Virtual Surgical Training
This week I am talking to Raimundo Sierra, PhD, CEO & Founder of VirtaMed (@VirtaMed) who are empowering surgeons to reach proficiency by integrating intelligent simulation into medical education. Raimundo original experience focused on electrical engineering and medical image analysis that led him on a path to simulation technology and focusing on surgical simulation
In the early innovations they looked at flight simulators for pilots and how they might create a similar solution for doctors and surgeons. Together with a group of 20 or more PhD researchers they started work on modeling to create realistic versions of tissue, force feedback, and the various aspects of anatomy creating simulators for a range of surgical specialties. Along the way they got pushback from the clinicians who compared the experience of the early Laparoscopic simulators that was “just like playing Pacman but not real”.
Like many other guests a key incremental learning point is the importance of the adjacent possible. Thanks to collaboration, in part driven by a frequent interactions with surgeons with Raimundo’s office “5 minutes walk from the operating rooms” and a close relationship with the users to ensure relevance by focusing on what “surgeons care about”, with a goal of educating future surgeons to build the skills that are psychomotor skills to really perform excellent surgeries.
Along the way he discovered that the their high cost high performance computer from Sun Microsystems was outperformed by a low cost gaming machine he purchased.
Listen in to hear how they have started to apply Artificial Intelligence and Machine Learning that can augment the surgeons skills, automating some basic activities like moving cameras to optimal positions, much like the sports cameras are done as live play unfolds, at different times during complex surgical procedures. And the future is bright with the potential for creating a Digital Twin patient and the exciting potential that offers to create personalized surgery.
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Raw Transcript
Nick van Terheyden
Today I’m delighted to be joined by Ray Mundos. Sierra. He is the CEO and founder of verta. Med Raimondo. Thanks for joining me today.
Raimundo Sierra
Great pleasure to be here.
Nick van Terheyden
So as I do with all of my guests, tell us a little bit about your background and how you arrived at this company, this activity and also share where you are as well.
Raimundo Sierra
All right, well, happy to do so. I do start at the very beginning. So I was I grew up in Chile in South America came to Switzerland when I was 11. And so certainly a bit of a mix of cultures there. I went into studying electrical engineering out of curiosity, because I have really no idea what a computer is. We didn’t have one at home. And so when I came to eth, was this. Please develop your website? What is a website? And where do I turn this thing on? What do I do with this? So there’s definitely a steep learning curve. And from there actually, at some point, there was this lecture called medical image analysis that piqued my interest. And I went in this lecture in got really excited about this intersection of technology and healthcare and software, and healthcare, ended up doing a master thesis in the field in Boston, came back and started a PhD with a topic of surgical training simulation. So that’s what brought me into this field. In the time in between, I went back to the US did a postdoc there, I went into consulting work for one of the largest consulting companies, and a bit of management there, let’s say, went into agriculture. I was building up corporate digitization at Syngenta at some point and then really go back to the roots to work demand as we were looking into how do we scale this company that I co founded, from the time maybe 25 people to where we are today. And so that was back to the roots and got me hooked since Because indeed, what we’re doing is fantastic is is energizing, in we share a lot of passion here in the team to advance actually healthcare with surgical training and simulation.
Nick van Terheyden
Fantastic. So, you know, wide and varied career, I think that’s always, you know, hugely valuable in terms of contributing to setting up a company one of the things that, you know, I think we learn over time is that to be successful, you’ve got to have a wide set of experiences you’ve clearly had that. Tell us a little bit about verta Med and what is it that they do?
Raimundo Sierra
So what we do at Vercammen is develop and market surgical training simulator. So think of flight simulators for pilot, exactly the same for surgeons. We started out have a project of about 20 PhDs from the Swiss National Science Foundation, working on this topic until 2007. That’s when we set up the company. And today we have products in orthopedics in gynecology in urology in abrasca. P and in robotic surgery. In the end, really it’s all about how do we use simulation, and the technology to train and educate future surgeons to build the skills that are psychomotor skills to really perform excellent surgeries.
