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The State of the Hybrid Operating Room: Technological Acceleration at the Pinnacle of Collaboration

Authors:
Alejandra Maria Casar Berazaluce at Cincinnati Children's Hospital Medical Center
Alejandra Maria Casar Berazaluce
Rachel E. Hanke
Rachel E. Hanke
Rachel E. Hanke
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Daniel von Allmen at Cincinnati Children's Hospital Medical Center
Daniel von Allmen
John M Racadio at Cincinnati Children's Hospital Medical Center
John M Racadio
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Abstract and Figures

Purpose of Review As imaging technologies expand to include image-guided anatomical navigation and surgical techniques evolve to accommodate increasingly complex interventions with minimally invasive approaches, interventionalists and surgeons have convened in a novel area of hospitals around the world, the hybrid operating room. Although these assets have long been used for cardiovascular procedures, the integration of these tools in a designated surgery suite has given rise to a variety of novel interventions and multi-specialty collaborations. Recent Findings In this review, we highlight current international hybrid room experiences in many fields, spanning from neurosurgery to urology. We also comment on our institutional journey of surgery-interventional radiology collaborations in developing our image-guided surgery program for a pediatric population. Summary As the hybrid operating room continues to gain traction globally, surgeons and interventional radiologists’ creativity and collaborative problem-solving skills will continue to be pushed to improve patient care. Identifying practice gaps and collaborating with industry is vital for further refinement of these tools.
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PEDIATRIC SURGERY (A.C. FISCHER, SECTION EDITOR)
The State of the Hybrid Operating Room: Technological
Acceleration at the Pinnacle of Collaboration
Alejandra M. Casar Berazaluce
1
•Rachel E. Hanke
1
•Daniel von Allmen
1
•
John M. Racadio
2
Published online: 18 March 2019
Springer Science+Business Media, LLC, part of Springer Nature 2019
Abstract
Purpose of Review As imaging technologies expand to
include image-guided anatomical navigation and surgical
techniques evolve to accommodate increasingly complex
interventions with minimally invasive approaches, inter-
ventionalists and surgeons have convened in a novel area
of hospitals around the world, the hybrid operating room.
Although these assets have long been used for cardiovas-
cular procedures, the integration of these tools in a desig-
nated surgery suite has given rise to a variety of novel
interventions and multi-specialty collaborations.
Recent Findings In this review, we highlight current
international hybrid room experiences in many fields,
spanning from neurosurgery to urology. We also comment
on our institutional journey of surgery-interventional radi-
ology collaborations in developing our image-guided sur-
gery program for a pediatric population.
Summary As the hybrid operating room continues to gain
traction globally, surgeons and interventional radiologists’
creativity and collaborative problem-solving skills will
continue to be pushed to improve patient care. Identifying
practice gaps and collaborating with industry is vital for
further refinement of these tools.
Keywords Hybrid operating room Interventional
radiology Image-guided surgery Innovative operating
room Surgical navigation Computer-assisted surgery
Introduction
Since the inception of the C-arm in the 1950s, physicians in
procedural specialties have sought to improve patient care
through image guidance. As imaging technologies evolved,
the breadth of modalities and techniques expanded,
enabling physicians to perform tasks that were previously
unattainable. As interventional radiologists gained
momentum and expertise, the complexity of their proce-
dures surpassed the capabilities of radiology departments
and thus began a transition to dedicated interventional
radiology (IR) suites. Parallel to this transformation, sur-
gical techniques shifted gears towards minimal-invasive-
ness and pre-, intra-, and post-operative image
visualization. Similarly, medical interventionalists made
strides with technical and technological improvements in
endoscopy and catheterization. Hybrid operating rooms
were developed in response to the increasing demand for
real-time image navigation and for simultaneous proce-
dures in a single sterile environment with multidisciplinary
collaboration. Now, as technology continues to accelerate,
interventionalists and surgeons rely on each other to bring
these new advances to patient care, shortening anesthesia
times and improving patient outcomes. This, in turn, has
created several management challenges in funding,
scheduling, and cross-training of technicians to meet the
needs of the changing tide.
This article is part of the Topical collection on Pediatric Surgery.
&Daniel von Allmen
Daniel.vonAllmen@cchmc.org
1
Department of Surgery, Cincinnati Children’s Hospital, 3333
Burnet Ave, MLC 3025, Cincinnati, OH 45229-7657, USA
2
Department of Radiology, Cincinnati Children’s Hospital,
Cincinnati, OH, USA
123
Curr Surg Rep (2019) 7:7(0123456789().,-volV)(0123456789().,-volV)
https://doi.org/10.1007/s40137-019-0229-x
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... Avoidance of postoperative revisions makes the initial investment in intraoperative 3D imaging technologies economically more attractive [9]. Hybrid operating rooms (OR) equipped with a motorized Carm coupled with a radiolucent surgical table as well as with integrated navigation capabilities, have been recently used for spine surgery [10]. The C-arm provides intraoperative cone-beam CT (CBCT) imaging. ...
