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TED演讲:一个工具,可以解决手术中最危险的一个环节

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2016年05月02日

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  The first time I stood in the operating room and watched a real surgery, I had no idea what to expect. I was a college student in engineering. I thought it was going to be like on TV. Ominous music playing in the background, beads of sweat pouring down the surgeon's face. But it wasn't like that at all. There was music playing on this day, I think it was Madonna's greatest hits. (Laughter) And there was plenty of conversation, not just about the patient's heart rate, but about sports and weekend plans. And since then, the more surgeries I watched, the more I realized this is how it is. In some weird way, it's just another day at the office. But every so often the music gets turned down, everyone stops talking, and stares at exactly the same thing. And that's when you know that something absolutely critical and dangerous is happening.

  我第一次进手术室 观摩实际手术时, 没预料会看到什么。 我当时是工科大学生。 我以为会像电视上演的一样, 播着紧张的背景音乐, 豆大的汗珠由外科医生脸上滑落。 但根本不是那样。 当天的确有播音乐, 我想是玛丹娜的金曲选辑。(笑声) 当时还有许多交谈, 话题除了病人心率外, 还有运动跟周末计划。 我手术看得越多, 就越懂那是怎么回事。 从某个古怪角度来看,这跟在办公室没两样。 但有时, 音乐声会被转小, 所有人停止说话, 眼睛盯着同样的东西。 那时你就知道,有很重要、 很危险的事情正在进行。

  The first time I saw that I was watching a type of surgery called laparoscopic surgery And for those of you who are unfamiliar, laparoscopic surgery, instead of the large open incision you might be used to with surgery, a laparoscopic surgery is where the surgeon creates these three or more small incisions in the patient. And then inserts these long, thin instruments and a camera, and actually does the procedure inside the patient. This is great because there's much less risk of infection, much less pain, shorter recovery time. But there is a trade-off, because these incisions are created with a long, pointed device called a trocar. And the way the surgeon uses this device is that he takes it and he presses it into the abdomen until it punctures through. And now the reason why everyone in the operating room was staring at that device on that day was because he had to be absolutely careful not to plunge it through and puncture it into the organs and blood vessels below. But this problem should seem pretty familiar to all of you because I'm pretty sure you've seen it somewhere else. (Laughter) Remember this? (Applause) You knew that at any second that straw was going to plunge through, and you didn't know if it was going to go out the other side and straight into your hand, or if you were going to get juice everywhere, but you were terrified. Right? Every single time you did this, you experienced the same fundamental physics that I was watching in the operating room that day. And it turns out it really is a problem. In 2003, the FDA actually came out and said that trocar incisions might be the most dangerous step in minimally invasive surgery. Again in 2009, we see a paper that says that trocars account for over half of all major complications in laparoscopic surgery. And, oh by the way, this hasn't changed for 25 years.

  首次遇到那状况时, 我正在观摩腹腔镜手术。 为不熟悉的人说明一下, 腹腔镜手术不像 传统大切口的手术, 腹腔镜手术中,外科医生 在病人身上开三个以上的切口。 接着插入这些细长、 附摄影机的器材, 并透过它在病患体内进行手术。 这很不错,因为感染风险低、 较少疼痛,恢复时间也更短。 但这其中有着取舍, 因为开这些切口 用的是个尖长的器械, 叫做穿刺套针。 而外科医生用这器械的方法 是他抓着这东西, 然后压在你的腹部, 直到它穿进去。 这就是为何在手术室的所有人 在当时都盯着那东西看, 因为他必须非常小心 不要穿太过, 以免刺穿下面的脏器和血管。 但这问题大家都很熟, 因为你们八成在其他地方看过了。 (笑声) 记得这个吧? (掌声) 你很清楚在某个时间点, 吸管会刺穿, 而你不知是否会穿透, 戳到你的手, 或把果汁喷得到处是。 你怕死了。对吧? 每次你做这件事, 所体验到的物理原理, 都和我那天在手术室经历的一样。 这显然是个大问题。 2003 年,FDA 甚至出面表示: 套针穿刺或许是在微创手术中 最危险的步骤。 2009 年,我们又看到一篇论文说: 腹腔镜手术的主要并发症 有半数以上和穿刺套针有关。 噢!除此之外, 这件事已经 25 年没变了。

  So when I got to graduate school, this is what I wanted to work on. I was trying to explain to a friend of mine what exactly I was spending my time doing, and I said, "It's like when you're drilling through a wall to hang something in your apartment. There's that moment when the drill first punctures through the wall and there's this plunge. Right? And he looked at me and he said, "You mean like when they drill into people's brains?" And I said, "Excuse me?" (Laughter) And then I looked it up and they do drill into people's brains. A lot of neurosurgical procedures actually start with a drill incision through the skull. And if the surgeon isn't careful, he can plunge directly into the brain. So this is the moment when I started thinking, okay, cranial drilling, laparoscopic surgery, why not other areas of medicine? Because think about it, when was the last time you went to the doctor and you didn't get stuck with something? Right? So the truth is in medicine puncture is everywhere. And here are just a couple of the procedures that I've found that involve some tissue puncture step. And if we take just three of them — laparoscopic surgery, epidurals, and cranial drilling — these procedures account for over 30,000 complications every year in this country alone. I call that a problem worth solving.

