If every patient is unique, why are surgeries standardized? Learn how Insight Surgery grew from a social enterprise started in east Africa developing prosthetic limbs to a company dedicated to helping surgeons access personalized surgery through digital planning and patient-specific devices.
Hello and good evening. Welcome to the fifth episode of season three of the Bay CV Live Innovation on the loose streaming live from the Houston Methodist Hospital here in the Texas Medical Center. I'm Doctor Stuart, Co Director of Innovation Engineering for the Heart and vascular Center. And tonight, I'm absolutely delighted to have on my show, the two guests. So we have Paul, founder and Chief Technology Officer for Insight Surgery and his colleague, Dr David Collins, head of engineering for USA operations. And they're here tonight to discuss their technologies for digital planning and personalized surgery. Now, before we proceed, I'd also like to invite the audience into our discussions. So please submit your questions via web at EV dot com using the, is the user name or text to 37607 alongside your question. You can also add your question into the live youtube stream. Now, going over to our guest, um I know Doctor Dave Collins is here in Houston. Um but Paul is actually in Barcelona and I believe it's 11 o'clock there. So Paul, how are you doing? I'm fine. Thank you. So we're, we're very eager and excited to hear more about insight surgery and I do apologize in advance if I call you 3d Life Prints. Uh, I know you just rebranded and changed your name there for your new, uh, launch in America. Absolutely. Yeah. Absolutely. Yeah. Well, thanks for inviting us to, to talk tonight. I'm looking forward to showing the audience um, a bit about what we do and, uh, I'll start off with a bit of background about myself and I'll pass on to Doctor David Collins. So, as mentioned, I'm Paul Ingham. Um I'm based in Barcelona, but spend quite a lot of time in the US um probably in Houston every couple of months. And um my background is as a computer scientist. Um my education and spent most of my career as a technologist um working in investment banking and also in the far east. Um But we'll talk a bit about where this, the company started from and our journey to where we are today. Dave over to you. Yeah. Thanks for uh hi, everyone. My name is Dave Collins and very briefly, I've got a bit of a diverse academic background but completed a phd in fellowship in biomedical engineering and computational biomechanics before moving into the medical device industry. I've now been working with insight surgery for well over four years. Um And a large part of this time was spent managing one of our embedded facilities in the market for the children's hospital in the full UK I spent most of my time designing and manufacturing patient specific medical devices or disciplines and more recently as have already alluded to have now hopped over the pond to Houston as insight surgeries us, head of engineering and John flagship um pub in Texas Medical Center and I growing us operations. That's superb. So again, let's jump straight in Paul. I know you got some slides and some info to share with us. Let's love to see it. I will do. Thanks chair. I hope tonight to not make this death by powerpoint. I want to make the slides nice and visual and exciting for everyone to try and give an understanding of what we do really and uh you know, the types of areas we work in. So I'll just share my screen now and we got one video in the middle of this um a short video, but I'll just um share now. OK, just to double check, you can see that one. Yep. Great. So as Stuart mentioned, we recently had a rebranding. Uh we record the light for about nine years and uh we decided that as we pivoted away from the organization, we were before to today to look at a new name, hence inside surgery. Um So what do we do? We do digital planning and provide personalized solutions and I'll talk you through the next few slides exactly what that means. But first of all, the beginnings, uh as I mentioned, we've got quite an interesting background. I started the organization as a social enterprise in Kenya back in 2012. And at the time, we're looking at using free printing for prosthetics, we worked a lot across the East Africa, uh and then into Southeast Asia in the provision of low cost preprinted prosthetics. As you can see here on the left hand side, our our poor first attempt as they moved down the chain towards having more realistic devices. And this also included lower body as well. Another interesting uh start as a social enterprise and in our humanitarian routes was around working with the United Nations. Um So for quite a number of years, we provided uh fake land mines and weapons of destruction to teach villagers uh on what not to do. Um So for example, the white helmets in Syria, something may heard of them uh very big at the time in terms of the great work they were doing. So you see from the picture here, we're providing the fake devices to allow them to understand how to tackle these devices. Um Also with the UN in places like Mali, where we had fake bombs were put into the ground to allow them to detect and and find the best method for that. Our journey with that actually accumulated uh for myself speaking at the General Assembly uh in Geneva at the UN, which is quite an interesting and daunting experience uh with 100 and 74 country directors within the facility um showing there as you can see in the screen. So, you know, we're really proud and pleased with the background of how we started. But as you'll see in a second, we pivoted towards a commercial entity um but still trying to help patients lives. So what is our vision? Um I'm just gonna move this a little bit here um for every surgeon to have access to personalized surgery um with digital planning and patient civic devices. And I'll show a second around what that means in terms of the gaps that are there today. Um We've always started with point of care. Um point of care being, we have people and tech that