... Hybrid ORs support multidisciplinary use of 2D and 3D imaging and navigation for open and minimal invasive procedures [10]. This cadaver study sought to assess the diagnostic performance of CBCT from a C-arm within a hybrid OR compared to diagnostic CT. ...
View
... Hybrid operating rooms (OR) equipped with a motorized C-arm coupled with a radiolucent surgical table as well as with integrated navigation capabilities, have been recently used for spine surgery [10]. The C-arm provides intraoperative cone-beam CT (CBCT) imaging. ...
... Hybrid ORs support multidisciplinary use of 2D and 3D imaging and navigation for open and minimal invasive procedures [10]. ...
View
... Hybrid operating rooms (OR) equipped with a motorized C-arm coupled with a radiolucent surgical table as well as with integrated navigation capabilities, have been recently used for spine surgery 10 . The C-arm provides intraoperative cone-beam CT (CBCT) imaging. ...
... Hybrid ORs support multidisciplinary use of 2D and 3D imaging and navigation for open and minimal invasive procedures 10 . This cadaver study sought to assess the diagnostic performance of CBCT from a C-arm within a hybrid OR compared to diagnostic CT. ...
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  • Feb 2021
Background CT is considered the gold standard for detecting pedicle breach. However, CBCT may be a viable and low radiation dose alternative, to provide intraoperative feedback to surgeons to permit in-room revisions of misplaced screws Methods To assess the ability and reliability of intraoperative cone-beam CT (CBCT) from a robotic C-arm in a hybrid operating room (OR) two hundred forty-one pedicle screws were inserted in cervical, thoracic and lumbar spine of 7 cadavers, followed by CBCT and CT imaging. The CT images served as the standard of reference. Agreement on screw placement between both imaging systems was assessed using Cohen’s Kappa coefficient (κ). Sensitivity, Specificity, Receiver operating characteristic (ROC), area under the empirical and fitted ROC curves (AUC) were computed to assess CBCT as a diagnostic tool compared to CT. The patient effective radiation dose (ED) was calculated for comparison. A systematic literature review was performed to provide perspective to the obtained results. Results Almost perfect agreement in assessing pedicle screw grading between CBCT and CT was observed (κ = 0.84). The sensitivity and specificity of CBCT were 0.84 and 0.98, respectively. The AUC derived from the empirical and fitted ROC curves were 0.95 and 0.96, respectively. Conclusion Intraoperative CBCT by C-arm in a hybrid OR is highly reliable in identification of screw placement at significant dose reduction.
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... Hybrid operating rooms (HORs) are surgical theaters equipped with radiological imaging systems, such as fluoroscopy, computed tomography (CT), or magnetic resonance imaging (MRI) devices [77], which enable the integration of surgical and interventional radiological procedures in a single setting. The first clinical employment of HORs was reported in cardiothoracic surgery [78], being then gradually implemented in other surgical endeavors such as neurosurgery, vascular surgery, and orthopedic surgery [16,79]. ...
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... The construction of these units, which are designed as a large area considering the presence of personnel working for each process, is quite costly. However, since most needs can be met in the same mirror, specialities such as neurology and general surgery have been preferred (Berazaluce et al. 2019;Drevets et al. 2019;Jin and Liu 2022). Considering that the amount of data produced by each process is high, it is known that large amounts of data are formed in the system formed by these units. ...
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... The construction of these units, which are designed as a large area considering the presence of personnel working for each process, is quite costly. However, since most needs can be met in the same mirror, specialities such as neurology and general surgery have been preferred (Berazaluce et al. 2019;Drevets et al. 2019;Jin and Liu 2022). Considering that the amount of data produced by each process is high, it is known that large amounts of data are formed in the system formed by these units. ...
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View
... The increase in interest in minimally invasive surgery comes hand-to-hand with the introduction of navigation platforms in the operating room (OR), and thus, an increase in the use of intraoperative modalities. Furthermore, hybrid ORs bring together radiologists and surgeons as it allows the use of intraoperative CT scanners as well as MRI scanners in the surgical workflow [52]. This market is expected to grow in the next years, increasing the use of CT images in liver surgery, for examination and navigation, as well as laparoscopic US for navigation [50,51]. ...
