Kurtis Auguste, MD, a Pediatric Neurosurgeon and Director of the Pediatric Epilepsy Program at UCSF Benioff Children’s Hospital Oakland talks about a new virtual reality mapping system and how it improves surgeries.
Interview conducted by Ivanhoe Broadcast News in May 2018.
Give me a little background about how Children’s Hospital is the first standalone Children’s Hospital to be using this VR system and why did they decide to use it?
Dr. Auguste: Well it is new technology and we are the first freestanding children’s hospital to use it. When it came along we hadn’t really advanced how we study imaging much in the past few years. Much of what we do is two dimensional, these are pictures on a flat screen. It’s a little ironic because brain surgery is one of the most three dimensional experiences that you can have. It’s one of the most three dimensional exercises that you do in medicine and yet everything that we do for learning purposes, training purposes, and for rehearsal purposes prior to surgery it’s all done in two dimensions. It’s all done on pages in a textbook or computer screens on flat images. This technology is the first of its kind to not just be three dimensional but is immersive and provides you a three hundred and sixty degree vantage point of the pathology. It’s striking just how much you learn when you study the same pictures that have been studied over and over again in two dimensions and look at them for the first time in three dimensions many new things become apparent. And as we started to explore this technology on our own we realized that this is something incredibly powerful and we wanted it for our patients and we wanted it for our children. And it’s made a very huge difference for many of our patients.
For neuroscience why is it even more important than like other fields?
Dr. Auguste: Neurosurgery and neuroscience is unique in its anatomy. Nature has built into a very small space lots of important structures. And there really is very little to spare. And so when you have that situation even in the absence of any pathology or any disease it’s a tight quarters and there’s a lot of good things packed right next to each other. Add to that mix a problem, a bleed, a tumor, a seizure focus and now you’re mixing in good with bad. You’re mixing in something that you want to ideally remove but in order to do so you have to navigate through the good. And it puts at risk many of those structures. And so any tool that helps us to safely navigate those tight quarters to remove and eradicate as much of the bad as possible but at the same time preserve and protect the good as much as possible any technology that lets us do that is going to be something that we’re going to seek out and strive for.
What’s the correct name for this?
Dr. Auguste: This is a virtual surgical planner. A virtual reality surgical planning station. And the name of the company is Surgical Theater.
I saw precision VR?
Dr. Auguste: It is a form of precision virtual reality. But it is specifically used for surgical planning.
Tell me how you use it with a patient from when you first do the consult and all that.
Dr. Auguste: I look at VR and the VR unit has a three step process and it helps in three different ways. The first is that it helps me as the patients surgeon to familiarize myself with the anatomy, to become comfortable with the three dimensional layout of all the structures again both the good and the bad. And begin to rehearse in my mind how the day of surgery is going to go. Traditionally we would do that by scrolling through a series of flat images and trying to reconstruct those 2D images in to a three dimensional structure but in our minds eye. What this allows us to do is create those three dimensional structures for us quickly and allow us to fly virtually through and around these structures. And in many ways rehearse the entire procedure well ahead of time mimicking the surgical corridors and giving us a preview of how the anatomy is going to look, giving us a preview of how the anatomy is going to look well ahead of time. This is happening before our patients meet these images for the first time. The next step is the actual patient experience where we bring in the families and in any given clinic visit there are moments where we spend explaining things to the parents who are obviously concerned and worried and anxious. Much of it is due to the fact that they have a pretty poor limited understanding of what the problem really is and where the problem lives and how could the surgeons possibly approach this delicate structure. This technology allows us in very vivid images to teach them about their child’s brain. And again share with them where the good is, share with them where the bad is and begin to outline the steps of a surgical procedure virtually. They see what we will see the day of surgery. And I’ve found whether it’s in 2D or 3D that the more you educate parents the more the anxiety level comes down about understanding what the problem is and how we’re going to go fix it. The problem with working with pediatrics is that we spend too much time talking to the parents in my opinion. We have these long drawn out conversations and we study all of these tests results and talk about intricate techniques and surgical procedures and we are speaking as if the most important person in the room is not even there. With kids it’s very, very difficult to communicate, to connect with them and share with them what’s going on inside their own brains. This is an opportunity to change that. The next part of the clinic visit is actually using the virtual reality headset to actually introduce the children to their own disease, their own problem, their own pathology. And in a very colorful and picturesque kind of way we can share with them their own brains and then virtually have them flying through their own anatomy. And this virtual world is their world. These are video gamers. We like to think that we’re sharing this virtual world with them but in reality we are visitors in their virtual worlds. And the moment I share this world with them it’s as if I’m now communicating in their language and I’m no longer the white coat. I’m the guy with the cool video game in his office. But at the same time I’m using that tool to teach them what their problem is and it gives them back some control. It empowers them, it brings them back in to the dialogue about this is our problem we’re going to fix this. And they understand this problem. And this is something that we’ve never ever been able to do so easily without words, with pictures. And I think we’re not just seeing a new way to image things we’re seeing a new way to communicate.