sit in the hospital itself and we over pinned by a digital platform that we made a few years ago called Embed Med that allows access to the personalized surgery. So where are we as a company? We have six and better facilities in UK hospitals uh ranging from the north of England to London. Uh we have two FDA clearances and our IO 13, 48 5 certified. Um Since 2015, when we commercialized in the UK, we have provided thousands of devices uh covering all certain disciplines, uh cardiology, orthopedic, oncology, et cetera. Um What we do is provide this as a platform as a service which is driven by A I and as Stuart will talk a bit later on about how we're working with Houston Methodist um for the VR uh David just now is sitting here uh in Texas Medical Center, which is our first US K hub which has recently opened. So what is the problem that we're trying to solve here? And what's our solution and the opportunities? The problem is that every person is unique but majority of surgeries are standardized. You know, a huge figure here that standardized surgical plans, medical devices, the fact that digital planning is not currently available or readily available and the delivery of patient devices is quite slow, uh weeks, uh months in some occasions. So really, for us, we saw a solution as a personalized uh for personalized surgery, which has been proven to improve patient outcomes. Um for our platform that allows surgeons access any time anywhere to this types of planning and the personalized medical devices. So for us, the inside surgery, we've taken the time for providing these from weeks down to days, for example, in surgical guides and then for implants for months down to weeks. So really, we're trying to optimize and streamline this process. So what is personalized surgery, um personalized surgery. So falls from our perspective into into these three verticals. So let's start with everything starts with the image from AC T, from an MRI uh from an X ray and so forth, we take that image and then we extrapolate the region of interest from that image that allows us then to go to the next stage. So for example, a scoliosis spine, if you're looking to have that for some remedial surgery, we would take the scan AC T or MRI and then extrapolate that spine and then turn it into a 3D model. And through the platform, as you can see in the the middle image here, the surgeon then has the ability to see the model to review the model and then to understand the digital plan, digital plan in terms of how will they do the surgery. So in order to optimize and make the surgeon most effective a hub is planned on before uh through both uh the digital plan and visualization. And in the end here is the personalized devices, you know, that could be a 3D model. Uh It could be a physical model uh in terms of a patient specific model of the anatomy or a surgical guide or an implant. And Dave will talk a bit more about his actual products in the next couple of slides. Yeah. So cheers. So yeah, in terms of the services and products we provide, these can broadly be broken down into four categories. And as Paul pointed out all of these use an individual scan data T I MRI their foundations. So the first of these um are our patient specific anatomical models. So you can see in the second picture here. Um and these can be used to better understand complex conditions and anatomy and they can be used by the surgical teams to plan, they can be used in theater for sense checking during an operation. Also as part of the patient communication and consent pathway, which particularly in pediatrics can be an important component of decision making. Um Secondly, we also provide digital solutions to these encompassed digital models of patient's anatomy, which can be used either on computers or VR environments in both clinical and educational contexts. Again, to better understand complex conditions in anatomy. And our digital solutions also encompass virtual surgical planning, whereby we can virtually plan the surgery ahead of time to improve accuracy in our books. Simple examples, cook food, helping to plant baffles in cardiac surgery or osteotomies and resections in orthopedic surgery. Uh The virtual surg surgical planning often goes hand in hand with our third category here, the patient specific surgical guides which you could see in Blue Sea on the boom there. Um When using these, we would, for example, virtually plan boom resection and then also go on to design and manufacture a patient specific sur cutting guide. The guide is designed to fit exactly onto the patient's boon anatomy. Again, as you can see in that picture and defines the locations, angles and depths of cuts that would allow a surgeon to actually replicate plan to cut theater. And finally, we also design and manufacture patient specific implants currently um in the UK like surgical guides, they're designed to exactly fit an individual's anatomy, unlike surgical guides tend to be permanent uh rather than temporary fixtures. But due to the complexity of the cases, custom implants are often associated with and useful. They can necessitate both the virtual planning component and the use of patient specific surgical guides or to show in short outcome. Right? Thanks Dave. Um So, moving on here, so point of care, uh what is point of care and why is it interesting for us and for the market? So as you can see here in the picture, uh this is children's Hospital in Liverpool in England. And this was our first point of care. Back in 2015, we were invited by the hospital and by Masonic to set up, you know, a first of a kind in the UK where we have three printers and technologies at the point of care. Actually in the hospital now been there for about eight years. And David, as you mentioned before has been uh uh leading the the hub management there for a number of years, we provide devices across everything from pediatrics or from cardiology to orthopedics, uh to oncology, etcetera. And Ray has been a great relationship with us with the in terms of the journey towards this and ray with