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Dr. Rania Habib (Host): This is Transformational Pediatrics with Children's Mercy, Kansas City. I'm your host, Dr. Rania Habib. Joining me today is Dr. Mark Ryan, a highly accomplished pediatric surgeon and Assistant Professor at Children's Mercy Medical Center in Kansas City. I invite you to listen as we discuss the use of virtual reality and 3D imaging in pediatric surgery, and discuss the impact it has on surgical planning, outcomes, and the future of pediatric surgery.

Welcome to the podcast, Dr. Ryan. We're excited to explore this state-of-the-art topic.

Dr. Mark Ryan: You bet. Thanks for having me.

Host: Let's begin with virtual reality. Dr. Ryan, how are you currently using VR technology and preoperative planning for pediatric surgery?

Dr. Mark Ryan: So, there's a company at Switzerland called Medicalholodeck. And so, similar to kind of how we do 3D reconstruction for CT scans and sometimes MRIs and stuff. What they do is, it's the same thing, but they'll take all the same pixels and things like that, that you use in your traditional imaging, and it will allow you to view that in VR and 3D.

And so, especially for a lot of the kids with congenital problems, like everything's very small and sort of packed together. And so, being able to look at stuff in 3D just kind of gives you a little bit more information as to where the problem is or where your target is for a surgery. And so, it just helps with preparation.

Host: That's excellent. So essentially, you're putting on the VR glasses and you're able to view that surgery before you even start.

Dr. Mark Ryan: Well, the surgery part, so it's the same as sort of looking at the scan. So, I can see the anatomy, but you can't manipulate it or move it around or cut it or anything like that. It just gives you a very detailed roadmap of where you're going to be going during the surgery.

Host: Okay. What are the main benefits of using VR compared to that traditional surgical planning when we use CT imaging or 3D imaging?

Dr. Mark Ryan: The big drawback to your conventional imaging is just-- and everybody trains on it, and that's part of medical school and all those things-- is that you got to look at these flat static slices and sort of piece it together in your mind to try and figure out where the structures are that are nearby and what your target is and where you're going. And you can make a 3D reconstruction to look at, but you're still looking at it on a two-dimensional screen. And so, that's why things like VR and 3D don't really translate to regular televisions.

Host: Okay. Now, how has the integration of VR into surgical planning impacted specifically patient outcomes and your surgical precision?

Dr. Mark Ryan: At the point where you're actually doing the surgery, it can guide you on a better path. It can sort of give you a better idea of where you're going. But for me, at least having these reconstructions in the OR. Occasionally, I'll bring them in to use as a reference. But at this point, the technology isn't where I would wear one in the operating room, like during a surgery just because, as it is right now, you're currently wearing, whether you're wearing the Apple goggles or the Meta Quest goggles, that you're not really seeing the world, you're seeing a video feed of the world through a camera that's in front of the device. So, it's never quite as good as looking directly at the thing.

And so, for things like orthopedics and things like neurosurgery or where you have a solid structure that's not going to move around, so if you're doing a spine, where you image the spine is probably where it's going to be while you're operating. Whereas for things like a liver tumor or for these solid organs, we're going to move them around during the surgery. And so eventually, it won't match the pictures that we make. And so, it can basically tell you where to go, but it can't necessarily tell you what to do once you get there.

Host: Dr. Ryan, how has the integration of VR helped with your position as an Assistant Professor in the Department of Pediatric Surgery?

Dr. Mark Ryan: I'm new to this institution. The way I used it personally for surgery planning, what I used it chiefly for was education for the residents and for the fellows, because that particular software lets me pull in like a 3D model of the anatomy in question. So, I can pull in a liver and all the bile ducts, or they have 3D scanned cadaver models, so if you want to see the cadaver version of that stuff. And then, finally, I can pull in the actual scan of the patient so I can kind of run through all three things and help them get an idea of the relevant anatomy of the surgery and also sort of what the plan is for this particular kid.

Host: Dr. Ryan, could you share a specific case where VR significantly improved the preoperative planning process and the overall surgical outcome?

Dr. Mark Ryan: I can think of a couple cases where it was really beneficial. One of them is for things like chest wall reconstruction. So, I had a patient with a sternal tumor that was sort of shaped like a dumbbell. So, there was a waist in the middle and then there was a round part going towards the heart and a round part extending outward. So, she couldn't wear a bra because there was this hard mass getting in the way. And so, what I needed to figure out to the best of my ability was figure out is this thing stuck to the heart or not?