  所以我上研究所时, 就想做这东西。 我试着跟朋友解释 我到底在忙什么, 我说: 「这就像你为了挂东西 钻墙壁那样。 钻子在钻穿墙壁那个瞬间 会爆冲一下。对吧?」 然后他看着我说: 「你是说,像他们钻人脑袋那样?」 然后我说:「啥?!」(笑声) 我后来查了一下,发现他们真会这么做。 很多的神经外科手术 第一步就是在你颅骨上钻个洞。 如果外科医生不谨慎, 他有可能会直接戳到脑部。 从那时候我开始思考, 好,颅骨钻孔、腹腔镜手术, 那其他医学领域呢? 你想想,哪次你去看医生 没被塞点什么,是吧? 事实就是, 在医学上,穿刺无所不在。 而这只是我查到的几种手术, 其中有组织穿刺的步骤。 如果我们只看其中三种── 腹腔镜手术、硬膜外麻醉、颅骨钻孔── 而这些手术引发了超过三万起的并发症, 而这只是这个国家一年的数字。 我认为这是个值得解决的问题。

  So let's take a look at some of the devices that are used in these types of procedures. I mentioned epidurals. This is an epidural needle. It's used to puncture through the ligaments in the spine and deliver anesthesia during childbirth. Here's a set of bone marrow biopsy tools. These are actually used to burrow into the bone and collect bone marrow or sample bone lesions. Here's a bayonette from the Civil War. (Laughter) If I had told you it was a medical puncture device you probably would have believed me. Because what's the difference? So, the more I did this research the more I thought there has to be a better way to do this. And for me the key to this problem is that all these different puncture devices share a common set of fundamental physics.

  让我们来看一些 用在这类手术的器械。 我提过硬膜外麻醉。这是硬膜外套针。 他用来穿刺脊椎韧带, 在分娩时注射麻醉药。 这是组骨髓切片取样工具, 用来做骨骼穿孔, 并收集骨髓,或做骨骼病变的取样。 这是南北战争的刺刀。 (笑声) 若我告诉你这是医学穿刺器材, 你说不定真会相信我。 因为这没什么不同嘛! 我越深入研究, 越是觉得 一定有更好的做法。 对我来说,问题的关键在于 所有的这些穿刺器材 都遵循同一套物理原理。

  So what are those physics? Let's go back to drilling through a wall. So you're applying a force on a drill towards the wall. And Newton says the wall is going to apply force back, equal and opposite. So, as you drill through the wall, those forces balance. But then there's that moment when the drill first punctures through the other side of the wall, and right at that moment the wall can't push back anymore. But your brain hasn't reacted to that change in force. So for that millisecond, or however long it takes you to react, you're still pushing, and that unbalanced force causes an acceleration, and that is the plunge. But what if right at the moment of puncture you could pull that tip back, actually oppose the forward acceleration? That's what I set out to do.

  什么原理呢? 让我们回到钻墙壁。 你透过钻子对墙施加压力, 牛顿告诉我们,墙壁会给我们反作用力, 等量且反向。 当你正在钻的时候, 两力平衡。 但在某个瞬间, 墙壁会被钻穿, 墙壁将无法再提供反作用力。 但你的大脑还来不及对变化作出反应, 有几毫秒时间 ──依你的反应速度而定,你还在施加压力。 而不平衡的力造成加速度, 导致爆冲。 但如果在刺穿瞬间, 你能够将针尖 往加速的反方向缩回呢? 那就是我要做的。

  So imagine you have a device and it's got some kind of sharp tip to cut through tissue. What's the simplest way you could pull that tip back? I chose a spring. So when you extend that spring, you extend that tip out so it's ready to puncture tissue, the spring wants to pull the tip back. How do you keep the tip in place until the moment of puncture? I used this mechanism. When the tip of the device is pressed against tissue, the mechanism expands outwards and wedges in place against the wall. And the friction that's generated locks it in place and prevents the spring from retracting the tip. But right at the moment of puncture, the tissue can't push back on the tip anymore. So the mechanism unlocks and the spring retracts the tip. Let me show you that happening in slow motion. This is about 2,000 frames a second, and I'd like you to notice the tip that's right there on the bottom, about to puncture through tissue. And you'll see that right at the moment of puncture, right there, the mechanism unlocks and retracts that tip back. I want to show it to you again, a little closer up. You're going to see the sharp bladed tip, and right when it punctures that rubber membrane it's going to disappear into this white blunt sheath. Right there. That happens within four 100ths of a second after puncture. And because this device is designed to address the physics of puncture and not the specifics of cranial drilling or laparoscopic surgery, or another procedure, it's applicable across these different medical disciplines and across different length scales.