Nick van Terheyden
Fantastic. I can only imagine the the brainpower of 20 PhDs in one room that were focused on this problem must have been an exciting time, obviously, a lot of work to get to that point of actually launching a company. Tell us a little bit about the sort of early days of that process. Because as I try and think back I’m I want to say I hope I don’t get this wrong, but that was was that even pre the iPhone? Time? Yeah. So and you know, think about that as a revolution of our sort of interaction with the world. Tell us a little bit about what was going on then and some of the things that you had and and the journey as you’ve seen,
Raimundo Sierra
absolutely very happy. Basically, in the 90s there was a project to build a simulator. The idea is very old. How can we train physicians? How can we use technology for it? I think that goes back to the 80s or 90s. Indeed, there was a project in the 90s to build laparoscopy simulator unfortunately at the end of it, surgeons would say yeah, that’s like playing Pac Man. And so indeed, the the effort to put so many PhDs behind it was the goal. Can we build the first simulator or certainly would say, yep, that’s like the real thing. I recognize what I do as an experienced surgeon, I believe this can really train people. And so indeed, this effort was 20 PhDs. Over time, it wasn’t everybody at the same time, but But indeed, in intensive collaborative work, next to the hospital, from my office to the operating room, it was five minutes. And so really being very close to the physicians. But then you mentioned the revolution with the iPhone. And indeed, we at that time, we bought a 1 million supercomputer because one of the limitations was the computational power. And I asked my professor, do you mind if I buy a gaming PC with a graphic card, the latest one for three 4000. And, and indeed, I managed to outperform this 1 million computer with a gaming computer in the early 2000s. And so this is where we really gain confidence as well, you know, what computational power is getting to the level that we can achieve such realism. And so, indeed, it was fun, right? Because you were like programming, and you have this company showing you how to program a million dollar computer. And then you hack it on a graphics card of a gaming PC. And you outperform it. And it was quite revealing. We also did a lot of focus, right? So somebody was doing blood flow simulation, somebody was analyzing tissue deformation, doing even experiments on humans to figure out what is the tissue behavior, variable model generation, cutting in tissue dissection, etc, all things that still today, you will not find in games in the consumer world hands. And so that was definitely a revolution back then. And I think it’s, it was really a testimony to this project in 2007, where the surgeons would say, Yep, this is indeed like doing a hysteroscopy. This is how it works. In reality, I see it in the simulation. And I would argue that that’s stayed with the company, this is our DNA, and how do we create simulators that are truly relevant, that really reflect what is needed to perform in the operating room. And that level of quality and relevance is something that we always pursue with the, with the work that we do. And so that’s also when when we went from from gynecology later on to urology, then to arthroscopy and only very recently into laparoscopy. It was because we, we really felt like we need to have more technology, more advancements to get into these procedures that are highly complex, because you’re really having the whole abdominal area to simulate and the interactions there, etc. So it took us a while to get there. But I do believe that indeed, what we’ve brought to market now is indeed, yet again, a substantial game changer.
Nick van Terheyden
So, you know, there’s some interesting elements in there that are worth unpacking. First of all, I think, you know, this is a recurring thing. In other areas that I’ve heard repeatedly, which is, you know, something I termed the adjacent possible. And you talk about being five minutes away from the operating room. How much of a contribution was that? Was there a lot of flow between the two areas, yours, which was obviously research based, and the surgeons that you were working with?
Raimundo Sierra
Oh, absolutely. I this was key and crucial. So Michael, also co founder, gynecologist, and I, we very quickly became friends. And today, were very close with each other. Being able to say, hey, Michel, explain that to me. How does it really work? And getting the answer and in this translation was so crucial. And then, if it was too difficult, or just really, hey, I’m in the operating room this afternoon, you want to come over and see what I’m doing to really understand and appreciate what it is that they’re doing and how they’re doing it? What are the challenges, what they care about? And I often compare this to, we want to build the best race car. And I’m sure every racecar driver can tell you if this car is better than the other, but they’re not the guys designing and engineering the car. And so this is maybe this working together that we need to understand what they actually need without being able to ask them Hey, please design it for me. And so this is indeed today as a company We, we don’t have surgeons or medical professionals hired in the company, we always work with them. But it’s really to work very closely together, whether they’re an individual, whether the part of Medical Society, also appreciating the difference is actually on a global level. surgeons here in Europe may do things different than in the US, in the US West versus East Coast versus in Asia. And so really understanding the other side, and working with them is essential.
Nick van Terheyden
I, you know, I absolutely. The other thing that you mentioned, and I want to go back to partly because it brings back a little bit of, you know, positive memory from my childhood, I was pretty good at Pac Man, I just want to say, and I’m curious to know why. What was it that that was describing that was ineffective about the experience? So I recognize that was a game, but we’ve seen a certain amount of gamification in some of the tools and experiences. So I don’t think it’s just that it was a game, what was it about that reference that made it ineffective at that time?
