Robotic and Computer Assisted Technology in Surgery: Opportunities to link the Global Health Community

1. Robotic and Computer Assisted Technology in Surgery: Opportunities to link the Global Health Community Satyan K. Shah, M.D. Director of Robotic Surgery Director of Minimally Invasive Urologic Surgery Today I want to talk to you about a technology that you probably have heard about before. But now I�m proud to say both the University of New Mexico and the New Mexico VA Health Care System both have recently purchased and have started utilizing. Just to give you some background after finishing my residency I did a fellowship at Roswell Park Cancer Institute where I focused on robotic and laparoscopic surgery and I just joined UNM and the VA in July. Today I want to talk to you about a technology that you probably have heard about before. But now I�m proud to say both the University of New Mexico and the New Mexico VA Health Care System both have recently purchased and have started utilizing. Just to give you some background after finishing my residency I did a fellowship at Roswell Park Cancer Institute where I focused on robotic and laparoscopic surgery and I just joined UNM and the VA in July.

2. Outline So My goal today is to first give you a broad overview of the technology, how it works, what are its advantages/disadvantages from both a surgeon�s and patient�s perspective. I�m then going to spend some time talking about prostate cancer. I think any surgeon who operates in the pelvis � urologic or general should have some knowledge about prostate cancer and so I�ll give you an update on diagnosis and staging and then talk specifically about radical prostatectomy because this is the operation that the robot has really found its niche in. And I�m going to try to discuss some anatomic reasons for why robotics is so ideally suited for prostatectomy. Of course, this technology is clearly going much beyond urology and so I�ll talk about other uses. Now that the machines are here, some of you might want to consider using the machine and so I thought I�d spend a few minutes on credentialing and educational issues. Lastly we�ll talk about future directions. So My goal today is to first give you a broad overview of the technology, how it works, what are its advantages/disadvantages from both a surgeon�s and patient�s perspective. I�m then going to spend some time talking about prostate cancer. I think any surgeon who operates in the pelvis � urologic or general should have some knowledge about prostate cancer and so I�ll give you an update on diagnosis and staging and then talk specifically about radical prostatectomy because this is the operation that the robot has really found its niche in. And I�m going to try to discuss some anatomic reasons for why robotics is so ideally suited for prostatectomy. Of course, this technology is clearly going much beyond urology and so I�ll talk about other uses. Now that the machines are here, some of you might want to consider using the machine and so I thought I�d spend a few minutes on credentialing and educational issues. Lastly we�ll talk about future directions.

3. History So My goal today is to first give you a broad overview of the technology, how it works, what are its advantages/disadvantages from both a surgeon�s and patient�s perspective. I�m then going to spend some time talking about prostate cancer. I think any surgeon who operates in the pelvis � urologic or general should have some knowledge about prostate cancer and so I�ll give you an update on diagnosis and staging and then talk specifically about radical prostatectomy because this is the operation that the robot has really found its niche in. And I�m going to try to discuss some anatomic reasons for why robotics is so ideally suited for prostatectomy. Computer Motion, a company from California, originally worked under contract from NASA and the jet propulsion laboratory to develop a robotic system that could be used to inspect satellites and payloads on the space shuttle, so that�s how NASA is involved. So My goal today is to first give you a broad overview of the technology, how it works, what are its advantages/disadvantages from both a surgeon�s and patient�s perspective. I�m then going to spend some time talking about prostate cancer. I think any surgeon who operates in the pelvis � urologic or general should have some knowledge about prostate cancer and so I�ll give you an update on diagnosis and staging and then talk specifically about radical prostatectomy because this is the operation that the robot has really found its niche in. And I�m going to try to discuss some anatomic reasons for why robotics is so ideally suited for prostatectomy. Computer Motion, a company from California, originally worked under contract from NASA and the jet propulsion laboratory to develop a robotic system that could be used to inspect satellites and payloads on the space shuttle, so that�s how NASA is involved.

