Fred Moll: Good morning everyone. And first I’d like to thank Dr. Landman for the opportunity to speak with you today, and I’m going to take a very high-level approach to talking about translation. And I think Jaime made a very important point at the beginning of the talk about, how many of you have good ideas? All of us have good ideas once in a while and some more than others. But, I think the focus on translation today. You need to make the point is invention is a lot easier than translation and that’s too bad for all of us, but it is a special process that has a lot of moving parts.
I’ll give you a little bit about my background in order to talk about that subject. So, I look at my career as a being fortunate enough to be in the right place at the right time and to really jump on this sort of inevitable force of this train that took off, that when I first entered training in surgery, the minimally invasive train had not left the station yet, but it obviously certainly has in the last 35 years and my career has been all about trying to stay relevant and make a contribution to what I feel is this inevitable process that if you look at it holistically, that surgery is going to morph into something that is extraordinarily less invasive, even than it is today.
So what are the lessons there? If you look at the changes in surgical technique, there are lots of opportunities along the way to improve surgical technique by observing what isn’t working. And when I first got into, as a surgical intern, got into a laparoscopy and really looked at how challenging really is the technique, but also how extraordinarily opportunistic the procedure was with regard to the visualization and the access and obviously the minimally invasive effect.
So this process of going from open surgery to laparoscopy in a variety of procedures started with the gynecologist. And the great thing about being an intern is, you know you don’t know anything and so you have no preconceived notions of what is right and what is wrong technique. And as an intern, I was asked to spend some time in the gynecology… I was in the general surgery program, asked to spend some time in the gynecologic service. And the first thing I learned was, you’re not gonna learn anything there cause gynecologists don’t really know how to operate. And so I walked into my first laparoscopy and it was really love at first sight, because I had been, as a general surgical resident does, holding retractors not being able to see a damn thing about what was going on in the procedure, and not really learning very much.
And so I looked at laparoscopy and was confronted with this cathedral of anatomy that was in the perfect spot, looked like a Frank Netter drawing and said, “Why isn’t this the way… The view that a general surgeon would want to operate, and why can’t a laparoscopic technique progress to something more than where the gynecologist are using it,” which was essentially when I was looking at it was primarily for tubal sterilization and really required looking through a telescope, not a camera, or not a screen, but a telescope to burn the Fallopian Tube. So got very excited about what the future was there and the training wheels for my a career and innovation was the lowly safety trocar, was the first idea I had for how to improve technique, and what problem were we solving there?
Well, when I looked at laparoscopy, they were using essentially a metal spike to puncture through the abdominal wall and a hope to hell they didn’t hit anything of too much importance. And I thought, “Here’s a place where not knowing a ton about surgical technique, there sure seems like there would be a better way to poke through the abdomen.” And so the safety trocars have launched my career and was a great way to get started. And I think I showed this slide a little prematurely, but when I saw a laparoscopic technique go from the gynecologic aspect to gallbladder surgery, I also saw this, which is suddenly, a well-trained surgeon struggling to tie a knot, intracorporeally. And I said, “If this is the technique that laparoscopy’s going to provide and the precision it’s going to provide, this probably isn’t going to go very far. At least it won’t be able to progress to more sophisticated or complex procedures.”
And you know, that’s where I understood very clearly that all hands aren’t created equal, Because some people have no problem tying knots with straight laparoscopic sticks, some certainly do. And so it was sort of a lesson in innovation that I think is a really important one, and a lesson in maybe more in translation, which is you are not developing, technology to assist a technique that is extremely hard to learn, or that only a few people can master. And so the idea, whether it’s a technology or a technique, it has to be understandable by the majority of people, or you’re not gonna make as big an impact. And so I got excited about the ability to, address this sort of one seemingly very significant problem in minimally invasive technique is, you don’t have your hands inside the abdomen. And so how are you going to deliver precision if you’re a foot and a half away holding a long straight stick?
And that was really the impetus for the development of robotics. And it was quite a journey where it started out with, sort of the majority of people saying, “That is a really bad idea and why would anybody want to operate that way?” But the idea was also that it probably wasn’t going to go very far if you couldn’t translate what the intent of the problem solving to something that was fairly easy to use and could make an impact over a large group of people. And so that worked out very well. And as I said, I’ve been trying to stay relevant in the robotics field primarily now in looking at, if we can solve the problem with straight stick laparoscopy from a standpoint of articulation and precision and provide more accurate movement than the tip of a tool, where else can that be relevant?
And you know, now being part of Johnson & Johnson, I think we have the opportunity to enable new approaches to intervention that aren’t limited to laparoscopy. Certainly, laparoscopy is one of them, but endoscopy, percutaneous technique, vascular intervention are all, we think, domains of the robot. And we think even in open surgery, the use of robotics not only can be valuable but in getting surgeons that are not comfortable with robotic technique, more comfortable in open surgery with sort of light assistance by a robot, it can push more procedures and more people towards the use of robots.
So, very excited about where robotics can go that isn’t inside the confines of intra-abdominal laparoscopy. And you’ve seen some of the techniques earlier today that we’re working on in, in endoscopy, both in urology and pulmonary intervention.
And so, my lessons in a translation are kind of summed up here. That you need the ability to be able to withstand first the criticism. Oftentimes the bigger change you’re trying to make, the more obviously severe criticism you’re going to get on whether it makes sense as to what you’re doing. And in translation, it really is a process of translation. It’s all about being able to withstand not only the criticism but the early mistakes you are going to make and the deficiencies in your own thinking about what might make sense. So it is a journey and it is a journey that takes some persistence. And depending on what you’re trying to do, it’s also very important to be well-financed. And if you look at the correlation between successful financing’s and successful companies, there’s a direct correlation there, and it is something that, not all good ideas need a lot of money to get to where they need to go. But it is important to match the complexity and the journey that you’re about to undertake with the proper plan for the financing of that journey.
So finally, when we introduced robotics, which is now more than 20 years ago, the question is, “Do you really need that complex technology to get more precision?” And you know what? We’re still arguing about it. And what is interesting to me about the fact that I think the market has spoken, particularly in urology, about what’s the best way to do a prostatectomy. Having said that, there is enormous debate as to what makes, what “Has to be robotic” in order to get better and what can be improved without robotic technology. And I think those debates are really asking the wrong question and I’ll go back to my statement about all hands are not created equal.
There is a varying level of skill in any therapeutic intervention that can be brought to bear from a clinician. And so the idea is not, in my mind, the idea is not whether you need a robot or not, but how can we progress in technique so that we can level the playing field between people with perfect technique that are never gonna need a robot and people that probably are never going to get to that ideal technique? And this is where you see this whole idea of data, machine learning, AI, which are pretty complex notions of how they’re going to integrate themselves into surgery. But also I think directionally very correct in this progress towards better intervention. And so I think the debate is not robot, no robot. It’s, how can technology create a platform that assists the surgeon in a way to make he or she the best interventionists they can be. And I think from that standpoint, the future is very bright. So let me close with that and thank you for your attention.