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

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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.
... 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]. ...
... 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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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.
... 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]. ...
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Deep learning-based methods, in particular, convolutional neural networks and fully convolutional networks are now widely used in the medical image analysis domain. The scope of this review focuses on the analysis using deep learning of focal liver lesions, with a special interest in hepatocellular carcinoma and metastatic cancer; and structures like the parenchyma or the vascular system. Here, we address several neural network architectures used for analyzing the anatomical structures and lesions in the liver from various imaging modalities such as computed tomography, magnetic resonance imaging and ultrasound. Image analysis tasks like segmentation, object detection and classification for the liver, liver vessels and liver lesions are discussed. Based on the qualitative search, 91 papers were filtered out for the survey, including journal publications and conference proceedings. The papers reviewed in this work are grouped into eight categories based on the methodologies used. By comparing the evaluation metrics, hybrid models performed better for both the liver and the lesion segmentation tasks, ensemble classifiers performed better for the vessel segmentation tasks and combined approach performed better for both the lesion classification and detection tasks. The performance was measured based on the Dice score for the segmentation, and accuracy for the classification and detection tasks, which are the most commonly used metrics.
... 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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... Our test statistics would therefore be expected to be valid for spine deformity cases at similar tertiary care institutions. A hybrid OR can improve facility utilization by covering many procedures-from endovascular to minimally invasive or open surgery-and enable exploration of new procedures that leverage intraoperative high-quality imaging and high level of device integration [41]. The results of this study indicate that the intraoperative CBCT imaging generated in a hybrid OR is of sufficient quality, comparable with that of conventional CT, to reliably identify pedicle screw misplacements. ...
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Objectives: To test the hypothesis that intraoperative cone beam computed tomography (CBCT) using the Allura augmented reality surgical navigation (ARSN) system in a dedicated hybrid operating room (OR) matches computed tomography (CT) for identification of pedicle screw breach during spine surgery. Methods: Twenty patients treated with spinal fixation surgery (260 screws) underwent intraoperative CBCT as well as conventional postoperative CT scans (median 12 months after surgery) to identify and grade the degree of pedicle screw breach on both scan types, according to the Gertzbein grading scale. Blinded assessments were performed by three independent spine surgeons and the CT served as the standard of reference. Screws graded as Gertzbein 0 or 1 were considered clinically accurate while grades 2 or 3 were considered inaccurate. Sensitivity, specificity, and negative predictive value were the primary metrics of diagnostic performance. Results: For this patient group, the negative predictive value of an intraoperative CBCT to rule out pedicle screw breach was 99.6% (CI 97.75-99.99%). Among 10 screws graded as inaccurate on CT, 9 were graded as such on the CBCT, giving a sensitivity of 90.0% (CI 55.5-99.75%). Among the 250 screws graded as accurate on CT, 244 were graded as such on the CBCT, giving a specificity of 97.6% (CI 94.85-99.11%). Conclusions: CBCT, performed intraoperatively with the Allura ARSN system, is comparable and non-inferior to a conventional postoperative CT scan for ruling out misplaced pedicle screws in spinal deformity cases, eliminating the need for a postoperative CT. Key points: • Intraoperative cone beam computed tomography (CT) using the Allura ARSN is comparable with conventional CT for ruling out pedicle screw breaches after spinal fixation surgery. • Intraoperative cone beam computed tomography can be used to assess need for revisions of pedicle screws making routine postoperative CT scans unnecessary. • Using cone beam computed tomography, the specificity was 97.6% and the sensitivity was 90% for detecting pedicle screw breaches and the negative predictive value for ruling out a pedicle screw breach was 99.6%.
... The standard imaging tool for gaging cerebrovascular flow is digital subtraction angiography (DSA)-an invasive fluoroscopic technique that is typically used preoperatively and may help surgeons assess the safety of sacrificing a major vein (Mizutani et al., 2016). More recently, the efficacy of DSA in intraoperative settings (e.g., hybrid operating room) has been documented (Casar Berazaluce et al., 2019). While this technique remains the standard, it carries various limitations, including the risk of vasospasm and other procedure-related complications such as groin hematoma and cerebral ischemia. ...
Chapter
Approximately 7%–12% of all intracranial meningiomas are located in the posterior fossa (PF), a region which contains—among many other critical neurovascular structures—numerous major veins and sinuses draining blood away from the PF structures. There is a growing body of evidence indicating that venous sacrifice or injury during surgery are linked to serious postoperative complications—which may lead to significant morbidity and mortality. Thus, it is of paramount importance that clinicians charged with the preoperative, surgical, and postoperative care of patients undergoing treatment for meningioma are familiar with the general anatomy of the PF veins, as well as their structural nuances and drainage variations. The present chapter surveys the relevant anatomy in a manner that aims to be useful for an interdisciplinary team of clinicians and concludes with a discussion of emerging imaging technologies that may assist them in their clinical decision-making.
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