Hybrid OR SYMPOSIUM | April 20th 2018 | Berlin
Hybrid OR SYMPOSIUM | April 20th 2018 | Berlin
The convergence, complementarity and connectivity of advanced technologies in the Hybrid Operating Room is enabling extremely complex procedures to become simpler and more accessible. Increased focus on surgical workflows in combination with new technologies has the potential to dramatically improve effectiveness and efficiency of surgical procedures, with the expectation of improved patient outcomes as well as positive economic value.
This presentation will demonstrate technology contributing to the advancement of patient care in minimally-invasive surgery and will give a glimpse into the future of hybrid ORs.
In Spring 2017, Charite opened the new hospital facilities at its Campus Charite Mitte. With this opening, the Neurosurgical Department moved its headquarter into one of Europe´s most advanced clinical seetings. Three hybrid ORs were established with the aim to foster the further development and optimization of Neurosurgical operations and care. One hybrid OR is equipped with an intraoperative angiography suite (Artis zeego, Siemens) which is devoted to the interdisciplinary treatment of complex cerebrovascular diseases, together with Neuroradiologists and Neurointerventionalists. The same system is also used for image guides spine surgeries. The second hybrid OR is equipped with a mobile CT scanner (AIRO, BrainLab). The 32-slicer is a versatile tool for image guided spine surgeries, minimally-invasive cranial procedures as well as sterotactic surgeries. The third hybrid OR provides a 3T MR scanner (Skyra, Siemens) which allows for the intraoperative assessment of the extent of resection of intrinsic brain tumors, identification of perfusion/metabolic abnormalities as well as visualization of brain functions. This versatile hybrid OR concept enables us to not only perform cuttung-edge Neurosurgery but also to bring interdisciplinary Neuroscience research into the Neurosurgical OR.
The mid-90´s brought the proof of concept for intraoperative MRI. The most elaborate set-up was the “double-doughnut”, combining surgical and imaging space, albeit confining standard microsurgical techniques. Currently the division of surgical and imaging space prevails, either as “dedicated MR-OR” or as “shared resources” (in separate rooms).While iMRI is primarily an addition to the surgical armamentarium, a closely knit interdisciplinary team unlocks the scientific potential.
Practically, elaborate set-ups have become time consuming, accentuating the interruption of surgical flow. Potentially optical imaging methods integrated into our surgical microscope, may provide actionable online information to complement the increasingly “offline” and more complex iMRI information. The judicious use of iMRI in regards to scan-timing and expected diagnostic yield relies on a thorough knowledge of the technical capabilities but even more decisively the limitations. In the final analysis, intraoperative MR bestows the surgeon with a challenging but powerful tool.
This presentation highlights the current scientific literature on the value of intraoperative MRI in glioma surgery, and reports on the clinical benefit of extensive glioma resection.
Based on our experiences with iMRI since 1996 the use of 1,5 T high field iMRI in transsphenoidal surgery for pituitary macroadenomas leads to significantly higher GTR rates: in our actual series about 15% using a 1,5 T Siemens Espree, in the literature up to 40%, depending on the surgeon’s experience. It thus prevents additional operations and reduces the number of tumor remnants.
Typical location of (resectable) tumor residuals after descensus of the elevated diafragma sella are detectable posteriorly, anteriorly and lateral to the medial wall of the cavernous sinus. The complication rates, including additional pituitary insufficiency, do not exceed the incidences reported for surgery without iMRI. If complete tumor resection is not possible iMRI guidance can facilitate tumor volume reduction.
High-field iMRI is mainly used to identify residual disease in resection of various intracerebral pathologies, mainly gliomas. Very often standard imaging protocols consist of conventional sequences like T1+/-CM, T2/FLAIR and sometimes additional diffusion imaging. However, high-field iMRI scanners have the capability to perform more sophisticated sequences including spectroscopy and perfusion imaging. These technologies might help to achieve an even more detailed planning and subsequent resection of low- and high-grade gliomas. We present our experience with these advanced imaging sequences.
Identification of eloquent cortical brain areas identified by fMRI or MEG was the basic concept of functional navigation to preserve neurological function. Diffusion imaging allows reconstructing major fiber bundles, which also have to be preserved during surgery, so the concept of functional navigation was expanded to multimodal navigation.