4. Aesop The aeosop was a rather simple robot that had a foot controlled and voice control over one single arm and typically that arm would hold a camera (a laparoscope) and so the surgeon would not have to hold the camera or have an assistant do so � it also offerred a stable image because you didn�t have the slight movements you would get if you had your assistant driving the camera for you. Computer Motion of California AESOP � Automated endoscopic system for Optimal PositioningThe aeosop was a rather simple robot that had a foot controlled and voice control over one single arm and typically that arm would hold a camera (a laparoscope) and so the surgeon would not have to hold the camera or have an assistant do so � it also offerred a stable image because you didn�t have the slight movements you would get if you had your assistant driving the camera for you. Computer Motion of California AESOP � Automated endoscopic system for Optimal Positioning

5. Zeus robot So My goal today is to first give you a broad overview of the technology, how it works, what are its advantages/disadvantages from both a surgeon�s and patient�s perspective. I�m then going to spend some time talking about prostate cancer. I think any surgeon who operates in the pelvis � urologic or general should have some knowledge about prostate cancer and so I�ll give you an update on diagnosis and staging and then talk specifically about radical prostatectomy because this is the operation that the robot has really found its niche in. And I�m going to try to discuss some anatomic reasons for why robotics is so ideally suited for prostatectomy. Of course, this technology is clearly going much beyond urology and so I�ll talk about other uses. Now that the machines are here, some of you might want to consider using the machine and so I thought I�d spend a few minutes on credentialing and educational issues. Lastly we�ll talk about future directions. So My goal today is to first give you a broad overview of the technology, how it works, what are its advantages/disadvantages from both a surgeon�s and patient�s perspective. I�m then going to spend some time talking about prostate cancer. I think any surgeon who operates in the pelvis � urologic or general should have some knowledge about prostate cancer and so I�ll give you an update on diagnosis and staging and then talk specifically about radical prostatectomy because this is the operation that the robot has really found its niche in. And I�m going to try to discuss some anatomic reasons for why robotics is so ideally suited for prostatectomy. Of course, this technology is clearly going much beyond urology and so I�ll talk about other uses. Now that the machines are here, some of you might want to consider using the machine and so I thought I�d spend a few minutes on credentialing and educational issues. Lastly we�ll talk about future directions.

6. Zeus robot So My goal today is to first give you a broad overview of the technology, how it works, what are its advantages/disadvantages from both a surgeon�s and patient�s perspective. I�m then going to spend some time talking about prostate cancer. I think any surgeon who operates in the pelvis � urologic or general should have some knowledge about prostate cancer and so I�ll give you an update on diagnosis and staging and then talk specifically about radical prostatectomy because this is the operation that the robot has really found its niche in. And I�m going to try to discuss some anatomic reasons for why robotics is so ideally suited for prostatectomy. Of course, this technology is clearly going much beyond urology and so I�ll talk about other uses. Now that the machines are here, some of you might want to consider using the machine and so I thought I�d spend a few minutes on credentialing and educational issues. Lastly we�ll talk about future directions. So My goal today is to first give you a broad overview of the technology, how it works, what are its advantages/disadvantages from both a surgeon�s and patient�s perspective. I�m then going to spend some time talking about prostate cancer. I think any surgeon who operates in the pelvis � urologic or general should have some knowledge about prostate cancer and so I�ll give you an update on diagnosis and staging and then talk specifically about radical prostatectomy because this is the operation that the robot has really found its niche in. And I�m going to try to discuss some anatomic reasons for why robotics is so ideally suited for prostatectomy. Of course, this technology is clearly going much beyond urology and so I�ll talk about other uses. Now that the machines are here, some of you might want to consider using the machine and so I thought I�d spend a few minutes on credentialing and educational issues. Lastly we�ll talk about future directions.

7. Overview of current technology Now I want to take a step back for a moment and critically evaluate this technology in terms of outcomes. Because really, for this technology to be here to stay we have to see hard evidence that there is a benefit to surgeons, patients, and even hospitals when you think about this in terms of our health care crisis and spirally costs. And I think you will see that like any technology, there are advantages, there are disadvantages, there are limitations and there are certainly controversies. So let�s talk about some of them.Now I want to take a step back for a moment and critically evaluate this technology in terms of outcomes. Because really, for this technology to be here to stay we have to see hard evidence that there is a benefit to surgeons, patients, and even hospitals when you think about this in terms of our health care crisis and spirally costs. And I think you will see that like any technology, there are advantages, there are disadvantages, there are limitations and there are certainly controversies. So let�s talk about some of them.

