Set-up of a hybrid operating room at Rikshospitalet in Oslo, Norway. The robotic multi-axis system offers high flexibility and advanced 3D imaging capabilities in the operating theatre. Convenient park positions maximize space in the room and keep the system out of the way when not needed. Courtesy of Professor Fosse, Rikshospitalet, Oslo, Norway. 

Context in source publication

Context 1

... (ICD), particularly bi-ventricular systems, may be optimally implanted in a hybrid OR environment because the hybrid operating theater offers the required superior angulation and imaging capabilities in comparison to mobile C-arms and higher hygienic standards compared to cath labs (Figure 3). The need for hybrid operating theaters is not restricted to cardiac surgery. Vascular surgeons and neurosurgeons have equally developed hybrid procedures necessitating angiography systems in the OR. Furthermore, hybrid ORs are already in use by abdominal surgeons, traumatologists, orthopedic surgeons, and even urologists. Imaging needs, hygienic requirements, and room set-up—particularly for neurosurgery—may be considerably different. Other surgical disciplines may want to introduce navigation systems, mag- netic resonance imaging, endoscopy, biplane angiography systems, or lateral position of anesthesia equipment; however, the hybrid ORs are more commonly shared with interven- tionalists including cardiologists, interventional radiologists, electrophysiologists, neuroradiologists, and pediatric cardi- ologists. Their specific needs have to be carefully considered and weighed when planning the hybrid theater. The hybrid room is used by an interdisciplinary team of sur- geons, interventionalists, anesthesiologists, and others, and it is good practice to involve all stakeholders deeply into planning and keeping such a facility. Ideally, the hybrid OR is located next to interventional suites and ORs in order to keep logistics simple. If the ORs are separated from the interventional cath labs, however, it is recommend to establish the hybrid OR next to the other ORs [Bonatti 2007] because all OR equipment and personnel (eg, heart-lung machine and perfusionists) are imme- diately ready, and anesthesia and intensive care is available. Interventional rooms have excellent imaging capabilities but frequently lack the prerequisites, size, and equipment required for formal ORs. ORs meet those required standards, but usually lack high-level imaging capabilities. A hybrid OR should be larger than a standard OR, and the basic principle for planning is the larger the better, because it is not only the imaging equipment that needs sufficient space. Staff calcula- tions have shown that in hybrid procedures 8 to 20 people are needed in the team including anesthesiologists, surgeons, nurses, technicians, perfusionists, experts form device com- panies, and so forth [ten Cate 2004]. Expert opinions recom- mend for newly built ORs at least 70 m 2 [Benjamin 2008]. Additional space for a control room and a technical room is mandatory, adding up with washing and prep rooms to a total of approximately 150 m 2 for the whole area. If a fixed C-arm system is considered, an OR size of 45 m 2 is the absolute lower limit. Rebuilding in terms of lead shielding (2 to 3 mm) will be needed. Depending on the system, it may be necessary to enforce the ceiling or the floor to hold the weight of the stand (approximately 650 to 1800 kg). Planning of the hybrid room is truly an interdisciplinary task. Clinicians and technicians of all involved disciplines should define their requirements and form a responsible plan- ning team. The concrete planning is refined in several steps by specialized architects and vendors of OR equipment and imag- ing systems in a close feedback loop with the planning team. Virtual visualization of the room, visits to established hybrid rooms, and information exchange with experienced users help tremendously during the planning process. Several case studies for planning guidance have been published in recent literature [Eagleton 2007; Hirsch 2008; Peeters 2008; Sikkink 2008]. In general, all members of the team need access to all important information. Therefore, multiple moveable and flexible booms need to be installed in the operating room. If there are 2 booms to be installed, a boom on every side of the OR table serves the operative team. Collision of the ceiling- mounted displays with operating lights or other ceiling- mounted equipment should be avoided. Large displays are now available capable of showing multiple video inputs in various sizes and decreasing the need for multiple screens. A dedicated ceiling plan with all ceiling-mounted components including air conditioning should be drawn to ensure the function and usability of all devices. Conventional surgical lights may collide with the imag- ing equipment, particularly with ceiling-mounted systems. If a laminar air flow is present in combination with a ceiling- mounted system, light pendants need very long arms mak- ing them cumbersome to handle. An alternative may be new light concepts with ceiling-integrated multiple theater lights, as developed at the Interventional