Guest Podcast: Transforming Healthcare, VR Surgical Planning

Hi Steaker and family. This is Anton Bash. I'm a research fellow at Cincinnati Children's Hospital Medical Center and one of the hosts of our brand new podcast, Transforming Healthcare. With this podcast, we wanna highlight different companies, software, and technologies that we believe are changing healthcare for the better by innovations. Our first guest was Doctor Matt Bramblett, a pediatric cardiologist at Children's Hospital of Illinois and the University of Illinois College of Medicine, and we talked about VR surgical planning and its impacts on everyday cases. Give it a listen. I hope you will like it. Find us on any platform wherever you get your podcasts. We are transforming healthcare. Now let's jump in. This podcast created by Cincinnati Children's Hospital Medical Center. You are a pediatric congenital heart surgeon. You just started your day at the clinic and this is your first patient of the day, a young one who has heterotaxy syndrome, and you know that without corrective surgery, most children with heterotoxxy syndrome and congenital heart problems will not survive beyond the first year of their life. And your patient has anomalous drainage of both systemic and pulmonary venous return to the common atrium. So this patient didn't have an atrial septum. Also had transposition of great vessels in which condition the right ventricle pumps through the aorta and left one pumping through the pulmonary artery. The main question on your mind for this child is, after several palliative operations, could she undergo complete two ventricle repair? Oh, by the way, you have the option to study and plan the case with VR software. What would you do? Hi everyone. This is Anton Bash. I'm a research fellow at Cincinnati Children's Hospital Medical Center. And this is Transforming Healthcare podcast. Welcome to our first episode. Today I'm joined by my two co-hosts. Hi, I'm Doctor Todd Bonski. He's the director of the Clinical Growth and Transformation Lab and a pediatric surgeon at Cincinnati Children's Hospital. Hi, I am Rami Shain. He's an assistant professor of instructional technology and learning sciences. Today we are gonna talk about using virtual reality for surgical planning with Doctor Matthew Bramblett. He's a pediatric cardiologist at Children's Hospital of Illinois. And the University of Illinois, and he runs the advanced imaging and modeling lab. Here at the Children's Hospital, every complex congenital heart or surgical oncology patient is viewed in VR before they go into the operating room. They have an entire lab focused on the operations of the VR for surgical planning, and they have a research mechanism that supports scaling this up so hopefully it can be distributed to the world one day. Let's talk about the process. There are 5 stages for surgical planning process. The very first step that we take whenever we're going to go down this path is we have to identify a patient that's going to benefit from this process. This first step called order entry, content acquisition, it's making sure that you're selecting a patient that's going to actually. Benefit from it. So it's both patient selection and an imaging selection. One of the important points is talking with radiology and making sure that they are going to order the right imaging, whether it be CT or MRI. And we have a process where we for 3D modeling and rather than saving only thicker. Slices on the CT scan as the standard. And Doctor Bramlet said in many instances for soft tissue tumors, they're going to find that the MRI is going to be preferred. So it's changing practice for the purpose of being able to generate those 3D models. Once we have the 3D data set and DO format, the imaging format. We'll export that into our process for segmentation. Segmentation is the process of going slice by slice on those 2D images and drawing out the CAD software for the purpose of the surgical planning. If you need VR segmentation for your surgical planning, anybody can go to jump simulation segmentation service, it's linked below. And they offer that at no cost to any institution. Wow, that's incredible. So anyone anywhere in the world can send their images? Yes, Dad, anyone, anywhere. That's cool. That's amazing. There are two options we can send them via VR if they if they have VR hardware. That's the easiest. We can turn that around in a day if they want it shipped physical heart, then we'll print the heart. Shipping a 3D printed heart is, it's not our preferred more cost and time for us, but we will do that if we believe it's going to. Help the surgeon for prepare for the case. We'll do either one. So the next step is QA process. And so we do this hand in hand with the radiologist, with the surgeon or the cardiologist or whoever it is that's going to be reviewing this for the sole purpose of creating an exact replica of that specific patient. So when they experience that A virtual environment and then do the operation that may have a better simulation of what they are going to do. Yes, you're totally right, Rami, and