Tell me a little bit about that meeting with Mathis and his family.
Dr. Auguste: Mathis had a very, very long hospital course and hospitalization. I’ll never forget the day I got to talk to him for the first time myself. It wasn’t in clinic it was in the ICU. He was in his ICU bed and the nature of his problem was such that he had a tumor that caused a bleed and the bleed caused enough swelling in his brain that he needed several surgeries to relieve the pressure, relieve some of the bleeding and it occurred in just the right location to interfere with his ability to move the right side of his body and to speak. He was lying in his ICU bed paralyzed on one side and literally unable to say a word. Fully awake and aware what was going on but unable to communicate. And I can only imagine how much torture it was for him. And I’ll never forget just looking at his images and studying them with his mom I told her, I feel as though he’s going to recover, I think we’re going to get him to a point where he’s going to speak and move again. I can’t be entirely sure but I feel really confident about that. I sat by his bedside and I said, listen this is the first of many conversations we’re going to have and I know you understand, I’m going to do all the talking this time but I promise you you’re going to be talking to me later on and we’re going to have a much better conversation later. Fast forward many weeks, many months, long hospitalization, more surgeries, more rehab and he thrived and he quickly, quickly regained his ability to move his right side, he started speaking again. And then I brought him back to clinic after he had healed and he had some some rehab and we were able to look at his pictures together virtually. And I was able to fly through his brain with him and it was the first time that he was able to fully appreciate the complexity of his problem and why it had such an impact on him and why it affected him so seriously. I think it was very valuable. I think it was valuable for him and his family to see all that. And then to engage the next steps because we had more surgeries to do, we still had a tumor to remove but I shared with him the plan and he was very clear and at that moment he was part of the team. I mean it was very much let’s go get this thing. And it’s great when you have everyone on board, it’s scary enough to have to have brain surgery but to know we’re all on the same page and we’re in this together it makes a huge difference.
I understand that you use it for the family and you use it for the mapping but tell me how you use it in the OR.
Dr. Auguste: Yeah. The last phase or last category of how VR is helpful is that it’s linkable. We can link it to things that we use in the operating room already to help us navigate for surgery. There are stereotactic systems that we use in brain surgery now which is standard of care where we have basically wands that we move in space. And these wands show us where we are with respect to vital structures during surgery. They relate though back to MRI’s which are 2D images on a screen. What this does is it communicates with that system. And while we can still look at these images in two dimensions with this wand that wand also appears on our virtual models as well. And so well ahead of time we rehearse the surgery we’ve identified points and trajectories and corridors, we can line up all those predetermined corridors, that perfect rehearsal we can recapitulate that in the operating room by linking the technology we already have. In the operating room we have yet another opportunity to do a virtual fly through right there on the screen to once more rehearse if it’s been a little while since the last rehearsal. We have the ability during surgery to link up our navigation systems to the pre-existing virtual plan. And then we also have different kinds of headsets where while we are actually physically operating in sterile we have the ability without contaminating ourselves or using hand controllers we can actually use our own hands to manipulate the images by virtually wearing certain headsets. Its one more layer of rehearsal and conformation to study anatomy. Sometimes we are well prepared ahead of time but things can change a little bit and be a little bit disorienting under the microscope when you have active bleeding or structures that look a little bit different than they look on scans. It’s one more opportunity to confirm that you know where you are and not allow yourself to get disoriented.
How much has this VR advanced your surgery? You said it’s giving you a 3-D image when before you had a 2-D, was there guess work involved in how deep something was?
Dr. Auguste: I would say that the quality of our understanding, the richness of our understanding of the anatomy is advancing with this technology. Because again, there are simply just structures that are simply not easily visible in 2-D. That despite your best attempts to scroll through these images through these sliced images, it simply doesn’t reconstruct these complex relationships in three dimensions very well. I think it’s facilitated that. I think we’re spending much less time having to sit in front of a screen flipping back and forth among different planes. It’s not gray scale, it’s not black and white it’s a vivid colorful picture that we can see and it really teases apart neighboring structures in ways we never have been able to before. I think the fact that we are able to virtually rehearse our corridors and it’s actually striking how closely the virtual rehearsals mimic the actually intraoperative scenes in terms of dimension and angles and lighting. These are really valuable steps for the more difficult surgeries or even for surgeons who have not done certain kinds of surgeries before this is something can really prepare them ahead of time. So I think it would make it safer and then of course there’s the family component which can never be underestimated. I think that our ability to communicate problems to the ones that matter the family members and parents, the kids themselves, that’s incredibly valuable for any physician not just a surgeon but all doctors.
