The Future of Surgery and ISMICS

Wolf, Randall K.

Innovations: Technology & Techniques in Cardiothoracic & Vascular Surgery:
doi: 10.1097/IMI.0b013e31802f43d8
Presidential Address
Author Information

Randall K. Wolf, MD, Presidential Address, Director, Center for Surgical Innovation, University of Cincinnati, Cincinnati, Ohio.

Presented at the annual meeting of the International Society for Minimally Invasive Cardiothoracic Surgery. San Francisco, CA, June 2006.

Send correspondence and reprint requests to Randall K. Wolf, MD, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45627. E-mail:

When I sat down and put my thoughts together about what I wanted to say today, I realized that I needed to look no further than 30 inches away on my desk in my office in Cincinnati. And what I was looking at was a picture of my family (Fig. 1). I owe a debt of gratitude to my wife, Amy, truly not just for all the work that was done this year at home in my absence, but the last 4 years that I have tried to attend every ISMICS board meeting and the extensive travels. Although Billy said I was teaching, I guarantee you I was learning much more than I ever taught. And I thought it was sad that maybe I missed Andrea's best golf day, Travis's first baseball hit, or Kevin's first lacrosse goal. But I pondered on it a little bit more, and I saw younger son Travis in the front of the photo (Fig. 1). That picture is from a couple of years ago—a Japanese heart surgeon took the picture. Travis was doing a rope trick in front of 250 Japanese heart surgeons at the Annual Meeting in Fukuoka, Japan. So, I thought, yes, I missed some things but maybe there were some advantages for everybody in the family as well. There are two sides to every story, I guess you could you say. We had some family outings. But even though I missed a lot, my family did travel with me when possible and experienced some great places. Last year, I was performing a case in Milan with Drs Alfieri and Benussi, and, afterward, my family and I went to Rome. We visited the Trevi Fountain. So, yes, all of us in this room who have traveled from afar can appreciate that we have been away from home and missed some things, but we hope that in some way or fashion we have tried to make up for it.

We have also realized other advantages. My older son Kevin, back in 1999, was with me actually not far from San Francisco, when Intuitive was in Mountain View, working on some of the prototypes of 2 of the surgical devices (Fig. 2).We were devising a cardiac technique for endoscopic CABG. Kevin can now say that he has 7 years of experience on DaVinci. The children have had opportunities not only to experience some of this research, but to also proctor test-drives for others. Many of you probably don't recognize the person in Figure 3, but he was taking a test drive in Cincinnati on the DaVinci. This is Neal Armstrong, the first man to walk on the moon. And how many kids can say they taught Neal Armstrong how to use the Intuitive surgical robot? In fact, leaving our laboratory in Cincinnati, Kevin who's got the green shirt on there did Michael Jackson's moon walk in front of Neal Armstrong and said to him, “I guess you're pretty good at this.” Well, my wife Amy told me that Neal whispered in her ear, “I really don't know how to do the moon walk.”

I would like to dedicate this talk to my mother and father who were here 3 years ago and were looking forward to returning to San Francisco (Fig. 4). I have been able to accomplish what I have so far because of their loving care. We grew up on a farm, and on a farm one learns to improvise. On a farm one does not pick up the phone and call somebody if something is broken. And I think that has helped me immensely in cardiac surgery. Unfortunately, my dad died about 6 weeks ago. He didn't make it back to this meeting, but certainly I dedicate this lecture to him. And I also dedicate this lecture to all the people, many of you, who are here in this room, who worked with me on different projects. This slide shows an Innovative project from the year 2000 in Germany. In 2000, a group and I in Germany (Fig. 5) worked very diligently on an anastomotic device that never made it to market. But we still had a great time working on it, and we all learned a lot from it. These types of labs have occurred all over the world. This type of project is one of the things I am most proud of.

I want to thank the previous President of ISMICS, who was really a role model for me. Naresh Trehan has a way of looking at the big picture and finding where there is an opportunity for compromise. I learned from his skill, and I have tried to emulate his spirit of compromising this last year at ISMICS. I was with Naresh and his wife, Madhu, during the Day of Colors in New Delhi, India (Fig. 6). Naresh is a great guy, and it is my pleasure, Naresh, to follow you as the President of this organization. I want to personally thank you.

