The Hybrid Operating Room:

The Instrument of Modern Stroke Care

By Bruce Landau RT (R) ARRT

As new surgical endovascular procedures increase, anesthesiologists, cardiologists, cardiac, neuro and vascular surgeons are requiring and enjoying a new idea in optimizing patient care, the hybrid operating room (OR).

In late 2003, the Hospital of the University of Pennsylvania (HUP) in Philadelphia, PA, started pursuing the idea of building a hybrid OR. In January of 2005, HUP open its first hybrid OR, one of the first in this area. The second hybrid OR opened in January of 2010 (see Fig. 1).

My role in the design, construction, and operational phases was a valuable experience and an exciting journey in a new way to care for patients. Today, as lead radiologic technologist, I am assigned to Penn Vascular Surgery and in charge of the daily imaging operations of 2 hybrid OR.

So what is a hybrid OR? Simply, the hybrid OR is the merging of a regular operating room with sophisticated radiological imaging “Xray” machine. These systems are not fixed to the wall like old Xray machines.  They are mobile and free moving and can rotate around the patient to allow the surgeon better angles to view the patient’s blood vessels.  For the patient, the major benefit of the hybrid OR is that it is a multi-procedural room allowing for non invasive catheter based procedures to be performed with state-of-the-art imaging equipment and the safety of full surgical backup should the need to convert to an open surgical procedure ever arise. That is this equipment is IN the Operating Room so if there is a problem then emergency surgery can commence immediately on the same table in the same setting saving valuable time.  This combination gives the greatest patient care, safety, and best possible surgical outcome.

Advances in digital radiologic imaging systems have new features that allow the operator to monitor and manage patient radiation dose. Today’s digital technology gives the surgeon quality, high definition images. In years past, portable c-arm fluoroscopy was used with advanced endovascular surgical procedures. The image quality was poor, as a result, increasing fluoroscopic time and radiation to patients.  Because of the increased fluoro time, portable c-arms would over heat and would have to be switched out for a new c-arm. This created a patient safety issue. Hybrid OR imaging systems have superior quality images and dose management systems which help decrease radiation exposure times, reducing patient and physician dose (even the doctors and the other staff in the room are subjected to less scatter radiation from the device. Imaging systems in the hybrid OR also are equipped with a cooling system to prevent overheating.

At HUP the development of a bank of monitors (see Fig. 2) that can be moved table side, gives the surgeon a wide variety of information from many sources. This feature routes to monitors such data as patient vital signs, live fluoroscopy images, digital subtraction angiography (DSA), 3-D rotational angiography, computed tomography (CT), 3-D reconstructed images, intravascular ultrasound (IVUS), intracardiac- echocardiography(ICE), transesophageal echocardiogram(TEE), and online patient charting and reports. All of these diagnostic real time studies are performed in the hybrid OR during the surgical procedure. This is a direct benefit to patients because it optimizes patient care during a hybrid OR procedure by putting into the hands of the surgeon every conceivable piece of information about their patient in a tableside presentation.

In addition to minimally invasive stroke surgery, there are many other applications to this technology for general surgery, spine surgery, and cardiovascular surgery.

Procedures most commonly performed in the hybrid OR are:

• Abdominal Endovascular Aneurysm Repair (EVAR)
• Cerebral Arteriogram for Aneurysm Treatment and Intracranial occlusive disease
• Kyphoplasty
• Hybrid Aortic Arch Procedure
• Hybrid Aortic Valve/Peripheral Component Interconnect (PCI)
• Hybrid Catheter/Thoracic “MAZE” for Atrial Fibrillation
• Hybrid Coronary Artery Bypass Graft (CABG) with Angiography
• Percutaneous Carotid Angioplasty
• Percutaneous Cardiac Intervention
• Percutaneous Left Ventricular Assist Device (LVAD)
• Peripheral Vascular Procedures
• Inferior Vena Cava (IVC) Filter Placement and Retrieval
• Thoracic Endovascular Aneurysm Repair (TEVAR)
• Trans-catheter Aortic Valves (TAVI)

It should not be hard today to find a hospital close by that has a hybrid operating room. In a 2010 survey performed by the Advisory Board Company, the number one most requested hospital technology insight project was the hybrid OR. In the same survey, the percentage of hospitals nationally with hybrid ORs was just over 50 percent (see Table 1)

Within the Mercer County area The Capital Health System’s new hospital in Hopewell, NJ has a hybrid OR. The University Medical Center at Princeton will be opening a new hospital this May, 2012 in Plainsboro, NJ with a new hybrid OR and a new revolutionary idea. Not only will a new hybrid OR be built, the cardiology catheterization lab and the interventional radiology suite will be located in the operating room.  This will centralize endovascular and catheter based supplies, give them the ability to cross train staff, and have OR and recovery room staff available in one location. This concept is truly the next level of development in hybrid OR design.

St. Mary Medical Center has recently opened a new hybrid OR for stroke and neurovascular patients as well as minimally invasive spine surgery.  St Mary medical Center is the only Bucks County hospital that has been designated a primary stroke center.

If you would like more information about hybrid ORs, please contact me at my e-mail address at Bruce Landau RT (R) ARRT