Center for Surgical Innovation

A collaboration of the University of Cincinnati (UC) Departments of Surgery, Bio-medical Engineering, Emergency Medicine, and Cincinnati Children’s Hospital, the Center for Surgical Innovation (CSI) was established in 2003 to develop, assess and disseminate new technologies in biomedical and surgical care. Partnerships with the military, NASA and numerous industry and academic partners have enabled the CSI to develop and validate new surgical tools, advanced training, and to define and refine best practices.

Located in UC’s Medical Sciences Building, the CSI has a 3,700-square-foot state-of-the-art research and teaching facility. Completed in June 2006, the space includes both a teaching laboratory and a sterile operating room equipped with the latest surgical technology, including Intuitive Surgical’s da Vinci Surgical System for robot-assisted procedures, purchased through the generosity of Cincinnati business leader and philanthropist, Mr. Carl Lindner. Support from strategic partnerships with Ethicon EndoSurgery, Stryker Communications, Cincinnati Bell, Trumpf Medical, and gracious philanthropy have further extended CSI’s technical capabilities, which include:

• Global linkages through a robust telecommunications and information network.

• Expertise in minimally-invasive surgical techniques.

• World-class biomedical engineering and design capacities.

• Telemedicine, telehealth, telesurgery, and medical informatics capabilities.

• Processes for shepherding technology from concept to product.

• Strong industrial and research track record.

• Experimental information technology.

• Virtual reality simulator technology.

• Continuing medical education opportunities.

The UC Department of Surgery has a rich history of innovation with advances in clinical care, research and education. Several years ago, the Department of Surgery committed to investing in innovation with the establishment of the CSI and initiation of robotics research. This investment constituted a major commitment in capital equipment, technology, and dedication to a specific theme and direction. The Department of Surgery was fortunate to have this initiative financially supported by a generous gift by Mr. Carl Lindner. This allowed a program in innovation to initiate research and development in the form of robotics, surgical simulation and education, and provided for extensive research in the area of telesurgery. With the passage of time, substantial progress was made in all of these areas including robotics, telemedicine, and surgical simulation. Over the ensuing months and years, this investment proved fruitful with contractual partnerships and funding between our Department of Surgery, governmental agencies, military services, and other organizations.

The innovations engendered in the CSI have made the Department a recognized leader in life-saving medical advances as well as breakthroughs in research and education, including the following milestones:

• The first robotic-assisted surgery performed at University Hospital, a minimally invasive coronary artery bypass graft.

• Perfection of the “mini-maze” procedure for treatment of atrial fibrillation.

• Training and clinical application of robotic-assisted surgical techniques for general, cardiac, transplant, and urologic surgery.

• The first telerobotic surgery conducted over the Internet.

• Training of several hundred surgeons in robotic-assisted and other minimally invasive surgical techniques.

• Development of simulators for realistic surgical training of residents and medical students outside of the operating room.

• Advances in telemedicine and surgical expertise under harsh conditions in remote areas.

• Collaborative efforts by researchers in basic science, biomedical engineering, and the biology of surgical diseases.

With the passage of time, we leveraged that investment to programmatic success in areas which were not necessarily anticipated, but for which we were prepared to take full advantage of when opportunities presented themselves. Such opportunities included the Center for the Sustainment of Trauma and Readiness Skills (C-STARS) program and our extensive relationships with the United States military. We are taking these innovations to the next level through collaborative partnerships with community physicians and institutions, business leaders, our fellow citizens, industry, and the government. Our innovations in life-sustaining care of wounded soldiers and our unique CSTARS training facility for preparing military medical personnel to treat and transport wounded combat soldiers are responsible for saving lives at a level never before imaginable.

The evolution of the CSI has resulted in an entity that leads the world in surgical care, device development, research, education and training. Each of these focus areas represents a unique component, but the great strength of the CSI is the integration of its sum parts in a manner that creates synergy that is leveraged to benefit the local, regional, national and world communities.

