Two software engineers and a University Hospitals doctor are the brains behind Surgical Theater, a new technology that offers surgeons a way to simulate their next procedure using a virtual model of their patient’s body.
Alon Geri flew a Black Hawk helicopter for two decades before spending the last 12 years of his military career as a software engineer, working on flight simulators for the Israeli Defense Force. He understood how to model the effects of lift, drag, thrust, altitude and temperature on an aircraft, but creating a program that mimicked the human body was another story.
Geri spent the summer of 2009 in his apartment in Ramat HaSharon, a city of about 40,000 people outside of Tel Aviv, trying to wrap his head around how to model human tissue for a surgery simulator he hoped to create. Armed with DICOM image files — the standard output for CT and MRI scans — medical journals and input from University Hospitals brain surgeon Dr. Warren Selman, Geri finally had a breakthrough.
“The first time I was able to create a 3-D image on the computer screen and I actually saw a blood vessel, I really yelled,” Geri recalls. “My wife was on the second floor. She came running down, asking, ‘Whats wrong? What happened?’ I told her, ‘I can show this thing.’ ”
Selman, UH’s neurosurgeon-in-chief and the medical director for Surgical Theater — the company he founded with Geri and his friend, Moty Avisar, also a former Israeli Air Force major with 18 years experience developing flight simulators — wasn’t as enthusiastic from the start. When he first looked at Geri’s creation, all Selman saw was a three-dimensional cube.
To demonstrate, they poked and prodded it with a virtual surgical instrument. “And it’s like a piece of Jell-O vibrating. They look over at me all excited, and I look back at them [like], Are you kidding me? This is it?”
Selman quipped that if they wanted a cube of Jell-O, he could go get them one from the hospital cafeteria. But Geri knew what he created would work once he took the next step of merging his conceptual cube with a computerized map of human tissue.
“Once we crossed that path,” he says, “the rest just fell into place.”
In February, their Surgical Theater’s simulator — formally known as the Selman Surgical Rehearsal Platform — received Food and Drug Administration approval vital to the company’s plan to put its product in the hands of doctors inside operating rooms.
“Without FDA approval, we can use it for guidance, and we can put yesterday’s case on it for residents to train,” says Geri. “But the FDA approval allows us to use the system for tomorrow’s case. That’s a big leap.”
Currently, the system can be used for neurological cases involving tumors and aneurysms, but Surgical Theater hopes to expand into cardiovascular and spinal procedures. The platform works by importing a patient’s DICOM files into a computer, which is then converted into a 3-D image of the tissue and displayed on a monitor.
The surgeon can rotate the image, zoom in and access a virtual tray of operating-room tools, which are manipulated through two controllers that look like miniature gun turrets from Star Wars.
The software’s patented technology prompts the virtual tissue to react in lifelike ways. When a user tries to clip an aneurysm, for example, it bulges like a squeezed balloon. The power of the technology offers surgeons a practice run of their next procedure on a computerized body generated from their patient’s own scans.
But FDA approval was just the start. Continuous, small improvements and refinements followed. In addition, Geri jokes, there were a lot of interruptions of Selman’s daily schedule for his suggestions on how to make the experience as realistic as possible.
“If my hands aren’t feeling what it feels like, I’m not rehearsing,” Selman says. “It’s like trying to rehearse a golf swing with a baseball bat.”
If a partnership between two ex-Israeli Air Force majors and a Northeast Ohio neurosurgeon seems unlikely, that’s because it was the product of an impromptu meeting, after Selman overheard Avisar talking at a Cleveland Heights Starbucks in 2008.
At the time, Selman was the chairman of the American Board of Neurological Surgery. He and his colleagues had been in ongoing discussions about better ways to certify brain surgeons when he overheard his future business partner discussing his latest and final project for the Israeli Air Force: a flight simulator being built through a partnership with Lockheed Martin’s Akron office.
“I butted in and said, ‘We would like to know if there is a way to simulate surgery,’ ” Selman recalls. “We struck up a conversation, a friendship and then eventually, a partnership.”
Selman wants to offer doctors the same preparedness and practice afforded military pilots.
Before a mission, a drone flies over an area and collects data. That information — elevation, climate and surroundings — is fed into a flight simulator, allowing a pilot to rehearse the mission as many times as possible and have the best possible idea of what to expect after takeoff.
“We’d like to do that for surgeons,” Selman explains. “To be able to quickly review what they’re going to encounter, practice the muscle movement involved and then walk into the case saying, ‘I know what I’m going to see. I know what I’m going to do.’ ”
The rehearsal platform is now at the product stage. University Hospitals has already bought two systems. The Mayo Clinic has an order in place and the UCLA Medical Center is among other possible customers for the system, which ranges from $200,000 to $250,000 and comes in two varieties: a desktop version with two monitors and a laptop solution that can be connected to a 3-D monitor. The desktop systems are on wheeled carts so they can be moved from operating room to operating room, allowing a surgeon to practice moments before a surgery or even consult the system midprocedure.
Surgical Theater is also in the beginning stages of a study to measure the rehearsal platform’s effectiveness. It will compare cases done with and without the system to discover its effects on treatment
“We want to prove that it actually improves outcome and safety,” Selman says.
He stresses that especially in today’s connected world, where patients can go online and choose surgeons based on outcome reports, more and more doctors are going to look for ways to improve themselves. The surgical rehearsal platform can be part of that, he says.
“I know from everything else in my life, if I rehearse, I do a better job,” Selman says. “Perfect practice makes perfect. This allows perfect practice.”