8. da Vinci S So here pictured is the da Vinci surgical system. Now unlike C3PO, this machine is a multicomponent robot. Now a basic principles of currently available robotic systems is that they do not operate independent of the surgeon � it is a �master-slave� system so that it is always the surgeon who is in control and there are many checks built into the system to that end. At the left of the screen is pictured the surgeon sitting and operating on the �console.� This part of the robot would be anywhere from 5 to 10 feet away from the operating room table. To the right of the surgeon is the vision cart which holds the camera and light box, insufflation and the monitor for the assistants. And next to the patient is what�s called the surgical cart which is what is brought in and �docked� to the patient. Now pictured here is actually the first generation machine. The one that we have is the S model and is a bit more streamlined and have some other advantages which I�ll talk about. So here pictured is the da Vinci surgical system. Now unlike C3PO, this machine is a multicomponent robot. Now a basic principles of currently available robotic systems is that they do not operate independent of the surgeon � it is a �master-slave� system so that it is always the surgeon who is in control and there are many checks built into the system to that end. At the left of the screen is pictured the surgeon sitting and operating on the �console.� This part of the robot would be anywhere from 5 to 10 feet away from the operating room table. To the right of the surgeon is the vision cart which holds the camera and light box, insufflation and the monitor for the assistants. And next to the patient is what�s called the surgical cart which is what is brought in and �docked� to the patient. Now pictured here is actually the first generation machine. The one that we have is the S model and is a bit more streamlined and have some other advantages which I�ll talk about.

9. Surgeon�s Console So here�s a better view of the console. This is usually placed in the corner of the room. It�s here that the surgeon sits and is able to view a 3 dimensional high definition picture provided by the special camera. Once the assistants have docked the robot and transferred control to the surgeon, he or she can control each of the arms, and the camera. There�s also a microfone and speaker system so that the assistants and the surgeon can communicate easily. And on the S model there is also a feature where the surgeon can view real time ultrasound images or the OR via a laptop type camera. So basically you can do picture in picture. There�s even a feature where if the assistant wants to point to a structure, he can �tellestrate� that on the monitor at the vision cart and that can come up in the console. Many of these features � tellestration, high def, picture in picture were not available on the 1st generation robots.So here�s a better view of the console. This is usually placed in the corner of the room. It�s here that the surgeon sits and is able to view a 3 dimensional high definition picture provided by the special camera. Once the assistants have docked the robot and transferred control to the surgeon, he or she can control each of the arms, and the camera. There�s also a microfone and speaker system so that the assistants and the surgeon can communicate easily. And on the S model there is also a feature where the surgeon can view real time ultrasound images or the OR via a laptop type camera. So basically you can do picture in picture. There�s even a feature where if the assistant wants to point to a structure, he can �tellestrate� that on the monitor at the vision cart and that can come up in the console. Many of these features � tellestration, high def, picture in picture were not available on the 1st generation robots.

11. Robotic Basics: Control Surgeon directs the instruments Intuitive motion Thumb and Index fingers Foot controls

12. Surgical Cart So the surgical cart is what people really think of as the robot � the surgical cart. So for an intraperitoneal surgery, you would begin by placing a veress needle and putting in laparoscopic trocars just as you might for any other laparoscopic case. For those ports that you want to have the robot arms work through, you place specialized 8mm laparoscopic ports that are designed to allow the robot to grab on to them. There are some rules in placing the ports � they must be at least 8-10 cm away from each other otherwise the arms can clash during the surgery and cause faults. There are some additional rules you must obey in maintaining the sweetspot � basically that is, they have to be placed such that they give you the maximum range of motion in all directions. But anyway, once the ports are in, the circulating nurse wheels this cart in so that it is lined up straight with the target anatomy and camera. You hook up the camera, place the instruments and the give control over to the operating surgeon. Now one thing about instruments � once the arms are hooked to the ports, it takes 2-3 seconds to switch from one instrument to another � and there are a myriad of instruments available � everything from blunt scissors, monopolar scissors, bipolar, maryland, hook electrode, harmonic scalpel, needle drivers, hemolok clip appliers � basically everything that you can think of.So the surgical cart is what people really think of as the robot � the surgical cart. So for an intraperitoneal surgery, you would begin by placing a veress needle and putting in laparoscopic trocars just as you might for any other laparoscopic case. For those ports that you want to have the robot arms work through, you place specialized 8mm laparoscopic ports that are designed to allow the robot to grab on to them. There are some rules in placing the ports � they must be at least 8-10 cm away from each other otherwise the arms can clash during the surgery and cause faults. There are some additional rules you must obey in maintaining the sweetspot � basically that is, they have to be placed such that they give you the maximum range of motion in all directions. But anyway, once the ports are in, the circulating nurse wheels this cart in so that it is lined up straight with the target anatomy and camera. You hook up the camera, place the instruments and the give control over to the operating surgeon. Now one thing about instruments � once the arms are hooked to the ports, it takes 2-3 seconds to switch from one instrument to another � and there are a myriad of instruments available � everything from blunt scissors, monopolar scissors, bipolar, maryland, hook electrode, harmonic scalpel, needle drivers, hemolok clip appliers � basically everything that you can think of.

