Futuristic technology maps the brain and transforms the operating room

September 28, 2020
the camera is peering between screens to get a view of Dr. Eskandari operating
Dr. Ramin Eskandari performs surgery using the Modus V. With this device, he can look up at a screen instead of down into microscope eyepieces. Photos by Brennan Wesley

An industry partnership means doctors and researchers at the Medical University of South Carolina will not only have access to groundbreaking technologies to improve patient care but will have a hand in developing uses for these new tools that could ultimately aid patients across the continent.

MUSC and Synaptive, a medical device and technology company based in Toronto, Canada, signed a five-year affiliation agreement earlier this year as the culmination of several years of discussion. The agreement brings two Modus V 3D robotic digital microscopes to MUSC Health, making the new MUSC Shawn Jenkins Children’s Hospital the first pediatric hospital in North America to own and operate with the 3D scope system. The full Synaptive system, which has been in place at the children’s hospital since its opening in February, is now also installed in an adult operating room at MUSC Health University Hospital, and plans are underway to also bring Synaptive’s imaging technology to the Charleston hospital.

But calling the Modus V simply a “new microscope” would be like calling smartphones just newer versions of landlines, said Sunil Patel, M.D., chairman of the Department of Neurosurgery. When they debuted, smartphones were seen primarily as a means for people to communicate via calls, email or text. Today, with the explosion of third-party apps and faster internet connections, people can use their phones to shop, play games, watch TV, get real-time driving directions, visit the doctor and even do their schoolwork.

Patel said the Synaptive technologies will enable the same sort of explosion of uses in surgery – and MUSC will be working with Synaptive to develop those uses.

“This is an instrument that’s going to have a lot of other applications, and it’s going to need modifications,” he said.

Pediatric neurosurgeon Ramin Eskandari, M.D., first saw Synaptive’s technology during a conference five years ago and was immediately drawn to the possibilities. He alerted MUSC Health leaders, and a subsequent group visit to Synaptive headquarters to look at the technology in development blew everyone away, he said. 

"We just see such an alignment in vision of how imaging and automation and robotics can be integrated to offer not just better care for the patients, but better care across the health care system.”

Cameron Piron
president, Synaptive Medical

Now, MUSC Children’s Health is the first children’s hospital to begin using Synaptive’s integrated suite of technologies that includes the Modus V 3D robotic digital microscope in conjunction with its planning software and navigation system, according to Synaptive president and co-founder Cameron Piron.

Piron said his team was inspired by conversations with surgeons as well as watching surgeons in action. Having already begun work on rethinking the MRI, they saw the physical limitations of traditional viewing devices like microscopes, loupes and endoscopes, not to mention the visual limitations, and realized the two types of technologies weren’t working together as well as they could.

“What we recognized is those two worlds were not fused together. There's this really awkward handoff happening in the operating room, where you’re diagnosing with MRI and then handing over to optics, and there was no way to bring those two worlds together. That became a really obvious challenge,” he said.

Neurosurgeons already plan out their surgeries using tractography, a modeling technique that shows the nerve tracks in the brain by using MRI images, Patel said. But during the actual surgery, he said, “When you look at the tissue of the brain, it doesn’t have labels on it.” That, he added, changes with the Modus V.

“Now when you’re looking at the screen, you see the brain live, but superimposed on it is all these labeled highways of nerve fibers. It also superimposes on the image you’re seeing where the tumor is or where the lesion is. Now when you’re operating, you’re actually able to see on the screen exactly where those functional tracks are in relation to the surgical path or lesion,” Patel said. “This will improve surgical outcomes by avoiding neurological deficits and allowing the surgeons to remove the lesion completely and safely.”

The Modus V also tackles some basic logistical challenges of the operating room. Instead of the surgeon having to move it by hand to get the right view, the Modus V responds to voice commands and tracks the location of the surgeon’s hands via navigated surgical instruments.

But the most elemental difference is the view it provides.

“You can see everything from the skin layer all the way down to the depth of the brain tumor – all in focus, all at the same time – and that’s never been done before,” said Eskandari, who has used the system in about 30 surgeries and is co-authoring a white paper about the experience with surgeons from Stanford Children’s Health who have been using the 2D Modus V system.

Dr. Eskandari looks at a screen that shows an enlarged 3D image of the area where he is operating 
Dr. Eskandari uses the 3D view on the screen during surgery.

Eskandari explained that with traditional microscopes, the surgeon is looking through a viewfinder quite similar to the microscope that most people are familiar with from high school biology. There are several drawbacks to this during surgery, though. First is that it reduces the surgeon’s field of view to only what is directly in front of the microscope. The surgeon doesn’t see the larger surgical site or even what is going on in the operating room.

Secondly, the microscope looks only where the surgeon’s head is facing. Eskandari used as an analogy the example of someone sitting in front of a computer looking down at the keyboard. Put a microscope up to your eyes, and what do you see? Still the keyboard, except in greater detail.

But what if you wanted to see the back of the computer monitor? You’d have to place the microscope behind the computer, where it wouldn’t do you a bit of good unless you also got up and moved behind the computer.

With the Modus V, however, Eskandari can maneuver it to look at the surgical site from any vantage point while he remains in his original position. The Modus V’s 3D heads-up display is shown on a large 4K screen visible to everyone in the room.

“That took some getting used to. But once you get it, now you’re using the camera in ways that you physically would never have been able to before, even with a microscope,” he said.

Furthermore, not having to crane their necks over microscope eyepieces for hours makes surgeries physically more sustainable for surgeons, he said, noting that he recently completed an eight-hour tumor surgery.