point of care. Why is it important is important because you have the proximity to towards the surgeon uh within the hospital itself, the time to delivery the ability to have the feedback from the surgeon and interaction. So our business model from the start has always been point of care plus a remote. So we call it the hub and spoke. So within example, we can service a number of hospitals in the same region from a central manufacturing facility and a central staffing facility. So the next section of this, we're going to talk about surgical planning and then talk about surgical guides. So I wanted to show a picture here to show, you know, 100 years ago what a surgery looked like. And the surgery, this was pre x-rays. So the first time that a surgeon actually saw the, the problem of the condition with the patient was in the surgery, they opened the patient up and they thought, wow, ok, that, that's what's going on here. And so ray when x-rays came in, that gave the surgeon's ability to pre plan before the surgery to understand the broken nature of the bone or something else like that. So if you fast forward now 100 years or so forth where we are today, you know, with plans of surgery, they're still mainly done by two D images on a screen from x-ray, from CT and from MRI, um they may create a surgical plan that's on paper. So they know what they want to do before they go in the surgery. Um But often they don't know what's going on until they open the patient up. So what they will talk about in a second, in terms of surgical guides and digital planning allows the surgeons to go a lot faster for more accurate uh ability to treat that patient faster within the surgery. Um More accuracy in terms of the cuts of planning to do less blood loss and so forth. So really, it allows less experienced surgeons also um to do complex operations. So really, you know, the path as I mentioned has gone from, you know, zero foresight towards what's going to happen in the surgery to towards where we are today with 3D and two D technologies. Um with the ability for us to plan the surgery entirely before the surgery actually happens. Ok, Dave. Yeah. So I know we've already touched on these, but surgical guides often provide, I find they provide an intuitive and easy to understand example of the important role 3D tech can play in modern day surgery. So I think it's worth delving into a little bit more of uh detail about how they work. So, um you see lots of complex orthopedic oncology cases um in our line of work, whereby the surgical team will want to remove a tumorous portion of bone for this, they want to maximize bone conservation, um which is particularly important where they want to reconstruct and restore function, for example, at the hip joint. Um But they want to do this while also ensuring there are no positive margins. So positive margin just means that cancerous cells remain in the affected bony region after surgery, which understandably we all want to avoid in a particular surgical team. So by leverage leveraging 3D patient scan data, we can pull out and reconstruct re relevant anatom Forbes for the surgery. We can then use the resulting models to leverage our 3d virtual planning processes in order to help virtually plan the surgery and then go on to design resulting surgical cutting and drilling guides. Finally, we can then leverage our 3D printing and regulatory processes to safely manufacture these devices in time for surgery. And while I've touched on orthopedic oncology here, um you know, the surgical guys can be used in a, in a multitude of ways, for example, to help with cutting and reigning bones that room are healed properly, or they can be designed to complement sub subsequent implant systems. Um so that the implant systems are fixed in optimal safe positions, they last for a long time. And so in these ways, we can see how the the 3D tech that we that we use and provide lends itself to augmenting that the amazing stuff surgeons are already doing um kind of the process to help improve surgical outcomes. So, but rather than take our word for it, um we do have a short video now to see from doctor a Siddiqui who's a consultant orthopedic surgeon at Oxford University Hospital in the UK. Um And he's gonna describe his experience of working with inside surgery, not card service A box. My name is Arthur Saki. I'm a consultant orthopedic sarcoma surgeon. And I work at the Orme Center based in Oxford, part of the Oxford University Hospitals. I must also congratulated inside surgery for their launch in the US. They already have five centers who are doing remarkable work here in the UK. We've done about 20 plus cases with inside surgery. What I found really is one, we are very lucky to have an on site facility where they not only do the planning but also the printing of the 3D models and jigs. It is quite easy for us to get access to them, not only physically by actually visiting the hub where all the magic happens, but also we can do it electronically insight surgery has given us is one that they have delivered very professional service with highly trained engineers have got absolute confidence and trust in the products that they've delivered to us. And finally, they are very, very accessible results of our audit. What we have found is with the use of these shapes. We have not had any positive burnie margins. We have definitely had shorter hospital stay. We have had smaller blood loss, which obviously has ended up in needing less transfusion. So the patient outcomes have been good as a surgeon. My stress level is low because I know that I have planned the resection margin and the results are there to prove this uh similar results have been observed from around the globe. But yeah, we have absolute confidence that we are replicating all of those good results for the use of this technology. So the guy that are produced by inside surgery are quite easy to use. There are some prerequisites though. And one of the prerequisites is that you should have worked with the engineer on getting these guides plan. The