I also have to thank my Administrative Associate who was instrumental in orchestrating this past year for me. Nessie makes it possible for me to keep current with a busy schedule. Nessie, thank you for everything. And one other bit of appreciation—Billy has already mentioned it briefly, but this is one of my favorite pictures (Fig. 7). John Flege, my mentor and now associate at The University of Cincinnati, is with me in the operating theater looking intently over my shoulder. I presented this photo to John, and it hangs in his office. Over the last 20 years, John has stood over my shoulder, helping me to move things along and guide me, sometimes in our crazy ideas. I cannot thank John enough for really making all of this possible.

There are other people to thank. The reason that a President of any organization gets anything accomplished is due to the involvement of the Board of Directors and the Executive Committee. My warm personal thanks to all of them (Figs. 8 and 9 list the ISMICS Board of Directors and Executive Committee). The Executive Committee took the ideas that we had and made them a reality. Nothing happens in any Society unless the Board of Directors agrees. The current Board of Directors has been incredibly helpful this last year; attending meetings anywhere in the world. Now a special magical thank you to this year's program chair, Billy Cohn. It is an honor to be the Program Chair, and it is also a curse. Billy had a very busy year doing other things, but, bless his heart, he really hung in there. He has done a fantastic job with the program this year. Billy, thank you very much.

This was the inaugural year for the Innovations journal. The main reason that Innovations has been successful is because of two people who have really taken care of the day-to-day activities. As you know, Ranny Chitwood and I have served as coeditors, but, in fact, the daily work for the journal is accomplished by the associate editor, Dr John Flege, Jr, and the managing editor, Dr Leslie Dye. We need to show our appreciation for John Flege and Leslie Dye, who have really done a tremendous job, everything from making sure reviews get in, to sometimes rewriting the manuscript to improve the English. In part because of their diligence, Innovations will grow and become a larger voice for this Society.

Last, and you usually do not see a slide like this, but these are the folks who work behind the scenes, some of whom you see around this room. This is the PRRI group. These are our administrators for this Society. They are excellent. They also are the administrators for AATS. It is through their work that the Board, the Executive Committee, and the President of the Society are able to run ISMICS smoothly. The folks at PRRI include their fearless leader, attorney, Ms Aurelie Alger. We thank you very much for your continued support of ISMICS. You don't do it just as a job. It is your passion, and we appreciate that.

On this slide (Fig. 10), I have listed the milestones for this year. I think this is probably one of the most important slides I have of my presentation. These were the projects we tackled this year. We were successful, again because of the continued involvement of the Executive Committee and the Board of Directors of ICMICS. We successfully launched Innovations this year. The Publications Committee, chaired by John Puskas, deserves some of the credit for launching Innovations. Our own journal will be a key to our ISMICS organization, as I will mention later.

We reviewed the bylaws this year. The bylaws were written for a nascent Society 9 years ago. We revisited the bylaws and rewrote them. I thank the people who led that effort. I asked Past President Ranny Chitwood and also Aurelie, who is an attorney, to tackle the bylaws and make them reflect a more mature society. We got it done. It has resulted in an opportunity for us to do electronic voting. The Board of Directors is no longer required to wait until the annual meeting to pass something that needs an up or down vote. We also added a Vice President to the make-up of the Board. There is now a natural succession to the presidency. Future presidents of ISMICS will now have at least 2 years' experience on the Board.

I asked two other past presidents, Drs Mack and Emery, to look at our investments. I am very happy and proud to report that ISMICS has some money in the bank. Bob Emery presented the findings of the financial committee to the Board 2 days ago. The financial committee's plan has been initiated. Bob and Mike also presented to us some very novel ideas, which will be addressed by Jim Fonger this year.

One of the keystones of the year for me was to initiate a mechanism to really involve cardiothoracic residents in ISMICS. This is the kind of Society in which residents have a good chance to present at the annual meeting. Residents can exhibit their innovation and their imagination, which has not been dulled too much by some of us older members. Residents can really have an impact in ISMICS. We were successful in aligning the Thoracic Surgery Residents Association (TSRA) with ISMICS. The best way to give you the big picture is to report that TSRA in the United States has traditionally aligned itself with the American College of Surgeons, as well as with American Association for Thoracic Surgery (AATS) and Society of Thoracic Surgery (STS). TSRA is switching part of that alignment from the American College of Surgeons to ISMICS. So, that is a significant event. We received a report from John Mehall, who is President of Thoracic Surgeons Residents Association to our Board of Directors 2 days ago. This TSRA report to the ISMICS Board will continue each year. In addition, the ISMICS Board passed a resolution that one of the TSRA members will get a seat on the Annual Program Committee. This will introduce our residents to committee workings in the Society. I think the word will get out to the other residents—the word will spread that ISMICS is really a cool place to be.

