Chapter 11: Technology to Support Neurosurgery
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Description
Dr. Sawaya begins this Chapter by noting that Dr. John Tew, chair of Neurosurgery at the University of Cincinnati Medical College in the 1980s, saw that technology was essential to a strong department. Dr. Tew secured many of the first prototypes of devices in order to test them. When Dr. Sawaya came to MD Anderson, he made sure that he secured all of the technological advances. Dr. Sawaye describes the advantages of the following: brain mapping; drills to open the skull; navigation systems for the brain and spine; the first robotic microscope and Surgi scope; Brain Suite and the Intra-Operative MRI; Vector Vision.
Dr. Sawaya states that the next important advance will be the ability of the MRI to image microstructures in the brain, such as the speech areas. He also notes that a professor of neurosurgery in Calgary, Canada, has built a robot for use in the operating room. Dr. Sawaya explains the importance of robotics for neurosurgery, then talks about mastering the challenges of Brain Suite. He admits that he hesitated about investing in Brain Suite, but was convinced when he realized that it would allow surgeons to remove an entire tumor, leaving no pieces behind.
Identifier
SawayaR_02_20130625_C11
Publication Date
6-25-2013
City
Houston, Texas
Interview Session
Topics Covered
The University of Texas MD Anderson Cancer Center - Devices, Drugs, ProceduresOverview; Definitions, Explanations, Translations; Building/Transforming the Institution; Multi-disciplinary Approaches; Growth and/or Change; Technology and R&D; Understanding Cancer, the History of Science, Cancer Research; The History of Health Care, Patient Care; Professional Practice; The Professional at Work
Transcript
Raymond Sawaya, MD:
Whatever you’d like. Technology—the interesting technologies, because the field of neurosurgery is heavily dependent on technology. And being a neurosurgeon, clearly I needed to pay attention to that. I also had a mentor in Cincinnati when I was a faculty there, by the name of Dr. John [M.] Tew [Jr.], T-E-W. John was the chairman of Neurosurgery in Cincinnati after I returned from NIH. So I was his faculty member. And I learned a lot from him, because he is a politician in many ways. But he saw the technological advances in the field as essential to building a very strong neurosurgery program. And so he teamed up with many, many companies, was able to get some of the first prototypes—like a microscope that is ceiling-mounted. That wasn’t common at all, yet there is so much advantage in that, that it frees the space on the floor for other equipment and so on. So he got the companies to give him one of their first for free. You know what I mean? He was very good at that. So I learned from that. And so when I came here, I wanted to make sure we had all the technological advances that relate to tumors of the nervous system. And one of the first techniques that we needed to develop here is called brain mapping. You’re hearing a lot about it now, but back in 1990, almost nobody was talking about it. And that’s one of the reasons I hired Ian McCutcheon in 1991, because Ian came from Montreal Neurological Institute where Wilder Penfield was and where we did the first mapping back then in the ‘60s. So I established that. Then we, of course, had to get better drills to open the skull. We had to get the microscopes. We had to get the retractors for the brain. Eventually, we had to get the navigation system, which is like a GPS in a car. There is a navigation system for the brain and the spine. And I went to Toronto and saw and bought the first prototype in ’93 and then moved on with the newer systems. In 2000, I bought the first robotic microscope. I went to Grenoble, France, where they built it and was impressed by it. And went to Paris to two hospitals where they were using it, and it looked very promising. So I bought it. It’s called SurgiScope. And we installed the first one in 2000, when the new Alkek Building was built and the new OR’s were established. I couldn’t put it in the old OR’s. The ceiling was too low. And so this is a microscope on a track that is led by a computer. That’s why it’s robotic. I can make the computer move the microscope with navigation and go straight onto the target without me touching it. So it’s phenomenal. I’ve had it now for 13 years. And then what came after that was the intraoperative MRI in 2006. And we were the first one here in Houston and practically in Texas. Dallas got one right about the same time as we did.
Tacey Ann Rosolowski, PhD:
And this allows the metabolic—
Raymond Sawaya, MD:
No, this allows us to—well, it allows us to look at tracks of the—fiber tracks that connect the functions between the brain and the arms and the legs and the spinal cord and where the tumor is. So you can see where the tumor is and where the tracks are. This way you limit the likelihood of damaging those tracks. If you know where they are, if you see them, then you are likely to avoid them. In the past, we didn’t see them. They looked like brain, so we didn’t know which were the important tracks and which were the non-important tracks. Now we can visualize them. That’s one. But equally important is, we don’t finish the operation until we finish the job. And how do you know that you’ve finished the job—that you got all the tumor out? We don’t have x-ray vision. We don’t. Frequently, we think we’re done. You finish the operation. You send the patient for a scan the next day—bang! There’s tumor left behind. That’s very common—very common in neurosurgery—because we don’t have x-ray vision. So having the MRI in the operating room, you image the brain before—when the head is still open under anesthesia with sterile condition, and you find there is tumor left behind that I can remove. And I’ll go and remove it. And this way you have really completed the job in one time rather than having to do two operations. So what I’m sharing with you here is a number of technologic advances that continue to occur in our field, probably in other fields too, but certainly in neurosurgery. And you have to remain abreast with that. We don’t get technology that some people may consider a gimmick. There are some of those. But we get the technology that we feel makes a difference either in doing better surgeries or in leading to fewer complications or both. Those are the long-lasting technological advances. And those are the ones that I’ve described to you that we use today.
