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I'm joined today by Dr. Oren Tepper . Dr. Tepper is on the faculty at Albert Einstein College of Medicine
and is the director of the craniofacial program at the Montefiore Medical Center.
Dr. Tepper, thanks so much for joining us today.
Thanks for having me.
Excited to be here.
Now, your initial research career was in basic science, but it seems like you've moved
a lot more towards the technological aspects that we can bring into the operating room.
I think this was nowhere more present than in your work on the separation of the conjoined
twins, Anias and Jadon McDonald, in October of 2016.
Can you tell us about that case and how technology played a role in reconstructing the skulls
of these twins who were conjoined?
Yeah, sure.
For me, it was interesting because I have been involved in this technology and 3D research
for quite some time, almost 10 years.
It sort of parallel not only my clinical interest, but the timing of all this as the technology
got better and better.
It just became more applicable for what we're doing on a day-to-day basis.
So, the separation of Anias and Jadon was really kind of the culmination of all that
research and planning that I have been doing really for the last decade that made a case
like this possible.
But for those twins in particular, we really did a number of things that we brought in
a number of different aspects of technology that were critical for this.
The first was the ability to plan out the procedure on the computer first – that's
a concept called VSP, or virtual surgical planning – and we've been doing that do
for some time in reconstructive surgery.
This was rather the first time that something like this has ever been applied for a set
of conjoined twins.
Then the other is 3-D printing.
What 3-D printing allowed us is to really have anatomical models that we could use,
that we could study and we could really plan out the different portions of the procedure.
Then in terms of the virtual plan, it's great to have an ideal situation on the computer,
or plan out the procedure, but the key is making that happening in the operating room.
What 3-D printing allows is to begin to plan out that procedure and then print guides and
different references that you can use in the operating room to actually execute what you
had planned out first on the computer.
That's something I certainly wanted to touch on.
Because when we think 3-D printing, we think printing pieces of a skull or something like
that, printing a structure that you're going to leave inside the patient potentially.
But with these guides, it's something different.
Can you go into a little bit more detail?
These are actually helping you get to the position you need to get to?
Yeah.
And your point about guides or rather printing parts that are missing, that's where this
is all heading.
I have that no doubt in the coming years that essentially being able to bioprint or print
materials that are compatible with the human body is going to be available to us.
But in this case, what was unique, and I think what's more kind of happening today on a
day-to-day basis is not printing parts, but printing guides.
What I mean is this all began with, let's say, the skull… these patients' normal
or their normal anatomy, their baseline anatomy.
Then we were able to print the representations of their brain and the critical vessels, etc.
So, we have a baseline input.
But on the computer, we can then plan out how we're going to separate the boys, what
type of reconstruction we need, and to make that happen in the operating room, now we're
talking about printing guides that can be sterilized and are essentially part of the
operating room table, part of our instruments that we're using in the OR.
That's another thing that we bring into the operating room to begin to tell us where do
we cut, where does the reconstruction begin, what would be an ideal reconstruction, what
would be safe procedures, things like that.
What we found in some research that we're doing in other cases, and I think just anecdotally,
was the situation for these boys, is these things not only help us be more precise, but
I think it really cuts down on operative time because there is less variability.
Sounds like less guesswork.
Absolutely.
When you say you're planning these operations beforehand, walk us through that.
You've got, I presume, a 3-D model of the anatomy of this case of these two children,
and in the computer model you can make incisions, you can tie vessels, how long does that does
that process take?
Yeah.
It can be anywhere from something very simplistic to something very extensive.
In this case, it was pretty complex, but it's an interesting kind of collision of different
specialties.
For a typical virtual planning session, in the case of these boys, what we had was the
neurosurgeon, Dr. James Goodrich.
We had myself.
We had a radiologist, Joaquim Farinhas, who really helped us understand the images and
some of the intricacies of the anatomy, and then we have medical engineers, in this case,
it was using 3-D systems.
But imagine all four of those specialties on a virtual web meeting beginning to say,
"Well, this is what I would like to do surgically."
