VR Simulator for Endoscopic Spine Surgery – Revolutionary Way for Teaching and Upskilling Surgeons: Gayathri Venkat, Simulatory

Gayathri Venkat, Simulatory: 0:00

The more you damage the virtual patient, the better your learning curve is going to be.

Alex Jani, X-Health.show: 0:08

Hi, I'm Alex and welcome to the X-Health.show where I talk to visionaries behind the latest innovations in healthcare. For the eXtra health of the future. We're in startup space in Schlieren, near Zurich, Switzerland, where a dog bed reminds of a fluffy guardian of robotic arms overlooking glass atrium. I met my guest thanks to Hemex. Gayathri Venkat, the CEO of Simulatory, comes from a family of doctors but instead pursued a successful career as a software engineer and quality assurance expert. Now her skills revolutionize surgeons' training. Simulatory is a Swiss startup that developed VRspine, a smart spinal endoscopy simulator that feels like real surgery thanks to advanced haptics. Whether you're a junior or senior surgeon, AI mentor will challenge you accordingly. You'll hear about ultra-minimally invasive endoscopic surgery, herniated disc, spinal stenosis, startup-medical doctors collaboration, and how I caused a major bleeding a couple of minutes into surgery. [INTRO ENDS] Gayathri, how much time or attempts does it take to go through the surgery without hurting the virtual patient?

Gayathri Venkat, Simulatory: 1:18

You mean in the simulation that we do? Oh! Initially, they have to get

Alex Jani, X-Health.show: 1:20

Right. adjusted to the dexterities. And usually about five or six times, six times the patient gets killed – the virtual patient. I mean, the reason predominantly is the learning curve. They are still getting to know the anatomy in and around, even the virtual reality simulations. So if you can compare it to what happens in OR, that's just bad, you know. But but the good thing about Virtual Reality is that you can reset and start from where you left off. I've just asked that guys, because I actually tried it. So I tried VRspine and I caused a major bleeding in a couple of minutes. I actually couldn't stop it in six more minutes when we just exited the simulation. It was interlaminar discectomy and apparently the patient was a bleeder. So I mean, I'm not a doctor and Gayatri, you're also not a doctor – it is a disclaimer, guys. We are not doctors.

Gayathri Venkat, Simulatory: 2:25

Yes, absolutely.

Alex Jani, X-Health.show: 2:27

How long is the training with the use of your simulation?

Gayathri Venkat, Simulatory: 2:34

That's a great question, Alex, because the training that we provide, it's not one size fits all solution. What I mean by that is, it adjusts according to what is your competency. So let's say a chief of surgery comes in and wants to take a crack at it. For him, it would probably be anywhere between 45 minutes to an hour, depending on what case is matched to his skill level. But for a resident, even the simplest case takes that much time. This is the problem. Because it takes that much level of competency and technical advantage or advancement in yourself to gain that proficiency that you're able to wrap this case as soon as possible. And that's where we are trying to bridge the gap in the learning process itself. Right now studies say that a surgeon, even anybody who wants to learn this, the experienced surgeons also, who are currently operating on spine, minimally invasive spine – 44 attempts.

Alex Jani, X-Health.show: 3:34

44 attempts to learn this ultra-minimally invasive endoscopic procedure.

Gayathri Venkat, Simulatory: 3:39

Exactly. This is a published study in Journal of Spinal Disorders and Techniques. And that is how long the learning curve is.

Alex Jani, X-Health.show: 3:46

But they counted real cases, I mean, on real people?

Gayathri Venkat, Simulatory: 3:50

Real people. It is as simple as this, you need to do 44 surgeries to be able to be proficient in the steps that need to be done. There are steps. First, you remove the muscle, like you saw. Then comes the flavum, which is 10 depending on the patient. Then comes the the fat and then you see the spinal cord or the systems. So to reach and to understand those steps and to know what to do next and what not to do, it takes 44 times.

Alex Jani, X-Health.show: 4:18

I can imagine, totally. I got to this first step of muscles and this is when I actually ended.

Gayathri Venkat, Simulatory: 4:25

Correct.

Alex Jani, X-Health.show: 4:26

What can go wrong in this virtual world, in this simulation?

Gayathri Venkat, Simulatory: 4:31

That's the beauty of simulation, right? You can make mistakes, there is no right or wrong. What we offer as a company is a safe place for you to play around and we import real operating room feel into it. You can see the force that you apply, you get to know where you went wrong, and you get to try it again, which is not possible or should not be done in a real surgery. So it's a safe environment to train and play around to make mistakes, because we all learn from mistakes and improve. So there is not much that I would say can go wrong. The more errors you commit, the better for you because then you're not gonna be able to repeat those in the real environment.

Alex Jani, X-Health.show: 5:19

I'm still asking, stubbornly, about what can go wrong because it might be, what, the bleeding. You mentioned that virtual patients don't survive some of these.

Gayathri Venkat, Simulatory: 5:31

Correct. One of the major errors that we track is you go and nip the spinal cord, which could paralyze the play patient in real OR, God forbid, no one does that, but if that happens, you can completely paralyze the patient hip down. Or death – because your spine is directly connected to your brain. So that is one of the biggest problems and in the virtual world, you can actually commit that because you have to know your way around, how not to do it. And that is one major error that we track. If they are too close to the spinal cord, you will see some indications coming in saying "Move back, move back". Even despite that, if they are too into it, sometimes the surgeons who learn they get too excited, hey, I want to go a little further, I want to do this, I want to do that, so they, unknowingly, they just do it. But that's the beauty of it, you play, you understand what not to do. And you kill the virtual patient, which is okay. Because we do track the errors. This is a major error. Once this happens, this is what is called in the neurosurgery world, the Japanese flag. You know, the Japanese flag, it's white...

Alex Jani, X-Health.show: 6:48

and there is a red dot.

Gayathri Venkat, Simulatory: 6:49

And you saw how small the incisions are, I showed you the tools.

