攝護腺是為在骨盆內較深的地方

and delicate manipulation

所以它需要精細的切割

to be able to get a good surgical outcome.

並且要很小心地操作

You can also sew bypass vessels directly onto a beating heart

才能得到很好的手術結果

without cracking the chest.

你也可以不用打開胸腔

This is all done in between the ribs.

就在跳動的心臟縫上繞道用的血管,

And you can go inside the heart itself

這都是在肋骨之間完成的

and repair the valves from the inside.

你可以進入心臟

You've got these technologies -- thank you --

從內部修補瓣膜

(Applause)

現在這些技術都有了-- 謝謝 --

And so you might say, "Wow this is really cool!

(鼓掌)

So, smartypants, why isn't all surgery being done this way?"

所以你可能會覺得，“哇! 這真酷!”

And there are some reasons, some good reasons.

“可是如果你真的這麼厲害，為什麼不是所有的手術都可以這樣做?”

And cost is one of them.

這是有原因的，有些理由很充分

I talked about the large, complicated robot.

成本是其中之一

With all its bells and whistles, one of those robots

我說的是複雜的大型機器,

will cost you about as much as a solid gold surgeon.

為它那些花俏的附屬配件，一組機器的花費,

More useful than a solid gold surgeon,

幾乎跟一個真的頂尖外科醫師一樣,

but, still, it's a fairly big capital investment.

也許比外科醫師有用

But once you've got it, your procedure costs do come down.

但是它還是一項龐大的投資

But there are other barriers.

不過一但你擁有它，手術程序上的成本的確會下降

So something like a prostatectomy --

當然還是有其他的障礙存在

the prostate is small, and it's in one spot,

所以像是攝護腺切除術

and you can set your robot up very precisely

攝護腺很小而且就位在一個點上

to work in that one spot.

你可以很精準地設定機器

And so it's perfect for something like that.

只在那一點上工作

And in fact if you, or anyone you know,

所以對這類手術是非常合適的

had their prostate taken out in the last couple of years,

事實上，如果你或你認識的人

chances are it was done with one of these systems.

在過去這幾年中把攝護腺切除

But if you need to reach more places than just one,

很可能就是用這其中的一種系統做的

you need to move the robot.

但是如果你的手術部位不只一個,

And you need to put some new incisions in there.

你就需要移動機器

And you need to re-set it up.

而且你會需要新的切口

And then you need to add some more ports, and more.

你需要重新設定

And the problem is it gets time-consuming, and cumbersome.

你會需要增加更多的連接點以及其他的物件

And for that reason there are many surgeries

問題就出在時間變長，且笨重難處理