Institute for Military Medicine

The combat theater represents an austere environment for medical professionals. Innovation in virtually every aspect of operations is required in order to ensure that all of our brave young soldiers return home safely. The CSI has built upon the excellence established by our Division of Trauma and Critical Care and partnered with other University of Cincinnati departments to establish the Institute of Military Medicine. The missions of this institute are: to develop new technology that can be applied in military environments to advance patient care; to discover the scientific basis of severe injury and utilize this knowledge in the treatment of combat casualties; and to provide state-of-the-art training for those caring for our wounded heroes.

Combat Casualty Research

With our nation at war on two fronts, we have redoubled our research efforts to be responsive to the needs of our country. The CSI represents tight collaborations between our Division of Trauma and Critical Care and Division of Research which have resulted in a multidisciplinary research team focused on determining how traumatic injuries sustained during combat can lead to changes at the cellular and molecular levels that contribute to increased rates of infection, multiple organ failure and death. The organization of this research group provides a unique approach that advances our “bench to bedside to battlefield” mission. The research being conducted by the Institute is currently funded by the Department of Defense, United States Air Force, Office of Naval Research, and the National Space Biomedical Research Initiative.

Current projects include:

• Development of a closed-loop oxygen regulator that would automatically regulate oxygen delivery to critically injured patients. This will revolutionize military patient care by providing sophisticated respiratory support in restrictive environments. The unit being developed is completely automated and therefore does not require the additional personnel necessary to maintain conventional respirators. In addition, it delivers oxygen more efficiently than its conventional counterpart and therefore will conserve this most critical resource in combat operations.

• Development of oxygen concentrators for use at high altitudes and/or space. Missions conducted at extremely high altitudes require oxygen for life support. Carrying oxygen stores on combat missions presents a cargo problem as well as an increased risk of fire. Development of oxygen concentrators would reduce both the amount of stored oxygen needed and the associated fire hazard.

• Effects of altitude on aeromedical evacuation of severely injured soldiers. Severely wounded soldiers in Iraq and Afghanistan are stabilized in theater and then transported by plane to hospitals in Germany and the United States. It has been found that the environment at high altitudes (low oxygen levels) associated with rapid aeromedical evacuation may have detrimental effects on existing injuries, leading to increased morbidity and mortality. This project models severe injury in animals and will test the effects of high altitude on resolution of these injuries. The ultimate goals are to determine the biological mechanism by which high altitude affects existing injuries and secondly, to determine the best time after severe injury for aeromedical evacuation.

• Repair of burn injury with autologous engineered skin substitutes. Burn injury is a major cause of combat-related morbidity and mortality. Our institution has pioneered the development and application of autologous engineered skin substitutes for the treatment of severe burn injury. These substitutes are derived from the patient’s own skin and therefore are not rejected. This project will further develop the use of these skin substitutes such that they have improved blood supply and pigmentation which will increase graft success.

Advanced Center for Telemedicine and Surgical Innovation (ACTSI)

ACTSI is a program that conducts telemedicine and robotics research. Working closely with the U.S. Army’s Telemedicine and Advanced Technology Research Center (TATRC), the ACTSI team is conducting research that will help improve care in remote places including the battlefield. Federal partners include the Department of Defense, NASA, and the National Science Foundation. Local partners include UC Colleges of Medicine, Engineering, and Design, Architecture, Art and Planning. It is strategically aligned with relevant government, industry and UC initiatives, including the newly founded UC Space Exploration Institute, established through an anonymous philanthropic gift and directed toward interdisciplinary transformative space exploration research and education.

Recent ACTSI projects include:

• Robotic telesurgery during flight on a NASA DC-9 in partnership with SRI International and Cincinnati C-STARS. The goal of this research was to evaluate deployment of an acceleration-compensating surgical robot for use in critical care air transport and space flight.

• Defense Advanced Research Projects Agency (DARPA) Trauma Pod to help the military develop an autonomous mobile robotic platform for far-forward combat casualty care.

• NASA Extreme Environment Mission Operations (NEEMO) 12. NASA’s 12th undersea mission focused on further refining surgical technologies to be used in long space voyages. Aquanauts tested two remotely controlled surgical robots in a variety of advanced medical experiments, including robotic telesurgery on simulated patients. This mission showcased the world’s first semiautonomous medical task where surgeon and medical instruments were separated by a great distance.