“Usually by the end of those cases, your neck is just dying, your head hurts, your eyes hurt because you’ve been looking through a microscope for ‘X’ number of hours. You’ve been in all kinds of contorted positions, or you're having to turn the patient into all kinds of contorted positions in the operating room on the table, which is also not good,” he explained.

Put all that together – better visuals with more detail and a larger field of view that is visible to everyone working on the surgery, along with improved ergonomics – and the result is better outcomes for patients, Eskandari said.

It’s simple – the better view that surgeons have, the better they can do their job. Patients see the results with increased options for surgical intervention, shorter surgeries and quicker recoveries. Just this month, Eskandari said, he was able to remove a tumor deep in a child’s brain by performing surgery through a half-inch tube utilizing only a small incision in the child’s eyebrow. The youngster was able to go home three days later.

Although the technology was developed with neurosurgery in mind, Patel believes other specialties will want to use it as well. This takes medicine one step closer to true robotic surgery, he said.

The realization of what the technology can do has sparked a long list of ideas of things to try. Kevin Gray, M.D., assistant provost for research advancement, is one of the people on a joint oversight committee who is charged with ensuring that this creative innovation remains at the forefront of the partnership. 

“We can answer questions that Synaptive has, but we can generate questions they may not have thought of – clinical scenarios they didn’t realize are really important to us.”

Kevin Gray, M.D.
assistant provost for research advancement

In years past, Gray said, a relationship with a medical device company would be more transactional: Either the hospital wanted to buy equipment, or the company wanted to test its equipment in a hospital setting – and any hospital would do. The partnerships that MUSC has entered into in recent years have instead emphasized working together to develop new techniques and devices that ultimately can improve patient care, he said.

“The purpose of this innovative approach to partnerships and the role of the joint oversight committee is to ensure we don’t slip back to a transactional relationship. We have to keep challenging the status quo to make sure we’re innovating in a complex health care system,” Gray said. That includes ensuring that the partnerships focus not just on clinical care but also on research and education, he said.

“We can answer questions that Synaptive has, but we can generate questions they may not have thought of – clinical scenarios they didn’t realize are really important to us,” Gray said.

Jesse Goodwin, Ph.D., chief innovation officer for MUSC, is part of the joint innovation subcommittee with Synaptive that ensures research proposals are aligned with MUSC and Synaptive’s mutual goals. In addition to expanded uses for the technology, Goodwin expects that surgeons and Synaptive will work with the Zucker Institute for Applied Neurosciences at MUSC to develop new medical devices that will work with the technology.

It’s been great working on a partnership where there are so many ideas bubbling up from the operating rooms, Goodwin said. Surgeons aren’t the only ones who are excited, though. There’s also a great deal of excitement about the possibilities offered by an MRI developed by Synaptive that allows imaging directly at the point of care in critical care settings. Synaptive and MUSC are working to add the MRI, which received U.S. Food and Drug Administration clearance in April, into the research and clinical innovation mix.

MRI stands for magnetic resonance imaging, and for years, bigger has meant better. Bigger magnets yielded better images. The typical MRI machine weighs somewhere around 10,000 pounds and requires a 1,000-square-foot room, Piron said. That means it can’t be placed just anywhere in the hospital. The floor has to be reinforced to handle the weight. Plus, the room has to be shielded.

“You can’t have this powerful magnet sitting on the third floor – everybody's wallet or necklace is going to be stuck to the floor or wall. So every time you put in an MRI, you’ve got to build a room with shields so that the magnetic field doesn’t get out,” Patel said.

Nor is the MRI particularly patient-friendly, Piron said. It’s loud, it’s claustrophobic and it can be problematic to use when patients have implants. Most low-field alternatives are more patient friendly, but the trade-off is less clear images.

Piron’s team decided that rather than making the magnet even bigger and stronger, they would instead make the magnet smaller and weaker and concentrate instead on improving the receptor to amplify the signal and produce quality images, specifically of the head area. They chose to aim between the high-field and low-field MRIs currently on the market, reducing the magnetic field enough that it doesn’t require shielding or complicated maintenance.

“We get imaging that is astounding and consistent in a smaller platform and better price point,” Piron explained. “We're really excited about that, because no one has really pursued this area.”

The smaller magnet means a smaller machine, which has a number of practical applications. Because it weighs only about 2,000 pounds and can be placed in a 250-square-foot room, hospitals have more flexibility about where to locate the MRI and can situate it closer to emergency departments or ICUs, Piron said.

Aside from offering more options in clinical care, the weaker magnet also enables more opportunities for research. Gray, a psychiatrist who is part of a national study that scans adolescents’ brains to understand normal development, said he can envision multiple uses for such an MRI in both clinical and research settings. This offers a lot of hope.

“One of the ideas is imaging brain development of premature infants and getting a better understanding. There’s not a lot of data now because it wouldn’t be safe to take them to an MRI suite,” he said.

Goodwin noted that, if MUSC and Synaptive move forward with adding the MRI here, it would be a good fit for stroke research happening at MUSC. As far as the Modus V, there’s no shortage of ideas coming from the surgical team for both research and medical devices, she said.

Piron said Synaptive is just as enthusiastic about the partnership as MUSC.

“It's a very important partnership for us because it’s the first partnership that will be working across all our products,” he said. “We just see such an alignment in vision of how imaging and automation and robotics can be integrated to offer not just better care for the patients, but better care across the health care system.”

About the Author

Leslie Cantu

Keywords: Features, Research, Pediatrics