Raimundo Sierra
I think it’s about change management to a certain degree. So what we’re doing by providing technology for education, health care, is to a certain degree change how people are educated how to learn and get the skills. And and so you also need to overcome this disbelief that something more basic can teach you a skill if you don’t see how it actually translates to the ultimate skills that you need. And so indeed, you the answer is not to trust to really the high fidelity and as close as possible to the patient or to the cadaver, but we need to have these steps to get you there. And so nowadays, we do have what we call basic skills learning, which is more depatment style, which is maybe you need to move boxes, you need to hold a thread, you need to learn to navigate with the camera, the endoscopic view, etc. So you need to learn those skills. But then you need to build upon those and put them into the context of a body and connect the complexity of the anatomy in which you are with the limited space that you have to navigate the bones that may be in the way the the space, the tensions that you need to create the forces that are necessary, the use of these instruments, put this all together. And then you also need to learn the procedure. These are complex procedures, right? I mean, I take an example rotator cuff repair. I mean, I, I couldn’t do it even on the simulator myself, because there are so many steps. And then you have different anchors in different sutures that you need to pull. And you need to do all of this right to do this proper rotator cuff. And so it is a very complex procedures involving many dozens of steps. And so once you have that, you can start to feel confident, okay, I can actually do this on a patient. And obviously, the gold standard in the past was see one do one teach one this type of apprenticeship model, which I think trivializes a little bit because reality was more sophisticated than they still is. Nevertheless, it is about really getting very quickly into a cadaver lab, getting into a surgery and assisting of surgery. But the complexity of the medicine of the procedure, etc, can really be taught and learned on simulators nowadays, as I was describing, essentially on steps and phases. And 20 years ago, I guess indeed, just seeing the first step clearly wasn’t enough to convince a professional this is the way to go. And I understand it because indeed the gap from the basic skills all the way to procedure is huge.
Nick van Terheyden
So for those of you just joining I’m Dr. Nick the incrementalist today I’m talking to Raimondo Sierra. He is the CEO and founder of verta. Med, we were just talking about the innovation beyond see one do one teach one I know all of my clinical colleagues will resonate with that mantra that was part of our sort of training and the innovation. You know, exciting times and I think, you know, the inflection point that I heard in what you described was, you know, the million dollar computer that was I don’t want to say replaced but certainly superseded by a gaming computer and You know, the offload into the GPU that was really one of the great innovations at the time, that obviously added a huge amount of potential. But the other thing you talked about was these different teams focused on different areas, blood flow, tissue, you know, the way that things feel you talk about the force field. I mean, I can only imagine the level of excitement you must have, at this point with all of the tools that are able, tell us a little bit about where you see this whole digital surgery and this innovation going I mean, I think the world must be sort of opening up almost.
Raimundo Sierra
Absolutely. And indeed, fantastic times, with so many opportunities, but also fundamental challenges that we need to get our heads around and get into. And so obviously, as a company coming from the simulation world, what are we doing with the simulators, I say we were doing a digital twin patient, we’re creating a replica of the human patient, as a simulator. And so indeed, with I mean, you talked about innovation and inflection points. Another one is definitely the cloud, and the ability to collect data on the cloud. And I would add another one, which is the the advancements in the gaming industry, when it comes to gaming platforms. And so those are all technologies that we indeed, have mastered by now as a company, that I believe, are setting us up for a future in this digital surgery space, using simulation, and not only the simulation of the patient, but also the simulation of the surgeon. So we’ve been doing now about three years of research in this field, machine learning to see where can we bring algorithms to actually do parts of the task? Of course, not the whole procedure, but just parts of it? And how can an algorithm learn to, for example, maneuver a camera, given a certain task given a certain goal function. And so indeed, this is, this is where I do see us going in terms of understanding medicine and surgeries, mapping that into InSilico, digital world, and leveraging that digital world for training, but then also, obviously, for surgeries, and innovation.