Centre at Rikshospitalet in Oslo, which therefore solve the problem of collision with the imaging equipment. A remote control offers the possibility to focus the light where needed (www.lightor.com; Figure 4). Hygienic requirements differ from country to country and even among surgical disciplines, with the highest standards in orthopedic surgery. In order to guarantee the highest flex- ibility in room use, hospitals tend to equip all ORs according to the highest standards, and that includes a laminar air flow ceiling. Some hospitals even require skirts around the laminar air flow field, and this set up may preclude ceiling-mounted systems. In any case, ceiling-mounted systems with running parts above the operating field, which are difficult to clean and interfere with the air flow by causing turbulences, are least recommended from a hygienic standpoint [Bonatti 2007]. Mobile C-arms have been commonly used in cardiac sur- gery and are readily available in every department, eg, for pacemaker implantation. Mobile C-arms may depict larger stents or catheters well; however, their technical specifications do not meet the recommendations of the cardiology societies [Bashore 2001]. The power (2 to 25 kW versus 80 to 100 kW recommendation) and the frame rate (up to 25 f/s 50 Hz or 30 f/s 60 Hz versus 30 to 60 f/s 50Hz recommendation) are below the standards. The cardiology recommendations are to be met, because cardiologic or neuroradiologic interventions are often part of the hybrid procedure. Thin guide wires (0.2 mm) and stents must be visualized even in obese patients, and stenoses of small vessels have to be quantified, which requires adequate power. Mobile C-arms generally have a heat stor- age capacity of up to 300,000 heat units (HU) (exception: rare water-cooled systems). A heat storage capacity of more than 1 million HU is recommended by cardiology societies for cath labs to avoid overheating and a dangerous shut down during complex procedures, which may occur in mobile C-arms. For these reasons, expert consensus recommends use of fixed C-arms [Bonatti 2007]. A semi-mobile system with a fixed generator (80 kW, AXIOM Artis U; Siemens AG, Forchheim, Germany) may accommodate high-power imag- ing demands even in average sized operating rooms too small to house a fixed C-arm (<45 m 2 ). Modern fixed C-arm systems are equipped with a flat panel detector (FD). Contrast resolution is far higher compared to image intensifier (II) systems, leading to a higher image qual- ity in detector systems. Additionally, in II systems the image is slightly distorted at the edges compared to the center. As a consequence, II systems are not capable of 3D imaging with soft-tissue contrast resolution. Expert consensus recommends floor-mounted systems for hygienic reasons. In fact, some hospitals do not allow running parts immediately above the operative field because dust may fall down and cause infections. Despite these facts, a large number of hospitals decide to have ceiling-mounted systems because they certainly cover the whole body with more flexi- bility and, most importantly, without moving the table, which is a sometimes difficult and dangerous undertaking during surgery because many lines and catheters have to be moved as well. Some ceiling-mounted systems are capable of 3D imaging from a surgical position, perpendicular to the patient from both the right and left table side. Moving from a parking to a working position during surgery, however, is easier with a flexible floor-mounted system because the C-arms turn in from the side without interference with the anesthesiologist, whereas ceiling-mounted systems can hardly move during surgery in the park position at the head side without colliding with the anesthesia equipment. In an overcrowded environment like an OR, biplane sys- tems add to the complexity and interfere with anesthesia, except for neurosurgery, where anesthesia is not at the head side. Monoplane systems (Figures 4 and 5) are therefore clearly recommended for rooms mainly used for vascular, car- diac, and orthopedic surgery. There are certainly exceptions: If pediatric cardiologists, electrophysiologists, or neuroradi- ologists are important stakeholders in room usage, a biplane system may also be considered. The operating table should meet the expectations of both surgeons and interventionalists. This is in fact a special chal- lenge, because the expectations may be mutually exclusive. Surgeons expect a table with a breakable tabletop. For imag- ing reasons, the table has to be radiolucent and should allow coverage of the patient in a wide range. Therefore, unbreak- able carbon fiber tabletops are used. Cardiovascular surgeons in general do not have very sophisticated positioning needs and are used to having fully motorized movements of the table and the tabletop. Inflatable cushions are sometimes used for positioning of the patient if no breakable table is available. Interventionalists require a floating tabletop to allow fast and precise movements during angiography, and in some coun- tries floating tabletops are among the technical requirements (or are at least highly recommended by expert ...