Healthcare in Japan: Traditional

Medicine Meets Frontier

Medical Technology
Caleb Busch
M2
Research Question
• Does the widespread use of traditional Japanese medicine contribute
to the high life expectancy in Japan?
• Hypothesis
• The combination of traditional Japanese medicine (Kampo) and frontier
medical technology provides a culturally unique environment that promotes
the world’s leading life expectancy in Japan
• Objectives
• Clinical observation
• Understand the role of Kampo in Japanese healthcare
• Explore frontier medical technology
• Observe other cultural factors influencing health
Background
• Rapid economic growth following WWII leads to drastic increase in
life expectancy
• 1947: Males (50 years) Females (54 years)
• 2009: Males (80 years) Females (86 years)
• Antibiotics
• Access to modern healthcare
• Universal Healthcare (1961)
• Japan reaches baseline of modern health care access

Ikeda, Nayu (17 September 2011). "What has made the population of Japan healthy?". The Lancet 378 (9796): 1094–105. doi:10.1016/S0140-6736(11)61055-6.
Why does Japanese life-expectancy continue
to lead other nations?
• Focus on primary prevention
• Mass screenings
• University healthcare
• Cultural factors
• Diet
• Physical activity and infrastructure
• Literacy and education
• Shintoism: cleanliness of body and mind
• Kampo: traditional Japanese medicine
To Japan!
Kagoshima University
• Department of Psychosomatic Internal Medicine
• Kampo study
• Daily rounds
• Outpatient clinic observation
• Language study

Logos retrieved from http://www2.kufm.kagoshima-u.ac.jp/

Kampo: Traditional Japanese Medicine
• Derived from traditional Chinese medicine
• Diagnosis
• Pulse (speed, strength, depth)
• Tongue
• Abdomen
• Treatment
• Kampo formulations
• 140 covered by insurance
• Many mechanisms unknown
Image retrieved from: https://kampo.ca/concepts/

E. C. Moschik, et al., “Usage and Attitudes of Physicians in Japan Concerning Traditional Japanese Medicine (Kampo Medicine): A Descriptive Evaluation of a Representative
Questionnaire-Based Survey,” Evidence-Based Complementary and Alternative Medicine, vol. 2012, Article ID 139818, 13 pages, 2012. doi:10.1155/2012/139818
Mt. Sakurajima
• Natural disaster
• Tsunamis, floods, typhoons, earthquakes, and
volcanic eruptions
• “Readiness”
• Four distinct seasons
• Geographic location
And For This Month’s Forecast

Umbrella

Bike

The Weather Channel. N.p., 13 June 2015. Web. 13 June 2015.

Next Stop: Fukuoka!
 Kyushu University
• Department of Advanced Medical Initiatives
• Frontier robotic surgery research
• Weekly research meetings
• Seminar for endoscopic surgery
• Robotic surgery observation
• Language study

Logo retrieved from: https://www.kyushu-u.ac.jp/english/

Robotic Surgery Versus Conventional Laparoscopy:
A Clinically Applicable Performance Comparison

Caleb Busch
Supervisor: Prof. Makoto Hashizume, MD, PhD
Dept. of Advanced Medical Initiatives
Kyushu University Faculty of Medicine, Fukuoka, Japan
Minimally Invasive Surgery
• Benefits:
• Reduced analgesics
• Faster recovery
• Reduced wound complications
• Improved cosmesis
Conventional laparoscopy

• Two methods:
1. Conventional laparoscopic surgery
2. Robot-assisted surgery

Robot-assisted surgery (da Vinci System)

Laparoscopy versus Robot-assisted Surgery

• Shortcomings of conventional laparoscopy have been determined

• Robotic-assistance addresses many of these shortcomings
Visualization DOF Fulcrum Operator Posture Haptic
Effect Feedback
Conventional 2D 5 Yes Sometimes Poor Reduced
Laparoscopy
da Vinci 3D 7 No Good, Consistent Absent*
System
Research Question
• By using a new computerized objective assessment system to
evaluate suture task performance of the da Vinci system compared to
conventional laparoscopy, can we assess the merits of robotic surgery
in a more clinically relevant manner?
• New method of performance comparison
• Clinically relevant data
Novel Measurement Methodology for
Performance Evaluation of Medical Equipment

Dexterity Several criteria for suture evaluation

Intestinal Anastomosis Model
• Suture task performed on an intestinal anastomosis model
• Consists of four layers to accurately mimic real tissue

Uemura M. Objective assessment of the suture ligature method for the laparoscopic intestinal Serosal side Mucosal side
anastomosis model using a new computerized system. Surg Endosc. 2015 Feb;29(2):444-52
Performance Analysis System
• Five variables measured:
• Air pressure leak
• Number of full-thickness sutures
• Suture tension
• Wound opening area
• Performance time

Suture evaluation device

utilizes air pressure and
computer visualization
from the mucosal side
Participants
• Six laparoscopically trained medical
students or researchers at Kyushu
University Hospital
• Well trained in conventional laparoscopy
• First time using da Vinci system
The Task: Three Vertical Sutures
• Performed under three conditions:
• da Vinci 2D
• da Vinci 3D
• Conventional laparoscopy

2D da Vinci field 3D da Vinci Surgical Robotic System Conventional Laparoscopy

Data Analysis
• Group comparison
• Pairwise and group comparisons for each of five criteria
• Performance order
• Conventional laparoscopy first; then 2D and 3D da Vinci order randomized
• Statistical analysis
• Mann-Whitney U Test
• Nonparametric pairwise comparison
• Holm Test
• Three group comparison Mann-Whitney U Test