engineers would you would find them really keen to have an open discussion, uh They're very well trained now, so they will give you their own points. This is service that you and I know that we need for our patients. We have shown in our audit as well that we have reduced pro social complications. Patients have had a faster rehabilitation, shortening their hospital stay and improving the discharge times. We have had less patients going to IC U uh earlier discharges. But at the same time, uh we've also had uh overall better patient reported outcomes and less of, you know, the need for additional procedures afterwards. So all in all, I think it's really helpful to have this technology at your disposal. It's very user friendly. I would welcome you all to get really involved with this new journey on your sarcoma pathway. Well, thank you Arthur uh for virtually giving us those glowing words. Uh Arthur is one of our wonderful surgeons, as I mentioned based based in Oxford. Um So really just the next page here around, you know, a quote from a leading surgeon, Mr Rob Pollock. Um he is the, the chairman of the British Orthopedic Oncology Society, a very influential uh entity within the UK. And Europe, a senior consultant sarcoma surgeon who works at a number of institutions including the Royal National, the Public Hospital. NHS are probably the biggest one in the UK for uh working with complex oncology cases and really strong statements from Mr Pollock. Uh in terms of, you know, now that he's been working with us and with the technologies, he would not do this again. Uh he's referring to bone sort of cover procedures, but for us, he's the kind of sort of really positive both from a business and from a patient outcome perspective to hear that the surgeon has adopted this technology and, and now can't do without it. So what are the benefits of surgical guys? You know, we just sort of touched upon it before and there's no planning patient specific models. So I'm gonna go through sort of four or five different verticals here. So faster recovery. Um you know, we do have lots of stats and lots of studies in the background here, but with the use of guides, it allows faster rehabilitation rates, ability to, for patients to have less time in itu. Um and, and have a better patient outcome. So all in all, you know, the less invasive the surgery is uh the more dependent patient will benefit less major issues, major complications, infections and and so forth. So, with the use of the guide and the planning and the models that can be used uh preoperative inter operative or post operative uh for surgeons use for visualization. And they've seen less major issues in terms of the complications arising from the surgery, less positive margins. Uh Dave mentioned that before, so I won't go through again. Um But with the use of guide uh in one of the cohorts of study, we saw no positive margins. Uh whereas without guide, there are positive margins and positive margins obviously are terrible for a patient and could lead to death. Less blood loss is quite an interesting one. blood is expensive. Uh And so within the studies and within the theater uh by the use of our products and services, we've seen less blood loss by about 20% which then means less cost to the hospitals. So, one of the slides after this, I'll talk a little bit about the health economics uh for this. And why should hospitals and medical device manufacturers pay us for the service? And lastly, and probably the most interesting point is around less time in theater. So less time in theater doesn't actually give money back to the hospital. Uh Obviously, it's better for the patient because there are less time under anesthesia, uh less chance of infection. But really, it means that they can increase the surgical waiting lists. So if you can work out, that is 80 minutes saved in a particular operation that allows you then to schedule more operations per day, which obviously is a revenue generating exercise. So onto the health economics, I just wanted to go through four points very quickly here. As I mentioned, the reduced theater time, for example, a certain hospital has a 53 operation a day break even point. Now, if they can push that to 58 or 60 operations a day, then obviously, it's better for the hospital. Um The fact is that if you save an hour or two hours at the time and in some operations in some types of procedures, um we've seen almost a 50% reduction um by the use of digital planning. Um So at the time, it doesn't actually allow them to do more on the same day or the same month. But in the future, they can then understand the the the patterns to towards that lower cost in theater. Now, that could be uh less instruments used, uh less blood packs used uh and less, more expensive staff that are in there. So if you're in a huge operation, that's nine surgeons over a three day period. Um The the less you know time in there, the lower cost it overall is for the institution in many cases. Uh there is a reduction in thor surgical procedures or our entire um they don't need to do it. Um So in the study we did with 100 and 80 anti models, uh they saw 43% reduction in the need for procedures, um which is obviously great for the hospital and even better for the patient. And the fact that they don't need to have a, a further, you know, invasive surgical procedure. Um as I mentioned in the last slide, reduced complications and less litigation exposure. So for all four of these points uh to monetize this and to say, right, what is the value for the hospital they'll see different between the UK and EU and the US. But there is ability to put figures against these which allow them to the business case justification for the hospital um for us to provide them with the services. OK. So the next section uh Dave's gonna go through four slides. Now, uh going across our major surgical disciplines are from orthopedics, oncology, cardiology, pediatrics, and give some examples and some background for them. Yeah, exactly. I thought following on from the overview benefits, I thought