Alex Jani, X-Health.show: 6:54

It's, like, what...

Gayathri Venkat, Simulatory: 6:55

Seven millimeters or less.

Alex Jani, X-Health.show: 6:57

I wanted to say five.

Gayathri Venkat, Simulatory: 6:58

Around five to seven is the usual size. But different manufacturers have different comfort levels and tools, and the sizes. So it's usually between five and seven millimeters.

Alex Jani, X-Health.show: 7:08

That's the incision and the cannula dimension.

Gayathri Venkat, Simulatory: 7:11

Correct. And I showed you it's like half, or even one-fourth of your pointer. If you see all red, like what we saw when the bleeding happened for the bleeder, that's called a Japanese flag. That means that you have hit something that is some major issue. And that's where you need to retrace your steps back on the virtual patient and see how you can improve. You either cauterize, you come out, you take a different approach. You see it from different angles, you adjust your optics. So these are things that they have to learn. No one can teach every step of it, because a person who learns from his mistakes knows how not to commit it. And to answer your question, circling back to that, the more you damage the virtual patient, the better your learning curve is going to be.

Alex Jani, X-Health.show: 7:59

How do they train now?

Gayathri Venkat, Simulatory: 8:03

That'san excellent question.

Alex Jani, X-Health.show: 8:05

It's the opposite, right? I mean, they can't hurt anyone.

Gayathri Venkat, Simulatory: 8:08

Correct. Right now, the trainings happen in two phases. One is, they have these cardboard boxes, I can show you. It's a cardboard box and they have these small holes cut into the cardboard box. Through that they send these tools and ask the surgeons to get the dexterity. I mean, come on. That's like building a mousetrap for your kid. It looks like arts and crafts. And this is not in some third world country, okay, this is in Switzerland.

Alex Jani, X-Health.show: 8:35

Can they feel...?

Gayathri Venkat, Simulatory: 8:37

Nothing.

Alex Jani, X-Health.show: 8:39

Because with your simulation, this VR spine, you actually can feel it.

Gayathri Venkat, Simulatory: 8:44

Exactly. And that's the advantage. And the second part is these 3D printed anatomies, where you print a particular case, and then you keep training on it. But that's not gonna be the case that you will face in the OR and it's a printer cartridge model, so it's very expensive. And there is a lot of waste, plastic waste. And you have to book out your OR, so to do a training on those printed cartridges, you need to book your own whole OR. So that time lost on the hospital, time lost on the overtime where they can actually make money. This is where the virtual training kicks in because you don't need a specific setup. You saw how small the system was. It can sit in one corner of the surgeons table and he can just import the case and start training.

Alex Jani, X-Health.show: 9:32

Let's describe it now, the VR spine. We have two joysticks, can I call them joysticks?

Gayathri Venkat, Simulatory: 9:39

Yeah, you can call them that.

Alex Jani, X-Health.show: 9:41

We have a screen, a laptop or some bigger system and that's it, right?

Gayathri Venkat, Simulatory: 9:46

Exactly. So the VRspine system itself is very compact. It sits about, I would say, half a desk space, a small desk space, and it usually comes with a laptop or a desktop system of your choice. So we give these desktop systems for bigger training centers, where there is not a lot of movement. Some of our doctors like to carry it in the briefcases and they like to take it around. Maximum, it's five kilos. That's it. And it comes with two haptic devices, which are those robots that you saw, a protective casing and optional, extra screen and keyboard, that's it. And then pedals to cauterize, that's it. So it's very, very small, and very, very portable.

Alex Jani, X-Health.show: 10:50

So when there is a surgeon that does training, he or she can take the suitcase with him or her and then do the training. Or if there is like a training center, they have a bigger training station.

Gayathri Venkat, Simulatory: 11:06

Yes, correct. The training centers usually get deployed at training station. Sometimes they request a laptop, because it gives them mobility, but usually it's the training center, the training systems or the desktop systems, because they are stationary.

Alex Jani, X-Health.show: 11:20

And what procedures can now residents train with Simulatory?

Gayathri Venkat, Simulatory: 11:28

Immediately, we can offer all the uniportal ones. So there are two approaches to endoscopic surgery. One is uniportal – you just make one small incision and then all the tools go through that one incision. The other one is called bi-portal. It's the same endoscopy but you make two incisions and through one goes your camera and the other – the tools, just like in laparoscopy. The beauty of the bi-portal is that it can cover more area of the spine because your spine is divided into five sections, right? You have your sacrum, you have your lumbar, thoracic, cervical, and then you have the brain. So that's the whole spectrum for you. So with the bi-portal, you can pretty much go from the sacrum or your tailbone all the way up to the cervical bone, which is the neck. It's beautiful, and the incisions are still seven millimeters maximum.

Alex Jani, X-Health.show: 12:17

With one incision?

Gayathri Venkat, Simulatory: 12:18

Yeah. Oh, with one incision you can cover the lumbar, all the lumbar. With two incisions you can go all the way up. And right now we offer all the modules for uniportal which is single port, under development is our bi-portal with our excellent KOLs. So right now the residents can easily train on interlaminar discectomy, transforaminal, and stenosis. Stenosis is what you saw – the drilling of the deformed bone.

Alex Jani, X-Health.show: 12:50

Actually I was drilling into the bone. Which was kind of a disaster, you know, because just imagine, you have this cannula, which is five to seven millimeters and you need to find the right place to drill. I mean, neurosurgeons, they are amazing, they see where to go in that space. That's absolutely amazing. So we said about the procedures, but what, from the patient's perspective, what diseases or what spine conditions does it cover?

