Surgical Rehearsal Platform – An Illustrated Case Presentation by Dr. Justin Singer M.D. (PGY5)
A few days ago, I was called to assist in an urgent surgery to treat a ruptured distal basilar artery aneurysm in a 79 year-old comatose female who was presented to our emergency room from home via ambulance and whom was found to have a severe subarachnoid hemorrhage.
Case Medical Center is using the Surgical Rehearsal Platform (SRP) for preparation for intracranial procedures, including aneurysm clipping and tumor surgery. We have used the SRP for numerous elective procedures; however, this was the third instance in which we have used the SRP for an urgent procedure on a patient with an aneurysmal subarachnoid hemorrhage and our first experience with rehearsal for a basilar artery aneurysm.
The patient’s CT angiogram was sent from Case Medical Center’s PACS system to our SRP, and in less than twenty minutes, the SRP was able to generate a module for interactive rehearsal of the case.
Given current advances in endovascular treatment of aneurysms, the majority of posterior circulation aneurysms, especially basilar artery aneurysms, are treated with coil embolization. This fact has reduced the opportunity for hands-on education for residents during their training. However, the patient had severely tortuous arteries and the aneurysm had a very wide neck, which made coil embolization impossible. The SRP allowed my fellow res Dr. Brian Rosenstein (PGY-4) who participated in the surgery to maximize our involvement, participation and contribution to this case. We used the SRP to rehearse, to obtain the proper orientation and approach for optimal visualization of the aneurysm, including the bilateral superior cerebellar and posterior cerebral arteries. Additionally rehearsal facilitated selection and placement of the ideal permanent clip. Given the patient’s anatomy and projection of the aneurysm, the 3D rehearsal enabled the team to visualize the aneurysm via the view from the surgeon’s perspective and from the reverse position to better appreciate the positioning of the distal vessels and their relationship to the clip tines. All of those actions were performed on the SRP.
When the clip was applied to the ruptured aneurysm during surgery, we used the exact clip that I had pre-selected with the SRP and I successfully placed the clip with a single attempt.
(Figure 3 – Side by Side SRP and Microscope Snapshots)
Justin Singer M.D (PGY-5)
Department of Neurosurgery, University Hospitals Case Medical Center
UNIVERSITY HOSPITALS CASE MEDICAL CENTER SURGICAL REHEARSAL PLATFORM -RUPTURED ANEURYSM CASE STUDY
Dr. Warren R. Selman, M.D is the Harvey Huntington Brown Jr. Professor and Chairman, Department of Neurological Surgery, Case Western Reserve University School of Medicine. He is the Director of University Hospitals Neurological Institute and Neurosurgeon-in-Chief of University Hospitals in Cleveland, Ohio. Dr. Selman is former Chair, American Board of Neurological Surgery.
Case Medical Center is using the Surgical Rehearsal Platform (SRP) for preparation for intracranial procedures, including aneurysm clipping. Before this case, we had used the SRP only for elective procedures, and had not used it for emergency procedures or ruptured cerebral aneurysms.
The patient’s CT angiogram was sent to Case Medical Center’s PACS system, and in less than twenty minutes, the SRP was able to generate a module for interactive rehearsal of the case.
Surgical Rehearsal Platform – Ruptured Aneurysm Case Study – Read More
First-Person Account of Surgical Theater’s Selman Surgical Rehearsal Platform (SRP)
Vascular neurosurgery and, more specifically, aneurysm surgery is at a point today where fewer cases are being treated by direct clipping, and those which are appear to be the most complicated to treat in terms of wide neck and arterial branches taking off from the dome or base of the aneurysm. As a result, the learning curve for young neurosurgeons has been minimized.
In addition, a large neurovascular medical center should have the equipment to achieve the highest level of clinical outcome and patient safety, according to Dr. Sagi Harnof, Chief, Vascular Service and Deputy Chairman, Department of Neurosurgery, Sheba Medical Center, Israel. This means a comprehensive neurovascular team, good collaboration with endovascular surgeons and routine use of intra-operative imaging modalities such as ICG based Video Angiography, IntraOperative Angiography, etc… Still, the main limitation to achieving the best patient outcome is lack of neurosurgeon experience and the challenge of dealing with complicated aneurysms.
In all fields of medicine, the simulation based learning method gained popularity over the past decade and for aneurysm clipping it seems like the only option to keep with the high-level of surgical skills and education required for the next generation of vascular neurosurgeons, Harnof said.
Harnof, who recently had the opportunity to try out Surgical Theater’s Selman Surgical Rehearsal Platform ™ (SRP), sees the platform as being the future in neurosurgeon training.
“I believe this is going to be the best way for a surgeon to master one of the most complicated surgical tasks. Any modern neurovascular surgeon should own such a system to keep the highest level of aneurysm surgery.”
Using standard scanned images from any patient, the SRP generates 3D patient specific and accurate models of interactions between life-like tissue and surgical instruments. The tissue responds “realistically” to actions taken by the surgeon, thus allowing accurate pre-surgery planning and rehearsal. The unique software utilizes flight simulator technology to permit remote connection of multiple SRPs; participants anywhere in the world can work together simultaneously and practice the same case with real-time feedback and collaborate on the planning of a specific surgery case.
“I had the chance to operate the SRP on a real case uploaded to the software. I used the system to rotate the aneurysm under 3D display and selected the best clip to apply,” Harnof said. “I then returned to the surgical approach and clipped the aneurysm. The clip was too short and posterior part of the neck was excluded from the clip, so I changed the clip to a curved and longer one.
If I had operated on the same aneurysm the next day, I would know to use the most fitted clip, and be aware of exactly the best angle and my pitfalls. The 3D display is available during surgery making it possible for the surgeon to compare and apply his pre-surgical simulation based plan to the real situation.”
Sagi Harnof M.D.
Chief of Vascular service
Deputy Chairman Department of Neurosurgery
Sheba Medical Center
Featured on the front page of Case University Hospitals, Neurological Institution, 2011 Annual Report
Surgical Theater featured Warren R. Selman, M.D- Harvey Huntington Brown Jr. Professor and Chairman, Department of Neurological Surgery, Case Western Reserve University School of Medicine. Director, University Hospitals Neurological Institute. Neurosurgeon-in-Chief of University Hospitals.
Dr. Warren Selman is former Chair, American Board of Neurological Surgery.