13. Robotic Basics: Vision 2 lenses in 1 3 Dimensional High Definition Surgeon controls camera via foot Stable image So I want to emphasize some of the key features and principles of the robot. The first is vision. It is So I want to emphasize some of the key features and principles of the robot. The first is vision. It is

14. Robotic Basics: Dexterity Endowrist� 7 degrees of freedom Versatile instruments Tremor reduction

15. Surgeon�s perspective

16. Surgeon�s perspective

17. Current Applications UROLOGY Prostatectomy Nephrectomy Reconstruction GYNECOLOGY Hysterectomy Myomectomy Sacrocolpopexy Bottom line is you can use it for many many things but it�s probably only worth it for surgeries requiring complex reconstruction. But Urology is really where it has found it�s niche initiallyBottom line is you can use it for many many things but it�s probably only worth it for surgeries requiring complex reconstruction. But Urology is really where it has found it�s niche initially

18. Computer Assisted Surgical Technology: Beyond the Surgeon So now that you have an overview and some concepts of the advantages and limitations of the technology let�s switch gears to prostate cancer, which is really where this system �took off� so to speak. And since prostate cancer is something that all pelvic surgeons � general or urological should understand, I thought I�d give you a brief update on what�s new in diagnosis and staging, a review of anatomy to kind of help set the framework for why robotic prostatectomy is rapidly becoming the standard of care in localized prostate cancer.So now that you have an overview and some concepts of the advantages and limitations of the technology let�s switch gears to prostate cancer, which is really where this system �took off� so to speak. And since prostate cancer is something that all pelvic surgeons � general or urological should understand, I thought I�d give you a brief update on what�s new in diagnosis and staging, a review of anatomy to kind of help set the framework for why robotic prostatectomy is rapidly becoming the standard of care in localized prostate cancer.

19. Penelope � Robotic OR nurse So My goal today is to first give you a broad overview of the technology, how it works, what are its advantages/disadvantages from both a surgeon�s and patient�s perspective. I�m then going to spend some time talking about prostate cancer. I think any surgeon who operates in the pelvis � urologic or general should have some knowledge about prostate cancer and so I�ll give you an update on diagnosis and staging and then talk specifically about radical prostatectomy because this is the operation that the robot has really found its niche in. And I�m going to try to discuss some anatomic reasons for why robotics is so ideally suited for prostatectomy. Of course, this technology is clearly going much beyond urology and so I�ll talk about other uses. Now that the machines are here, some of you might want to consider using the machine and so I thought I�d spend a few minutes on credentialing and educational issues. Lastly we�ll talk about future directions. So My goal today is to first give you a broad overview of the technology, how it works, what are its advantages/disadvantages from both a surgeon�s and patient�s perspective. I�m then going to spend some time talking about prostate cancer. I think any surgeon who operates in the pelvis � urologic or general should have some knowledge about prostate cancer and so I�ll give you an update on diagnosis and staging and then talk specifically about radical prostatectomy because this is the operation that the robot has really found its niche in. And I�m going to try to discuss some anatomic reasons for why robotics is so ideally suited for prostatectomy. Of course, this technology is clearly going much beyond urology and so I�ll talk about other uses. Now that the machines are here, some of you might want to consider using the machine and so I thought I�d spend a few minutes on credentialing and educational issues. Lastly we�ll talk about future directions.