• Mobile Telesurgery. Our ACTSI led the first test of a prototype communications platform for mobile telesurgery – the High-Altitude Platforms for Mobile Robotic Telesurgery. This model, developed in collaboration with US Army Telemedicine and Advanced Technology Research Center (TATRC) and the University of Washington, uses a unmanned aerial vehicle (or drone) as the communications connecting point between a surgeon in one part of the country and a patient located hundreds of miles away. This research resulted in the world’s first wireless robotic surgery using an unmanned aerial vehicle.

Training Programs

The Institute of Military Medicine is home to two outstanding, yet fundamentally different training programs that educate and prepare our future leaders in trauma and critical care medicine.

Center for the Sustainment of Trauma and Readiness Skills (C-STARS)

The Division of Trauma and Critical Care serves as one of three U.S. Air Force Centers for the Sustainment of Trauma and Readiness Skills (C-STARS) training. This unique collaborative process provides specialized training to members of the Air Force’s elite Critical Care Air Transport Teams (CCATT), who care for and transport severely injured warfighters around the world. Cincinnati C-STARS has garnered significant national recognition for the quality and timeliness of this unique program. Five of the Division’s faculty members have been deployed to the combat support hospital at Balad Air Base, Iraq, in support of Operation Iraqi Freedom. These include Dr. Jay Johannigman, Director of the Division of Trauma and Critical Care, and Dr. Warren Dorlac, Director of C-STARS Cincinnati. Since the C-STARS program began in 2004, more than 200 medics and ancillary staff have been trained at the C-STARS Cincinnati facility at University Hospital.

The C-STARS team has a one-of-a-kind, high-fidelity simulation center for training CCATT teams. This center incorporates two adult METI (Medical Education Technologies, Inc.) simulator mannequins which are positioned within a realistic flight cabin and are capable of generating physiologic signs such as respiration, peripheral pulses and cardiac arrhythmias. They have been programmed to mimic the medical conditions encountered during the evacuation of combat casualties. Cincinnati C-STARS has received letters from deployed CCATT students who have credited their experience in the Cincinnati C-STARS simulation center with being responsible for improving care and saving many soldiers’ lives.

National Institutes of Health Trauma Training Program

The Department of Surgery is home to a basic research training program funded by the National Institutes of Health that provides surgical residents and research scientists focused training on the cellular and molecular aspects of the host response to trauma. This program is unique in that it is tightly coupled to the research activities of the Institute and therefore trains the next generation of scientists that can apply their knowledge to the problems associated with the types of injuries sustained in combat. The program funds surgical residents and post-doctoral research fellows for a period of 2-3 years to conduct research on a topic related to injury biology. Examples of current trainee projects include determination of the effects of different fluid resuscitation strategies for hemorrhagic shock and the effects of traumatic brain injury on the systemic inflammatory response. This training program is in its 16th year and to date has trained over 30 individuals.

Woliver Laboratory for Simulation and Training in Surgery

UC's surgical residency program has expanded its simulation curriculum to allow the acquisition and refinement of skills and techniques in a safe environment. Our goal is to better prepare and train our surgeons in patient care before they ever enter an operating room. The enhanced program, which has been implemented in the new Woliver Laboratory for Simulation and Education in Surgery, is made possible by a gracious donation from retired surgeon and 1939 UC College of Medicine alumnus Edward Woliver, MD.

Located on the ground floor of the College of Medicine's Medical Sciences Building, the Woliver Lab includes an array of simulation equipment designed to allow surgical residents to practice new skills outside of the operating room in a safe, faculty-mentored environment. Training under the time pressures of a real-life operating room setting can be very stressful for both the instructor and the surgical resident. The more experience residents get before stepping into the operating room, the better prepared they will be to care for patients.

The Woliver Lab has both low- and high-fidelity simulation equipment including simple models to simulate suturing vessels and intestine. It also includes sophisticated devices, such as the Simbionix Lap Mentor II laparoscopic virtual reality simulator, which incorporates haptics (sense of touch) and tracks a surgeon's performance during the training session.