Gayathri Venkat, Simulatory: 13:29

It covers the lumbar disc herniations. What is the disc herniation for people who don't know? We all know that the spine is made up of distinct discs, and there is this nice little cushion between two discs. What happens is sometimes those cushions either press on each other or there is a bulge, especially in older patients who have, for whatever reasons, hereditary, slouched position, occupation – the disc actually bulges out, the material splits out and instead of protecting what is next or what is underneath or upwards of it, it starts pressing on it. You can imagine this, as a I like to tell people, as a box of crayons that you have, there should be 12 individual crayons, let's say you purposely add few more. So what happens, you disturb the space, one goes on top of the other, you cannot close the box, and then it bursts out. That's exactly what happens. And because of this, there is pain, the first symptom is pain, shooting pain in the legs. And the interesting thing is the cervical discs, what we used to call spondilities, that is also a symptom. You start having pain in your arms. This is more predominant in rugby players, athletes, people who do extreme activities. So that's exactly what happens. These are the conditions that we address in our simulations today. A lumbar discectomy – that can be done endoscopically.

Alex Jani, X-Health.show: 15:07

Going back to your simulation, there is some, what you call, AI mentor.

Gayathri Venkat, Simulatory: 15:13

Correct.

Alex Jani, X-Health.show: 15:14

So... Oh, it's, what, minute 14 and we have AI on the show. What's the role of AI in your simulation?

Gayathri Venkat, Simulatory: 15:25

That's actually a really good question. When we started Simulatory, we were with this vision that we want to be different from what is available there. Because we worked with a huge surgical company, so we know exactly what they were doing. It was repetitive. So when our AI mentor comes in is, like the name suggests, it's a mentor. If you enable it, it records the whole session for you. It does three key things, it records the whole session, it monitors what you do but it doesn't disturb you in between when you're actually doing this training – just monitors and takes notes, like a mentor – and in the end of the training, you have a performance metrics or a performance sheet. It attaches videos, where it feels you made a mistake, and where you can improve, and you get an email, or whatever you have subscribed, you get your performance sent out, and you can actually see the errors that you made in small snippets from the mentor itself, saying that this is where you did wrong, this is not how it should be done. It also gives you the perspective as to how you can improve and if you have a training scheduled in two weeks or three weeks or in the future, it resends the same email again, a couple of days before your training. This way, you don't forget. And when you come back to the training session on that day, you know what not to do. So this is one. The second one is as you begin your training, it tracks and it is able to adjust your difficulty. Let's say, the bleeding step, 10 minutes, we cannot do anything. What it does is it changes the scene for you in the background, makes it look like you did something right and then what happens is it reduces the difficulty at that step by helping you. This way, you can pass that step and go to the next one. So let's say you just got it in the first attempt. Next time you train, it's gonna make that step three difficult for you to pass. So this way, it gives you a variety and challenges you, and doesn't bore you. Because one of the feedbacks that we got from our initial iterations with the doctors is that, three or four times on the software, I know how to get around it. That's not what you want. I mean, that defeats the purpose of having a training system, right. So this is the second thing. The third thing is as you build your history on the VRspine system, it matches you with an appropriate case pulled from the database for you to train on. So let's say after 10 attempts, you know that you are excellent in interlaminar. So for the 11th attempt, you're gonna get a bleeder, you're gonna get someone who is diabetic, all these conditions that happen in real time in OR. So this is the job of the mentor.

Alex Jani, X-Health.show: 18:18

I totally can imagine what patients gain when they don't have an unexperienced surgeon operating on them. And what does senior doctors say about that?

Gayathri Venkat, Simulatory: 18:29

Oh, one of our biggest customers have been the senior doctors because they are the people who have the least time to train. So even them, you have to keep up or upskill yourself and they have to maintain their certifications, and they have to have some of these credits done for them to keep up the specialities. It's even true for Chief of Surgeons. They have to attend certain courses, certain things, but they are the people who are bogged down with a lot of administrative tasks. And these guys are one of our target audience because for them, we have a separate training called a freeform mode or problem-based learning mode. Let's say the Chief of Surgery has 10 minutes on his hand and he just wants to keep his dexterity warm. So he goes there, he locks into this mode, and then the system asks him, what step do you want to train. These guys are experienced surgeons, they are not going to have hiccups in knowing this is the next step I have to do. So let's say they say, Give me a case where the patient has two herniations or there is a few, there is scoliosis, or there is decompression in two or three places. So in the 10 minutes, they can actually use it effectively because then the system picks up only those steps and challenges them again with AI proctor. They can go in, utilize the 10 minutes, and train on what they want and not be forced to go through the entire pathway which is a waste of time because they exactly know where they have the problem. Because they have done at least 100 or 200 surgeries in the lifetime until now. Their need is very different from that of the residents, and the Facharzt or the Oberarzt. So this is where the extra learning modes called problem-based learning helps because we identify where they have the issues and we can tackle it at that specific point. So the Chief of Surgery at one of the hospitals really liked this approach because it was most efficient. And it is much, much easier for them to utilize the time. It is time that is valuable.,

Alex Jani, X-Health.show: 20:43

I saw videos on your website, when surgeons say that, well, it feels real. So could you tell now a bit more about the 3D haptics that you use? How did you learn, or taught the machine, how it should feel like? Because I mean, so I cut through the muscle on VR spine, I have no idea how does it feel to cut through the muscle but the surgeons, they exactly know what they are talking about. So how did you learn what should it feel like?

Gayathri Venkat, Simulatory: 21:26

That's the beauty of haptics. It's revolutionary and it's life changing if you use it properly. Most people have what is called as passive haptics where they put in dummies or, I don't know, rubber material, inside, and say it's tactile. What we have on our cell phones is haptic still, but it is tactile. So what you feel here is kinesthesia. What that means is, I like to say, haptics as reverse robotics. So if you have a robot, like we all played with these robot toys, you have these joysticks, you press forward, it goes forward, that's a robot. So haptics is the reverse of that. Let's take the same robot example. So now I say forward, the robot is in forward position. So the robot needs to know that it has to go forward to achieve from point A to point B. But in haptics, it is the reverse, I already am at point B, it knows that it has to be in point B, now, it has to push me back to tell me what kind of feel I get. So it is basically the reverse. You're backtracking with the robot. And haptics is very subjective. What feels like soft to me, to you it might feel as firm. How do we compromise? This is where one of our patents come in. We have developed our custom, in-house libraries for these material properties, what I showed you, you remember?