We made an agreement with Most of the people in this room are familiar with When one goes online at, one sees the covers of several journals: EACTS Journal, The Annals of Thoracic Surgery, JTCVS, and the “Asian Annals.” I am very happy and pleased to report that you will also see a thumbnail of the front page for the cover of Innovations. Innovations is being added to that list of important journals, so that will give us a significant notoriety in the cardiothoracic field.

For the first time in ISMICS history, the Annual Meeting contents are being recorded. There will be a DVD made available, not only to the members of ISMICS but to our guests and also to our industry partners. All discussions are being recorded as well, and transcripts will be made so that the discussions from this meeting accompany manuscripts that are accepted for publication.

Keep in mind that Innovations is nascent as a journal. Last year at the annual meeting we did not have Innovations yet off the ground. It has only been available for 10 months, so, for the first time, after this annual meeting, there will be manuscripts submitted to the journal for peer review. Along those lines, it is very important to note a request John Flege made at our Innovations meeting. We request all members of ISMICS to become reviewers for Innovations. This is good for members both inside academia and in private practice. Reviewers have advantages, and the members of ISMICS can benefit by becoming a reviewer. Please remember when you turn on your computer next time and check your email or when you get home and check your email, look for an email from ISMICS Innovations, with an invitation to join our review panel and please, please enter your area(s) of expertise. Your areas of expertise are what Leslie, John, Ranny, and I use to identify the appropriate members that may assist with reviews of manuscripts. We are trying to turn over manuscripts faster than any other journal—we need your help to do that.

What opportunities did we not realize this year? I had hoped to transmit this meeting live to South America, China, and India. We were working with Edgar Lama to try to make this happen in South America. We did not get it done. I am hopeful that future Boards and Executive Committees and Presidents will make this a reality. There are many people who are interested in what we do and say, here, but are unable to attend our annual meeting. Live electronic transmission of the annual meeting is needed.

I also wanted to extend the residents' involvement to other continents, not just the United States. So, again, I am going to leave that to the incoming committee and Board members. I think we can involve residents from around the globe. It is going to take some work, but as an international organization, we really need to seize the opportunity and engage the cardiothoracic residents from around the world.

And, last, I made some attempts to partner with different countries with respect to manuscript submissions. We would encourage submission of selected regional annual meeting papers to Innovations for the review process. For example, I talked with Dr Oto, who leads a successful Turkish meeting. Could we take what he thought were the top five manuscripts at last year's CT Turkish meeting and make arrangements for those to be submitted to Innovations for peer review? I think this is a huge opportunity. Just as the “Annals” works with Southern Thoracic and the Journal of Thoracic and Cardiovascular Surgery works with Western Thoracic, we can do the same. We are not limited to the United States. This should be international and an important goal for the future. Jim Fonger, as incoming President of ISMICS, can make some inroads on this project.

Now back to the title of the Presidential address—“The Future of Surgery and ISMICS.” Where are things going? Well, this is traditional surgery. And this is the way I was taught initially; this is what you do in surgery. You cut it off, or you cut it out, or maybe if somebody else cut it out you put it back on. If there is a hole that should not be there, you close it. If there should have been a hole there, then you make one, and for surgeons, for everything else, just drain it (Fig. 11). I submit to you that in the next 5 or 10 years this is not going to work. We are already seeing tremendous change.

Here is another very important slide (Fig. 12) that I wanted to show you that explains where we are headed and why we are headed in this particular direction. The slide shows the rate of change over time in response to scientific discovery in the different sectors. As you would expect, the rate of change over time in scientific discovery and technology is extremely rapid. Many of you lament the fact that the fantastic cell phone that you impressed everybody in your office with a year and a half ago is obsolete. You must get a new one already. Many of you will understand that business actually moves fairly rapidly as well. It changes quickly. Most of you would not be surprised to see society does not change very quickly. But you might be surprised to see that health care changes even more slowly than societal changes. That is going to change. Why is it going to change? Because now we are linking technology to health care every day. We will experience a health care technology boom that is already taking shape. The combination of health care and technology is going to change not only cardiothoracic surgery but all of medicine. We as surgeons have a unique opportunity to lead some of that change.

The next level is going to be a biosurgical or a biointervention era. Going back to the slide I showed you earlier, it is not going to be “just cut it out or put it on or make a hole,” anymore. It is going to be a whole other level. This is a definition that Rick Satava and I came up with for the term biosurgery: “The ultra-precise manipulation and delivery of a specific therapeutic (and possibly diagnostic or monitoring) modality to a specific organ, tissue, or anatomic site for the purpose of affecting the biological function” (Fig. 13). The key to this definition is that now, instead of just cutting something out, we are actually going to affect the biological function. This is a new paradigm for surgeons, and we are already seeing it. Gene therapy for ischemic heart disease is a good example. We are not just going to cut it out; we are going to change the biological function.

