Speaker 0 00:00:00 The human brain is critical to a child's development within a few years of life. Indeed enables us to sit, walk, talk, and even eventually make decisions. But for those suffering from neurological conditions such as epilepsy, that journey can be complicated. I'm Dr. Derre, a pediatric neurosurgeon at Children's Hospital in London, Ontario, Canada. And today I'll be talking about the Rosa Robotic arm. A life-changing technology that allow teams at L H S C Children's Hospital to perform creative surgeries on children with drug resistant epilepsy. The Rosa allows us to provide leading edge care while saving resources, reducing wait time, and ultimately enhancing the quality of life for children with epilepsy.
Speaker 2 00:00:49 Hello everyone and welcome to the Robot Industry Podcast. My guest today is Dr. Sandrine du Re. She earned her MD at the University of Geneva in Switzerland after a neurosurgery residency in Losan, Switzerland. She completed an epilepsy fellowship in the fund, Rothchild in Paris, then a pediatric neurosurgery fellowship at the Hospital for Sick children in Toronto. She's currently working as a pediatric neurosurgeon at the Children's Hospital in London Health Sciences Center in London, Ontario, with some involvement in adult trauma and skull-based cases. In April, 2022, she was appointed as research chair of pediatric neurosurgery and neuroscience at Children's Hospital at L H S C. In this role, she leads a multidisciplinary team to improve neurosurgery outcomes by furthering our understanding of brain development and how it is impacted by complex diagnoses like epilepsy, hydrocephalus, tumors, and traumatic brain injury. The team also leverages augmented and virtual reality tools to improve surgical planning and patient experience.
Speaker 2 00:01:56 Dr. Du RPI is also a professor at the Schulich School of Medicine and Dentistry at Western University in London, where her main research areas are medical education using virtual and augmented reality as an educational tool with a special interest in neuroanatomy and neuroimaging investigating both the normal brain development and how it is affected by some neurological pathologies. Sandrine, welcome to the podcast. I'm glad you hear, and a fun fact for our listeners is we're recording this in London, Ontario, and we live only a few blocks away from each other. London is also a city rich with important medical research and discovery as a dad to a physician. Uh, Sandrine, I understand that the road to your practice and research is rarely a straight one. Can you tell us about your path to this very niche practice and application of your surgical skills?
Speaker 0 00:02:47 Okay. So after completing my neurosurgery resident in Laan, where I was lucky to be trained by Professor gi, who's a kabe, who actually was, uh, one of Rasmussen students who already had a special interest in epilepsy, I went on to complete a pediatric epilepsy fellowship in Paris with Olivia Delon, who at that time was already using, uh, a robotic arm to implant electrodes and then a pediatric neurosurgery fellowship at the hospital for sick children in Toronto. While I already had completed a research thesis, like a PhD in Switzerland, I then underwent a master thesis in neuro imaging for research at the University of Edinboro, which allowed me to further on my understanding of the application of technology to assist how the brain is, uh, developing and how it is impacted by complex diagnosis like epilepsy tumors and traumatic, traumatic brain injury. Through my research and clinical practice, I've all spent spent time looking on how surgeon can leverage augmented and virtual reality tools to improve surgical planning and the patient experience.
Speaker 0 00:03:48 I was first involved with our, uh, national research center in Canada and was part of the con neurosurgical consultant helping them to design the neuro touch, which is a virtual reality neurosurgical simulator. Then I continued in that direction with my closest colleague, professor Roy Eagleson, here in engineering at the University of Western Ontario, to design and evaluate augmented and virtual reality simulators. And when we think that survival rates of patients with complex neurosurgical diagnosis have increased in the last decades, the goals of my practice have been to advance personalized surgical planning to optimize their outcome and focus on improving the quality of life after surgery.
Speaker 2 00:04:31 Thank you for that. Tell us about the impact that Rosa has had on patients and the neurosurgical team at LHS C'S Children's Hospital.
Speaker 0 00:04:40 Yeah, so if we think of, uh, children with epilepsy, there have been historically an underserved population and disease can cause lasting damage for, from seizure to behavioral problems and intellectual disabilities, as well as depression and severe anxiety. In Ontario alone, 95,000 people have epilepsy, including about 15,000 children. While most epilepsy can be treated with medication, around 30% of them are drug resistant, which means that take me medication will not help in stopping their seizures. Surgery might then be an option if the seizure coming from a relatively localized area in the brain in order to know that we conduct a series of tests such as m mri, PET eeg, and in some case scalp eeg. So basically having the, the electrodes on top of the head, which is the, the things that people think of when they see an eeg, that's not enough. It's not specific enough to localize that brain area, and therefore we need to implant electrodes either on the surface of the brain or within the brain in order to have more, a more precise localization.