Alex Jani, X-Health.show: 22:56

Right.

Gayathri Venkat, Simulatory: 22:56

The different material properties. Those were developed by us, we did a lot of research, our CTO Venkat, he was the pioneer in haptics, he came out of SensAble Technologies, which was the world's first haptic company out of MIT, Massachusetts Institute of Technology in Boston. And he worked for that for almost 14 years. So we had the patents, now 3D Systems onset, and we take the systems out of 3D Systems. So our CTO, who we are extremely blessed to have, he developed this in house from scratch. And it took us four years to get those libraries properly working and aligned, and applied to these different materials that you see in the virtual scene. A blood should feel like this. And we had to go through a lot of feedback loop with our surgeons, and it's just not one or two people.

Alex Jani, X-Health.show: 23:47

This is this is what I wanted to ask, how did you collaborate? Because I can imagine you also didn't have that knowledge about how it should feel like.

Gayathri Venkat, Simulatory: 23:56

Correct. The good thing about haptics is, just like AI models you can have haptic models, and you can train them. We had these videos, anonymized videos, like the one you saw with Dr. Peter Derman. We had some of those videos. And you can tell the system or ask, what are the parameters that it thinks can be extracted out of it. And that was step one for us. That gave us a bit of a baseline. And we had to improve on it by feedback from our KOLs. So if you see in our website, we have some fantastic KOLs, Dr. Fournier, Dr. Simonin, Dr. Gerhard, who was the who was our first supporter, indeed, and Dr. Loibl, I don't want to miss anybody, Dr. Wälchli, and we have Dr. Ralph Wagner now. So it has been amazing. We went through this feedback loop predominantly with Dr. Fournier, from hospital of Sion in Valais. They were very, very supportive. They helped us throughout this journey. For the past two years they have been giving us feedback and they also bought one of our first systems. So there are surgeons in Switzerland who are pioneering these techniques, who are not known that well because they choose to be like that. They are very humble. And when given an opportunity to talk to you on people like you, I just put that name out because people should know. These surgeons are really making a difference. Dr. Jean-Yves Fournier, Dr. Alexandre Simonin, Dr. Gerhart, who is retired now, Dr. Beat Wälchli and Dr. Markus Loibl. And we also have Dr. Martin Stienen. These guys are pioneering in the field of endoscopic spine in Switzerland. And it is really a blessing that we got to work with each of them. It gave us the opportunity to iterate and understand. And as this became more and more matured, we started this project in 2019, but we floated the company only in 2021, once we had an MVP, a minimum viable product.

Alex Jani, X-Health.show: 26:22

It took you a couple of years to create this library?

Gayathri Venkat, Simulatory: 26:27

It took us about two and a half years to create the libraries and come up with our first minimum viable product, both on the haptics and also on the interlaminar was our first module.

Alex Jani, X-Health.show: 26:39

Why didn't you become a doctor yourself?

Gayathri Venkat, Simulatory: 26:42

That's a question I get asked multiple times. It's a valid question. I was destined to be a doctor, let me actually put it that way. I mean, it's in the Indian culture that if you have a family of doctors, you just take the path and that's how it is.

Alex Jani, X-Health.show: 26:58

So your father, mother, they both are...

Gayathri Venkat, Simulatory: 27:02

My dad used to be in the MedTech field for a very long time. My mom used to teach and my brother is a cardiologist. My dad is very exposed to the nuances of how to sell and the procurement side and whatnot. My mom is a teacher. And my brother took up cardiology, and he is very successful in India. So when it came to me, I like medicine, and I like what he does, I have seen him come home... half the day I don't see him because he has some emergency cases, and he just bunks. So that dedication and the fact that you can save a life that's something that no other profession can give you, the satisfaction, you know. And the heartbreak. When it was time for me to decide which direction I'm gonna take, I always loved medicine, I love dogs, I wanted to be a veterinarian, actually. It was either a veterinarian or it was a neurosurgeon. Crazy, right? Crazy life. But I became neither. The reason for that was when I had a discussion with my brother, he was very encouraging and he said, Yeah, it's a good thing, but veterinary field is this, this this, you need to have a heart of stone, because there is more depth there, for obvious reasons. And I was not that great. I cannot see an animal suffer. Then and there I decided that's not the field for me. Then the second one option was neurosurgery, which fascinated me, because there was very less people doing that in India, and very less all over the world. After I moved to the US and started working for 3D Systems, I learnt it, then I was like, huh, but by the time it was too late. So tracing back or coming back. I started exploring these options, and you have to pick up your speciality. In India, you either go into medicine or you go into engineering. These are the two forks that divide when you are in your high school. I had a discussion again with my brother, and he said, You know what, I have this training course, which has basics of these anatomies in the brain that we teach in the college, why don't you come and you can just see what happens. So I went with him.

Alex Jani, X-Health.show: 29:10

And you fainted.

Gayathri Venkat, Simulatory: 29:11

I hated it.

Alex Jani, X-Health.show: 29:12

You hated it!

