Dr. Robert Louis, a neurosurgeon at Hoag Memorial Hospital Presbyterian
in Orange County, CA, is pitched some type of new technology, gadget or
medication every day. He’s shown things so often that he developed
an internal filter that automatically sets expectations a lot lower than
the enthusiasm of the rep. But that all changed in October 2015.
That’s when Surgical Theater reps dropped by to showcase the Surgical
Navigation Advanced Platform, or SNAP. Designed by former Israeli fighter
pilots, the technology uses virtual reality to allow neurosurgeons to
“fly” through a patient’s brain to get a better look
at tumors, nerves, blood vessels and tissue prior to surgery. Before surgery,
the patient’s brain is captured and recreated as a 3D model for
Dr. Louis or his colleague Dr. Christopher Duma, neurosurgeon and director
of Hoag’s Brain Tumor Program, to navigate.
Hoag is currently using an Oculus DK2, but the FDA recently cleared the
consumer Oculus Rift for use and that will be deployed moving forward
in all medical facilities, according to Jim Breidenstein, president and
COO at Surgical Theater’s SNAP division.
Louis said prior to the introduction of this technology, he’d have
to reference black-and-white 2D “slices” of the brain and
then use his imagination (and 20 years of surgical experience) to map
out the surgical procedure in his head before entering the Operating Room.
Since SNAP is registered with both Stealth, a technology Hoag uses, and
Brainlab, that 3D model of the patient’s brain is used to track
the tips of the instruments as the neurosurgeon navigates the brain. It
works like a GPS inside the head, allowing doctors to track their instrument
“Instead of looking at a 2D model, I can now see the tips of the
instruments on the 3D Surgical Theater System on screen and compare that
to what I’m seeing through the lens of the microscope,” said
Louis, who is also director of Hoag’s Skull Base and Pituitary Tumor Program.
Hoag, one of 10 hospitals using this technology, has already used SNAP
on 100 patients.
“We’ve seen an increase in the rate of complete tumor removal
and a decrease in the rate of neurological complications,” Louis said.
Louis said this new technology helped him save Marcus Barnes, 41, who had
a brain tumor. Louis focuses on non-evasive surgeries whenever possible,
preferring to take tumors out through the nose, ear or eyebrow whenever
possible. His original plan was to make a small incision by the eyebrow
for Barnes, but when he put on the Oculus headset and explored the virtual
reality model of his brain, he found that the patient’s optic nerve
would block him from extricating the entire tumor that route.
“We changed the approach and we did a small incision behind the hairline
instead,” Louis said. “We made this change before even touching
the patient and we were able to get the entire tumor out successfully.”
SNAP also played another role in this particular operation. The technology
has been designed so anyone, including patients, can get a look inside
their head. Louis wheeled the headset into Barnes’ room while he
was being prepped for surgery so he could show him why he was changing
the operation the morning of, which Louis admits is something that would
normally make a patient nervous. But this technology allowed the patient
to see exactly what the doctor sees – and will see during surgery.
“Everybody loves seeing their brain in 3D and in color,” Louis
said. “They feel much more engaged in their own process with VR.
It goes from ‘I trust you’ to ‘I understand what’s
going on with my body.’ Research shows patients who are more engaged
and have a better understanding of their pathology will have a better
In September, Louis will begin testing a brand new augmented reality technology
from Surgical Theater. The new technology will be used inside the OR,
and use the 3D model of the patient’s head to project a real-time
20-30% shadowed view of exactly where the tumor is via AR while the neurosurgeon
is performing the operation through the lens of a microscope or viewing
the screen of the endoscope.
“The tumor is visible partially in my field-of-view so I know exactly
what direction I’m going,” Louis said. “I don’t
think AR will replace the pre-op rehearsal in VR, but it adds to the tools
we use during surgery and it’s another big advance to be more precise.”
Louis said the less disruption of normal tissue and critical anatomy in
getting to the tumor, the fewer neurological complications and less blood
loss there is for the patient.
There are 10 hospitals using this VR technology today, including University
Hospitals Case Medical Center, University Hospitals Rainbow Babies and
Children’s Hospital, The Ronald Reagan UCLA Medical Center, The
Mount Sinai Hospital, Mayo Clinic and NYU Langone Medical Center. Some
of these hospitals are using SNAP in an additional way.
VR can also be used to train residents, Breidenstein said.
“Students can see in 20 minutes what has taken neurosurgeons like
Dr. Louis 20 years to perfect in his own mind,” Breidenstein said.
“It can dramatically shorten the learning curve of tomorrow’s
At UCLA, Dr. Neil Martin uses Surgical Theater to travel pre-operatively
through a patent’s head.
There are multi-user options, so the doctor and the student each can have
an individual avatar and they can look at the anatomy of the brain from
a teaching perspective. This option is also available online, so that
the doctor and student don’t have to be in the same state or country.
Breidenstein said over 2,000 patients have been treated using Surgical
Theater technology to date.
“By design, we’ve had a limited launch and strategic plan with
10 centers for the current physical year,” Breidenstein said. “In
2017, we’ll take our technology and expand and scale it based on
the learning and volumes of clinical data we’re collecting. Our
goal it to get SNAP into all key centers in the surgical world.”
Alon Geri, co-founder and executive vice president of engineering at Surgical
Theater, said SNAP has been designed to evolve with technology. The Windows-based
technology already works on both Oculus Rift and HTC Vive, as well as
several enterprise AR devices. Geri said any headset that will be available
in the market will be supported in the future, when it makes sense.
Geri, who used to fly Blackhawks in the Israeli Air Force, ended up designing
this virtual reality technology on a challenge. He had spent several years
developing a virtual reality flight simulator for pilots when a neurosurgeon
asked him if he could do the same thing for doctors. He accepted the challenge.
“Once surgeons started to experience it, it blew their minds,”
Geri said. “It allows them to prepare for complicated surgery cases
and gets them into the zone to go under the microscope.”
Louis said using SNAP “is a no-brainer.”