Robert M. Popilock, BS, RTR, RTN, Manager Strategic Alliances & Hybrid OR, STERIS Corp.

Robert M. Popilock, BS, RTR, RTN, Manager Strategic Alliances & Hybrid OR, STERIS Corp., gives his take on the Hybrid OR.

The critical function of the hybrid operating room is its ability to visualize the internal workings of the body, table side, and non-invasively, without the need to open the patient. This allows surgeons to plan an optimal management approach and concurrently perform minimally invasive treatments. The key enabler is imaging and image guidance.

The most commonly utilized imaging modalities are fluoroscopy and ultrasound. These modalities have broad clinical relevance, and the equipment has lower capital costs and is relatively easy to place onsite. However, interest is growing in the use of computed tomography and magnetic resonance imaging in hybrid operating rooms, which offer higher degrees of image quality and three-dimensional evaluations.

The bottom line is that imaging is transforming how patients are being managed and is a critical driver behind the creation of a new hybrid surgical imaging science; a science known for its sophistication and need for close collaboration between medical specialties. When working in a multi-disciplinary manner with multi-disciplinary surgical imaging tools, these specialists can deliver procedures associated with reduced hospital stays, shorter rehabilitation times, lower infection rates, and fewer repeat procedures.

Choosing Proper Equipment
There a four closely related factors that must be considered when outfitting a hybrid operating room; clinical focus, procedure utilization, room design, and budget.

It is tempting to try to create a room that is everything to everybody, considering the total cost of build-out and capital expenditures and the fact that such a state-of-the-art procedure room will be coveted by all surgical disciplines. It is important to establish the clinical focus for the room, remembering that equipping a room for cardiovascular, electrophysiology, neuromuscular, or genitourinary procedures, for example, will require very different imaging, robotic, and navigation configurations and vastly different room designs.

This being said, a thoughtful room design equipped with scalable surgical equipment such as suspension arms and surgical light heads, equipment management systems with supply heads and supply columns, and fiber-based integration systems with universal interface ports can help protect the facility’s investment. Such scalable flexibility delivers life-cycle benefits by allowing the room to be modernized on-site without the need to forklift existing equipment. It also offers room utilization benefits since the room can be re-configured to accommodate sub-specialty needs.

The next consideration is procedure type and utilization, which helps determine pro forma models, specific equipment selection, and room design. In a simplistic example, a room designed to perform cardiothoracic and vascular procedures on an adult population will likely require the use of a mono-plane c-arm while a room intended to perform pediatric cardiovascular procedures may require a bi-plane c-arm. In the case of a neurologic hybrid OR, procedure utilization can drive the use of surgical microscopes with fluorescence imaging, computed tomography with navigation, or MRI with navigation.

In the case of procedures requiring CT and MRI, the level of utilization that justifies dedicated intra-operative CT or MRI may be hard to achieve for many hospitals. An alternative can be a suite model that consists of adjoining rooms; one room that hosts the imaging equipment that can be used for non-surgical imaging, and an adjoining room that allows the CT or MRI scanner to be moved into the surgical suite when required. Another way of satisfying low volume CT needs cost effectively is through the use of portable CT or O-ring scanners. Such systems can be shared among a number of rooms to drive economies of scale.

A closer look at procedure type as a driver of specific imaging requirements reveals some well-established standards of practice. For example, fluoroscopy’s role in visualizing anatomy (in particular vascular anatomy) makes it an ideal tool for guiding catheters, pacing, and ablation wires. The 3D visualization and image fusion provided by rotational angiography and navigation devices are well-established facilitation tools for stent placement and valve repair. There are also several ultrasound techniques to be considered; trans-esophageal echo (TEE) for pacing and hemodynamic evaluation, Doppler for blood flow assessment, and intra-cardiac echo (ICE) for intracardiac support for ablation. As can be seen from these examples, procedure type and utilization plays an important role in the selection of imaging equipment.

Room design and budget are two constraints that have an obvious inter-relationship with equipment selection. For example, a mono-plane c-arm will be less costly than a bi-plane c-arm as well as less demanding to site. This would also hold true for a c-arm in comparison to a CT scanner.

Another influencer of room design and budget is the level of surgical integration that’s required. A primary objective for the hybrid OR (and what makes the hybrid OR so efficient) is the ability to bring critical data tableside and to centralized locations in the operating room. Centralization is extremely important as it allows the entire surgical team to be ‘on the same page’ during every step of the procedure.

Achieving tableside management and centralization hinges upon the capabilities of the integration system, which is responsible for routing a number of audiovisual inputs to any number of destination devices in or outside of the room. Additional complexity is added when multiple inputs such as live and reference c-arm, vitals, hemodynamics, ultrasound and 3D fusion are co-logged on a single destination.

In Addition
Hybrid operating rooms have become known for their sophistication, shifting paradigms, and for helping to establish new standards of care. They are characterized by the merging of traditional and more advanced surgical elements with imaging, robotic, and navigation techniques, all within sterile environments. A growing body of evidence indicates that hybrid ORs can help facilities achieve clinical benefits related to efficiency, improved outcomes, and delivery of the most advanced levels of surgical and interventional care.

Through the hybrid OR and its dedicated imaging capabilities, the surgical team can assess the current state of a disease, determine the most minimally invasive approach to manage the disease, use image guidance to perform a minimally invasive technique, and then assess the efficacy of the technique, all in a single episode of care. This drives procedural efficiency through real time assessment, helps improve outcomes by enhancing decision-making confidence, and helps deliver the most advanced care with minimally invasive procedures.