Gayathri Venkat, Simulatory: 29:14

The reason for that was the smell of the cadavers, man! It was death, so pungent. And oh, I couldn't. And we had to wear these big lead vests. I developed back pain and it didn't go away for seven days or more than that. So painful. Leave aside that, that we can work with it, you can probably build a muscle for it and do something. But the cadavers, you know, they put me off. And it was gross! See, I mean, if a real patient bleeds, the blood is gonna be red, you know certain things, you know how to patch him up. Trust me, you don't want to cut up on a cadaver. That threw me off. And I was like, Nope, no way. And then when I went home, I had this retrospective. And I was thinking to myself and said, You know what, no, if I go that route, where I'm not fully into committing myself to that kind of a lifestyle and going through these things, I don't think I'll be a good doctor. So I did the next best thing, I became an engineer and my master thesis involved, in fact, Why people are refraining from taking up medicine. Because in my own high school 80% of the girls, or the women, we went into engineering. Only 20% went into medicine. And even in that 20% – none of them took up doctors. Most of them ended up being nurses or midwives. So there is something that is going on in that community, which none of us are able to see. I did my thesis on that. And it was startling to know that women were put off by the amount of bad training equipments that were there for medicine training. They were not hygienic. They were not pleasant. I mean, we don't expect rose petals, okay, but it's gross. Ask a female surgeon. I spoke to one today morning, Dr. Marisa Gandía, she is a pioneer in EANS, The European Association of Neurosurgical Societies. She's the first female board member in EANS. Big shout out to her. So these are women who were able to overcome these hurdles, heart of steel. And I didn't have it, I didn't have the stomach for it. And apparently most girls didn't. So out of 10, eight of them went to engineering only two and that gets cut down. How many do you think will end up in neurosurgery? Point one? That was the result. And it was startling. And when I went to 3D Systems, and when I got exposed to this technology of digital training, it changed my mindset. And God, why didn't people have this when I wanted to do medicine? And I went back to those same cohort. I told them, I sent the study again to them saying that, if you had a digital option to train on, would you pursue? You wouldn't believe. 60% of them said yes. The 20 were outliers, they said we lost interest, we are happy with the money we make, I don't have the thing. But 60%! These are women in their late 20s at that time.

Alex Jani, X-Health.show: 32:19

So actually, your VRspine can also encourage. Or maybe there will be less dropouts at this point.

Gayathri Venkat, Simulatory: 32:21

That's the point. So that's the study that I want to do with some of these residents saying you don't want them going away, right? Training or the pathway to education should not gross people out. If it starts grossing people out, you're not gonna be able to study, it's gonna be a bad study, if you push in that direction. How many have we heard stories saying that I didn't like that, but I still had to do because I was forced to do it. That's one of the reasons why I didn't become a doctor, I took the second best thing, if there is a change that I can bring about through this company Simulatory and our VRspine on and our up and coming surgical training systems and get more women involved. Because women are better doctors, I'm sorry, all our KOLs out there,

Alex Jani, X-Health.show: 33:20

More caregivers. but we are more patient.

Gayathri Venkat, Simulatory: 33:27

More mothering that's in our nature. And more women have to be doctors, if we had to better our society to achieve a better quality of life. That doesn't mean that men are not okay. But it is in our inherent nature, our gut instincts are stronger. So why not encourage them to go there, which can better the society, along with the men, which is going to only make things better for us. But it's a totally different problem. But it's true and the studies don't lie. This is one of the areas that I personally have my own agenda for becoming part of Simulatory and taking the CEO position, and standing there, and telling people that don't get grossed out, there are options.

Alex Jani, X-Health.show: 34:15

[MID-ROLL] This episode is brought to you by the X-Health.show. And me. So if you like this podcast, be generous, hit Follow, leave a review, that will help me invite more such amazing guests for you. Thank you. [MID-ROLL ENDS] I also noticed that, in your team, there is a gaming expert. What does gaming have to do with the spine surgeries?

Gayathri Venkat, Simulatory: 34:40

Let's put it this way: the gaming expert's main job is to gamify the simulation, make it more fun. He brings in a lot of experience working with bigger companies, AAA-titled companies. We use Unity, which is the game engine that you had to put out as an EXE or an executable file. He works closely with Venkat, Venkat works on the haptics and there are other things that are needed, like GUI, your UI, UX, user interface, user experience, and then combining them and making these executable so the gamification aspects come into play on how you present it and how interesting it looks. If I just show you when you open the screen and see all blood everywhere, are you gonna be motivated to try it? No. So how do you gamify it? That's exactly where the gaming expert comes in. And he is very critical for the team. And he's been excellent, Louis, thank you so much. So his main job is to keep the users hooked, just like how it happens in other games, PS4 or something. It's still game, right? I mean, people can ask the same question, Okay, why do I need Unity or some sort of an engine to run the game? You can just put some steps out, and I can do it with my mouse, right? But that's not the point. How do you keep your users engaged? And that is where the gaming engines have come a very long way. And how do you make haptics work with those games? So this is where both of them come in. And they work hand in hand to make this happen for us.

Alex Jani, X-Health.show: 36:22

Can you go a few steps back? How did you come up with the idea of software and this whole training station for spine surgeons? So you knew what elements you want in

Gayathri Venkat, Simulatory: 36:36

That's the beginning story. It's an the station. interesting one, because honestly, we didn't start with Correct. From our experience, working in 3D Systems and getting to knowing this huge surgical company, what they didn't have and what we can have. Because you have to be smart about it, right? They were a great company, they still are a great company, but you need to differentiate yourself and also keep up with the trends that are coming up the technology trends, and also the deep tech. At first we started with brain, we wanted to do open craniotomy. But when we presented the concept, and that was our MVP, our minimum viable product was for brain surgery, for open craniotomy. It was called New Robotic. spine. What we had was, what is today patented as the Smart Simulation Platform, which had the combination of kinesthetic haptics, Artificial Intelligence, and smart sensors.

Alex Jani, X-Health.show: 37:49

Why are you laughing?

Gayathri Venkat, Simulatory: 37:51

It's because, whenever I say that name, New Robotic, it sounds like a Roomba.

Alex Jani, X-Health.show: 37:59

Well, yeah, fair enough.

Gayathri Venkat, Simulatory: 38:01

So think about it, you say New Robotic, all you remember is that round Roomba going around in your room. But that was the logic behind it. We wanted people to relate and because that's what brands do. And that was our MVP. So we presented it to our then KOLs, Dr. Jean-Yves Fournier, Simonin, and Dr. Stienen, and and they were like, You know what, these components would be great for spine, just go a bit down to spine. Because if you do spine, we will buy it from you.

Alex Jani, X-Health.show: 38:35

They didn't want the brain or they were fine with what they do?