Tacey Ann Rosolowski, PhD:
And there is Brainsuite as well.
Raymond Sawaya, MD:
Brainsuite is that intraoperative MRI.
Tacey Ann Rosolowski, PhD:
Okay.
Raymond Sawaya, MD:
That is one and the same.
Tacey Ann Rosolowski, PhD:
All right. One that you didn’t mention, or maybe I didn’t recognize, was the viewing wand—the ISG Viewing Wand. Did you mention that?
Raymond Sawaya, MD:
Not by name.
Tacey Ann Rosolowski, PhD:
That was quite a while ago.
Raymond Sawaya, MD:
The ISG Viewing Wand is the first prototype we bought in ’93 when I went to Toronto. That’s the one I mentioned. This was the ISG Viewing Wand. And it’s called viewing wand, because it’s like the wand images. It’s an articulated arm with a point, and when you touch a point on the head, you could see on the screen—on the MRI—where you are. That’s why it’s called a viewing wand. And then this evolved into newer systems, the viewscope was the next prototype. And now we use the Vector Vision from Brainlab—Vector Vision. And Brainlab is the same company that created the Brainsuite. One is navigation, the other one is imaging. And then the two come together. We use navigation even in the Brainsuite after you image.
Tacey Ann Rosolowski, PhD:
So what is the next thing that’s coming technologically that will really make a difference?
Raymond Sawaya, MD:
I think two things. One is the ability of the MRI to image minute structures that we, to this day, have not been able to see. What the MRI shows you are the macrostructures, the big things. But frequently what gets us into trouble—of course, if you damage the big thing you’re going to get into big trouble. But damaging the smaller things, especially in the language area, speech area, can be devastating even though they are tiny. And there is improvement in imaging that. So getting there and bringing that information in the operating room is, I believe, a big thing that’s coming down the way. Another one is—I was in Calgary two weeks ago as a visiting lecturer—and they have there a professor of neurosurgery that has been at the forefront of robotic neurosurgery. He has built a robot and has been using it in the operating room in helping remove brain tumors.
Tacey Ann Rosolowski, PhD:
And how does—in what way is the robot used?
Raymond Sawaya, MD:
So the robot has two arms. These arms can hold instruments. They are extremely steady. They are guided by the surgeon who is not even in the room—who is in the control room behind glass. But that surgeon has access to the images with all the details that may be made available. The robot’s arms are limited to work within a specified field, so there are safety measures in there. It cannot veer and get off. And they have the absolute steadiness of a robot and the strength. So you could have tremendous precision, more than a human hand, steadiness, more than a human hand, and an effort done on the basis of specific images, not on the basis of what our eyes may or may not see. If there is a blood vessel behind this tumor, you see it on the screen and you will know—and the robot will know to avoid that. So it is just enhancing all that information that we are gathering now—it’s all digital information. It’s all allowing a computer and a robot to digest, translate, and act with still a human guiding it, but guiding it behind a machine, not doing direct work.
Tacey Ann Rosolowski, PhD:
In terms of the relationship between the hand and the robot—I mean—it’s kind of interesting, because for so long we heard that the goal was for a robot to mimic human movement, but it seems as though this particular robot—it does, to a certain extent, but eliminates, for example, shake. So it interprets human movement.
Raymond Sawaya, MD:
And plus I can do big movement in my hand that translates into this robot’s arm moving two millimeters while here I am moving two centimeters—you see? So any of this gross movement is translated into such a minute, precise movement that it’s obvious the safety of this activity is enhanced because of that.
Tacey Ann Rosolowski, PhD:
What’s the learning curve for using a device of that sort?
Raymond Sawaya, MD:
It’s fairly unique to play on a lot of animals before you get into working on humans. So I don’t know. I don’t have experience in that field. I’m just watching it. Just like with the intraoperative MRI, I was very hesitant to go that way, because I was afraid of the complicating environment and the risks, the nursing, and the anesthesia, and the machines, and the tools, and the OR—I was fearful of a very complicated environment. But it turned out—it is a complicated environment but one that you can conquer relatively easily.
Tacey Ann Rosolowski, PhD:
Why are all of those supports so different with Brainsuite?
Raymond Sawaya, MD:
Because you have a magnet. The magnet is a weapon. Can you imagine if I were to walk in here with this? Nobody knows, and I’m clueless, and this thing becomes a projectile, and the patient is in the magnet, and this is going to create a hole in the patient’s head.
Tacey Ann Rosolowski, PhD:
I see.
Raymond Sawaya, MD:
That’s a gross example of a problem that can happen. So it is a risky environment until you master it through education, through training, through paying attention to detail. So it took a lot of effort and work to make it possible. And we had an imaging physicist involved in that, and he has been a tremendous person in enhancing the safety. So—you know—so much of that needs to happen and to plan for. So I was very hesitant to go that way, and finally when I was seeing those MRI scans after surgery showing that there is tumor left here that shouldn’t have been left there—but I don’t know, it’s not only me, others too. Then I said, “Well, in a place like this where we have the volume that we have, the expertise that we have, we cannot afford this.” So I made a request to the administration, and in record time it was approved. It was so appealing that they didn’t hesitate.
Recommended Citation
Sawaya, Raymond MD and Rosolowski, Tacey A. PhD, "Chapter 11: Technology to Support Neurosurgery" (2013). Interview Chapters. 1547.
https://openworks.mdanderson.org/mchv_interviewchapters/1547
Conditions Governing Access
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