Tell me about Mathis’s surgery and how it went.
Dr. Auguste: So the problem with Mathis’s tumor is we didn’t know it was a tumor in the beginning. He initially presented with a hemorrhage, with a bleed. And there are many different causes of bleeds and hemorrhages in kids, more often than not they actually tend to be abnormal blood vessels or even a bleeding disorder. It’s less likely to be a tumor in an otherwise healthy kid. And this is an athlete, this patient is someone who is living a full athletic life, cross country runner out on the trail. He bled and the first goal of the surgery was to relieve pressure in his brain from the bleeding. He was in a very, very tough situation in that his mental state and his level of consciousness quickly, quickly declined because the pressure was building inside of his skull. And so the first procedure was a life saving procedure just to minimize that pressure, give him space to swell and if possible, if he and his brain would allow me begin to alleviate some of that blood clot and see if I could find a source for the bleeding. My suspicion actually having studied some of the CT scans is that there may have been an abnormal structure or maybe even a tumor hiding. But the resolution of the CAT scan didn’t really give us that much detail. So the surgery went otherwise very smoothly. In fact when I did relieve the pressure by removing some bone his brain was very relaxed. He and his brain actually gave me an opportunity to take a look in some of the areas that I was concerned about. And low and behold when I did look in one corner of our opening I did see a tumor. And it was an angry tumor, the kind of tumor that you just touch and it bleeds avidly. And I can understand you know partly why he bled so much is that this was not a friendly tumor. The problem is that it was sitting right on top of and possibly inside of a very, very large venous structure called asgalus sinus. And I ran the risk of uncapping that sinus by removing too much of the tumor. So on purpose I had to chase it back and purposely behind some tumor to cap it and leave that seal because I still had not yet had an MRI in this patient. So it wouldn’t have been safe for me to try to do that. So on purpose I left a cap. Where this was, was tucked underneath the edge of the bone, my visibility was limited and it was very difficult for me to reach and see. I got to a point where I felt it was still safe but I was still able to actually get a significant amount of tumor out and decided that the safer thing was to get an MRI and restudy him. The MRI showed the problem, that this tumor was blocking a very important venous structure that caused the bleeding and eventually we were able to model it virtually and design a surgery where we could uncap it, that little edge of bone and remove the tumor from the topside of the covering of the brain. And it went very smoothly and the tumor came out with very little bleeding. And he underwent radiation therapy to follow that and now he’s back on the trail. His speech is normal, his strength is full and he’s this close to matching his best time on the trail. And that’s music to my ears. That’s the goal that we’ve been striving for all along. And that’s actually what I have been hoping and praying for when I was chatting with him that first day at his ICU bed when he couldn’t speak with me.
His future is wide open?
Dr. Auguste: I think yeah, the world is wide open for him I think his future is bright. He obviously still needs lots of care and attention. We have to continue to study his brain, continue to study that location where we were operating so far so good. He’s healthy, he’s an athlete he takes care of himself, he’s a great patient. I think if you have that recipe that spells success and we’ll continue to do our part to help him in any way we need to with his healing and his brain.
Tell me how big of a game changer do you think this technology is?
Dr. Auguste: If you look at how neurosurgeons are trained and how we prepare and get through our jobs it is locked traditionally in a two dimension world. And to think that we can do such a good job three dimensionally with just two dimensional preparation … if you zoom out and think about that for just a second it’s shocking. But I do think that leaves open the possibility for human error and mistakes. And under appreciation of anatomy and really not fully understanding relationships because even though we get really good at that task of creating a virtual world in our minds eye we have the technology now to not leave it to human error to make mistakes. I think we are seeing something that’s allowing us to unlock this transition from 2-D to 3-D, to be on a flat screen to an immersive three hundred and sixty degree environment. It’s a huge, huge leap forward. It’s the ultimate game changer in my opinion about visualizing and preparing and teaching and learning. And again I feel it’s not just about pretty pictures I think it’s a whole new form of communication and connecting with each other.
END OF INTERVIEW
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