Conv 2D 3D

Holm Test
 Results
p < 0.05 p < 0.05 p < 0.05
[kPa] [%] [mm²]
+ + +
35

10 12 14
80
Volume of air pressure leak
30

Wound opening area

70
25

Suture tension
60

8
20

6
50
15

4
40
10

2
30

0
-
5

3D 2D Conventional
- 3D 2D Conventional
-
3D 2D Conventional
Air Pressure Leak Suture Tension Wound Opening Area
p = 0.05 [pairs]
[sec]
- +

3.0
Number of full-thickness sutures
Overview
400 500 600 700 800 900
Performance time

2.5 There were significant differences between

conventional and 2D da Vinci groups
2.0
1.5

Novice (N = 7)
Novice (N = 7)
1.0

Novice (N = 6)
+
3D 2D Conventional - 3D 2D Conventional
Performance Time Full Thickness Sutures
Discussion
• Hypothesis: 3D dav > Conv; 3D dav > 2D dav
da Vinci Conventional
• However, 3D dav = Conv
• da Vinci is intuitive
• 7 DOF: Too many to control under 2D
conditions 7 DOF 5 DOF

• Complex maneuvering requires 3D vision

• New robotic system -> 3D vision required
• Future research: 2D 3D 2D
• Well-trained da Vinci group vs well-trained
conventional group
Conclusion
• By using a computerized objective assessment system, we
successfully evaluated suture task performance of the da Vinci system
compared to conventional laparoscopy in a new, clinically relevant
manner.
• 3D vision is necessary for complex maneuvering during minimally
invasive surgery.
• Future surgical robot systems should utilize 3-D vision to be effective
References
• Kenngott, H. G., Fischer, L., Nickel, F., Rom, J., Rassweiler, J., & Müller-Stich, B. P. (2012). Status of robotic assistance - A less traumatic and more
accurate minimally invasive surgery? Langenbeck’s Archives of Surgery, 397(3), 333–341. http://doi.org/10.1007/s00423-011-0859-7
• Tanaka, K., Shigemura, K., Ishimura, T., Muramaki, M., Miyake, H., & Fujisawa, M. (2014). Evaluation of a 3D system based on a high-quality flat screen
and polarized glasses for use by surgical assistants during robotic surgery. Indian Journal of Urology : IJU : Journal of the Urological Society of India,
30(1), 13–6. http://doi.org/10.4103/0970-1591.124199
• Byrn, J. C., Schluender, S., Divino, C. M., Conrad, J., Gurland, B., Shlasko, E., & Szold, A. (2007). Three-dimensional imaging improves surgical
performance for both novice and experienced operators using the da Vinci Robot System. American Journal of Surgery, 193(4), 519–522.
http://doi.org/10.1016/j.amjsurg.2006.06.042
• Badani, K. K., Bhandari, A., Tewari, A., & Menon, M. (2005). Comparison of two-dimensional and three-dimensional suturing: is there a difference in a
robotic surgery setting? Journal of Endourology / Endourological Society, 19(10), 1212–1215. http://doi.org/10.1089/end.2005.19.1212
• Moorthy, K., Munz, Y., Dosis, a, Hernandez, J., Martin, S., Bello, F., … Darzi, a. (2004). Dexterity enhancement with robotic surgery. Surgical Endoscopy,
18(5), 790–795. http://doi.org/10.1007/s00464-003-8922-2
• Lee, E. C., Rafiq, a., Merrell, R., Ackerman, R., & Dennerlein, J. T. (2005). Ergonomics and human factors in endoscopic surgery: A comparison of
manual vs telerobotic simulation systems. Surgical Endoscopy and Other Interventional Techniques, 19(8), 1064–1070. http://doi.org/10.1007/s00464-
004-8213-6
• Uemura, M., Yamashita, M., Tomikawa, M., Obata, S., Souzaki, R., Ieiri, S., … Hashizume, M. (2014). Objective assessment of the suture ligature
method for the laparoscopic intestinal anastomosis model using a new computerized system. Surgical Endoscopy, 444–452.
http://doi.org/10.1007/s00464-014-3681-9
• Fay, M. P., & Proschan, M. A. (2010). Wilcoxon-Mann-Whitney or t-test? On assumptions for hypothesis tests and multiple interpretations of decision
rules. Statistics Surveys. http://doi.org/10.1214/09-SS051
Kyushu University

Dr. Hashizume

Dr. Uemura (right), Dr. Nakadate (left)

The Old and the New: Conclusions
• Japan is one of the world’s leading countries in medical technology
• Traditional Japanese medicine is used daily in conjunction with
frontier medical technology
• This unique medical environment is likely one contributing factor to
the excellent health in Japan
• Health is deeply rooted in Japanese culture
Future Research
• How does Kampo usage differ in areas without access to modern
medical technology?
• Islands surrounding Kyushu
• Assess Kampo efficacy in the United States?
• Isolated from cultural factors
Thank You!
• KUMC Department of History and Philosophy of Medicine
• Advisors: Dr. Christopher Crenner; Dr. Arthur Daemmrich
• Kagoshima University
• Dr. Inui and the Department of Psychosomatic Internal Medicine
• Dr. Ken Sazaki
• Kyushu University
• Dr. Hashizume and the Department of Advances Medical Initiatives
• KUMC International Department
Questions?