it might be useful to dive into a little more detail about, you know, what our work actually involves and what, what it is. So starting with orthopedics. So yeah, we're very active in orthopedics and the bulk of our work often comes in the form of anatomical models and surgical guides across a full range of orthopedic anatomies, the shoulders, hips, knees, you name that we do it and we're able to print our patient civic um orthopedic anatomical models in the boon like material. And what this means is as you can see in this picture. Um Here, this gives surgeons a chance to simulate on the model in one of our simulation labs prior to theater, which can have real value for them, particularly in the more complex cases where they really need to think about how they're going to achieve a desirable outcome. Um We also do a lot of cool work designing manufacturing social guides, which is designed not only to achieve optimal um osteotomies that help restore function in the bones and joints also to complement implant systemss, such that these systems can be fixed onto the bone more quickly. And in a way that naturally puts the bone uh back into or into the preplanned position that we'd uh virtually planned before surgery. So that yeah, oncology. So I've already kind of talked a bit on oncology. So I didn't leave on this too long. But um you know, we, we do do a lot of work with the oncology, oncology teams throughout the UK. We find anatomical models, they can take it into the theater for sense checking during operations and also use uh prior to theater for patient communication and consent. And as you now know, we also design and manufacture our patient, civic surgical guides to help surgeons optimally put the bone fe location into planes and angles. Um and where joint restoration function wants to be restored. Also to complement the implant systems that being used to achieve that. Moving on to cardiology. Yeah. With cardiology, we work cross both congenital and age related defects and produce patient specific anatomical models and one of the most flexible 3d polymers available. Um And this last surgeons cook and simulate surgery prior to theater slightly orthopedic guys come with their boon like models. Um These models can also be used to size devices, devices, which are the devices that essentially I just plug the holes that shouldn't be in the heart and before they are inserted to make sure they fit with our complication. Um And perhaps the area we're seeing most uptake and utilization of our models at the moment um is for planning for certain transcatheter procedures, um which are increasingly being explored as alternatives to surgical intervention and cardiology. So these percutaneous procedures, they're many invasive, but they require very careful planning to ensure that the devices are being asserted during these procedures and are done so safely are aren't gonna cause unintended problems. Um We also do help with effectual planning when needed often in cases where be routing of the heart and the blood flow is needed. So for example, we can work out where the can happen if there's enough room for a baffled and things like that. So, yeah, so we do lots of work in CMF as well and CMF work often represents some of the more complex work we do. Um and often involves a full suite of products and services. So that its models include planning includes patient specific guides and also includes custom implants. Um not only is the anatomy complex in this area of the body, but a good aesthetic outcome is also uh desirable. So the pictures here, uh detailed fibula, free flap surgery. So you can see in the right hand picture here, that's the the the fibula uh being cut. So in fibular uh free flap surge, um our helper often requested for these, the surgeon wants to remove one of the bones in the leg, the lower legs with the fibula um and remove it in segments to then go on to reconstruct parts of the jaw. So the fibular bone runs on the outside of your leg bone um from from the knee to the ankle and it's a small thin bone that can just be removed. So that affecting your ability to bear weight, be a perfect candidate for this kind of surgery. Um So the fibular bone is removed along with two blood vessels and can then be used for reconstruction in the jaw, our guides, which you can see in the right hand picture. This this white um device here allows the surgeons to cut segments of the fibula at the right lengths and angles such as these segments can then be pieced back together in in a jaw like shape and then our custom implant, which you see here, it's placed on the left hand side of the screen can then be used to fix those segments together to store function, aesthetics or pieces. I think just to add there, Dave um as part of our FDA certifications, we are cleared for maxim facial work as well and uh work in a whole bunch of areas for orbitals for my um for Zygoma, et cetera and or as well. Yeah. And then finally, yeah, we do lots of pediatric work. And I spent, as I said, it's part of my, my time at insight surgery, working across pediatric surgical disciplines. Um but perhaps one of our favorite stories, it's come from our work in pediatrics and it really stands out um to us as an example of our leveraging 3D tech. In this case, just an anatomical model can really help clinicians and their complex cases. So the little girl in the picture is called Leah. She presented with a large abominable rare abdominal tumor that they didn't even have a name for. It was so rare and the tumor had grown around the A and IVC, two of the most important biggest vessels in the body and also into a spine. And so the the amazing surgi surgical team, all the hospital hospital decided to operate, requested a model to help them communicate with and their parents and also carefully plan the operation. Um And using the model be before and during surgery, they were able to remove to 95% of the tumor without complications. And with subsequent treatment, Leah was able to ring the bell and return to a very happy and healthy, healthy