Speaker 0 00:05:49 So it is essential to treat the these children early, um, because the longer you have epilepsy, the more negative impact of the repetitive seizures and the side effect of medication, um, are important. On the developing brain, there are two options to record the brain directly, either an open craniotomy, so an opening in the skull to place a sheet of plastic containing electrodes on the surface of the brain called a grid or subdural electrodes, or to place really thin wires with electrodes within the brain, a procedure that we call sterile encephalopathy or S E E G. This second option is mini, mini minimally invasive. That requires to be extremely precise in order to avoid the different vessels present on the surface and within the brain. So s EEG is a method that allows three-dimensional recording of activity anywhere in the brain. The, it can be done using a frame.
Speaker 0 00:06:48 So basically you can take off a metal box with open side that is screwed on the head of the patient, and then you do an image. So you read a CT scan and you calculate the trajectory. If you don't have a robotic arm, you can go with that frame. And it has been done, um, that way for more than 60 years. It was, uh, first done in Paris with people called the <unk>. Um, and it's still used in a lot of centers that don't have the advantage of having a robotic arm. However, doing it manually, it's about four to five times longer in the operating room. Each trajectory needs to be calculated and then manually address that for each electrodes. So you have a little computer telling you the coordinates in the X, Y, and Z access, and then you have to reproduce that on the frame of the patient.
Speaker 0 00:07:41 Uh, and therefore you can imagine there is a large risk of human error, which is eliminated with the robotic arm. In average, you can think that we put about 10 to 20 electrodes in, in each patient. So the Rosa robotic arm arrived at the, uh, children's hospital in London just in time for the epilepsy day on Saturday, March 26th last year. We were able to obtain it thanks to our epilepsy director, Dr. Andrea Andra, as well as the Children's Health Foundation, who was able to raise the money and local donors while we had access to a robotic arm of a different model at University Hospital before that, um, and actually using the University hospital robotic arm, we were the first center, um, to perform a pediatric, uh, robotically assisted case in Ontario in 2018. Um, having robots rights, uh, at Children's Hospital is life-changing to assist children with, with epilepsy.
Speaker 0 00:08:40 First, it enables to us to treat the children in the children's hospital without having to transport them right after surgery across the city. And for people that don't know London, it's about a 20, 25 minute, um, ride if you don't, don't have the train stucking you in the middle <laugh>. Um, but uh, also the model that we have is slightly different than the one that is at University Hospital, and our model of robotic arm is able to work without first placing a frame on the head of the patient. So you, you don't have to put the frame, go back to, uh, do an image and re-register the, uh, patient, and therefore it's smashed safer. As you cannot put a frame with screws on the skull of a patient, adults can tolerate that in children, you have to put them asleep, and therefore it means having to move, move an a sleep patient and intubated across the hospital from your to the radiology area and back before surgery.
Speaker 0 00:09:39 Okay. Um, to give you an idea of the workflow, so after discussing each case as a multidisciplinary new team, we plan the trajectory of the electrodes on the software link to the rosa as discuss earlier, this electrodes allow us to pinpoint to the seizure origin on the brain and then move forward with a treatment plan. So without the S E E G, um, we would need to do a more invasive procedure with opening the skull to place a grid or a subdural electrodes. Um, and that larger surgery is typically associated with higher risk of bleeding infection, and typically causes children more pain and nausea for several days afterwards. They also need to go to our, uh, pediatric critical care unit unit after the operation. But since with the rosa, we typically make tiny holes in the skull in order to insert the electrodes. The children can recover really well with few side effect and without going to intensive care after the implantation of the electrodes.
Speaker 0 00:10:42 So using the ROSA really reduces the risk for a pediatric patient and improves their quality of life. Another advantage of having a robot directly at Children's Hospital Inti, instead of using the adult one across the city is the access to operating rooms. So, and children hospital have made the children as epilepsy a priority, and therefore this decreased the wait time for this surgery. Instead of being impacted by the adult epilepsy wait time, a young patient will no longer have to wait multiple years for lifesaving surgery. Rosa is also also saving staff time and hospital resources. Um, as previously we needed to move the full pediatric team across back and forth, um, in the city, uh, having anesthesia and nursing go to University Hospital and come back. For each cases, the ROSA has already demonstrated the potential to innovate care for pediatric epilepsy patients at Children's Hospital.
