Surgeons & radiologists combine, improving outcomes in ‘hybrid’ ORs

By Dianne Daniel

Not that long ago, there was a physical divide between the operating room (OR) and the radiology suite. The more surgeons rely on sophisticated imaging data to perform minimally invasive and complex surgeries, the more those walls are coming down, giving rise to the hybrid OR.

A hybrid OR is a sterile environment that combines the diagnostic functions of a catheterization lab and radiology suite with the traditional surgical functions of an operating room, along with real-time, intraoperative image guidance to support minimally invasive procedures. It’s a place where you find multiple modalities and multiple disciplines collaborating in one super room, where surgical and diagnostic imaging (DI) teams work side-by-side instead of across the hall.

Though no two hybrid ORs are designed and equipped in the same manner for the same purpose, they all provide safer, more accurate treatment, and in some cases even allow diagnosis and treatment to occur in one place. Which is why they are on the rise, including here in Canada.

Occams Business Research, a global provider of consulting and information services, expects the global market for hybrid ORs to grow at a compound annual growth rate of 16.66 percent from 2015 to 2021. Increasing demand for minimally invasive surgeries is driving growth, as the healthcare industry gradually transforms from conventional operating methods to more intraoperative approaches.

One example is the interventional trauma operating room (ITOR) in the McCaig Tower at Calgary’s Foothills Medical Centre, the first of its kind in North America. Launched in 2013, the $6-million hybrid trauma suite is eliminating the need to make life-or-death decisions about whether to take patients for imaging prior to surgery. Instead, surgical and diagnostic teams work together simultaneously, meaning radiologists can scan for internal bleeding while surgeons operate.

“It’s basically a room on call for trauma cases,” said Greg Thompson, Territory Manager for Winnipeg-based Meditek (, the company involved in the design and planning of the Foothills hybrid OR. “Depending on the trauma, you can pull in whatever surgical teams you need,” he said.

In the fall of 2014, Foothills opened a second Meditek-designed hybrid OR to focus solely on the heart. Called the interventional cardiac operating room (ICOR), it supports both traditional and endovascular methods and is one of only a few clinics worldwide to lead clinical trials of the world’s smallest pacemaker.

Measuring three centimetres long and no wider than a pencil, the pacemaker is inserted into the groin area and guided up into the lower right chamber of the heart using an X-ray. The fully integrated room includes wall cameras, surgical lights, flat-screen arms, booms and other hardware, in addition to advanced imaging equipment.

As Thompson explained, the biggest challenge in implementing a hybrid OR is the design. “Every room is different. There is no template,” he said, noting that decisions are primarily driven by physician personality and what each hospital is trying to achieve. The Meditek design team solicits input from multiple stakeholders, including DI teams, OR staff, management and surgical teams.

“Typically what happens is the room ends up being a beautiful compromise,” said Thompson. “None of those players gets exactly what they want because it’s just not possible.”

At the core of most hybrid OR designs is the fixed C-arm, which can be floor- or ceiling-mounted. Selection and placement of all other equipment, from endoscopes, ultrasounds and monitors to surgical lights, booms and cameras, hinges on the DI vendor chosen.

Meditek provides a vendor-neutral strategy, supported by its relationship with Skytron LLC, an OEM and distributor of medical equipment. Foothill’s two hybrid ORs incorporate equipment from Philips, whereas a more recent Meditek implementation at the Peter Lougheed Centre in Calgary uses equipment from Siemens.

“The biggest challenge is getting the design right the first time,” said Thompson. “Without a doubt it’s a developing process and a learning process.”

At the Peter Munk Cardiac Centre in Toronto, two hybrid ORs are changing the way surgeons approach complex vascular procedures. One incorporates a CT scanner and fluoroscopy machine from Toshiba; the other uses DI equipment from Siemens. Both are enabling surgeons to perform complex therapies that were previously not possible, said Dr. Thomas Forbes, Chair in the Division of Vascular Surgery at the University of Toronto and a practicing vascular surgeon at the Peter Munk Cardiac Centre.

“The rooms allow more accurate and precise placement of stents, stent graphs and valves,” said Dr. Forbes. “It’s a new environment that takes into account the strengths of both the operating environment and imaging.”

At one time, the only option for treating a thoracic aortic aneurysm was open surgery, which resulted in a long incision in the patient, from chest to belly. In some cases, the procedure would last all day and it was therefore not recommended for elderly or frail patients.

The rise of the hybrid OR is changing that, he said. These days, the procedure is performed in one of the cardiac centre’s two hybrid rooms and is becoming so simple, it’s nearing the point of transitioning to day surgery.

“With the advances that have been made with medical device companies, we’re able to do an operation like that through a small cut at the top of the leg,” explained Dr. Forbes. “There were a lot of patients prior to this alternative who were not treated because the only treatment was too large an operation for them and they would succumb to that aneurysm.”