Gayathri Venkat, Simulatory: 38:39

So on the brain, there is still very low number of surgeons taking up neurosurgery apparently, for the reasons of risks. And the neurosurgeons cannot operate on brain after a certain age. But that's not the case with the spine. So their point was, if you do the spine first, with these components, we can actually have a broader audience. First point. The second one is, this is interesting because we come from the US and in the US, it's completely a different game, I'll tell you what is different. So in the US, if you are in the neurosurgery department, you only do brain surgeries, at least in 90% of the hospitals that we were exposed to. If you are spine surgeon, you only work on spine. If you're orthopedic surgeon, you only work on the knee, hip, hand. But here in Europe, the neurosurgeons work on spine, the spine surgeons work on spine, the orthopedic surgeons work on spine, okay. But the interesting thing is the orthopedics and the spine surgeons cannot work on the brain, only the neurosurgeons can. So now you see why we went or why we formed into spine because it expanded our audience. And as a growing company, it was very important for us to have a broader audience or a broader sales funnel, let's say, to address the market and grow because neurosurgery is a sub-sect of spine. So why don't we target spine and when these doctors gave us the confidence that this product is going to revolutionize the market, build this, get it to a certain stage, we will buy it from you.

Alex Jani, X-Health.show: 40:26

How did you learn their trust? Because I mean, it's an awesome feedback a startup can get.

Gayathri Venkat, Simulatory: 40:33

Exactly.

Alex Jani, X-Health.show: 40:33

And also... There's a couple of questions really. The trust. And the second thing is, did you

have a second thought? : 40:40

ike, Nah, why would we? We have a great product already?

Gayathri Venkat, Simulatory: 40:49

See, that comes with experience. So I'll answer your second question first. The reason for that is it ties to the first question. So you said, Why would I listen to you, I will go with New Robotic because I have built it...

Alex Jani, X-Health.show: 41:03

...I spent so much time on it, it's

Gayathri Venkat, Simulatory: 41:04

You have to listen to your market. ready. Because these guys are just KOLs, right? They are going to

Alex Jani, X-Health.show: 41:07

What was your first startup, you just be our customers and if they say that this thing is great, but there is potential if you apply it to another field, you shouldn't be stupid enough not to listen to that. Most startups when they pivot, at least what we have seen, it comes with experience, because we are not out of college. We exited our own companies, we pre-funded and this is our second company. So first, you always listen to what the market tells you. If you have a component that can be expanded into other areas of surgery, you go there. And let's say hypothetically, we don't listen to the doctors, instead of having 300 customers, I would end up having 100 customers. So why should I shoot myself on the foot? There is a reason these guys are called Key Opinion Leaders. They know not just the technical or the medical know-how, the steps, they are skilled and they know the market trends because some of these big companies are always interacting with them. So we listened and we pivoted. So that's your second question, tying it back to the first one. And how did we earn the trust? It's because, again, we listened to them, despite us coming from a medical simulation perspective, and doing or not doing what you just said, Who are you to tell me I know this field better, we listened to them, went back to them with a spine product. That made them believe that we value their opinion. And when someone that you are interacting with knows that you value that feedback, trust comes automatically. And we did have a lot of interactions with them, we were very open. We won trust over a period of time definitely, mostly because we took their advice to heart and we implemented it. And we are successful because of it. We don't shy away from telling in public that these doctors were one of the main reasons for our success. That built the trust or solidified the trust even further. mentioned that you exited one.

Gayathri Venkat, Simulatory: 43:18

We were part of a huge surgical company, when it got sold out, we cashed out our shares.

Alex Jani, X-Health.show: 43:25

Okay. And this is also how you were able to bootstrap?

Gayathri Venkat, Simulatory: 43:28

Yes, exactly. Simulatory, as you know, was a COVID, baby, and we absolutely were terrified when that happened, to be very honest. I don't want to sound arrogant and say, I know this is gonna succeed. No, we were terrified because the funding was running low, even now it is low, the market is not that great. But we had the luxury or we were fortunate enough to have some cash on our hand from our exiting out and cashing out, and selling, and using some of these to bootstrap. That's why we started it as a GmbH because it needed less incorporation capital, and we used whatever money was left to actually make the Minimum Viable Product. We sold these products out to these doctors, we have revenue, so pretty much that helped us to sustain the company until the right type of investors came in.

Alex Jani, X-Health.show: 44:27

VRspine is already on the market, right?

Gayathri Venkat, Simulatory: 44:28

Yes, the first version is already on the market.

Alex Jani, X-Health.show: 44:31

And how did you go about the pilots? What did they look like? The pilots with with the surgeons – what feedback did you get? What changes did you implement?

Gayathri Venkat, Simulatory: 44:46

We went through a lot of feedback, we still keep improving it. I would say the product is already commercialized but we do take feedback very seriously. We had a couple of revisions on the way. The setup – if you see it now, the arms sit side by side, they are beside each other. One of the feedbacks that we got was, initially when we started out, they were facing each other, like that. So the surgeon said, that's not how it is, the patient doesn't feel like, so turn. And it's not very ergonomic. So we turned it. That was one design change. The second one was on the way we interact. Some of the surgeons wanted to know how much force they are applying – force meters. The main feedback was on what metrics can we actually measure. Because most of our surgeons, they love publishing papers and with the cadaver or a 3D printed anatomy, or with the cardboard box it's not possible. So what would you measure – time was the only measure. So the surgeons, who are the guys that I mentioned, they wanted to revolutionize how these things are quantified, how do you track a resident's performance. It's a robot, it can track everything. We narrowed down on what are those things that can be tracked

using this: 46:09

the wrong wrong tool is used, you are too deep into the muscle layer, you're gonna nip the patient, you kill the virtual patient. Those kinds of metrics, which you cannot track in a cadaver or on a dummy plastic anatomy, or on the cardboard box. So these were some of the major changes that we did during the course of our improvement cycles.

Alex Jani, X-Health.show: 46:34

Just to mention for you guys who are not familiar, cadaver is a corpse. So, basically, they can have quantified assessment of a resident, right?