The talk will focus on the concept of multimodal navigation integrated in intraoperative imaging, allowing identifying risk structure with high precision, while preventing neurological deficits. Major challenges and potential pitfalls of fiber tracking will be discussed in detail.
Pediatric intraoperative MRI has perils and pearls. The transfer of small patients for intraoperative MRI bears specific risks, positioning and head clamping as well. With adequate precautions and good training these problems can be minimized. Intraoperative monitoring is another important aspect and still possible, but needs special precautions. Checklists become a very important tool for this procedure. Infection rates are not higher than in similar cases without ioMRI, despite the prolonged operating time.
The introduction of imaging into an operating theatre introduces a short-loop feed-back, with the objective to increase surgical precision and improve patients´ outcomes. In the pioneering era rigid antagonism led to an overly simplified discussion. However, as single center studies confirmed the postulated value of iMRI, additional centers followed and an International Intraoperative Imaging Society (IOIS) was founded in 2007.
The German members of this Society constituted the German Study Group of Intraoperative MRI (GeSGIM) in 2013 to initiate multicenter controlled trials and to establish a thorough scientific basis for its clinical application, the role of complementary techniques (e.g. awake craniotomy, electrophysiology) and potential alternatives (e.g. US, CT, fluorescence guidance). Future developments, particularly in the realm of optical imaging methods, promise interesting new avenues. Ultimately the introduction of iMRI has triggered a more categorical demand for intraoperative information and simultaneously provides a framework to study current and future supplementary or alternative methods.
This talk gives an overview of state-of-the-art mapping of cognitive functions to brain topography along with potential applications in intraoperative MRI.
To date, speech mapping of eloquent tumors is still only possible by exposing the patient to the burden of awake surgery. Besides being challenging for the patient and the surgical team, this technique might come to its limits when an additional intraoperative MRI is performed. Limitations are due to the limited possibility to drape the awake patient’s head to keep the sterile situs, and to have the spontaneously breathing patient not limited with his airways. We discuss different techniques to overcome some of these limitations, discuss the literature and show an advanced imaging technique which might overcome some of these issues in the future.
Complex vasular pathologies represent a major challenge for the involved medical disciplines. The interisciplinary treatment of these pathologies becomes possible in the Hybrid-OR which enables the combination of imaging, endovascular intervention and surgical treatment in a one-staged setting. This becomes especially important in difficult and highly complex pathologies which may require different imaging and treatment approaches to accomplish therapeutic success.
The Charité experience of combined treatment strategies is presented focusing on Giant-aneurysms treated by extra-intracranial revascularization techniques in combination with endovascular intervention and on treatment of complex arteriovenous fistula.
Notably in the field of vascular neurosurgery 3D augmented-reality-guided approaches are increasingly used in head positioning, craniotomy planning and to target aneurysms, parent arteries and donor and graft vessels. Pre-operative imaging data are super-imposed on the surgical field and visible through the surgeons' oculars of the surgical microscope. This allows to approach these vascular structures, and to anticipate critical situations in a logical and transparent fashion and to mentally prepare for their management. Results from more than 200 such surgeries, as performed in a dedicated hybrid environment shall be reported and discussed.
(Karl Schaller, Philippe Bijlenga, Paolo Machi)
The value of augmented reality-guidance in neurovascular procedures, notably in the field of aneurysm surgery and EC-IC bypass surgery has been established in recent years. In order to improve its usability, improvements in intra-operative microscope-based image acquisition, co-regsitration with pre-operative data sets, and auto-correction are necessary. This objective may be attained by i.e. the implementation of optical recognition tools for vascular landmark structures. Furthermore, 3D angiographic data from complex vascular malformations need to be presented in a more intuitive and reliable fashion. This should include haemodynamic data and data on vascular properties and geometry, so as to facilitate surgical orientation and management.
(Karl Schaller, Philippe Bijlenga, Paolo Machi)
To describe the possibilities and limitations of vascular neurosurgery with intraoperative angiography (iAngio) in a dedicated multidisciplinary (Neuro-, Trauma-, Vascular- and Cardiac Surgery) Hybrid OR inaugurated in 2012 at the University hospital Ulm.
Analysis of a consecutive neurovascular series (08/2012-03/2015) performed in an Artis zeego (Siemens, Germany) combined with a TruSystem 7500 OR Table (Trumpf Medical, Germany) . Image analysis and comparison to microscope based ICG. Workflow analysis highlighting the key procedural steps and efforts.