Deep learning for image-based liver analysis — A comprehensive review focusing on malignant lesions
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... The system is based on a hybrid OR solution providing a number of benefits. 38 The integration of video cameras in the ceiling-mounted C-arm simplifies the registration process. Once the initial CBCT scan is performed, the patient is automatically coregistered. ...
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Image-Guided Surgery in Patients with Pancreatic Cancer: First Results of a Clinical Trial Using SGM-101, a Novel Carcinoembryonic Antigen-Targeting, Near-Infrared Fluorescent Agent
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Background: Near-infrared (NIR) fluorescence is a promising novel imaging technique that can aid in intraoperative demarcation of pancreatic cancer (PDAC) and thus increase radical resection rates. This study investigated SGM-101, a novel, fluorescent-labeled anti-carcinoembryonic antigen (CEA) antibody. The phase 1 study aimed to assess the tolerability and feasibility of intraoperative fluorescence tumor imaging using SGM-101 in patients undergoing a surgical exploration for PDAC. Methods: At least 48 h before undergoing surgery for PDAC, 12 patients were injected intravenously with 5, 7.5, or 10 mg of SGM-101. Tolerability assessments were performed at regular intervals after dosing. The surgical field was imaged using the Quest NIR imaging system. Concordance between fluorescence and tumor presence on histopathology was studied. Results: In this study, SGM-101 specifically accumulated in CEA-expressing primary tumors and peritoneal and liver metastases, allowing real-time intraoperative fluorescence imaging. The mean tumor-to-background ratio (TBR) was 1.6 for primary tumors and 1.7 for metastatic lesions. One false-positive lesion was detected (CEA-expressing intraductal papillary mucinous neoplasm). False-negativity was seen twice as a consequence of overlying blood or tissue that blocked the fluorescent signal. Conclusion: The use of a fluorescent-labeled anti-CEA antibody was safe and feasible for the intraoperative detection of both primary PDAC and metastases. These results warrant further research to determine the impact of this technique on clinical decision making and overall survival.
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Indocyanine green-based fluorescence imaging in visceral and hepatobiliary and pancreatic surgery: State of the art and future directions
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A single-center experience of 100 image-guided video-assisted thoracoscopic surgery procedures
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Image-Guided Navigation in Lymph Node Biopsy
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Background and objectives: Image-guided navigation is an effective intra-operative technology in select surgical sub-specialties. Laparoscopic and open lymph node biopsy are frequently undertaken to obtain adequate tissue of difficult lesions. Image-guided navigation may positively augment the precision and success of surgical lymph node biopsies. Methods: In this prospective pilot study, pre-operative imaging was uploaded into the navigation platform software, which superimposed the imaging and the subject's real-time anatomy. This required anatomical landmarks on the subject's body to be spatially registered with the platform using an infrared camera. This was then used to guide dissection and biopsy in laparoscopic and subcutaneous biopsies. Results: Image-guided lymph node biopsy was undertaken in 15 cases. Successful biopsy locations included: retroperitoneum, porta hepatis, mesentery, iliac region, para-aortic, axilla, and inguinal region. There was an 87% total absolute success rate in biopsies (89% in laparoscopic image-guided navigation [LIGN] and 83% in subcutaneous image-guided navigation [SIGN]). There was a 92% absolute success rate in lesions with fixed locations. There was a 67% absolute success rate in lesions with mobile locations. Conclusion: The investigators successfully incorporated image-guidance into surgical biopsy of lymph nodes in a diverse variety of locations. This image-guided technique for surgical biopsy can accurately and safely localize target lesions minimizing unnecessary dissection, conversion to open procedure, and re-operation for further tissue characterization. This technique was useful in the morbidly obese, instances of limited foci of disease, PET-active lesions, identifying areas of highest PET-avidity, and lesions with critical surrounding anatomy.