Gayathri Venkat, Simulatory: 46:48

Yeah, they can track whatever they want. And the beauty is, everything is recorded. And if they want to publish a paper, they can just rip out all the names and publish it in two days work as opposed to 14, or even three weeks currently.

Alex Jani, X-Health.show: 47:07

From your perspective, was there or is there anything the most important in testing a solution like this? Are there any steps that you should take to bring a solution like that to the market? You've had career in quality assurance, right, so how do you make sure that the product you bring to the market has the quality you want it to have?

Gayathri Venkat, Simulatory: Absolutely, that's one of the focuses of what we call as Customer Engagement Program. Even if we don't hear back from customers that we have sold to, we either go in person, it's either me or Venkat, we are the founders of the company, so we go in person, we set up an appointment, we talk to them, we understand what they like and don't like. We gather all that input. And we implement and we go back to them, and we keep this loop open. So that is one way to be sure that your product is meeting the standards or even exceeding. The second is this. We did an exercise in Sion Hospital with Dr. Fournier and Dr. Simonin. They are, I would say, the most driven and most focused surgeons, who want to improve endoscopic spine training, I have ever worked with. They both are excellent. What they suggested, when we reached out to them for an appointment, is that: 47:39

You know what, this is excellent, we will keep your system open, we will go into a live surgery, I'm going to do the surgery, after I am done with the surgery, I'm going to come out, try the system and then I will know where exactly you can improve better. Now that's commitment.

Alex Jani, X-Health.show: 48:58

Exactly. That's commitment. That's totally amazing.

Gayathri Venkat, Simulatory: 49:02

And they did do it. And we do have some of the improvements that they have suggested, some of them are graphic improvements where the muscle is not botched, they wanted colors improved – stuff like that. But to have that much amount of involvement, that's commitment. When you have people like that, who surround you, automatically your product is going to stand out and it's going to exceed the expectations because it is a one on one comparison, what they see in real time and what they are training on. There is no way that it's going to be of a lower standard. This is how we keep up. Once this was successful in Sion, we started asking our other customers if they would be open to this approach, and all of them that we reached out, they really liked it.

Alex Jani, X-Health.show: 49:49

This is amazing, because I wanted to ask about first adopters, but these are not first adopters only, I mean they go beyond that, right? That are like co-creators even. Is the market like that?

Gayathri Venkat, Simulatory: 49:59

They are who we call Key Opinion Leaders. They take what they do seriously in every aspect of it. These are people who can call us perfectionists. They really want to help you and they want to leave a legacy behind when they are no longer able to do these surgeries. That's the focus of some of the surgeons that we work, to get some of them like that on board says a lot about the technology that we have, and the founders that we are, and the company itself. You need to have a level of trust like you brought up and a level of confidence that, hey, if I tell them that this is wrong, they will improve it. That motivation comes only if you show them that you are equally serious, and you take their word seriously. And that is exactly the type of relationship we have with our Key Opinion Leaders. So these guys, that's why they are called KOLs. And that is the main role of a KOL, the medical know-how, the knickknacks and how to improve, and how to keep on improving it. You mean, is the market is so critical? That's the fun part. Because our KOLs themselves are so critical, I wouldn't say critical – so perfect, they are perfectionists, when we take this product out to the market, we hardly get any negative comments. Oh, the couple of them that we get are some of them who don't know the haptics, they struggle a bit to get acclimated. So: how do I hold this pen? How do I do this? What are the physical limitations? And some of them are terrified because they are afraid that they will break the system but it's a very resilient system, nothing happens because you're putting it in a hospital – it has to be resilient. Those are the only few feedbacks that we keep hearing. And as for the procedures itself, the steps, we were never challenged. Every one of the others, or our late adopters or our early market, we'd never got challenged on why you're doing this, this is wrong. Not one. These are guys who are in the industry, these are doctors who do the surgeries.

Alex Jani, X-Health.show: 52:08

I can imagine there might be some doctors who are like, Well, man, I've been doing it for 40 years, why would I need this, you know, glitter of tech?

Gayathri Venkat, Simulatory: 52:20

There are always those outliers, these late adopters or who don't conform or those who don't want to conform to that path that somebody else cut. You know Kodak, right, the camera company.

Alex Jani, X-Health.show: 52:39

Oh, yeah, I love that example.

Gayathri Venkat, Simulatory: 52:42

These are the Kodak guys. For people who don't know, me and Alex discussed this in our first call. These guys are the Kodak guys. Kodak – they had the best camera, the best film everything. They were pioneers in technology for photography. But then came your beautiful, beautiful iPhones, smartphones, your your digital cameras. Then Kodak sat there and said, Well, these guys are not gonna survive and why should I digitize? I am a market leader already. And what happened? Now – does any of us remember Kodak? And do any of us use those films?

Alex Jani, X-Health.show: 53:19

The funniest part is actually that Kodak had a digital camera designed and they kept it basically hidden.

