report Medtech
Alfredo E. Bruno in front of «Carlo». (Img: AOT)

Alfredo E. Bruno in front of «Carlo». (Img: AOT)


«We will be certificating the world’s first autonomous robotic surgical device»

The laser physicist and entrepreneur Alfredo E. Bruno is co-founder and CEO of the medtech start-up Advanced Osteotomy Tools (AOT) in Basel. Their surgical robot «Carlo» (acronym for Computer Assisted, Robot-guided Laser Osteotome) is an award-winning project (Pionierpreis 2014 and CTI MedTech 2015). The company will exhibit «Carlo» at the Swiss Innovation Forum 2015 on 19th November.

In the i-net interview, Alfredo E. Bruno explained his roadmap for AOT and what drives him to be an entrepreneur.

You are a laser physicist – what brought you to medtech?
Alfredo E. Bruno*: My younger daughter needed difficult orthognathic surgery to correct conditions of the jaw and face. This brought me into contact with Professor Hans-Florian Zeilhofer and Dr. Philipp Jürgens from the Department of Oral and Maxillofacial Surgery at the University Hospital Basel. I was worried about my child, but the surgeons devoted a lot of time to explain the procedure to us. Their pre-operative approach to surgery fascinated me more and more. I asked the surgeons why they were not cutting bones with a miniaturized laser instead of mechanical tools to best reproduce the software-planned intervention. In another project, I had developed a laser of this kind to cut and drill through nails. At this point, we all realized that we could create something very useful together.

How did you gain your knowledge in surgery?
I had absolutely no idea about surgery until I met the surgeons – despite the fact that my father was a rural medical doctor. Indeed, when I see a drop of blood, I panic. But I wanted to know more about this new type of planned and navigated surgery the surgeons were talking about. I managed to find a good 160 publications and about 20 patents in the field, read them during vacations and became a «theoretical» surgeon. Reading these documents, I noticed that Professor Zeilhofer appeared as co-author in many of these publications and realized that he knew a lot about pre-operative planning and navigation. I started to design «Carlo» from scratch using all available state-of-the-art technology, and trying not to be biased by the robotic surgery products already on the market. What worried me most was the software, which is crucial to integrating the whole system. Hans-Florian Zeilhofer introduced me to Professor Philippe Cattin, an expert in navigation who liked the idea from the outset. He was the «missing link» to the realization of «Carlo».

Was it always clear that «Carlo» would be the goal of AOT?
As an entrepreneur, I made it very clear from the beginning that I wanted to have a product rather than a nice academic idea. Instead of writing a business plan, we first applied for patent protection of the innovations. The business plan came afterwards with a business model in which we at AOT would only focus on core technologies and would outsource the technologies mastered by other companies under contractual partnerships in order to reduce development time.

Were you ever afraid that AOT might fail?
While writing the business plan, I clearly saw that there was a need for our product. We had the right founder’s team, but I was worried about the funding, because there was a global economic crisis and investors had become cautious. Therefore, I decided to talk to a few experts I knew in the start-up media in Switzerland before launching the initiative. They reviewed the AOT case and encouraged me to pursue the project, because it was truly innovative and, for this kind of project, they argued that there are always funds available in Switzerland. And indeed, with our first pitch in BioBAC, we gained a lead investor. Shortly afterwards, we won the three stages of Venture Kick and I was then asked to participate in the Swiss Venture Day of CTI Invest to make a pitch. Despite some doubts I had about the completely new surgical device, many potential private and institutional investors were literally queuing right after my presentation to talk to me about the «Carlo» device and AOT as an investment opportunity.

Why do you think your pitch attracted potential investors?
I think the every one of the technical founder’s team had a remarkable technical record which inspired trust, and I also have a good entrepreneurial record, all of which make up the ingredients investors are looking for to fund new projects. The pitch is key to convincing investors. We cannot afford to devote much time to making «professional» slides, but the audience realizes that we have an unbeatable project and know what we are doing; and they can see during the Q&A sessions that we are very authentic.

In the beginning, you faced some criticism with regard to the feasibility of a complex medical device such as «Carlo». Do you still face negative reactions?
No, not anymore! When I started speaking of «cold» laser ablation, many physicists questioned this paradoxical term. Today, after we assessed the remaining surfaces of the bones and captured the ablation process with thermal cameras showing that this cutting method is even cooler than mechanical cuts, nobody has any doubts about our assertion anymore. Another critical issue raised by some experts was depth control. Some argued that we would never be able to have depth control working in real time. Again, this is no longer an issue.

You recently presented this depth measurement system for the first time. How does it work?
With the help of external academic partners we developed a laser interferometric method suitable for our device that provides not only the depth of the cut but also its width right after every laser shot so its entire profile can be reconstructed in real time. This «probing» laser beam is co-axially mixed with other visible pointing laser beams to ensure that the surgeon can observe the cut on the monitor. There are many computer-controlled processes such as the depth control running in parallel during some of the tasks. They are processed by a microprocessor which sends values that are already calculated to the «Carlo brain» to decide what to do next. With this software technology, we are pushing the envelope in three disciplines: laser physics, data processing and synchronization.