20. Robotic surgeon & nurse So My goal today is to first give you a broad overview of the technology, how it works, what are its advantages/disadvantages from both a surgeon�s and patient�s perspective. I�m then going to spend some time talking about prostate cancer. I think any surgeon who operates in the pelvis � urologic or general should have some knowledge about prostate cancer and so I�ll give you an update on diagnosis and staging and then talk specifically about radical prostatectomy because this is the operation that the robot has really found its niche in. And I�m going to try to discuss some anatomic reasons for why robotics is so ideally suited for prostatectomy. Of course, this technology is clearly going much beyond urology and so I�ll talk about other uses. Now that the machines are here, some of you might want to consider using the machine and so I thought I�d spend a few minutes on credentialing and educational issues. Lastly we�ll talk about future directions. So My goal today is to first give you a broad overview of the technology, how it works, what are its advantages/disadvantages from both a surgeon�s and patient�s perspective. I�m then going to spend some time talking about prostate cancer. I think any surgeon who operates in the pelvis � urologic or general should have some knowledge about prostate cancer and so I�ll give you an update on diagnosis and staging and then talk specifically about radical prostatectomy because this is the operation that the robot has really found its niche in. And I�m going to try to discuss some anatomic reasons for why robotics is so ideally suited for prostatectomy. Of course, this technology is clearly going much beyond urology and so I�ll talk about other uses. Now that the machines are here, some of you might want to consider using the machine and so I thought I�d spend a few minutes on credentialing and educational issues. Lastly we�ll talk about future directions.

21. Opportunities in Global Health Now I want to take a step back for a moment and critically evaluate this technology in terms of outcomes. Because really, for this technology to be here to stay we have to see hard evidence that there is a benefit to surgeons, patients, and even hospitals when you think about this in terms of our health care crisis and spirally costs. And I think you will see that like any technology, there are advantages, there are disadvantages, there are limitations and there are certainly controversies. So let�s talk about some of them.Now I want to take a step back for a moment and critically evaluate this technology in terms of outcomes. Because really, for this technology to be here to stay we have to see hard evidence that there is a benefit to surgeons, patients, and even hospitals when you think about this in terms of our health care crisis and spirally costs. And I think you will see that like any technology, there are advantages, there are disadvantages, there are limitations and there are certainly controversies. So let�s talk about some of them.

22. The Global Health Opportunity So My goal today is to first give you a broad overview of the technology, how it works, what are its advantages/disadvantages from both a surgeon�s and patient�s perspective. I�m then going to spend some time talking about prostate cancer. I think any surgeon who operates in the pelvis � urologic or general should have some knowledge about prostate cancer and so I�ll give you an update on diagnosis and staging and then talk specifically about radical prostatectomy because this is the operation that the robot has really found its niche in. And I�m going to try to discuss some anatomic reasons for why robotics is so ideally suited for prostatectomy. Of course, this technology is clearly going much beyond urology and so I�ll talk about other uses. Now that the machines are here, some of you might want to consider using the machine and so I thought I�d spend a few minutes on credentialing and educational issues. Lastly we�ll talk about future directions. So My goal today is to first give you a broad overview of the technology, how it works, what are its advantages/disadvantages from both a surgeon�s and patient�s perspective. I�m then going to spend some time talking about prostate cancer. I think any surgeon who operates in the pelvis � urologic or general should have some knowledge about prostate cancer and so I�ll give you an update on diagnosis and staging and then talk specifically about radical prostatectomy because this is the operation that the robot has really found its niche in. And I�m going to try to discuss some anatomic reasons for why robotics is so ideally suited for prostatectomy. Of course, this technology is clearly going much beyond urology and so I�ll talk about other uses. Now that the machines are here, some of you might want to consider using the machine and so I thought I�d spend a few minutes on credentialing and educational issues. Lastly we�ll talk about future directions.

23. Zeus robot So My goal today is to first give you a broad overview of the technology, how it works, what are its advantages/disadvantages from both a surgeon�s and patient�s perspective. I�m then going to spend some time talking about prostate cancer. I think any surgeon who operates in the pelvis � urologic or general should have some knowledge about prostate cancer and so I�ll give you an update on diagnosis and staging and then talk specifically about radical prostatectomy because this is the operation that the robot has really found its niche in. And I�m going to try to discuss some anatomic reasons for why robotics is so ideally suited for prostatectomy. Of course, this technology is clearly going much beyond urology and so I�ll talk about other uses. Now that the machines are here, some of you might want to consider using the machine and so I thought I�d spend a few minutes on credentialing and educational issues. Lastly we�ll talk about future directions. So My goal today is to first give you a broad overview of the technology, how it works, what are its advantages/disadvantages from both a surgeon�s and patient�s perspective. I�m then going to spend some time talking about prostate cancer. I think any surgeon who operates in the pelvis � urologic or general should have some knowledge about prostate cancer and so I�ll give you an update on diagnosis and staging and then talk specifically about radical prostatectomy because this is the operation that the robot has really found its niche in. And I�m going to try to discuss some anatomic reasons for why robotics is so ideally suited for prostatectomy. Of course, this technology is clearly going much beyond urology and so I�ll talk about other uses. Now that the machines are here, some of you might want to consider using the machine and so I thought I�d spend a few minutes on credentialing and educational issues. Lastly we�ll talk about future directions.