life, so much so that we are now able to sponsor her league soccer team that she plays in on a Sunday every Sunday. Um And the story as you can see in the right hand picture there is, is now told at a national cancer exhibit um back in the UK, in Manchester, in England. And yeah, and, and as well as our, our virtual planning and our 3d printed devices, we are delving into the world of virtual reality and I've done some pretty um I think Stuart's going to talk about this, so I go into too much detail. But yeah, we've done some uh exciting work with, with Methodists around uh patient specific virtual reality models for, for education. Yeah. Thanks David. This is uh as we're talking in a second, this is actually the Houston Methodist. So really, we're trying to sort of augment what we do as the digital planning and the models with the A R and the VR world. Um So two more places to go. Um So this is one we're very proud of. Uh this is called the Beating Heart simulator. Um So we're tasked by the David Knott Foundation in London a few years ago. Um Come up with a solution um for a heart that was realistic. Um It had the internal details was inside it and could be cut and sutured while beating. And the reason I wanted to ask that is the organization is for war surgeon, the, the, the trained war surgeons in Syria, Iraq. And now, unfortunately, in Ukraine Yemen and so forth and within the, those, those war conflict or post conflict zones, they don't have access to the first ball facilities to stop the heart or bent of blood for the operation. It could be a bullet wound, it could be a blast wound and so forth. So from here, you can see a rugged solution that was used and is used in the field in many countries. And I was still a little video here to show we stay in the system, you can suture it. And again, we're very proud to be able to provide that with our technology. We also provide uh kidneys and livers as well that simulated bomb blasts um for the war surgeons. So a slightly more boring this line but very important uh towards the end here. So innovation will lose to a certain point. Um For us, uh as I mentioned, we're 5 10, we have 25 10 Ks from FDA and is a 13 45 so regulation because the medical device and the nature of this uh the class one or class two devices, uh it's very important for us to ensure that our quality management system, our processes and checks and balances are absolutely um and, and very, very strict. So we manufacture our circle guides in house uh in our own clean rooms. And for that, we need to make sure that the material and the rooms have been passed um for microbiology um have been passed for the materials not being harmful to human. Um The social guides are implanted for, for a couple of hours within the body. Um Obviously, they go through the same rigor as a medical device, uh an implant that's there for the longer term. So as we continue the journey, we're seeing a lot of organizations that are doing what we do in, in a smaller way um that are not regulated. And so we always sort of push for the hospitals to ensure that they are working with organizations that have the full approvals um which are there for a reason and on to the last slide. And really, um just to sort of say, thank you everyone for listening this evening. I'm looking forward to Q and A now um in the top right corner, a little bit of fun at the end here. Uh That was the first model we ever printed um back in 2015 and then in the middle here, you can see this wonderful model which was a series of models we created um by scratch, the University of Oxford Department of anatomy and number one in the world. And you can see the level of detail that can now be achieved with the technology um and need to be used to teach uh students within the facilities. So, thank you everyone and I'll pass back to Stuart. Ok, Paul and David, thank you very much for that. Um I love the fact how Dr Collins has been in America almost a week now and he's referring to the beautiful game of football as soccer, so great transition there. Collins avoid any. Um Now it really is fascinating work that you guys are doing and I kind of want to just highlight to the audience some of the stuff that we've been doing with site surgery over the last kind of six months. Now, the heart of Scar Center has a really robust and a comprehensive innovation program. Um And I'm delighted to be a part of that and, and what we try and do is pull in this cut and edge technology and look for new applications of it. So with insight surgery, you know, we actually had um, Doctor Collins integrated within the system here looking for new use case scenarios. And one of those that really landed was our um work in virtual reality. And if we go to the first slide here, um you know, back in 2020 with the pandemic, our reality changed, you know, we really had to change and, and pivot on how we actually give education and training programs. So we, we went head first into the extended reality, right? So that's augmented virtual, mixed reality, et cetera. Um You know, we were using Quest two system, we're using the Hollands, etcetera. And something that came out of that was what we're calling the Myer. And this is a for medical innovation and it offers a lot of things which you'll see in a second. But one of the main things that we can do in the verse is understand complex surgical procedures through case study video footage in conjunction with an anatomical 3D models. Now, if you go to our youtube site at D CV E dot org, you know where I'm streaming from now, you'll see hundreds if not thousands of surgical procedures. So we thought, well, we have all that patient data. Like we have the dico scans. Could we create an environment where you can not only watch the video, but you can actually hold the patient's anatomical regions of interest in your hand. And that's kind of what we've done. And I'm going to show a little clip there uh from inside the verse. Yeah, that's an overview of the mighty verse. But I'm going to jump straight into another video to show you our virtual