Then we had the radiologist saying, "Can that be done anatomically?"
Then, we have the engineer saying, "Well, let me print you something that can represent
that or help you achieve that."
I think that's a very interesting aspect of all of this technology because that hasn't
really been done to this level, and I think that's the future of this.
It's not just going to simply be the surgeons.
It's not going to be the radiologists.
It's not going to be the industry.
I think it's this kind of mix, this interdisciplinary approach, to 3-D printing that ultimately
is going to make it really routine.
So, you practiced in silico essentially before you actually gone to the operating room.
Take us into the operating room.
When you were actually operating, did you have a sense of familiarity?
Did you say, "Oh, I know where I am.
I have seen this anatomy a million times on the computer screen," or were you still
having that feeling of exploring a sort of uncharted territory?
With surgery, there is always uncharted territories.
To make you think that we know exactly what we were going to enter, etc. would be untrue.
But certainly, there was familiarity and I'll give you an example.
We had a printer.
I had a print available to me of just the external surface of these boys.
So, I could hours planning out where my incisions were going to be, where my cuts needed to
be made, the type of reconstruction that would be ultimately be required.
Imagine trying to turn these boys in the office.
It was very difficult to actually take them, maneuver them, examine them like we would
any other patient.
So, here we are at a very intricate, exact match of these boys' anatomy, their size,
that I could plan that out.
With the virtual plan, we had actual guides that we would put on the boys to tell us where
to cut and how the reconstruction should go.
So, that's exactly what was happening.
When I first made the incision and we prepared everything, we took these guides and they
fit exactly where we needed them to be.
At that point, Dr. Goodrich and I said, "This is where we're going to enter.
This is where we need to be," and then we had a model beneath that to tell us what would
we be approaching, what would be our next steps.
So, it really helped tremendously throughout the whole case.
Do you think this type of surgery would even be possible without this technology?
You know, it has been done before.
To say that this is the first time that conjoined twins have been separated, there have been
a few dozen cases historically.
This is the first to our knowledge where this technology was made possible, and I have no
doubt it certainly helped the success.
Ultimately, I think there are some really key points where we weren't sure if this could
be done, and I really believe the technology got us to that level saying we think we can
do this safely and successfully.
And I'll let our viewers know that it was a very long operation, but the kids came through
successfully as we're talking about this.
That's correct, right?
Yeah.
Excellent.
You spend a lot of time working with this technology.
If you don't mind, cast us forward 10 years.
What does the operating room of the future look like to you?
Well, I'll tell you.
For me, as a reconstructive surgeon and an aesthetic surgeon, 3-D printing is now starting
to be really routine for a lot of surgeons.
The idea that we can have models versus just traditional images, but real physical models
that we can hold and turn, I don't think we are a far way off from seeing that really
in every operating room, and that's kind of the planning session.
I think the next phase is going to be what I talked about is that interaction between
us, a biomedical engineer, or a radiologist.
At the moment, the way we all know medicine practices, the radiologist reads the films,
the surgeon looks it over, it goes to the operating room.
There is not much back and forth.
But I don't think we are very far from a situation where there's going to be real-time back-and-forth
communication with the surgeon, the radiologist, other specialists where they are a part of
that operating room rather than just preliminarily reading films or giving their assessment.
I think fast-forward 10-15 years, what we're seeing now in physical models is going to
be digital.
What I mean by that is that it's going to be a hologram, and we have some research,
and we've seen some interesting technology that will take, for example, in this case,
rather than have 3-D prints, imagine that was projected in space and you can call upon
that data.
It's infinite the amount of data that you can pull in that regard.
I think probably 15-20 years we're going to see a lot more digital integration in the
sense of virtual files in the operating room.
But for now, I think physical models are going to be where we're at.
Well, this is absolutely a fascinating area and it's very heartening for all of us that
you're obviously putting it to such good use.
Cngratulations on this operation and on the others in the future.
Thank you so much for joining us today.
Thank you.
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