And so, when you look at a traditional image, you're confined to sort of three planes. So, you can look at it in the coronal, the sagittal or the axial planes. And so, when you're looking at it in VR, there's no plane. You can slice it however you choose. And so, I can do 45 degrees to the left, or I can isolate the anatomy that I care about. And then, just closely examine that part of the image to try and figure out is there a plane in between this tumor and the heart? I didn't use it during, but in sort of planning and deciding sort of what preparations I needed to make and stuff like that.

Host: Do you feel that, in that specific case, it helped you cut down on your operative time because you had already visualized your planes?

Dr. Mark Ryan: It is hard to speculate, because it wasn't necessarily a short surgery. But if there's going to be time that's wasted trying to either locate a mass or trying to sort of pinpoint the anatomy that you're shooting for, it sort of would reduce that amount of time. But especially if a case is complex enough that I'm breaking out the VR goggles, then odds are there's just not that many of them to draw a comparison to. And so, it is tricky to try and figure that part out.

Host: No, that totally makes sense. It's hard to extrapolate exactly the amount of time it would save versus just doing it, without the VR. Dr. Ryan, how does 3D imaging technology enhance the creation of surgical blueprints for these complex pediatric surgeries?

Dr. Mark Ryan: There's been some studies on sort of the mental work involved in learning how to comprehend these images and whenever you're reviewing a scan, you're kind of reconstructing it in your mind to try and figure out where this structure is going to be in space. And so, that part is kind of handled for you. And so then, you can concentrate on which structures are nearby and which the trajectory and things like that, that you can't necessarily, I mean, you can do it, but it's not immediately apparent when you're looking at conventional imaging, so CT or MRI.

Host: And what challenges have you encountered when you're implementing this 3D imaging and surgical planning, and how have you addressed them?

Dr. Mark Ryan: So, the first part was trying to figure out how do I do it? And the whole reason I got started doing this was my pectus patients. And so for people that don't know, you know, they come in with a caved-in chest, an abnormal thoracic anatomy. And it's a long treatment course. Like, they have to get a CT scan, they have to get some cardiac testing, they have to do a bunch of stuff to get there. And then, the surgery itself is a few hours. And this place, Children's Mercy, actually has one of the quicker discharge protocols I've seen, because they have a lot of resources for prehab. So basically, education and training before surgery.

And so, they go home on the same day, which is crazy. But there's a lot of follow-up involved. So, you see these kids for like three years. And when they get their bars out, it's a big deal. And so, I kind of wanted something to help them celebrate, when they get their bars out. I was like, can I do something with the bars? Because at the time I was in Texas, so I wanted to make a belt buckle. But it turned out that to melt stainless steel and titanium, it has to get to around 2,700 degrees-- I want to say Celsius, but maybe not Celsius. But anyway, it had to get really, really hot and to do that-- because I thought I just melt it in my garage or whatever. But it turns out you need like some industrial level arc furnace or something that's subject to OSHA regulations. And basically, I was going to blow up my house. And so, my wife said no. And so, I didn't get that.

So then, I just kept asking ChatGPT, like, I just wanted to turn this scan into a 3D model and sort of gradually I got there and I found a free program called Slicer 3D that was made in the Beth Israel Deaconess at Harvard like 15 years ago. And people have just been adding onto it for 15 years. And so, at this point now, I can model things in a few minutes. And so, I print them out a little scan of their chest and give it to them as like a little present when they get their bars out.

Host: Oh, that is so great. They really get to see how far they've come then, which is fantastic.

Dr. Mark Ryan: Yeah, I mean, my orthodontist did it for me when I got my braces. When I was done, he gave me a little plaster mold of my messed up teeth, and I thought that was cool. So, I wanted to give them a version of that for their chest.

Host: That is such a great idea. They can really then visually see that before and after and see how big of a difference you've made in their lives. That's fantastic.

Dr. Mark Ryan: Functionally, in terms of being a grownup, I'm hovering around, most of my patients are like teenage guys. And so, we kind of like eat the same food and watch most of the same TV shows. So like, I get them and they get me. So, they're usually pretty into it.

Host: That's amazing. Now, Dr. Ryan, in what ways do you foresee 3D imaging and VR evolving over the next, let's say, five years to further improve surgical planning and also the execution?