There are other examples of this phenomenon, such as implantable biosensors. The pacemaker is an example of an implantable biosensor. And look how sophisticated pacemakers are today. We have discussed at this meeting that a biosensor for atrial fibrillation sensitive enough to pick up the atrial rhythms would be helpful in following patients with atrial fibrillation. Remote telemanipulators like DaVinci are another example that we have embraced in this society. There is a whole other level to remote telemanipulators, which I will share with you in a second. Another example is an engineered microprosthesis, such that a hip replacement that might contain a feedback mechanism that will notify the surgeon of a potential stress fracture before it happens. A remote telemanipulator such as the Intuitive Surgical DaVinci in the future will have multiple functions such as mini-GPS, simulation, and real-time imaging. Volkmar Folk presented some of this yesterday. Volkmar's talk was actually a fantastic presentation. I think his presentation was one of the best we have had at ISMICS. He talked about simulation, intraoperative management, and also, ultimately, preoperative planning. The residents can actually work with the surgeon and “perform” the operation the night before, by simulation. Ultimately, it is going to change the way that we do surgery. Not only just heart surgery, but I think heart surgery will be a good example.

The surgeon of the future may be like the surgeon pictured in Figure 14. What is the key to this picture? Imaging is in the operating room. How much have we heard about that just this last year or two with endothoracic grafting? Now I hope it is not exactly like this, because I do not want to wear one of those suits, but the point is, it is no longer going to be acceptable to get a CT scan and stick it up on the x-ray board and say, “Okay, there's the spot on the lung. I think it's going to be about here.” That is going to be obsolete. Imaging is going to be real-time. And we as surgeons are going to have to change. In fact, the surgeon of the future may not even be in the operating room. The operating room may be truly a sterile environment with the only bacteria in that environment being the patient's own.

Tomorrow, instruments will look like this (Fig. 15). This is no longer just a scissors. This is a diagnostic tool. It has ultrasound on it. It is a therapeutic tool. It could have a YAG laser on it, and it is the same size as an intuitive surgical instrument today, 7 mm. How do we get there? Microelectro mechanical systems (MEMS) and nanotechnology. There will be a featured talk tomorrow morning by Professor Montemagno on nanotechnology. Do not miss it, because if you are going to be in heart surgery for another 10 years, it will have an effect on what you do.

So, with biosurgery, “hold-feel-and-see” will probably have new meanings for the surgeon. Yes, I am holding it, I am seeing it, and I am feeling it. But your hands actually never touch the heart. That is where we are headed. Are we going to be like fighter pilots? I don't know if you are aware, but the US Air Force is investing in an unmanned fighter jet. The pilot actually sits on the ground and controls that fighter plane. There are tremendous advantages. One, a human being is not exposed to the dangers of flying in that situation and, two, two thirds of a fighter jet's bulk is to protect the pilot. So, if one places the pilot on the ground and out of harm's way, the plane becomes much smaller, much more agile, actually faster and better than the one that has the pilot in the cockpit. Are we going to be like this? I hope not, but somewhere in between, maybe.

Technology in medicine will evolve all implantable devices. An example is neurosurgical MEMS for monitoring a spinal fusion. With a pressure sensor, antenna, and strain-gauge mounted in the metal placed as the fusion, the fusion will become dynamic, changing the parameters of the stiffness of the device, depending on mechanical stress applied. That is just around the corner. As surgeons of the future, one may implant a chip on the heart. Surgeons may print out an entire new organ. Surgeons may work inside a cell. That is nanotechnology. These changes will require a new education system, too. There will be much work for future ISMICS members, including bioinformatics, engineering, MEMS, nanotechnology, and systems integration.

The last few comments I have came to me while I was sitting in my office looking at the maps of the United States and of the world that I keep on my wall. I am kind of a nut about that. I like to know where things are in the world. I was particularly looking at the map of the world, and I was thinking about ISMICS and ISMICS as a Society. New societies are formed to challenge the status quo and are the basis for meaningful change. That is ISMICS. ISMICS got started because there was another way to do bypass surgery other than going on the heart/lung machine. That is really how ISMICS got started. However, societies tend to stay in their own dimension as they mature. ISMICS cannot afford to stay in one dimension. Moving forward, things are going to continue to change—new technologies and superior therapeutic options for all types of thoracic diseases. Societies tend to view additional significant change as a threat. That is where ISMICS has to be different, and I think that is our strength. We are more agile, more mobile than other societies, in this respect. Remember what Charles Darwin said, and many of you have probably seen this slide (Fig. 16). As far as I know, this slide actually started with John Flege, who gave it to me approximately 10 years ago. This slide has made its rounds, all over the world in our talks. It is still very true. Darwin said, “It is not the strongest who survive, or the most intelligent, but those most responsive to change.” So, for this Society to mature, it must not just continue the status quo. ISMICS must evolve.