I think this is such a crucial part. If you can see it on a scan, you can segment it as a specific object. I paint a picture in my mind when I look at a CT or an MRI of the heart. By going through and creating mask on each layer, I'm now objectifying that object that I have in my head into the 3D file format that allows us to turn it into an actual either physical object or digital object that allows the surgeons to interact with it before surgery. After the quality control complete, then we have the content optimization process. You can't just throw a 3D file into a printer and, and get what you want. It really takes an engineering team. We have a standard way that we will cut through the heart in the same way every time. I think what we're talking about is simulating the anatomy, and there's 3 levels. There's reconstruction of an axial image, which means taking a CT or an MRI and reconstructing it on a flat screen. There's 3D printing it, or there is digital twinning, where it's dynamic. And you can be immersive. That's a good summary, Todd, and today we're focusing on the 3D printing and VR part. For VR it's more along the lines of taking the scale data and finding its color so that you have this visual variation of the different organs. We actually find that placing the tumors in a fluorescent type color is beneficial because you can make other things disappear in the virtual environment, but that fluorescent. Tumor kind of maintains its presence as you're interacting with it, and since 2018 we're pretty much nearly 100% VR. Oh, this is a transformative piece, really. There's a nuance to putting the digital model in a virtual space and being able to walk around it, being able to see where everything is in relationship. Todd, considering what you heard until now, would you think you would prefer this VR stimulation to prepare for your cases? I think I'd have to try it to know, because without having had that happen, I cannot tell you if I would get more out of it. That's fair. Let's hear what Doctor Brownlow's experience is. I've had 4 or 5 surgeons all come back and say to me, after the surgery is over, I felt like I'd been there before. That's the clinical impact in the final piece. I bet they felt that they gained more information, whether it's immersive or something about it, and I want to know what that was. We heard from Dr. Bramblett that the average construction of the VR image is between 30 minutes to 1.5 hours for congenital heart diseases, but usually they got about a week clinical lag time between imaging and surgery. So once we have the 3D model created, engineers will place it into VR and the software we use, which is Induvo, which was originated here, and this. Lab's first commercial exit. I think that's the important part. The thing about Eduo is allowing the surgeon to actually record. So you have the expert in the VR space recording different pieces about it. So this allows us to have derivative clinical vignettes for education, for our surgical oncology. Todd, do you have any idea what kind of cases that you can use this for? I really don't know, um. In my mind, I'm trying to think of what a neuroblastoma and having The tumor with all the surrounding vessels and attachments with it, so I could see exactly how things are. Position, but I can usually see that on the scan in my head, interpret what that would be, but maybe this would be better. Maybe a tracheoesophageal fistula case where you would get a real idea on the gap and how long the distance is and maybe the anatomic relations. I'd have to think about it, and that's why I think we have to see it to believe it. Then Todd, I have good news for you. Doctor Bramlett said they have a study where they're actually using this. Where they're letting the parents and sometimes the patient review the case in VR as the surgeons walking them through what's going to happen in the surgery. So Rami, I know Todd is a little bit skeptical, but I wonder what you think about this. I see a true value in that, in, for example, cases like conjoined twins where they want to have training on a procedure that lasts for Long hours and get a step by step strategy on that. And Todd, I know you're very passionate about innovating surgical education. So do you think this study would show us anything that tell us that we can use this technology for maybe trainees or residents or fellows? Teaching it would be an incredible Value malrotation is a great example because it's hard to conceptualize. If I can move the tissue, then that would be amazing. I would love to, to show an example of how I would do a procedure using this. And maybe hernia anatomy. I know you're one of the experts in the field, and maybe you can use this technique for your courses. Yeah, you're right, this is great. Let's keep going. I wonder how this segmentation process works. Is there a computer that does that automatically, or is it an actual human being doing this? So there are multiple CAD programs out there. 