Speaker 0 00:11:40 So since the arrival of the rosa, we have had seven of our kids. That's about 10% of our wait list that, um, received first D S E E G, but then a second procedure after that, um, to cure them of their epilepsy. And that has reduced our wait time by two or three months. So the, the rosa allows us to complete an important work onsite directly at children hospital, and therefore the family experience less distress than being moved around across the city. Uh, and they have more emotional support as they continue to access the pediatric specific resources, uh, such as, uh, li Child Life Specialist, uh, music and art therapy, and, uh, our, uh, Ali, our therapeutic clown in tandem with receiving less invasive and state-of-the-art, medical heart, uh, medical care. Our pediatric patients with epilepsy are also well supported to process the difficult emotion and anxiety that comes with hospital life and major surgeries.
Speaker 2 00:12:41 And that. That's awesome. Thank you very much for that Sandrine. And we don't really talk a, a lot about how technology can affect the family's experience in, in this, so I think that's really cool. I think we're gonna have to have another conversation about that, but I have another question. Is the technology developing rapidly and what work are you doing to advance children's neurosurgeries through these technologies?
Speaker 0 00:13:03 Yeah, so interestingly, it's, it's not developing that rapidly. So the ROSA has helped to advance our practice and raise a standard of care for p epilepsy patient in London and Southwestern Ontario region. Um, but I actually was trained on a previous version of that robotic arm years ago when I did my fellowship in Paris. Um, and, and that was in the earlier 2000, and, um, we can see over the year that there is some development in the software of the robot. Um, but overall the, the concept was there and, and we don't see major changes. The, um, the planning of the trajectory in the brain is however, a bit easier now than previously, and we have more way of displaying and rotating the image. So they, they did a lot of improvement trying to, to visually improve the surgeon experience. Um, but the, the robotic arm itself has not changed much.
Speaker 0 00:14:03 Um, however, if we think of the robotic arm compared to, uh, what the frame was years ago, then uh, it really allows us to, to pinpoint and plan neurosurgically, um, a lot faster. This Rosa compared to other arms is especially fitted for children as it does not need the support of a frame on the head of the patient. Um, and therefore it's the exact tool that our neurosurgical team needs, um, to perform life-changing surgery. And at Children's Hospital, however, there's still a lot of improvement that could be made in order to facilitate the integration of all information during the planning of surgery. The, um, integration of virtual and augmented reality when discussing the case as a medical team to plan the electro trajectory would be a bonus. At the moment, we discuss as a team, we look at multiple things that are all separate. If you want, you will look at the mri, we look at the skull, p e G, so the signal was it coming from the right, the front, the back, the, we have a, an idea where on the head we we're looking at different imagings such as pet and spec, but it's not integrated, um, into one, um, software where we could really be able to register everything and see them in three dimension.
Speaker 0 00:15:27 For example, if we were to use augmented, uh, reality, I, in addition, um, we have to plan extremely, uh, accurately where the vessels are, um, but we also need to know where language is, where motor function is. So all, all of that information that can be given by functional imaging such as an MRI where you ask the patient to do a task in the magnet and then re record where signal is coming from in their brain. We are trying to integrate that in the workflow of the robot. At the moment, it's not, but in our lab we're working on neuroimaging to understand the complex brain network and how they're modified by epilepsy, but also what are the best way to display them to a medical team in order to make complex information easier to, uh, process. I think robotic arms, such as the rosa, can also be used in other surgery, especially endoscopy, for example, in intra vegal tumor removal and some treatment of complex hydrocephalus.
Speaker 0 00:16:28 Um, especially if it's paired with imaging tools, um, when planning for the surgery in order to remove a brain tumor. So I think we need to work on how to integrate better other presurgical modalities such as functional imaging spec pets, m e g, and even scalp peg in the planning of specific trajectories. Um, however that's is a challenging, uh, aspect at the moment and requires knowledge of a multidisciplinary team composed of basic scientists and clinician. So the idea would be to be able to develop a workflow that would enable clinician to have access to that information and to that type of workflow without having the large multidisciplinary team of the, uh, basic, uh, scientists around. Um, but that will take a few years, I think, to get there.
Speaker 2 00:17:19 Thank you for that. And there sounds like there's some opportunities there for, uh, making it a lot simpler. So how do you stay ahead of the training and practicing skills when you're just trying to get or time and, and keep up the care of your patients?
