In orthognathic surgery the printed model simulates cutting and the new...
In orthognathic surgery the printed model simulates cutting and the new loctions of the jaws. Patient specific instruments are designed to execute the procedure according to computer aidded visual planning.
Source: Sheba Medical Center

The role of surgical 3D printing in hospitals

More and more hospitals are entering the world of 3D printing in surgery. Decision-makers and surgeons are getting a better understanding of the technology, realising the immense benefits for surgeons and patients alike. Because 3D printing technology enables fast and unique production at relatively low costs, patient-tailored tools that help to accurately perform operations can be produced easily and quickly. “As the technology itself is developing and accelerating at a fast pace, hospitals may be left behind if they choose not to adopt these advances,” said Limor Haviv, Surgical 3D Printing Designer at 3D4OP.

Interview: Sascha Keutel

How is 3D printing already being used in surgery?

In surgery specifically, 3D printing is being implemented in four primary applications: pre-surgical planning, customized surgical models, patient-specific instruments, and customized implants.

Before medical 3D printing was introduced, surgeons lacked effective tools for planning an operation. Their only option was to rely on two-dimensional CT and MR images to construct theoretical surgeries using their imagination. This means that when surgery began, information was limited and surgeons were largely unprepared which could result in surprises.

With presurgical 3D planning, the surgeons are presented with a virtual three-dimensional segmented model. This significantly improves their ability to prepare for surgery which, of course, helps to improve surgical outcomes. Using 3D printing, physical body parts are represented accurately and patient-specific instruments (PSI) and customised implants are designed and printed in advance.

PSIs printed in 3D are used to execute accurate surgical plans with no surprises in the operating room. Instruments are printed in biocompatible materials and they guide surgeons where and how to accurately cut, drill or fix organs during surgery. These instruments are widely used in orthopaedic maxillofacial and spine surgeries. The technology helps in bone and joint preservation, accuracy of cuts, reconstruction accuracy and functional outcomes are greatly improved.

Patient specific models enable surgeons to practice surgeries prior to entering the OR. Customized implants are designed exactly to match patient specifications, replicating their anatomy perfectly and printed in medical titanium.

My role as 3D Designer is to assist surgeons in pre-surgical planning processes from segmentation through simulated surgical planning to 3D printing. The tools I design and print are used to achieve better surgical outcomes, but the process begins much earlier. Operations can be visualised, practiced and developed before even entering an operating room, all in a 3D printing hub.

3D planning in orthognathic surgery replaced the old method that required the...
3D planning in orthognathic surgery replaced the old method that required the creation of subaccurate patient castings and demanded significant time and resources.
Source: Sheba Medical Center

What are other benefits of 3D printing in surgery?

Patient-specific anatomical models are printed and provide medical staff with new insights and potentially new surgical approaches. They also help to improve decision-making processes and communication between doctors from different specialties. By simulating surgeries in advance, surgeons and the entire operating room staff are better prepared, having exact tools and implants required for the operation.

Also, doctors can experiment with 3D printed PSI and customized 3D printed implants that were planned during the presurgical planning phase or explore the use of a variety of off-the-shelf surgical tools. Furthermore, implants can be manipulated for specific bone contours and for achieving an exact match for joint prostheses. It is now possible to design and print medical titanium implants and customized plates for patients and obtain much more accurate surgical results.

3D printing also allows surgeons to better match the right surgical tool for each step of an operation. Special tools can be printed to assist surgeons in achieving free oncology margins, resecting tumours safely while preserving joints. Cutting guide jigs are designed to execute accurate surgical plans by following the topography of the bone and guiding saw blades. Other jigs assist in allograft reconstruction.

A plate bended on a Patient Specific Model before surgery by maxillofacial...
A plate bended on a Patient Specific Model before surgery by maxillofacial surgeon and a patient specific instrument used to place the plate during surgery.
Source: Rabin medical centre - Belinson

What are 3D printing hubs and what role do they in the surgical environment?