24. Zeus robot � Transatlantic surgery So My goal today is to first give you a broad overview of the technology, how it works, what are its advantages/disadvantages from both a surgeon�s and patient�s perspective. I�m then going to spend some time talking about prostate cancer. I think any surgeon who operates in the pelvis � urologic or general should have some knowledge about prostate cancer and so I�ll give you an update on diagnosis and staging and then talk specifically about radical prostatectomy because this is the operation that the robot has really found its niche in. And I�m going to try to discuss some anatomic reasons for why robotics is so ideally suited for prostatectomy. Of course, this technology is clearly going much beyond urology and so I�ll talk about other uses. Now that the machines are here, some of you might want to consider using the machine and so I thought I�d spend a few minutes on credentialing and educational issues. Lastly we�ll talk about future directions. So My goal today is to first give you a broad overview of the technology, how it works, what are its advantages/disadvantages from both a surgeon�s and patient�s perspective. I�m then going to spend some time talking about prostate cancer. I think any surgeon who operates in the pelvis � urologic or general should have some knowledge about prostate cancer and so I�ll give you an update on diagnosis and staging and then talk specifically about radical prostatectomy because this is the operation that the robot has really found its niche in. And I�m going to try to discuss some anatomic reasons for why robotics is so ideally suited for prostatectomy. Of course, this technology is clearly going much beyond urology and so I�ll talk about other uses. Now that the machines are here, some of you might want to consider using the machine and so I thought I�d spend a few minutes on credentialing and educational issues. Lastly we�ll talk about future directions.

25. Future Directions Robotics 2008 Future of Robotics? I put this picture here just to remind everyone that despite the fact that we are looking at a very advanced machine, remember that this is still a new technology and . Just in the short while the robot has been around, we�ve already seen the incorporation of high definition (HD) vision and greater camera flexibility. Look for automization of instruments and many of the tasks that scrub tech currently provides. I put this picture here just to remind everyone that despite the fact that we are looking at a very advanced machine, remember that this is still a new technology and . Just in the short while the robot has been around, we�ve already seen the incorporation of high definition (HD) vision and greater camera flexibility. Look for automization of instruments and many of the tasks that scrub tech currently provides.

26. L.E.S.S. LaparoEndoscopic Single site Surgery �scarless�, �single port� LESS being used for Cholecystectomy Nephrectomy The Future?

27. L.E.S.S. nephrectomy We�ve shown that single incision surgery (LESS) is feasible even for challenging surgeries such as a nephrectomy, but still the limitations of free hand laparoscopy make it very challenging. However, if it was routinely possible it would be a tremendous advantage to the patient and that�s again where robotic and computer assisted technology come in.We�ve shown that single incision surgery (LESS) is feasible even for challenging surgeries such as a nephrectomy, but still the limitations of free hand laparoscopy make it very challenging. However, if it was routinely possible it would be a tremendous advantage to the patient and that�s again where robotic and computer assisted technology come in.

28. Future Directions I put this picture here just to remind everyone that despite the fact that we are looking at a very advanced machine, remember that this is still a new technology and . Just in the short while the robot has been around, we�ve already seen the incorporation of high definition (HD) vision and greater camera flexibility. Look for automization of instruments and many of the tasks that scrub tech currently provides. I put this picture here just to remind everyone that despite the fact that we are looking at a very advanced machine, remember that this is still a new technology and . Just in the short while the robot has been around, we�ve already seen the incorporation of high definition (HD) vision and greater camera flexibility. Look for automization of instruments and many of the tasks that scrub tech currently provides.

29. Summary

30. Thank you!