Other equipment in the Woliver Lab includes:

• Simbionix GI Mentor, a virtual reality colonscopy and endoscopy trainer. This allows trainees to master the principles of basic and advanced flexible endoscopy, including control of hemorrhage and polypectomy.

• Fundamentals of Laparoscopic Surgery box trainer, which is used to help surgeons practice laparoscopic (minimally invasive) surgery techniques and test learned skills.

• Two Mentice Procedicus Vascular Intervention Simulation Trainer (VIST)™ mannequin simulators, which will allow residents and fellows to practice inserting catheters, use fluoroscopy (moving X-ray images) to monitor the catheter as it travels up through the body, and learn sophisticated manipulations of blood vessels.

Industry Development

Through partnerships and collaborations with more than 30 companies, CSI is a national leader in developing innovations in biomedical science that can be applied directly to clinical care. At the heart of these partnerships is the Minimally Invasive Medical Technologies Center (MIMTeC). Supported by the National Science Foundation, MIMTeC represents a partnership between the CSI and the University of Minnesota and industry partners including Boston Scientific, Cordis, Ethicon EndoSurgery, Greatbatch, Medtronic and Procter & Gamble.

One of the primary goals of MIMTeC is to conduct research that will generate intellectual property, new scientific knowledge, and produce technologies that will form the underpinnings of major advancements in minimally invasive interventions. CSI’s mission through these partnerships is to help local, regional, and national industries develop new medical devices and information delivery systems and then facilitate the training of surgeons and other medical practitioners on these new devices and systems. In this manner, the CSI strives to not only help develop cutting-edge technology to advance surgical practice, but to enable the transfer of that technology to practitioners at every level, from cutting-edge University surgical groups to the lone rural surgeon, to ensure that all communities benefit from new advances in care. These activities are supported by a state-of-the-art research and teaching facility where surgeons from around the country interact with scientists, industry leaders, and information technologists to develop the technologies of tomorrow.

A few examples of these partnerships include:

• AtriCure – Development and evaluation of devices for the treatment of atrial fibrillation.

• CardioEnergetics – Development of a cardiac assist device, artificial tendon material, and coated suture material for wound closure.

• Ethicon EndoSurgery – Evaluation of devices and procedural training with instrumentation for minimally invasive surgery.

• Guided Therapy Systems – Development and evaluation of ultrasound probes for detecting liver cancer.

• Spine Vision – Development of therapeutic devices for spine disease and novel procedural training approaches.

Summary

The UC Center for Surgical Innovation develops and applies innovations in clinical care, research and education to real-world surgical treatment of civilians and soldiers. This mission of discovery and transformation is being accomplished through innovative collaborations with related disciplines at UC, industry, the government and military, as well as our partners in the community. These innovations play a crucial part in our Department’s mission to:

• Provide comprehensive surgical services for Cincinnati and the surrounding region.

• Train the next generation of surgeon leaders.

• Advance the state-of-the-art and scientific basis of the discipline of surgery.

• Provide leadership in ensuring surgical healthcare for all members of the Cincinnati community.

The synergy brought together within the CSI has unique abilities and can be highly competitive for funding from government, industry, and philanthropy. We look forward to developing new innovations through partnerships and collaborations in order to continue our ongoing mission to provide the best possible surgical care of civilians and soldiers, wherever they may be. To those who have invested money, energy, time and other resources, we say thank you. CSI is a defining uniqueness.

 

The Center for Surgical Innovation (CSI) laboratory facility is equipped for UC affiliates and members of industry to conduct training labs and/or research & development activities. For more information on using the CSI laboratory facility, please contact:

Elyssa Westrich
Program Coordinator
Center for Surgical Innovation (CSI)
Department of Surgery
University of Cincinnati
231 Albert Sabin Way
MSB 1466
Cincinnati, OH 45267-0558
Phone: (513) 558-5334
Fax: (513) 558-2026
E-Mail: elyssa.westrich@uc.edu