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By Paula Franken

“When you have something important to do, it’s a good idea to practice first,” says Sarah Flora, program director of Geisinger’s 3D Imaging and Printing Lab. “That hasn’t been possible with surgery — until now.”

The seven printers in Ms. Flora’s lab use data from computed tomography (CT) and magnetic resonance imaging (MRI) scans to create 3D printed replicas of a patient’s true anatomy. And whether the models are used for presurgical planning, surgical simulation or patient and learner education, the cost to the patient is nothing. 

“The CT and MRI scans produce cross-sectional or sliced images that depict segmented medical anatomy right on screen,” explains Ms. Flora. “But for some, it’s hard to look at sliced black-and-white data and mentally convert it back into a real person’s body. The printers use the information to create replicas of specific anatomy, giving surgeons the opportunity to hold a facsimile in their hands and see what they’ll be seeing in the operating room. Sometimes, after a surgeon visualizes a patient’s anatomy in such detail, they’ll decide to take a different approach than they’d originally intended.” 

A handy tool for surgeons

Interventional cardiologist Shikhar Agarwal, MD, says he has a 3D model printed at least once a month. “When a patient has a hole around the heart valve, or in the heart itself, the printed model lets me see the exact size and location of the defect as well as the surrounding structures,” he explains. “It not only lets me choose what device to use to plug the defect, it also helps me decide whether a minimally invasive approach using catheters or traditional surgery is the way to go.”

Pediatric neurosurgeon Nir Shimony, MD, has used 3D models to plan corrective procedures which include treating craniosynostosis, a condition where the sutures in the skull close prematurely, causing problems with brain growth and possible cognitive and developmental delay. “One of my cranial malformation cases was extremely complex,” Dr. Shimony explains. “The case involved a baby with complex hydrocephalus — a condition where there is accumulation of cerebrospinal fluid in the brain — and complex cranial malformation. The baby could barely hold his head straight. I asked Sarah to create several models of the skull and the skull base. Plastic surgeon Christian Kauffman and I booked an operating room days before the actual surgery and performed the procedure on Sarah’s 3D model, planning all our cuts and learning where we’d need to be especially careful. We also had the model with us on the day of surgery to refer to.”

Dr. Shimony used a different 3D model to study innovative methods of installing depth electrodes to treat epilepsy. “This was another time my team and I booked an operating room to practice on a model,” he says. “The technique we invented is one we use fairly often now — and we’re about to publish a paper on it. This couldn’t have happened without the 3D lab.”

Thoracic surgeon Matthew Facktor, MD, has nearly a dozen 3D models on a shelf in his office and says he finds them useful when planning to remove tumors in unusual and difficult-to-reach locations. “Being able to hold the model in my hand gives me an extra degree of confidence,” he says. “One especially challenging procedure involved removing a tumor from the trachea right where it branches into both lungs. Sarah’s model was so precise, and the texture was so lifelike, I could’ve used it to practice on — making cuts and reconstructing the anatomy. As it was, I used it to plan my procedure and even brought it to a national conference to see how other top thoracic surgeons would’ve approached the same problem. Sarah’s model was also extremely helpful when explaining the procedure to my patient.”

Surgical “cutting paths”

Ms. Flora explains that she can also create 3D printed guides to aid in cutting anatomy for pathological specimens or even help a surgeon plan to remove the anatomy in the first place. One such cutting guide, on display in the lab, holds a 3D model of a prostate. “Each line on the guide correlates to a line on the MRI,” Ms. Flora explains. “The lines are pathways for precision cutting and can mean less guesswork for upcoming procedures. You can see how a small idea like 3D printing has a large impact on our patients’ care.”

Orthopaedic oncologist Thomas Bowen, MD, not only uses the cutting guides to plan for procedures, he also places them temporarily within patients’ bodies to give him more accuracy and precision when he operates. “Because the guides are custom-created for the tumor I’m removing, I can push the margins closer,” he explains. “They also help when it comes to reconstructing deficient areas in the bone, whether I’m bending metal plates to fit the area or working with allografts (donated bone), the guides help me navigate. I don’t use them for routine cases. But for unique situations, I find them extremely useful.”

Helping patients see inside themselves

Kara Kurtz, RN, who works closely with Dr. Bowen, often uses 3D models to help patients visualize their conditions, understand upcoming procedures and even know what to expect the affected area to look like after surgery. “Sometimes it’s hard for patients to truly grasp the size of their tumors or where they’re located,” she explains. “The lab does a great job of coloring the models to help with visualization. We also use the models as teaching tools for our medical residents. The 3D examples illustrate conditions that are not typical, but they’re ones they may have to treat someday.”

“Our printers can create flexible flesh-like models, or objects that are hard as bone,” explains Ms. Flora. “The difference can be as subtle as a regular blood vessel or one that has thickened to the point of becoming sclerotic. Some of our models are biocompatible and can be implanted up to 24 hours in a patient’s body. The technology is that good.”

Part of what makes the technology in Ms. Flora’s lab so good is the fact that the original scans are coming from an American College of Radiology accredited facility. “Our radiology department is among the best,” says Ms. Flora. “The images are great for input, our software is approved by the Food and Drug Administration and there are rigorous safety checks and strict quality controls throughout the process. We make sure that the input coming from the CT or MRI technology is what’s actually being printed and handed off to the surgeon.”

The making of a model

If a doctor wants to get a 3D model created, they consult with Ms. Flora to go over their imaging and explain what their overall goal of the model is. She then segments and designs the data and has her plan approved on screen before the printing begins. The process itself is fascinating: Every printer in the lab uses a different technology to produce a part. Some machines act like a glue gun, laying down a liquid path on each layer. Some use a laser that hits a vat of liquid, creating solid residue. Yet others use powder and glue. And they all repeat their process for each layer until the model is complete. Once the model is printed, more work may have to be done before it’s ready for pickup. Post-processing can involve chemical baths, sanding or clear coating. The procedure generally takes about 7 to 14 days from the original consultation, depending on the complexity of the model.

“Our 3D models have the potential to reduce time in the operating room significantly,” says Ms. Flora. “They’re wonderful teaching tools and can even help parents through their grieving processes by providing something to remember their children by after they’ve passed. Everything done in this lab is done for the good of our patients — at no cost to them. I can easily say we have one of the best point-of-care 3D printing labs in the country, and we would not have been nearly as successful without the unwavering support and vision of our Radiology administration, chaired by Dr. Aalpen Patel. I am so proud to work for a healthcare organization that encourages this type of innovation.”

Sarah Flora, program director of Geisinger’s 3D Imaging and Printing Lab
Program director Sarah Flora reviews a 3D model prior to printing. 
 
Sarah Flora, program director of Geisinger’s 3D Imaging and Printing Lab
Models are printed by building layers of filament to create anatomical replicas.
 
Sarah Flora, program director of Geisinger’s 3D Imaging and Printing Lab
A finished model can serve as a guide prior to and during surgery.