reality Heart Vasco Center room. And this will give you a prime example of where we're, we're going with this. So next video, please guys. So you have the user here. That's you know, the wearing of your headset. This is what they're seeing and they chose a video there which is going to populate in the background and it's an ascending cycle aneurysm repair using goor cuffs. And what you see in a wee podium in the background is a heart, that heart is that patient's heart. And what we're seeing here is about six or seven of our colleagues coming into this room. I believe they were in Holland, the UK Portugal and the US C on different time zones and they're all able to interact and speak together and kind of discuss the video, discuss that patient's anatomy. So again, you can see, I'm selecting that heart model there and it's populating up. And what you're going to see in a second is our colleague coming up to us and actually handing over a 3D model that patient's heart. And again, this was segmented and rendered and texturizing and colorized by insight surgery. And you're gonna see they're gonna hand that off. Now. So again, that heart is based on um Dico CT data that we got from a patient here during an operation. OK. And if we just pull it back to the slides guys, now, the final thing I want to show what you'll see in a second is you have Dr Stephen Leno there who's at the AC C conference, which just happened in New Orleans in March the fourth to the sixth. He's holding a 3D printed version of that heart, which you just saw in the VR room. So again, just to do a full circle, you start with the video which is in the top right hand corner. So you can see the full procedure of that. Well, the full video of that procedure or you can then go into VR and see the heart for yourself, see the video or you could decide to print it out. And that's what we, we we took to the AC C. And if we um I've actually got that heart in the studio with me is another special guest we see here. So close up this guys. So again, this is it, it's hard. I hope you can see this at home folks, but this is a really beautiful um segmented rendered texture heart here and we got it on a on a hand now, just so, you know, that heart is actually to scale the hand isn't obviously that's, that's a big hand. Um Let me just use that for aesthetics, but that heart, you can compare it to my hand there, just the size of it. Obviously, the patient here has progressive heart failure here. But again, you can just see the, the intricate and detailed nature of that. And if anyone in Houston method wants to see this, um we're actually going to have this on display at Maori and we'll have all the other um models on display as well. So you know, jumping straight into Q and A and, and again, I, I hope the audience appreciate just that use case scenario, but I, I want to get a better flavor of some other use case scenarios, maybe in particular in cardiology. So. Well, let me take a step back. What is the most complex case that you guys have interacted with, Dave over to you in that one? I mean, the the different cases, the complex in different ways. I know that sounds like a bit of a cop out. But, you know, all the children's hospital, it's a, it's a national center um for, you know, pediatric surgery and medicine. And we see a lot of the, the really complex end of the congenital heart defects um where you have, you know, congenital defects occurring, you know, together. So not just one, not just a, a I say, simple VSD, but you've got a coo occurring with a whole host of other defects. Um and the work they do to repair that, you know, it, it, it's incredible and, you know, it's just nice to be able to help in some small way with, with, with our models to help them understand that anatomy or size of device. But as I said before, the, the trans cater and stuff, it's complex in a different way. The, the anatomy they're working with might be a bit simpler. Um but a lot can go wrong if they don't get the the, to see the stent placed in the right position and it can have some very serious unintended consequences. So, I'd say it's difficult to pick up one case. But um, certainly we, we definitely, um yeah, working across a whole host of complexity. So, so, you know, following on from that, I'm going to dig into tech a little bit more. Can you maybe comment on things like size constraints of your uh 3d printing technologies? And what type of materials can you print in different stiffness, different elasticity, that type of thing. Yeah, I can answer that one, Dave. So really, we try to be technology agnostic. As an organization, there's a lot of different competing technologies out there um from FDM to POLY to S A to SL S and so forth. So really within the materials, we can go from very uh toward a very short a hardness down the sort of 10 to 20 range um for that um that could be in multi color in the full CMYK range. Um This can vary between $5000 to a million dollars and we're trying to sort of keep a rate within there that's affordable. Um But really as to ask the build place sizes, there is limitations uh within this sort of more expensive technology, for example, Poly in the build places, you know, they're not huge, you know, probably the size of a microwave or two in terms of what you can print within there. Um but you can get much larger footprint, but on less detailed technology um for FDM, so you can, you know, you can print your entire self. Um but the detail level won't be as good. And the technology depends on if you're using resins or using a deposition methods for that. And we're trying to keep a raise and mention that uh affordable for the clients and for the market. So the bone like material, it's a lot cheaper than the model that Stuart just showed um which is uh the super expensive material. Got it. And, and again, you're going back into what you were saying about your ISO certification and after the approval, I believe you got 25, 10 cases. Um can you just comment on that a little bit more? You know, if you had a surgeon wanted to use