Dr. Forbes is currently part of a committee looking at creating a standard framework for vascular services in Ontario through the Cardiac Care Network of Ontario. The network helps to plan, coordinate, implement and evaluate cardiovascular care in the province and is looking to make a strong recommendation that any hospital performing advanced aortic repairs do it in a hybrid OR, he said.

“Sometimes we hear more about the firsts, or the weird and the wonderful and the very complex,” said Dr. Forbes. “That’s great. That’s what we talk about. But the everyday more common procedures impact a greater number of people and if those can be made safe as well, that’s a bigger impact.”

Both Foothills Medical Centre and the Peter Munk Cardiac Centre are taking the approach of adding DI services to traditional operating room environments when creating hybrid ORs. Toronto’s new Humber River Hospital took the opposite approach, becoming the first facility in North America to establish three hybrid ORs in interventional radiology suites. This means surgeons are now treating vascular cases in the same rooms traditionally used by interventional radiologists.

“The difference is it’s not taking up OR time,” said Dina Longo, Director of Medical Imaging at Humber River Hospital. “This is the way the future is going because imaging is hand-in-hand with the surgeon’s workflow.”

If a surgeon at Humber River Hospital is inserting a stent to treat an abdominal aortic aneurysm, and he or she realizes the procedure is not working, they don’t close up and book an OR. They open the patient and perform surgery right there in the hybrid room. As Longo explains, the rooms are sterile, surgery-ready environments, with all of the features of a conventional OR housed in an interventional radiology suite.

Each of Humber River Hospital’s hybrid suites is the size of a typical OR, providing the space required to house state-of-the-art robotic imaging equipment from GE Healthcare. The hospital had the luxury of a new build and therefore designed the rooms to specification.

Prior to moving to the new Humber River Hospital facility in October 2015, vascular surgeons were accustomed to using portable c-arms. Longo said they were amazed when they saw the difference in image quality for the first time.

“They’re in their glory in this space,” she said. “… They’re diagnosing, assessing and doing procedures all at the same time.”

The next step is to transition the pacemaker program to the new hybrid suites as well. As Longo explains, the implants are currently performed in the regular OR where they may be bumped if emergency cases arise.

“Our pacemaker program is in the operating room right now, but there’s no reason it needs to be there. It’s probably a better flow within interventional radiology,” she said. “Let’s say you don’t have a vascular case and I have another interventional radiology case that needs to go in because we’re full. We can push and pull because the procedures are done in the same environment.”

Regardless of the approach, all agree that hybrid ORs require a great deal of up-front planning in order to be successful. Not only are they are expensive to design and build, they are also difficult to tweak after the fact.

In addition to clearly identifying the clinical intent, and performing a thorough utilization analysis, planners need to carefully map out who will be in the room and what equipment they will be using. Proactive planning helps to remove potential collision points and will ensure workflows are optimized.

Calgary’s Foothills Medical Centre took an innovative approach to working out its logistical and workflow issues prior to implementing its interventional trauma OR. Enlisting the help of construction services company EllisDon, it built a mock room using wooden components to model the equipment as close to specification as possible. Hospital staff were able to walk through the room, obtaining a general idea about how it was going to function before it even got off the ground, explained Meditek’s Thompson.

“I’d highly recommend that if anybody is trying to design and develop a room that they go through that process,” he said. “You can map out your spacing and fully understand what you can accommodate in that room.”

As more cases are being performed in hybrid ORs across Canada, attention is also being paid to radiation safety. Rooms are outfitted with clear radiation shields to limit exposure to patients and care providers, and surgeons routinely wear lead-lined caps, gloves and aprons, as well as thyroid collars. They also learn to adapt their workflow.

“It’s not one thing; it’s being constantly cognizant of the exposure in the room,” said Dr. Forbes, noting that surgeons are trained to step away from the equipment during certain runs when they know the scatter of radiation will reach a certain distance.

“Without a shadow of a doubt, radiation exposure is a major factor in the whole design of a hybrid room. It has to be,” added Thompson, noting that dose awareness has heightened in the last few years. “Part of our design/development process is to look at where we’re going to be able to hang radiation shields so that we can protect the staff within the room.”

Both Forbes and Thompson expect to see 3D imaging impact workflow in the hybrid OR moving forward. The Peter Munk Cardiac Centre, for example, is collaborating with partners to develop 3D holograms that use patient-specific imaging to simulate a human heart. The idea is that surgeons can practice on the holograms, learning intricacies and difficulties they may not have foreseen.

“It’s a very exciting field,” said Dr. Forbes. “Initially, imaging replaced the visibility of our eyes. Now it’s providing better vision than our eyes could ever provide.”

Moving forward, funding will remain the biggest challenge. But Thompson expects pricing to come down eventually. “In 10 years’ time these rooms will be more of a norm as opposed to a speciality item,” he said.

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