Remember the “I's”. For cardiac surgeons we start out with this “I,” Imitation. Imitate your mentor. We as young apprentice surgeons need to emulate our mentors. That is drilled into our heads and is good advice, but in this Society, we as surgeons must then evolve some other “I's.” As Albert Einstein said, Imagination is more important than knowledge. Maybe it is more important than imitation. Another important “I” for surgeons in ISMICS is intuition. One evaluates a procedure and ponders, “You know what, I think we could do this better. I think there's a better way.” We must continue to use our imagination, just as I demonstrated at the beginning of this address with the card with the multiple spots. Heart surgeons, by nature, are imaginative. We improvise. We find ourselves in a situation where maybe it is unwise to go on bypass. I think that is some of how MIDCAB started. Necessity is the mother of invention. We think this CABG is going to be tough on bypass. Well, we will place this fork down here on the beating heart, hold this artery still and do a coronary bypass. Please let us all continue to innovate and as you innovate, all the people around us from the nurses to your trainees will be inspired (another “I”). And that is what keeps the circle going. So, there are a lot of “I's”. We should pay attention to these “I's” (imagination, intuition, improvisation, invention, and inspiration) in this Society.

In an article from Newsweek, OPCAB was quoted as having only 23% market share of total coronary bypass procedures. Therefore, they concluded that minimally invasive surgery is going nowhere in heart surgery. Not true. In the article, I countered that there has been a lot of emphasis on coronary bypass surgery because when business plans in heart surgery in the United States are formulated, the big numbers are in CABG. However, there are many other exciting thoracic technologies that do not deal with bypass surgery that have potential. Many of these new technologies in thoracic surgery are being presented right here Wednesday, Thursday, Friday, and Saturday morning at this annual ISMICS meeting. There remain many opportunities in this Society. We have the opportunity to meld medicine, surgery, engineering, and imaging into one clear focus for cardiothoracic surgery to move forward in this century. That is what we have to do. The people who will evolve these new technologies are right here in this room now—members and guests of ISMICS and industry. We have a new voice. It is a chance for evolution. ISMICS and Innovations are your opportunities to have your voice heard. It will be heard. ISMICS is an inclusive group.

I urge all members to embrace and contribute to our journal. And when I say, “our journal,” I am very proud about that for everybody in this Society. This is our journal. This is a quote from one of our famous North American philosophers, Wayne Gretsky, “I don't skate to where the puck is, I skate to where the puck is going.” And that is what I think we can do in this Society—skate to where the puck is going.

I am going to leave you with a couple of other quotes. Another one from Wayne Gretsky that I liked, “You miss 100% of the shots you don't take.” And one thing I admire about the people in ISMICS is that we are not afraid to take a shot. Just like I showed you that picture at the beginning, all the work we did on that one anastomotic device—it never was commercially released. Actually, it was a pretty good device, but it never was released. And, it reminded me of this picture from last week (Fig. 17). This is my older son, Kevin, who bought a model airplane. He paid for it with his own money. It cost $180 and he wanted to take it out and fly it right away. I said, “Kevin, aren't you afraid you're going to go up the first time, the plane will crash and you are going to lose your money?” “Not at all,” Kevin replied. Full of imagination, ready to go, that's the spirit. In this picture, he is looking up to the sky and learning how to fly for the first time. And, that's the kind of spirit that we have here today and that is really where inspiration comes from.

I have one last quote for you. It is a very appropriate quote for the cardiothoracic surgeon in this room who has spent long times in the OR, sometimes successful, sometimes unsuccessful, but who had to get up the next morning and go back in the operating suite and do it again. We can appreciate this Michael Jordan quote, “I've missed more than 9,000 shots in my career. I've lost almost 300 games. Twenty-six times I've been trusted to take the game-winning shot and I've missed. I've failed over and over and over again in my life. And that is why I succeed.” This is the essence, and I think why cardiothoracic surgeons will succeed in this Society, ISMICS. Thank you very much for the privilege to serve as your President.

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