Nick van Terheyden
Yeah, it’s interesting, you bring up you know, that learning capability and applying some of the augmentation because, you know, replacing some of that skill set. Very challenging, but you know, huge opportunity, what comes to mind, as you talk about moving the camera, I think about sports, and the capabilities of the, you know, fly by cameras that are following essentially live action, things change all the time. But I imagine that they’re doing some similar kind of, you know, modeling that says, How do we give the best view to our audience, you’re doing the same thing for surgeons and trying to automate some of that, which, you know, they do as part of the whole process. So there’s some tremendous sort of opportunities here, again, with that adjacent possible, I think,
Raimundo Sierra
and very true, very true. And these are exactly the exciting things that we’re exploring. I think that indeed, and we explore this really in depth and, and thought about this and have partnerships and collaborations and discussions with global thought leaders on the matter, but really, to see what is possible. And where are we pushing the boundaries? And where are we even naive thinking what will be possible one day, and I think that that’s, that’s an exciting field, we don’t have all the answers, but we do have early results from these are very, very exciting. And so in need, you mentioned that this drone following a person and taking the shots, etc. As we go into surgery, and these into human bodies, the complexity of the human body, the individual differences, etc, are challenges we don’t face also say of self driving cars, right? Streets are human made. But here we’re dealing with nature, the body, the human, etc. So I think that that’s clearly on a technical level, a certain challenge, but then also, validation and relevance. I mentioned that before, but really validating what we’re doing. And that’s not just about validation that I sort of made sure the bucks the Code has no bugs or that I follow an ISO process, etc. But fundamentally, how do you validate an algorithm that may be trying to solve things tasks, that we don’t even understand how they’re functioning. And so indeed, we are here entering the field, where this digital world and analogies fascinating, we’re just at the beginning, but will will really help us? Yeah, see how you can use supervised learning, right, that mimics human behaviors and human experts with the data that we’ve collected. But then beyond that, maybe things that we can do even better with it. And in the world trust starting we using these analogies to explain what we’re trying to do, like a self driving car started by telling you while you’re getting off the line, and you should move a little bit to the left, and you have now the blinking etc. It’s an analogy whose journey, but I think we’re really dealing with nature with the human body. And the expectation also, that in health care, we don’t want to take risks. So we need to manage all of that.
Nick van Terheyden
So you bring up an interesting point, with that sort of capability, obviously, the complexity or the variations in anatomy, you mentioned something that really sort of piqued my interest. And I feel like that’s somewhere in the future, which I’d like you to sort of close with. You mentioned the digital twin patient. And my sense of this is that you might get to a point where you fully simulate a surgery, especially a complex surgery, prior to actually doing it. And that would be the sort of standard of care.
Raimundo Sierra
All right. Well, I love your vision, I love the idea that you’re bringing here for Because indeed, that is a unique opportunity, I, I want to go one step further than that, which is, if I can replicate the specific patient, let’s say Mira Mundo need to go to surgery tomorrow, I have a scan of my body. And it’s all put into a simulator. In reality, and I don’t think this is going to change in the future, doing the whole surgery beforehand on the simulator is going to be it’s not going to be economical. And the surgeon needs to be in the operating room doing the surgery, and he will have skills to actually do this. And he will have robots and all the things that helped him. However, to figure out automatically, what is the critical step of that procedure to pay attention to to understand, look, all the things like removing the fat, etc, all that is routine. But here in minute, whatever 25, you will face this challenging situation. And we’ve run it for you. And we’ve simulated it and we tested it. And here are two, three options that you should look at. And maybe you want to try it out yourself. But so indeed condensing and compressing this preoperative planning to what is critical tailor to the patient tailor to the surgeon. That’s the vision that I think building on what you said, this is where we’re going.
Nick van Terheyden
That’s so exciting. I mean, that’s definitely the kind of surgery I want for sure. So, um, in the closing moments, tell us, what are you most excited about for your future in the future of virtual verta? Man?
Raimundo Sierra
Well, first of all the technology possibilities in healthcare, education in health care, and then also partnerships, working with this is not something we would do alone and solve alone. It’s it’s it requires the partnership with innovation institutions, universities, and partnerships with a medical side. And so really bringing this together on the table and pushing the frontier in healthcare. That’s what excites me. And I think it excites all of us here. advertisement.
Nick van Terheyden
Fantastic. Well, as usual, we’ve run out of time just remains for me to thank you Raimondo for joining me today. It’s been a fascinating conversation. Thanks very much.
Raimundo Sierra
Well, thank you also for my side. Dr. Nick. It’s a pleasure to be here and I hope this is indeed giving a glimpse into the future.