your devices, your materials, what can they do with it, you know, on a patient and a patient and what can they do with it at the current moment? Yeah, so we didn't start with the Ortho. Um So a recent orthopedic uh 5 10-K approval um this falls on from our isa 13 45 which is not applicable in the US. Um But it's very similar in a lot of ways. So it's a very encompassing 5 10-K approval. So basically all long bones in the body from neck down um for the muscle skeletal system. So for that we can provide them with sterilized models, digital planning and sterilize surgical guides, for example, a surgeon on a Friday evening, um, wanted to have a set of guides to the following Friday. Um, within us, you know, because we can do it rapidly, um, within those period, you know, we can provide that for, for the surgery. So really planning guides models. Um, anything else you can think of? I missed, I know, I think, I think that that puts it and can you maybe comment about timing? So if I come to you right now um with dico images, et cetera data, when can I, when can I get the thing off you? When can I get the 3D print or the VR model? Yeah. So you know, we can turn around within five days. So a lot of checks and balances that have within that five days and as part of what you have to do. So for the interaction with the surgeons, we have a platform called embed Med. The surgeon can instruct for us to provide with a model or a guide and so forth. And that then goes into our workflow into the back end, assigned to an engineer in one of our teams and one of our locations. Um That then allows that data to be extrapolated, then provided to the surgeon. So the surgeon will use the platform the whole time. Uh There may be a video phone call for a review period. Uh and then the manufacturing, depending on location could be handed to him by or her by the the following week. And, you know, in the future, I mean, obviously, you know, we, we used um your, your technology and your expertise for VR app, right? So do you really see there maybe being more work in the VR era because it's a little bit quicker, easier to access or is there always going to be um a place for where you need the 3D printed models? Can you comment on that a little bit? Yeah, sure. So I think there's sort of two folds in there. So, uh you know, VR has accelerated in the last 5 to 10 years. Um but you're still very rarely A R is more popular to have a surgeon that would have VR glasses on in the surgery, for example. So maybe used for planning purposes prior to the surgery. Um But our elements of that the surgeons like to touch things like to turn them around and to wear VR glasses in the surgery. Um You also have that uh ecosystem as you're not aware of your surroundings. This is very important for the surgeons and for the surgical team during the surgery. So really, you know, moving from looking at CT scans on TV S in the surgery towards putting a physical model, but the digital plan almost surpasses that. So I see it show the two technology is augmenting um, I think in the future when we move towards VR, that is got the list. If that makes sense, then it may be more than that. And in the surgery got it. And I think, you know, clarification, I guess when I see VR, I'm really meaning Xr. Right. Because, because like you show in the video earlier, um, I, I totally agree. We're finding a lot more uses more in augmented reality. Um, But what I'm hearing, it sounds like if they develop better technologies for haptic feedback, then you've got all bases covered, right? You've got augmented reality haptic feedback. It feels like you're interacting with the model. Um And I really like to know, you know, why did you guys decide to set up shop here in the T MC? Obviously, there's east coast, got Boston, you got the west coast. Um Why the third coast? Yeah. So we did a lot of analysis before we chose Texas and we, we, we've chosen the right place to, you know, working with yourself at Houston Methodist and being in TNC, I don't see the size of Texas, you know, the amount of hospitals, medical institutions, you know, a lot of areas in America uh deem themselves to be the MedTech Center of Excellence. Uh Irvine, for example, or Minneapolis. Um We also have very strong links via the British government and uh via the Association of British health care Industries. Uh We have regular missions um to Austin and to Houston. Yeah, you're absolutely right there. And I think a bh I is led by, um, Paul Benton, right? And we have obviously UK trade and development as well or, um, so, you know, call the action. What's the best way to get in touch with you guys? Now, for, for the Methodist employees, we've already done you guys a favor. So, through my, we actually got a service contract and by you guys, I mean, the audience at Methodist, we've done you a big favor. We actually got a service agreement in place to, for anyone at me to be able to utilize and use the services of insight surgery. So feel free to email me that um if you're interested. But what is the best way to get in touch with you guys just in general? I mean, just to, to email us directly, um you know, or, or go and see David. So we always welcome visitors um in the Texas Medical Innovation Center. Um We're just opposite the JNJ um Center for Device Excellence. And we're also, you know, happy to provide uh some interesting news cases um or have a phone call, you know, have a phone call ourselves to discuss the requirements. You might have super as long as that call is not in Barcelona time, right? Because it be easier to call Dave, I think. Um Well, guys, it's been absolute pleasure having you on. It's been really great working with you guys as well over the last year or so. You know, I'm, I'm glad I'm in the studio. You know what we're looking at the, the product here. Um People are using. It's fantastic. So once again, thank you very much and thank you to the audience as well for tuning in. We will be back, hopefully, I believe in May. So, um good evening and see you soon. Bye bye. Thank you very much.