Speaker 0 00:17:33 So I think as any physician and surgeon, one important aspect of our work is to stay up to date with current knowledge. Um, and I usually do that by attending at conferences and discussing with my colleagues at national or international levels. Um, we also learn constantly by having new and challenging cases. Um, so by saving over time, for example, Rosa allow us to have more time for research and to read in order to stay ahead, but also to operate on the larger volume, which increases our experience. Uh, that being said, children's Hospital and L L S C, um, our university hospital and we're training resident and fellow and the ROSA brings increased opportunity for training and expertise as people are interested in coming here to learn about it. It also helps us attract new talent as fellow really want an exposure to that technology. I think as, um, as a teacher where I've residents and fellows coming in the or, um, actually trying to explain things to them and to, to make them understand the case, um, actually also help us, uh, keep ahead of the training and practices skill.
Speaker 0 00:18:44 It makes us think about question that they might have and you never thought about. So being able to be in a training environment I is great in that aspect. Now with Children's Hospital as part of London Health Science Center, L E S C, academic Realignment Initiative, um, training with new technology and innovating technology is really encouraged in our environment. This year, our epilepsy fellow, Dr. Boan, was awarded an L H S C research fellowship, which enabled him to come from Argentina, for example, and be with our team to bu do both clinical work and research. And as I said earlier, observing training local or international operate and teaching them is also helping us to stay up to date and constantly question how to do things in order to improve ourself.
Speaker 2 00:19:35 Thank you for that. Sandrine. What does Rosa mean for patients and families in the region? What is the reaction you would've had from patients or their parents when they find out there's gonna be a robot involved in the surgery?
Speaker 0 00:19:46 L E S C was the first center in Ontario to perform a robotically assisted s eeg. Yeah. In a child, children hospital is one of two pediatric center in Ontario to have this specific technology available for, uh, epilepsy patient with sick kids in Toronto and they actually have a different version of a robotic arm there. But Di Rosa has helped us to advance our practice and raised the standard of care for epilepsy patient in London and South Ontario. Um, southwestern Ontario region before Children Hospital had the rosa, our pediatric neurological, uh, neurosurgical and neurological team and patient had to be transferred to another hospital campus for their surgery to use the robotic arm that was le large developed for adults. Patients and family are quite happy to know that they'll benefit from minimally invasive surgery right here at Children's Hospital. They understand that it allows us to be more precise and decrease the risk of the investigation. And many children like the idea of having a robot in the room, even if our robotic arm doesn't quite look like robots that they would have seen in movies, they're still quite excited at that idea.
Speaker 2 00:20:51 So, uh, from our conversation, Rob, the Rosa came to you in March, 2022, a year ago. How much have you had the opportunity in the last year to work with the technology?
Speaker 0 00:21:02 Yeah, so it arrived in March, um, last year, and um, basically it's an extremely expensive, uh, piece of equipment as you can think. So the Children has Foundation helped to fund over, um, $750,000 for this state of it, of the art equipment. It included donation from many generous families, foundation and individual to help bring this innovative technology at Children's Hospital. This, uh, fundraising effort and the arrival of the ROSA to the Children's Hospital allowed us to get to work and begin performing, um, the, uh, the surgeries in the late spring and over the summer. So over the summer and year, uh, early fall, we were able to treat seven pediatric patients, which is over 10% of our wait list, late fall and early winter. As you may have heard, due to COVID and R R S V, there were no hospital bed available for any elective surgery in the province and unfortunately that had to, uh, pose a bit our, uh, epilepsy program. But since then we have been able to resume our activity in February and we have, uh, a few surgery already planned in the next few months. Overall, the ROSAS reduced the wait list of for pediatric patient requiring, uh, epileptic procedure cutting the wait list for about three months.
Speaker 2 00:22:22 That's great news. Thank you so much for that. So I'm pretty sure that in any surgery you have a team around you. How does a team in a robotic surgery differ from a typical OR team?
Speaker 0 00:22:33 So yes, there is a large team involved in treating epilepsy and not only in the OR first the pediatric epileptologist, Dr. Andrati and Dr. Nori with their fellow, um, with whom we discuss the case in detail and decide which region of the brain need to be investigated with depths, electrodes. Then in the or, I typically have a neurosurgery neurosurgical resident and a fellow, and there is also a scrub nurse and a circulating nurse. We have the chance of also being assisted by an engineer coming from the company, selling the robot to assist during the procedure. So overall, the team isn't too different from a typical or team as we each have an important role to play, but the robot make it faster and more accurate. Um, it doesn't really replace any of us, it just make it safer.
Speaker 2 00:23:16 Thank you for that. Where does the surgeon stop and the robot begin, or are you, do you feel you're one in the same in the or?