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Simultaneous supervision by microscope of endoscope-assisted microsurgery via presigmoid retrolabyrinthine approach: A pilot study
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Objective: To examine the impact of integrated hybrid operating rooms for endoscope-assisted microsurgery using the presigmoid retrolabyrinthine (RL) approach, and to determine the value of simultaneous supervision of skull base endoscopic procedures by microscope. Material and methods: We retrospectively reviewed endoscope-assisted surgery using the RL approach at our institution between September 2013 and January 2017. The simultaneous supervision of endoscopic procedures by microscope was realized using the integrated hybrid system. Intra- or postoperative complications and surgical outcomes were analyzed. All patients were followed for at least 1 year. Results: In total, 32 patients were studied: 4 vestibular schwannomas, 5 cholesteatomas, 8 hemifacial spasms, 5 glossopharyngeal neuralgias, and 10 Ménière's disease. In patients with vestibular schwannoma or cholesteatoma, complete removal was performed in all patients. In patients with Ménière's disease, hemifacial spasm or glossopharyngeal neuralgia, satisfactory symptom relief was achieved in all patients. Two (6.3%) patients had hearing loss after surgery which did not recover. One (3.1%) patient with vestibular schwannoma had mild facial palsy (HB III) at 2 weeks after the operation and recovered to near normal facial nerve function (HB II) at 1 year after surgery. No permanent or transient dysfunction of the trigeminal nerve or the lower cranial nerves was observed during follow-up. No complications such as cerebrospinal fluid (CSF) leakage or meningitis were observed. Conclusion: The endoscope provided a clearer and larger view, which solved the limitations of surgery using the RL approach. Endoscopic surgery under simultaneous supervision by microscope was safe and efficient in hearing preservation as well as in preservation of facial nerve function. An integrated operation room provided better support and the ability to switch quickly between these various complex devices.
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Intraoperative O-arm-navigated resection in musculoskeletal tumors
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Background: Although emerging evidence has suggested that computer-assisted navigation allows surgeons to plan the optimal level of resection without compromising the surgical margins, the precise accuracy of the procedures has been unclear. The aim of this study was to investigate the accuracy and safety of the musculoskeletal tumor resection using O-arm/Stealth intraoperative navigation assistance. Methods: A retrospective study of six patients with bone and soft tissue tumors who underwent surgical resection using O-arm/Stealth navigation system was performed. The histological diagnosis was osteosarcoma, metastatic bone tumor, leiomyosarcoma, undifferentiated sarcoma, and synovial sarcoma, respectively. Tumor resection was performed according to planned osteotomy planes determined on O-arm/Stealth three-dimensional intraoperative images. The resection accuracy, length of time for the procedures, surgical margins, and perioperative complications were evaluated. Results: The distances between the entry and exit points for the planned and actual cuts were 1.5 ± 0.3 mm and 2.3 ± 0.3 mm, respectively, and the mean discrepancy of the osteotomy angle was 2.8 ± 1.2°. The mean length of time required for navigation was 14 min. A histological examination revealed clear margins in all patients. There were no complications related to navigation, and no patients developed local recurrence during a mean follow-up of 30.6 months. Conclusions: The O-arm/Stealth intraoperative CT navigation system provides safe and accurate osteotomy in musculoskeletal tumor resections. However, surgeons should keep in mind and be careful of minimal errors during osteotomy, which are around 2 mm from the planned line.
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Augmented reality in open surgery
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  • Jul 2018
Augmented reality (AR) has been successfully providing surgeons an extensive visual information of surgical anatomy to assist them throughout the procedure. AR allows surgeons to view surgical field through the superimposed 3D virtual model of anatomical details. However, open surgery presents new challenges. This study provides a comprehensive overview of the available literature regarding the use of AR in open surgery, both in clinical and simulated settings. In this way, we aim to analyze the current trends and solutions to help developers and end/users discuss and understand benefits and shortcomings of these systems in open surgery. We performed a PubMed search of the available literature updated to January 2018 using the terms (1) "augmented reality" AND "open surgery", (2) "augmented reality" AND "surgery" NOT "laparoscopic" NOT "laparoscope" NOT "robotic", (3) "mixed reality" AND "open surgery", (4) "mixed reality" AND "surgery" NOT "laparoscopic" NOT "laparoscope" NOT "robotic". The aspects evaluated were the following: real data source, virtual data source, visualization processing modality, tracking modality, registration technique, and AR display type. The initial search yielded 502 studies. After removing the duplicates and by reading abstracts, a total of 13 relevant studies were chosen. In 1 out of 13 studies, in vitro experiments were performed, while the rest of the studies were carried out in a clinical setting including pancreatic, hepatobiliary, and urogenital surgeries. AR system in open surgery appears as a versatile and reliable tool in the operating room. However, some technological limitations need to be addressed before implementing it into the routine practice.