Gayathri Venkat, Simulatory: 53:27

That's the problem with these people, because they think after a certain point, they know better than the others, which is not bad, okay. But when you see the turn and twist and the tilt and the way the world is progressing around you, and you keep holding on to your Kodak, that's not going to help you. And you're not going to help your residents, too. Do you think there are going to be more residents to a doctor who is opposed to technology? Because we have heard it all. We have heard things like, I don't trust digital technology. I don't trust simulations. I only want to do cadavers. But how long can you sustain on cadavers? Now with the CO2 emissions and problems coming up, cadavers are not gonna stay that long. And if there is a resident who does something wrong, the cadaver is distroyed. What happens to others who are patiently waiting? How do you help them get better? So we are not interested in the collapse of the medical world, what we are interested in those that are open to accepting and those who know digital is the future. So when these Kodak guys know that they are not going to exist anymore, either they are going to join the bandwagon which is going to be at a very late stage, or they are going to be left out like what happened to Kodak. That's the example I always give people when they ask. It's difficult. And if you go behind these people, they demoralize you. So it's better to stay away – this is also a learning we had – and focus your attention on those that are supportive of you and grow with them, which is the best strategy to have. You're not only, say, the tech guys now, because you have a doctor on board, you have Dr. Ralph Wagner, who joined your team. What would be his role? First of all, we are very, very, very fortunate to have such a huge surgeon. Just to give a brief outline or background on Dr. Wagner. He is the best uniportal surgeon that you can find in the world, he has done until today 5000 endoscopic surgeries. Most of the doctors in Germany learned from him. He is super, super, super talented. And we met him, he tried the system, and he said, You know what, this is going to change the world of endoscopic spine training. There are a lot of people who are begging me, this are the exact words he used, there are begging me to help them train, but I don't have the time. So if I had a company like yours, who could offset some of my time, put a system out there, and this AI proctor does everything, I can also see where they did the mistakes. And when I take them to a cadaver lab, I can tell them exactly what not to do there because I know. So this is revolution and I want to be part of this. He was very straightforward, which is what we loved about him. His main goal or his main idea in joining Simulatory, he's going to be our Chief Medical Officer. He's going to work with all of these other excellent KOLs. The best part was, all our KOLs get along excellent with him, which tells a lot about Dr. Wagner. Despite being such a huge personality, he is very down to earth, very straightforward and he gets along with everybody really well which is very difficult, because after a certain age you go... With him on board, this is gonna boost our status and the way Simulatory is perceived outside in the medical community, which is exactly what we need at this point. Because we have a good product, we have a tech team, we have the perfect KOLs behind it. We needed a doctor backing it. Now we have Dr. Wagner so what else can we ask for? This has been truly pivotal point for us in having Dr. Wagner join us as a co-founder and Chief Medical Officer.

Alex Jani, X-Health.show: 57:23

What is success for Simulatory? How do you see the big success success?

Gayathri Venkat, Simulatory: 57:29

Success for us... I mean, I am a greedy CEO, okay, I love to expand and be successful. The success for us is I want every single resident, every single person who thinks of endoscopic training, think of VRspine, think of Simulatory. We want to be synonymous with training and planning for endoscopic spine. Because that's the future. And we want to lead these people into the future. Give them an opportunity to take that and run with it and get better, which is, basically, we also grow with them.

Alex Jani, X-Health.show: 58:08

I can see you are already in full speed. What do you need to make it happen?

Gayathri Venkat, Simulatory: 58:13

Money. Funding. As any company, we are looking for funding. We do have some excellent investors already invested in us, some of the best. We have people from from Germany, predominantly. So most of our investors are from Germany. We have a lead on board, he is the best I can ask for, very supportive, very, very diligent lead. And all the investors that followed him are – couldn't ask for more. And we are at the best stage that we can be with the right type of people coming in. The next step for us was to close our 2.5 million round. So if you guys are interested, reach out to me.

Alex Jani, X-Health.show: 59:00

Yeah. Now, I also know that you don't want to stop with ultra minimally invasive spine endoscopic surgeries. What's the bigger plan? Or what's the bigger future for Simulatory?

Gayathri Venkat, Simulatory: 59:14

That's an excellent question. I take a very pragmatic approach. What I mean by that is, one of my jobs as the CEO of the company, is to have a proper laid out future pathway that is communicated effectively within all aspects of the teams. So I take a very pragmatic approach. We do a five-seven year plan. In those five years, I want Simulatory to be the global leader in synthetic patient data – number one. I will explain what that is. The second is, like I said, I want people to remember VRspine or think immediately of VRspine in the next five years when there is a topic of endoscopic training. Now the bigger picture that we have discussed is, complete the whole spectrum of the spine itself, and then go to the brain and then we are also targeting robotic surgery which is the future again. So we are not going to regress back into laparoscopy or arthroscopy, which is a very crowded place, there are people doing it, let them do it. We want to stay one step ahead of the curve always. Always have the first mover advantage and with the Smart Simulation platform, our next target is going to be robotics, robotic surgeries, robot-assisted surgeries, exoscopes, which are coming up at very, very fast pace. All the big companies – you have robot-assisted surgeries. You can search them, any of them, they have a robotic assistant. So that's the future. The next focus for us after that is going to be sports medicine, rehabilitation, prosthetics. Probably with haptics, we can go into sensation of bionic arms. But that's way, way, way out there.

Alex Jani, X-Health.show: 1:00:57

Wow. So this sounds real, real huge.

Gayathri Venkat, Simulatory: 1:01:00

Yeah, but that's way, way, way out there. But the two focus topics are gonna be neurosurgery, which includes the brain and spine, followed by robotic surgeries.

Alex Jani, X-Health.show: 1:01:11

Gayathri, thank you very much for this seriously super interesting conversation. We went deep into spine surgery, haptics, now – robotics even in the end. So thank you very much for this. And for you guys listening if you want to, you know, check at which stage Simulatory is now, go to thesimulatory.com. Thanks again.

Gayathri Venkat, Simulatory: 1:01:44

Thank you so much.

Alex Jani, X-Health.show: 1:01:44

[POST-ROLL] I'm totally impressed by the audacity of researchers turned startup founders, doctors turned entrepreneurs or ordinary parents turned healthcare innovators. People battling the battles that no one fought people. For the eXtra health of the future. So if you see a startup posting on LinkedIn, show them some love, hit Like, comment, That's fabulous. If you have a couple of drops more of that altruism, follow the X-Health.show, leave a review here. I'll be able to bring more of these visionaries to you. So big thank you. You're awesome. See you next week.

SPEAKER: 1:02:17

The information in this podcast is for informational purposes only and should not be considered medical advice. If you have any medical questions, please consult your healthcare practitioner. The opinions on the show are Alex's or her guests. The podcast does not make any responsibility or warranties about guests statements or credibility. While the podcast makes every effort to ensure that the information shared is accurate, please let us know if you have any comments, suggestions or corrections.