Surgical 3D printing hubs give surgeons from all disciplines 3D tools that help them to improve their surgical understanding and technique through improved visualisation, the opportunity to plan ahead and furthermore, providing exact surgical tools that improve the execution of surgical plans. There is something for everyone – each surgical discipline can benefit from different aspects of this broad technology.

Surgical 3D printing hubs include segmentation software, sophisticated CAD software, 3D printers, virtual reality stations for practicing and more. In the hubs, surgeons are encouraged to participate in all stages of the work process, from processing MRI and CT scans into 3D images, through brainstorming with surgeons from different fields and consulting with surgical 3D printing designers such as myself, running dry run operations at the VR stations with models that simulate the area to be operated on exactly, brainstorming issues and finding the precise tools and implants required for each operation.

Being able to see a 3D model or a 3D PDF image on screen brings different views and opens up discussion to new surgical approaches, improving decision making processes in multidisciplinary meetings. In addition, model and simulations are presented to the entire surgical staff prior to surgery; by understanding the procedure in advance, the overall efficiency of the team is improved. Every step is planned and expected. A well laid out plan helps surgeons to think outside the box and be more creative.

In my experience, surgeons who experience the benefits of 3D printing technology and the designs I help them bring to life, not only trust the technology more but also understand all the immense benefits it has to offer.

Photo: The role of surgical 3D printing in hospitals Photo: The role of surgical 3D printing in hospitals Photo: The role of surgical 3D printing in hospitals Photo: The role of surgical 3D printing in hospitals Photo: The role of surgical 3D printing in hospitals Photo: The role of surgical 3D printing in hospitals

What are the advantages of an in-house surgical hub opposed to outsourced 3D services?

Many surgeons use 3D printing technology through outsourcing. They send DICOM data to a dedicated company which executes segmentation, print models or cutting guides or patient-specific instruments. In these cases, surgeons will receive 3D products but will not be able test and simulate their use. Implementation of this technology in a hospital requires a different scope and different vision.

I am convinced that a 3D hub in any hospital will make a difference. Being part of the entire process helps surgeons convert their thinking from 2D to 3D rather than experience 3D only in the process of an operation. Often, surgeons only receive an outsourced model the day before surgery. With a hub in the hospital, surgeons are involved in all steps of the process, from segmentation through planning until, of course, surgery. An in-house hub, with an in-house specialist designer allows surgeons to experience the entire process. They take part in discussions and planning and can change and correct instruments in real time and practice what they have planned.

A 3D hub in the hospitals is the link between the technology, the printing companies and the imaging data. Even if printing is still outsourced, much of the process can be carried out in-house: imaging, designing precise instruments, models for simulation, patient-specific instruments, metal implants and more.

The closer and more often surgeons work with 3D printing designers, the more they trust the process and from surgery to surgery, they improve their use of PSIs. I myself work closely with the surgeons at the hospital, attend surgeries, thus improving my skills and creating better tools.

Limor Haviv, Surgical 3D Printing Designer at 3D4OP.

What does a hospital need to build such hubs?

In my experience, medical centres planning to establish a 3D printing hub should first concentrate on the first steps of the process, imaging and planning using dedicated software. These are crucial steps for better surgical planning. Technical issues such as materials and printing can be left to the dedicated companies at this stage. In the second stage, hospital labs can purchase a desktop 3D printer which is easy to operate, for printing basic anatomical models and simple jigs.
The transition from 3D lab to manufacturing plant for complex models, jigs and implants is a bigger leap and, in my opinion, unnecessary.

3D labs in hospitals should focus on the initial design stages and leave the manufacturing and complex printing to external companies. These stages require expensive machinery and include post-processing, packaging, labelling, sterilization and of course, compliance with legislation, medical regulations and ISO certification.

Limor Haviv received her Bachelor of Design (B.des) in Inclusive Industrial Design in 2015. From 2015 until 2018, Limor was the Director of Synergy3DMed and 3D Printing Surgical Lab at Sourasky Medical Center. In 2018, Limor established her own company called 3D4OP. In her role as Surgical 3D Printing Designer she assists surgeons in pre-surgical planning processes from segmentation through simulated surgical planning to 3D printing. She has already been part of more than 350 surgeries.

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