Speaker 0 00:23:23 Well, unlike other surgical specialty where dissection cutting or tying a knot is done by the robot directed by the surgeon, um, and I'm thinking, uh, of the da Vinci robots that's used in abdominal thoracic, uh, surgery where basically you are using the surgeon's hand are directly manipulating the robot through an interface. Here the robot is calculating a trajectory and placing itself in a specific point on the scalp with a specific angle, but all the cutting drilling, advancing the electrodes done by the surgeon. In the future, there might be further advancement of the technology with more steps being done through a robot, but there will always be a trained professional operating the robot on the other end.
Speaker 2 00:24:06 What does the future look like for robotics at the London Health Sciences Center through either your clinical practice or research and and what do you see yourself working on?
Speaker 0 00:24:15 Oh, that's a good question. So looking ahead, we have lots of project, but, uh, a few that, uh, that uh, I would like to highlight maybe is leveraging advanced medical imaging like functional, uh, M R I or FM I 3D ultrasound and functional near infrared spectroscopy and integrating them in the workflow of the plan, planning of the trajectory. So our research team is interested in collaborating with the developers of the robotic arm in order to help other centers to have access to a more integrated workflow. I also think that some more basic science question and research I'm conducting in order to understand the brain networks and how they're affected by neurosurgical pathology will also be relevant in advancing on comprehensive integrative planning SY system for the robots. So for example, um, the virtual and augmented reality are already touched on that, but during our multidisciplinary seizures conference, it is sometimes difficult to visualize the epileptic network a surgeon.
Speaker 0 00:25:13 We're used to seeing the brain in 3d, but that's not the case for all the members in the team. Therefore, advancing on the visualization and using, uh, virtual and augmented reality to discuss the case with different modalities in integrated would help everyone understand better. It can also be used to explain to the patient and their families. We are also looking at tools to design a virtual children's hospital in collaboration with child life specialist and other, um, physician in, in the hospital. This would allow patients to experience children's hospitals through virtual reality prior to hospital visit. So they'll be in a game, they'll be able to walk virtually, virtually into different rooms, enter the mri, lie down to get an M r. I then go to the operating room and experience different scenario tailored to their individual needs to help them understand what's going to happen. And the hope is that we will lessen their, their anxiety. Our goal with all this work is to enhance the patient and family experience while advancing Children's Hospital as a leader in pediatric neurosurgery. And together we hope to generate knowledge and greater understanding of the brain that will improve the lives of patient around the world.
Speaker 2 00:26:23 It sounds like you've got so many exciting projects coming up at L H S C Sandrine when you're not performing surgeries or working on your clinical research. What do you like to do in your free time? That is, if you have any
Speaker 0 00:26:36 <laugh> I'm fortunate to have a great family and I love to spend time with them. So we like to ski, hike, play games, read, uh, as well as Android traveling, which we do quite a lot since we're going to multiple international conference during the year.
Speaker 2 00:26:51 Crine, I'm very grateful for you taking the time to join us and educate us on what's fascinating research and and practice. And if our listeners are interested in learning more, uh, where can they find out more information about your work?
Speaker 0 00:27:03 So one way of, of following up with our research would be to, uh, look at our website, uh, from the lab, which is brain 3d vis.com, um, or through the lhsc, uh, website under my name, um, or through publications that, that we do as well.
Speaker 2 00:27:23 Thank you for that. And I'll put these notes in our show notes for today too.
Speaker 0 00:27:28 Okay, awesome. Well, thank you very much.
Speaker 2 00:27:31 I'd like to thank our sponsor today, established in 1922, children's Health Foundation. C H F Inspires caring people to donate to support healthcare excellence at Children's Hospital T v cc, formerly the Temes Valley Children's Center and Children's Health Research Institute. Children's Health Foundation help strengthen and transform the healthcare experience by funding equipment, programs and research that ensures better childhood for kids with life-threatening or life-limiting diagnoses. Thanks to the generosity of Children's Health Foundation donors, children's Hospital was able to purchase the ROSA one brain robotic arm and begin performing leading edge surgeries that cure children of their epilepsy. Purchasing the Rosa was funded 100% by donors. Having the ROSA is only possible because of community minded leaders like the podcast listeners today, you can start learning about leading edge care for our kids by joining us
[email protected] and on social networks. At C H F Hope Children's Health Foundation is honored to gather our community together in support of life-changing technology and medical innovations like the Rosa. We're so grateful to support the best possible care for our children, youth, and their families. If you'd like to get in touch with us at the Robot Industry Podcast, you can find me, Jim Beretta on LinkedIn. We'll see you next time. Thanks for listening. Be safe out there. Today's podcast was produced by Customer Attraction Industrial Marketing, and I'd like to recognize our team members, Chris Gray, for our theme music, Jeff Bremner for audio production. My business partner Janet, and our sponsor, children's Health Foundation of London, Ontario.