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Comparison of 3D intraoperative digital subtraction angiography and intraoperative indocyanine green video angiography during intracranial aneurysm surgery
Article
  • Jul 2018
  • J NEUROSURG
Objective: During the last decade, improvements in real-time, high-resolution imaging of surgically exposed cerebral vasculature have been realized with the successful introduction of intraoperative indocyanine green video angiography (ICGVA) and technical advances in intraoperative digital subtraction angiography (DSA). With the availability of 3D intraoperative DSA (3D-iDSA) in hybrid operating rooms, the present study offers a contemporary comparison for rates of accuracy and discordance. Methods: In this retrospective study of prospectively collected data, 140 consecutive patients underwent microsurgical treatment of intracranial aneurysms (IAs) in a hybrid operating room. Variables analyzed included patient demographics, aneurysm-specific characteristics, intraoperative ICGVA and 3D-iDSA findings, and the need for intraoperative clip readjustment. The authors defined the discordance rate of the two modalities as a false-negative finding that necessitated clip repositioning after 3D-iDSA. Results: In 120 patients, ICGVA and 3D-iDSA were used to evaluate 134 IA obliterations. Of 215 clips used, 29 (14%) were repositioned intraoperatively, improving the surgical result in all 29 patients (24%). Repositioning was prompted by visual inspection and microvascular Doppler ultrasonography in 8 (28%), ICGVA in 13 (45%), and 3D-iDSA in 7 (24%) patients. Clip repositioning was needed in 7 patients (6%) based on 3D-iDSA, yielding an ICGVA accuracy rate of 94%. Five (71%) of the ICGVA-3D-iDSA discordances that prompted clip repositioning occurred at the anterior communicating artery complex. Conclusions: A combination of vascular monitoring techniques most often achieved correct intraoperative interpretation of complete IA occlusion and parent artery integrity. Compared with 3D-iDSA imaging, ICGVA demonstrated high accuracy. Despite the relatively low discordance rate, iDSA was confirmed to be the gold standard. Improved imaging quality, including 3D-iDSA, supports its routine use in IA surgery, obviating the need for postoperative DSA.
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Proficiency-based training of medical students using virtual simulators for laparoscopy and robot-assisted surgery: results of a pilot study
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  • Jul 2018
Proficiency-based training has become essential in the training of surgeons such that on completion they can execute complex operations with novel surgical approaches including direct manual laparoscopic surgery (DMLS) and robotically assisted laparoscopic surgery (RALS). To this effect, several virtual reality (VR) simulators have been developed. The objective of the present study was to assess and establish proficiency gain curves for medical students on VR simulators for DMLS and RALS. Five medical students participated in training course consisting of didactic teaching and practical hands-on training with VR simulators for DMLS and RALS. Evaluation of didactic component was by questionnaire completed by participating students, who also were required to undertake selected exercises to reach proficiency at each VR simulator: (1) 12 tasks on LapSim VR (Surgical Science, Gothenburg, Sweden) for DMLS, and (2) six selected exercises on the dV-Trainer Mimic (Seattle, WA, United States). The five medical students reached the 60% threshold on the questionnaire-based didactic component. During selected hands-on simulation on VR simulators, students with previous experience with simulators (n = 3) outperformed those without (n = 2) in ten out of twelve LapSim tasks and all six at dV-Trainer, by requiring fewer attempts to reach proficiency although the difference was not significant (p < 0.05). In this work, we developed a proficiency-based training program for medical undergraduates based on surgical simulation for DMLS and RALS.z. Larger studies are needed to evaluate the benefit of this program in stimulating interest for surgical career amongst medical students after the qualify.
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Feasibility of a novel liquid fiducial marker for use in image guided radiotherapy of oesophageal cancer
Article
  • Jul 2018
Objective: To evaluate the feasibility of a new liquid fiducial marker for use in image guided radiotherapy (IGRT) for oesophageal cancer. Methods: Liquid fiducial markers were implanted in patients with metastatic or inoperable locally advanced oesophageal or gastro-oesophageal junction cancer receiving radiotherapy. Markers were implanted using a conventional gastroscope equipped with a 22 G Wang needle. Marker visibility was evaluated on fluoroscopy, computed tomography (CT), magnetic resonance imaging- (MRI) and conebeam CT (CBCT) scans. Results: Liquid markers (n = 16) were injected in four patients. No grade 2 or worse adverse events were observed in relation to the implantation procedure, during treatment or in the follow-up period. 12/16 (75%) markers were available at the planning CT-scan and throughout the treatment- and follow-up period. The implanted markers were adequately visible in CT and CBCT but were difficult to distinguish in fluoroscopy and MRI without information from the corresponding CT image. Conclusion: Liquid fiducial marker placement in the oesophagus proved safe and clinically feasible. Advances in knowledge: This paper presents the first clinical use of a new liquid fiducial marker in patients with oesophageal cancer and demonstrates that marker implantation using standard gastroscopic equipment and subsequent use in three-dimensional image guided radiation therapy (3D-IGRT) is safe and clinically feasible.
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