Cleveland’s Surgical Theater in CNN spotlight

Surgical Theater LLC of Cleveland was featured this week in a nearly 3½-minute segment of “Erin Burnett OutFront” on CNN.

Dr. Warren Selman, neurosurgeon-in-chief at University Hospitals and medical director of Surgical Theater, explains how the company’s software enables doctors to practice on 3-D images of their patients’ brains while supervised remotely by other surgeons. For instance, images of brain aneurisms can be rotated to enable surgeons to determine the best course of action.

The CNN piece notes that Surgical Theater’s launch stems from a chance encounter Dr. Selman had in a coffee shop with company co-founders Moty Avisar and Alon Geri, two former Israeli Air Force officers. The story likens Surgical Theater’s technology to flight simulators that help pilots practice critical missions.

Dr. Daniel Barrow, a neurosurgeon at Emory University in Atlanta, is impressed by the Surgical Theater technology. “Every time I’ve seen it, it gets better and better,” he says.

Ralph Whitworth’s Relational Investors LLC increased its holding in Canton-based Timken Co. in the first quarter as he pressured the company to sell its steel unit, according to this story from Bloomberg.

Brain surgeons get a practice run with simulator from Elyria-based Surgery Theater

For a number of years, pilots have used virtual reality simulators to practice critical missions before taking to the skies. Thanks to a revolutionary new virtual reality training tool developed by Elyria’s Surgical Theater, LLC, surgeons now have a way to practice brain surgery before setting foot in the operating room.

The Surgery Rehearsal Platform (SRP) simulator consists of a desk top computer, a portable laptop system, software, controllers and 3D glasses.

surgicaltheater“Using standard CT and MRI images from any patient, the SRP generates accurate models in 3D that show the interaction between life-like tissue and surgical instruments,” explains Moty Avisar, Surgical Theater president and CEO. “The tissue responds realistically to actions taken by the surgeon, enabling pre-surgery planning and rehearsal with complete accuracy.”

Beyond practicing on standard CT and MRI images, surgeons can also use unique images taken of the patient who will be undergoing surgery.

“Using the SRP prior to a procedure enables a surgeon to evaluate, experiment and do a ‘dry run’ on his or her approach beforehand, resulting in a better-prepared surgeon,” Avisar states. “Studies will be done to confirm this, but our belief is that SRP training will lead to improved patient outcomes and reduced risk.”

The Surgery Rehearsal Platform received full FDA approval in February. The SRP’s unique patient-specific capability is one of the key innovations that led to FDA approval, he notes. According to Avisar, it’s the only patented and FDA-cleared training platform for cerebral and spine pre-surgery rehearsal in the marketplace.

The SRP, which took approximately three years to develop, supports several cerebral procedures, including aneurysm repair and tumor resection. The team is working to add capabilities to support other brain-related procedures and spine surgeries.

According to Avisar, the first SRP was recently sold to University Hospital Case Medical Center, where it is being used on a regular basis.

The company, which started with one person in 2010, received funding from theOhio Third Frontier, private investors and angel groups. It plans to expand to 15 employees by the end of the year.

Practice Made Perfect

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.

EtoolkitSurgery1Geri 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.”

EtoolkitSurgery2Currently, 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.”

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