Virtual Blood Vessels, 3D Printed Organs: No Animals Were Harmed in Training These Surgeons

There are currently some 3,000 medical simulators in use in Israel and around the world helping physicians and other health professionals to practice carrying out a range of procedures

Ran Bronstein, Vice President of 3D Systems at his office in Lod, March 7, 2019.
Eyal Toueg

Surgeons using a Simbionix medical simulator for the first time often report feeling physical pain, in empathy with their virtual patient — the experience is that realistic. The organs and tissues look entirely real. When stitching an organ, the surgeon sees the needle entering the tissue, on screen, and pulls the thread taut. If it’s pulled too hard, virtual blood vessels break and the organ starts to bleed.

There are currently some 3,000 such simulators in use in Israel and around the world, helping physicians and other health professionals to practice carrying out a range of procedures. The simulators were developed by Simbionix, whose offices are in Airport City, outside of Ben-Gurion International Airport south of Tel Aviv. In 2014 the company was acquired by the U.S. company 3D Systems.

“In the past doctors practiced on cadavers and on animals, but medical simulators enable creating a precise experience for some cases, so that the doctors don’t encounter it for the first time during the operation — and they can also analyze their performance,” says Ran Bronstein, vice president and chief research and operation officer, health care at 3D Systems, who leads Simbionix. Many doctors still object to or don’t trust virtual simulators, and prefer traditional training methods, but Bronstein believes that most of the pushback has passed.

“In aviation it’s very accepted to practice on simulators, and everyone knows that pilots do it. But in the near future it will be obvious by the same measure that doctors also use simulators to practice and maintain their skills.”

Simbionix was founded in 1998 in Israel by Bronstein, Edna Chosack and David Barkay, as a project within the Chief Scientist’s incubator program. It specialized in simulators for minimally invasive procedures such as endoscopies and catheterization. But the first few years were tough: The market wasn’t ready.

Medical simulators for training doctors.

“It’s much harder to make a medical simulator than a flight simulator,” says Bronstein. “An airplane has known physics, but the human body has no technical specifications or fixed behavior. Creating a realistic simulator is a big challenge, and it took a long time to move forward.”

The company also faced the high-tech crisis of the year 2000. A turning point came in 2002, when the Cleveland Clinic Foundation invested in Simbionix, as a result of which the company moved its headquarters to Ohio. Another turning point came when China began using medical simulators, boosting sales.

In 2014 Simbionix was bought for $120 million by 3D Systems, which had focused on 3D printing. The simulators are still sold under Simbionix’s brand name.

“They decided 3D printing had massive significance for medicine,” says Bronstein. Now, the company’s technology enables doctors to print anatomical models of specific patients’ organs in order to plan medical procedures and operations, such as organ transplants or rebuilding a jaw and face injured in an accident.

The company has 125 employees in Israel, divided between Simbionix’s operations and the development of 3D printing.

Screengrab from a medical training simulator.

Simbionix’s simulators include a station with a computer, a screen with a graphic 3D simulation and the relevant medical instruments. The company offers at least a dozen different simulators, each of which addresses a different type of procedure, surgical method or medical specialty, including catheterization, laparoscopic surgery or gastroenterologic surgery. Some have physical feedback systems, similar to modern game consoles. For instance, if a doctor moves a tool within the simulator, she will feel resistance as if the tool is touching an organ.

The screen presents a virtual environment created by computer imaging, technologies generally reserved for video games. In many ways, it looks just like a computer game — the environment on the screen is as realistic as possible, and if the doctor makes a false move, virtual tissues tear and “blood” appears.

The simulators were created in cooperation with doctors. For instance, doctors tested one simulator and pointed out that they would generally stick their operating needle into a specific bone so that it wouldn’t “get lost” during the operation. The developers then added that as an option within the simulator.

The company says the simulators are still developed and produced in Israel. One-third of its market is medical device companies such as Medtronic. The remainder is hospitals with doctor training centers. The company’s machines can be found in hospitals throughout Israel. Another notable customer is U.S. company Intuitive, which develops the robotic surgical system Da Vinci. Simbionix built Intuitive’s medical simulator to enable doctors to practice carrying out complex operations with Da Vinci.

Simbionix has also started developing virtual reality systems. Their uses include team exercises, which may involve interruptions and interactions between surgeons. In addition, they give doctors a means of practicing on fully 3D models, instead of with a flat screen.

Doctors training on a Simbionix medical simulator.

The company is also examining the use of augmented reality, an imaging technology that combines real-world images with computer-generated additions. Talk of using such technologies in the medical sphere is beginning; one such application could be showing doctors a digital rendering of damaged organs on the patient’s own body. Simbionix is yet to have a product in this field, Bronstein notes.

The market for medical simulators is growing: Research company MarketsandMarkets forecasts it will be worth $2.5 billion by 2022, compared to $1.2 billion in 2017, propelled by the demand for minimally invasive procedures and an increased focus on patient safety. A forecast by Grand View Research puts the market at $5.25 billion in 2026.

Other players in the field include Canadian company CEA, Norway’s Laerdal Medical and Sweden’s Mantis. According to Bronstein, no other company has the wide range of simulators that Simbionix does.

3D Systems’ medical unit, which includes Simbionix and its medical 3D printing division, had revenue of $225 million in 2018, a 19.5% increase from 2017 and around one-third of the company’s total revenue.

“Our focus is on how to continue growing,” Bronstein says.