Dr. Mark Ryan: There's sort of this vision people have of wearing these goggles in the OR. But I think the issue is sort of similar to the thing I mentioned before is that, as long as you have a barrier between you and the patient, so in this case, it's the goggles that you're relying on a camera feed, and the cameras will get better.

But I think more likely what's going to happen is that they're going to come up with what's called an augmented reality display. So, you're seeing the world as you normally would through a pair of glasses or a visor or whatever, and then something is drawn on top of what you're looking at. And so, I know that there was a doctor named Caroline Park who was at Parkland Hospital in Texas, and she could tell us straight on top of what the residents were seeing while they were doing chest tubes and stuff. So, you can do some basic imaging, but the quality isn't quite there yet where I would necessarily want to see those pictures during a surgery. And so, I think as that comes along, I think that'll be helpful.

But also, the cameras are getting a lot better. And so for laparoscopy and even for some open surgeries, we have fluorescent imaging. So, we can give a medication that will emit fluorescent light. And so, we can image bile ducts and we can image tissue perfusion and stuff like that. And they're coming up with some newer cameras that can use near infrared light to look at vascular perfusion and see blood vessels without having to give a ton of contrast or basically just look through the camera and you can see it. And so, the reality is that a lot of this stuff, the cameras are going to get better. And I think for the reconstruction stuff, the augmented reality stuff will get better. But for planning, VR is currently pretty much as good as it gets. But I'm always looking into how can I use this stuff in the operating room.

And it turns out there's actually some screens that you can get some monitors that will allow you to see 3D images without wearing glasses. And so, I have a pair of those in my office, because it's one of those things where you can't watch a video about it, the video's on a 2D screen, so you can't tell if it's any good or not. And so, I've made some unwise purchases on Kickstarter and elsewhere. And so, I have a holographic monitor, which shows the same picture from 50 angles. So, no matter where you are, your eyes are going to see two different images, which your brain will interpret as 3D.

And then, another monitor with eye-tracking cameras, which actually they're selling now. So, Samsung makes one and a company called Acer makes one, but it will send a different picture to each one of your eyeballs and it will redraw the object based on where your head is in space. And so, it looks like the thing is floating in front of the screen. It's pretty neat.

Host: That's incredible. That will definitely help, like you said, with anatomy and as you were mentioning with tissue perfusion. And we can only deduce from that that it's really going to help with patient outcomes because now you know, if the organ's perfused, if hopefully maybe one day it'll show you all exactly where the vessels are that are feeding a tumor that you can tie off. So, that's really incredible technology.

Dr. Mark Ryan: The crazy thing is now initially there were some very fancy proprietary devices that would do all these things and, now, a lot of it I can do with my laptop. So, I've gone and given talks to surgeons basically about-- I kind of treat it like Ratatouille, like anybody can cook. And so, somebody else can do it, they can make this stuff pretty rapidly without too much work.

Host: Well, Dr. Ryan, you have shared so much information about VR and 3D imaging, and we're really excited about this technology. What is your final take-home message for our audience today?

Dr. Mark Ryan: So, it's a tool. It's like a pair of pickups or scissors or whatever. It is not necessarily going to do the surgery, it's not going to do anything besides help us to make up a better plan and to see what we're doing before we do it. Eventually, hopefully, it gets to the point where we can do a little practice beforehand. But as of right now, it's just gives you the best roadmap possible to go in and take care of a kid.

Host: Oh, that is excellent. And hopefully, you know, we'll see those dramatic improvements and outcomes because you're actually getting to view that in such detailed imaging ahead of time.

Dr. Mark Ryan: I mean, I hope so. It's a hard thing to measure. But for the most part, when I've used it, I felt pretty comfortable going in that I knew what my objectives were worthy.

Host: That's excellent. Well, Dr. Ryan, thank you so much for taking time out of your busy day to join us today.

Dr. Mark Ryan: Oh no. Thanks for having me. I appreciate it.

Host: Once again, that was Dr. Mark Ryan, Assistant Professor in Pediatric Surgery at Children's Mercy, Kansas City. To refer your patient or for more information, please visit childrensmercy.org/surgery. This will help you connect with one of our providers. I'm your host, Dr. Rania Habib, wishing you well. This has been Transformational Pediatrics with Children's Mercy, Kansas City. Please remember to subscribe, rate, and review this podcast and all other Children's Mercy podcasts.