  想象你有种器材, 它有用来刺穿组织的针尖。 把针尖缩回的最简单方法是什么? 我选择了弹簧。 当弹簧拉伸,针尖便伸出, 就能穿刺组织。 弹簧会想拉回针尖。 你如何在穿透前, 固定住针尖呢? 我采用这机械结构。 当针尖受到组织的反作用力, 这机构会向外撑向内壁。 而其产生的摩擦力 会锁定针尖,阻止弹簧将它缩回。 但在穿透瞬间, 组织不再提供反作用力。 所以机构解锁,弹簧将针尖缩回。 看一下慢动作。 这大约每秒 2,000 画格。 注意针尖的部分, 在画面下方,即将刺穿组织。 你会发现在刺穿的瞬间, 在这,机构解锁,针尖缩回。 我们拉近点再看一次。 你会看到那尖锐的针尖, 在它刺穿橡胶膜的瞬间, 会缩进那个钝边白色套管。 在这。 这一切都在百分之四秒内发生。 而且因为这项设计是遵循穿刺的物理原理 而非针对颅骨钻孔、 腹腔镜手术或其他手术, 其适用范围涵盖医学各领域, 以及各种不同规模。

  But it didn't always look like this. This was my first prototype. Yes, those are popsicle sticks, and there's a rubber band at the top. It took about 30 minutes to do this, but it worked. And it proved to me that my idea worked and it justified the next couple years of work on this project. I worked on this because this problem really fascinated me. It kept me up at night. But I think it should fascinate you too, because I said puncture is everywhere. That means at some point it's going to be your problem too. That first day in the operating room I never expected to find myself on the other end of a trocar. But last year, I got appendicitis when I was visiting Greece. So I was in the hospital in Athens, and the surgeon was telling me he was going to perform a laparoscopic surgery. He was going to remove my appendix through these tiny incisions, and he was talking about what I could expect for the recovery, and what was going to happen. He said, "Do you have any questions?" And I said, "Just one, doc. What kind of trocar do you use?"

  但它不见得长这样。 这是我作品的原型。 对,那是棒冰棍, 顶部那是橡皮筋。 做这只花 30 分钟,但成品就有用了。 它证明我的想法可行, 并让我接下来几年的付出有所凭据。 我投入其中, 因为这问题让我着迷, 甚至使我夜不能眠。 但我想这也该吸引你, 因为穿刺无所不在。 意味着在某个时刻,那也将成为你的问题。 进手术室第一天, 我没料到有天穿刺套针会用在我身上。 但去年,我在希腊时患上阑尾炎。 我在雅典的医院, 外科医生告知我 他将进行腹腔镜手术。 他将透过那些小切口切除阑尾, 接着他告诉我预期的康复状况、 接下来会做什么。 他说:「你有什么问题吗?」我说:「只有一个。 你们用的是哪种穿刺套针?」

  So my favorite quote about laparoscopic surgery comes from a Doctor H. C. Jacobaeus: "It is puncture itself that causes risk." That's my favorite quote because H.C. Jacobaeus was the first person to ever perform laparoscopic surgery on humans, and he wrote that in 1912. This is a problem that's been injuring and even killing people for over 100 years.

  8:20 关于腹腔镜手术,我最爱的引语 出自雅各布贝乌斯医师: 「造成风险的,是穿刺本身。」 这是我最爱的引语,因为雅各布贝乌斯 是在人体进行腹腔镜手术的第一人。 而他在 1912 年写下这句话。 这问题伤害人们,甚至致人于死已超过百年之久。

  So it's easy to think that for every major problem out there there's some team of experts working around the clock to solve it. The truth is that's not always the case. We have to be better at finding those problems and finding ways to solve them. So if you come across a problem that grabs you, let it keep you up at night. Allow yourself to be fascinated, because there are so many lives to save.

  你可以安逸地想说,重要问题 已有一群专家不眠不休致力解决。 真相是,事情并非总如此。 我们得找到这样的问题, 并找方法解决。 所以若你遇到那种「刺眼」的问题,

  (Applause)


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