3D slicer and open source freeware that some institutions use. We use mimics biomaterials. A lot of these softwares are very expensive and we have a budget for that allows us to do that. Let's say I have a non-contrast 3D data set of a heart. I can put that into a supercomputer over here and we built a machine learning program that will take it and generate a heart with a click of a button. And Dr. Bramman's team just presented an automated segmentation for brain tumor. One of the problems with the brain tumors is the turnaround time. They'll get the stealth images about 1 hour or 2 hours before surgery. So that's why they focused on putting some effort on automating that process, because they had to automate that to be able to deliver this technology in a manner that fits within the clinical time frame. That sounds like the future of this technology in this process, and since it's still developing, can you categorize different advantages and disadvantages using this VR simulation for surgical preparation? Well, the main advantage is we're creating a mental representation of the anatomy. And because we are very diligent about that QA process, every surgeon comes back and says, this is exactly what I found in the OR. Because we're creating the exact replica from the scan. And that brings us to another point, because one of the disadvantages of the 3D modeling for at least cardiac, probably is gonna be the valves, because if you cannot see it on the image, you cannot replicate it. We've written up our 4D heart, which is segmenting 18 phases of. Beating heart. We actually have in the lab a beating heart with two VSDs, and it's really mesmerizing to be able to see that. My personal impression about the digital twinning and metaverse, it will succeed if it includes real-time data. If you have any intervention with the heart, it reacts exactly. the same as it can react in the physical environment. So that will change the game a little bit. The dynamic moving 3D model could provide tremendous value, but that's still more on the research side, I believe, and takes a ton of effort to be able to deliver that. And please don't forget, surgical problems that are difficult to image, make it difficult to generate. So that's one of the things. That they are trying to have this automated processes to help overcome the difficulty in generating these 3D models. So, I believe you already answered my question, which was, do you believe this technology is changing the healthcare today or tomorrow? It's today's without a doubt. If the surgeon is finding the benefit enough to put that time and effort in, that speaks very highly to the impact. And Doctor Bramblett has a couple of advice if you are a healthcare provider or doctor or board member that you want to adopt this technology in your hospital or private practice. I would advise that they use existing radiology technologists to do this, but it requires them to learn a new software and the segmentation is where I would assert my first resources. I would not. A 3D printer. And they haven't printed a heart for surgical planning since 2018, which is the time they transitioned to the VR. I actually had one recent case where the, when you looked at the heart itself 3D printed, you can see the problem, but the problem was the orientation inside the chest. And so it wasn't really until you went into VR. That's the benefit of the VR over 3D print. There's such a nuance to. The understanding of these complex three-dimensional objects that I don't know why we wouldn't be seeking this out for all of these cases. So what do you think, Doc? Are you still skeptical? I think this is really an interesting technology. It's obviously something that's we see every day and it's making its way in the surgical specialty. We need to wait to see exactly how it will make its way into surgery, if it's gonna be just stimulation and training, or if it's really gonna be. Something that will impact patient care. It looks like it already has impacted patient care. I agree, Todd. It might be still early to comment on the full ability of the technology, but I believe we're still going somewhere. What about you, Rami? I think we are early in the process of dealing with this technology. Um, the technology still needs to be advanced, but I think it has a potential, and we can. See something interesting in the future using that technology in medicine. One way or another, we all agree that using VR for surgical planning is helpful and useful for some certain cases. Even though I still believe there's a lot of room for improvement, I would definitely use this for my practice and training. Like Rami mentioned, I hope we can see a better version of this in the near future, which includes the real-time data with the 3D construction in the virtual environment. Wow, what an episode. We covered a lot today with Doctor Bramblett. Thank you for sticking around to the end. Don't forget to subscribe wherever you get your podcasts. As a final note, huge thanks to our sponsor, Cincinnati Children's Hospital Medical Center for making this podcast possible. I'm I'm Tom Bash. I'm Todd Ponsky. I am Rami Chaban, and this is Transforming Healthcare podcast.