Could this know-how be used for other applications in or beyond surgery?
As pioneers in this field, we encounter many new problems to solve. But on the other hand, once we have found the solution, we file for patent protection and, in this way, we’re strengthening our patent protection. Some of these innovations could be used for other applications, but we have to remain focused on one thing: getting device certification. Once we «put our foot on the moon», we could follow up on other options with the technology we have discovered.

It sounds as if you are not facing any difficult situations anymore with AOT?
Problems are constantly arising, but we have a very professional and courageous team that brainstorms the problems at hand in complete transparency and always comes up with one or more solutions. Although scientists are trained to present nice results in conferences while leaving the bad results aside, we are upfront with the bad news. If a problem appears, it’s immediately brought to the attention of the team so we can find a solution together.

What in your opinion are the key factors for an innovative company?
Everyone knows what the main ingredients for innovation are: You have to have a product that addresses a need, a unique proprietary technology, the right people and the financial means. However these ingredients do not guarantee success, and many start-ups that have these ingredients fail. The causes of failure are often underestimated, but should be addressed in the risk analysis of the business plan. A classical killer of technological innovation is when investors strategically decide to sell the start-up to an established competitor. But the buyer wants to get rid of a potential competitor! A possible antidote is to have a good legal adviser. A lawyer can help you to set clear goals for the steps after the acquisition and implement penalties in the contract. Also, it is good to keep the founders of the company in-house, because these people are part of the success and often the «engine» of a start-up.

What makes Switzerland a good place for you to launch a medtech start-up?
I have worked with people and projects in a few countries. What I find unique in Switzerland is the scientific family: Everybody knows each other and has close relationships. For instance, when the issue of a suitable depth control appeared, we spoke to other scientists who had solved similar problems for eye surgery. They came up with friendly and open advice without speculating on what the benefit would be for them. This is by no means the rule in other countries, where often knowledge is seen as power. But the free flow of information in this country is crucial in ambitious high-tech projects.

Where do you see room for improvement of entrepreneurship in Switzerland?
Switzerland already ranks as leader when it comes to innovation, but I see there are three things that could be changed to foster even more innovation – namely, the no-risk mentality, the fear of failure and the loss of reputation. The Swiss education system teaches students to avoid risks instead of focusing on the possible reward associated with a risk. Indeed, the word risk has a negative connotation in Switzerland, but entrepreneurship without risk is as hypothetical as perpetual motion.
How can we overcome our fear of failure? One recipe for passing an exam is «to do the homework in time to get a good sleep the night before». In a high-tech start-up, this recipe means firstly drafting a comprehensive and realistic business plan and strong IP protection. Failure is part of the game, and the question needs to be how fast you can get back up after getting knocked down, not whether you are going get knocked down.
Regarding the loss of reputation, people look at you with suspicion when you’re trying to build your own company based on an unusual idea. And your employer may think you’re not happy with the job. But large established companies don’t have the framework for promoting new ideas. They should support their employees to pursue their own ideas and get trained on founding a new company.

What drives you as an entrepreneur?
I have always tried to do things I like and am capable of realizing. I have always been a curious person. As a child, I built rockets and blew the fuses in our house with my experiments – for example – to split water into O2 and H2 with 240 volts! My grandfather, who was a full-blooded entrepreneur, also taught me the basics of entrepreneurship. I guess the ideal situation for high-tech entrepreneurship is a «born scientist» with a flair for entrepreneurship, as management skills can be acquired.

Do you have any entrepreneurial role models?
Columbus has always fascinated me since childhood. Only later did I realize that he was an incredible entrepreneur who first had to convince the queen to get funds and had to overcome many odds. He definitely had the intelligence, the passion and the courage required to literally embark on such a project. And although pirates are not exactly good role models, they were excellent start-up entrepreneurs. Pirates planned their attacks rigorously in advance, had to get funding or develop advanced boats with higher masts to sail faster. Their structure was similar to a start-up nowadays, and they even had the equivalent to stock option plans, where the loot was distributed among all the hierarchies in proportion to their performance.

Interview: Fabian Käser and Nadine Nikulski, i-net

*Alfredo E. Bruno holds an M.Sc in Quantum Chemistry and a PhD in Laser Physics from the University of Saskatchewan (Canada). Alfredo came to Munich in 1985 as an Alexander-von-Humboldt fellow followed by a teaching position at the University of Zürich. In 1988 he joined Ciba-Geigy and later Novartis where he accumulated more than 25 years of experience in biomedical, preclinical and clinical research in joint projects with Spectra Physics and Chiron Diagnostics.

At Novartis, Alfredo Bruno invented Transungual Laser Therapy for nail diseases, which was the basis for the spin-off of TLT Medical Ltd in 2004, where he was the sole founder and CTO. After three years of successful operation under his leadership, TLT Medical was sold to Arpida Ltd in 2007, where he became the Head of Antifungals. In 2009, he co-founded FreiBiotics in Freiburg (Germany), where he was CEO until mid-2011. In 2011, he co-founded Advanced Osteotomy Tools (AOT), where he is the CEO. He has published over 35 peer-reviewed publications and holds more than 15 patents and has been on the editorial board of three international scientific journals.


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