Hybrid operating room

A hybrid operating room, (HOR) is a surgical theatre that is equipped with advanced medical imaging devices such as fixed C Arms, Computerized tomography or MRI scanners.

These imaging devices enable minimally invasive surgery.

In Neurosurgery, applications for hybrid ORs are for example spinal fusion and intracranial aneurysm coiling. In both cases, they have been rated promising to improve outcomes.

For spinal fusion procedures, an integration with a neuronavigation system can further improve the workflow.

In a case report from the Shinshu University Hospital, the extent of bone resection and anatomical orientation were confirmed intraoperatively. The postoperative course was uneventful and symptoms were improved after surgery.

The application of a hybrid operating room may make the endoscopic endonasal odontoidectomy (EEO) safe and precise for anterior decompression of craniovertebral junction (CVJ). This is the first case report describing the clinical experience of EEO in the HOR 1).

In 9 months, 109 pelvic and spine cases were performed using a hybrid operating room. Radiation dose of the surgeon and the assisting nurse was recorded using real-time dosimeters. Lower radiation doses for the main surgeon in navigated dorsal instrumentations of the thoracic spine were recorded. Standing between the C-arm during screw placement increased the radiation dose sixfold. Lumbar dorsal instrumentation showed a similar radiation dose compared to the previous studies in traditional operating room settings. The use of a hybrid-operating room for dorsal spine instrumentation showed no increase in radiation dose compared to traditional settings. Intraoperative navigation can help to reduce the radiation dosage for the operating personnel 2).

The ability of our cerebrovascular surgeons to perform minimally-invasive, image-guided procedures has been enhanced by the construction in 2011 of NYU Langone’s state-of-the-art “hybrid” operating room. This new OR of the future combines the facilities of a standard operating room with the technology of a digital flat-panel interventional neuroradiology suite, including built-in X-ray imaging, computer guidance systems, and video-integrated technology that projects and records 3-D images of the surgical field onto high-definition plasma monitors. In addition to being ideal for minimally-invasive cerebrovascular procedures, the OR’s multiple capabilities also allow our surgeons to customize neurosurgical procedures for each individual patient, utilizing both minimally-invasive and open microsurgery as needed.

The direct interaction between neurosurgeons and neuroradiologists in a joint environment changes and accelerates all diagnostic and therapeutic steps because all relevant procedures, including treatment control can be performed in a single room. Interventions of the skull base or the spine are also a domain of such hybrid theatre.

As this new concept requires organisational changes throughout the entire patient management, a change of mindset is also needed at the institutional level in order to attain maximum benefits from such a setting 3).

The cases of CAVMs treated in Qilu hospital and People's Hospital of Xinjiang Uygur Autonomous Region from July 2011 to July 2016 were analyzed retrospectively.Two modes of hybrid surgery, “angiographic diagnosis-craniotomy lesion resection or/and hematoma clearance-intraoperative angiography evaluation” and “angiographic diagnosis-intraoperative embolization-craniotomy lesion resection or/and hematoma clearance-intraoperative angiography evaluation” were applied for all the cases.We placed an aneurysm clip as marker in surgery field during real-time angiography.If CAVMs residues occurred during surgery, we re-resected the residue according to the guidance of the marker (clip) and DSA imaging. Intra-operative angiography evaluated the results of CAVMs resection one more time.Postoperatively, follow-up CT scan was performed for all the patients. Results: Of all the cases with CAVMs, there were 8 cases of scale Ⅰ, 13 cases of scale Ⅱ, 10 cases of scale Ⅲ and 6 cases of scale Ⅳ according to Spetzler-Martin Scale.There were 28 cases of acute hemorrhagic CAVMs and 9 cases of chronic hemorrhagic CAVMs or no-hemorrhagic CAVMs.Intra-operative angiography showed CAVMs residues in 6 cases of acute hemorrhagic CAVMs and only one in chronic group.About 18.92% residual rate of CAVMs were found for the first time intra-operative assessment angiography.With the guidance of intra-operative angiography and aneurysm clip as Marker, all residues of CAVMs were resected totally.Follow up CT showed the hematomas disappeared in all the cases of acute hemorrhagic cases.The cure rate of CAVMs with hybrid surgery was 100% according to the final intra-operative assessment angiography.

(1)Hybrid surgery for the treatment of CAVMs in one session could evaluate the results of CAVMs resection and instruct the surgical procedure according to real-time angiography.This model could improve the treatment safety and efficacy for patients with CAVMs.(2)Patients with higher Spetzler-Martin Scale (Ⅲ-Ⅳ) who need intra-operative embolization and patients with hemorrhagic CAVMs are more suitable for hybrid surgery 4).

Hybrid cerebrovascular surgeon.

Ogiwara T, Miyaoka Y, Nakamura T, Tsukada K, Yamazaki D, Ito K, Hanaoka Y, Koyama JI, Horiuchi T, Hongo K. Endoscopic endonasal odontoidectomy in the hybrid operating room: A case report. World Neurosurg. 2019 Aug 2. pii: S1878-8750(19)32113-8. doi: 10.1016/j.wneu.2019.07.197. [Epub ahead of print] PubMed PMID: 31382069.
Schuetze K, Eickhoff A, Dehner C, Schultheiss M, Gebhard F, Richter PH. Radiation exposure for the surgical team in a hybrid-operating room. J Robot Surg. 2019 Feb;13(1):91-98. doi: 10.1007/s11701-018-0821-6. Epub 2018 May 10. PubMed PMID: 29748746.
Schaller K, Cabrilo I, Pereira VM, Bijlenga P. [Hybrid operation theatre from the perspective of neurosurgery]. Chirurg. 2013 Dec;84(12):1041-7. doi:10.1007/s00104-013-2555-3. German. PubMed PMID: 24218082.
Wu HX, Paerhati R, Feng GJ, Yang XP, Zhao P, Liu QL, Li G, Li XG, Wang DH. [Clinical application of hybrid surgery for the treatment of cerebral arteriovenous malformations]. Zhonghua Yi Xue Za Zhi. 2017 Mar 21;97(11):817-821. doi: 10.3760/cma.j.issn.0376-2491.2017.11.005. Chinese. PubMed PMID: 28355735.
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