Series: 31 patients (36 anterior circulation aneurysms: AcomA (n=8, n=4 previously coiled, MCA (n=19, n=3 previously coiled, ACI (n=9); 14 AVMs and 2 DAVFs. Technical failure of the Zeego system in one case. Adverse events: one (2,2%), angio-related thrombembolic, no postoperative infections. Residual aneurysm not detected in ICG: 2 patients (5,6%) (1 ACM previously coiled, 1 supraophthalmic ACI). Complete resection of AVMs: confirmed in all cases. Prolongation of OR-time: 52 minutes (preparation, iAngio, postprocessing) and a significant learning curve.
Despite its invasive nature iAngio seems feasible and safe. Decisive information obtained in 2 aneurysm cases not detected with ICG. In advanced arteriosclerotic disease indication for iAngio should be carefully assessed. The routine application of iAngio in neurovascular surgery is before all limited by the institutional and OR organization.
(R. König, T. Kapapa, C.R. Wirtz)
Recent studies and meta-analysis have evidenced the superior accuracy of navigated spinal instrumentation compared to non-navigated techniques with further improvement through additional implementation of intraoperative computed tomography (iCT). However, current solutions for navigated spine surgery remain hampered by restrictions in surgical workflow as well as a limited versatility and applicability. In particular, the benefit of iCT compared to more widely used 3D C-arm-based spinal navigation remains unclear. Against this background, we report our experience of navigated spinal instrumentation with the mobile AIRO® iCT scanner in a hybrid OR setting implemented in our Department in 2014. The indications for navigated spinal instrumentation with AIRO® were anatomically complex deformities, revision cases, regions of the spine that are typically difficult to visualize with conventional 3D C-arm imaging, cases that required multilevel (>3 segments) instrumentation and minimally invasive spine surgery (MISS). Together, our experience suggests that the AIRO® system is an easy-to-use and versatile iCT for navigated spinal instrumentation with high pedicle screw accuracy rates and advantages compared to 3D C-arm-based spinal navigation, particularly in anatomic areas that are difficult to visualize by conventional fluoroscopy, such as the cranio-cervical and cervical-thoracic region. Although the learning curve associated with AIRO®-based spinal navigation is steep, a systematic user-based approach to the technology is required.
In frame-based stereotactic surgery intra-operative imaging is crucial. It generally follows a workflow including pre-operative MRI and intra-operative frame-based CT. The intra-operative transport of the anaesthesized and intubated patient to and fro the CT unit can be time-consuming and cumbersome. Here, we report the first ten patients, who underwent stereotactic biopsies using the mobile AIRO® intraoperative CT (iCT) scanner.
A conventional stereotactic frame was mounted to the AIRO® carbon table via carbon adapter. 0°Gantry thin sliced iCT was performed. The imaging data was transferred to a conventional stereotaxy working unit. After fusion of the pre-OP MRI and AIRO® iCT, the stereotactic system was build based on the iCT and trajectories were calculated, accordingly.
The frame based stereotactic iCT was easy to implement and successfully accomplished in all patients. The MRI/iCT-image fusion, which is only based on bony landmarks, was feasible in all of the studies. A conclusive histological result was obtained in each of the ten cases. There was no bleeding complication. Net surgery time was reduced by 30 min. on average.
The AIRO® system is a safe, easy-to-use and sufficiently accurate iCT for CT-frame-based sterotactic biopsy planning that results in a considerable reduction of surgery time. In the future, it remains to be evaluated if the accuracy rates and intraoperative workflow will permit its application in DBS and other functional procedures, as well.
(Katharina Faust, Peter Vajkoczy / Klinik für Neurochirurgie, Charité – Universitätsmedizin Berlin)
We report our experience with a series of patients, treated in a new concept of an intraoperative double room CT scanner (DR-iCT), which was used by several surgical disciplines simultaneously.
A high resolution (128- slice) CT scanner was installed in between two operating rooms, transferring directly imaging data from the scanner to a connected neuronavigation system. Both operating rooms were used by several neurosurgical teams (skull base, vascular, spine, microsurgery, stereotactic surgery) as well as in various surgical procedures. During image acquisition, the sliding gantry moved into one operating room, whereas a moving wall was closed to the other one. Procedures, image quality, workflow and infection rates are reported. The DR-iCT installed in between two operating rooms facilitates a broader and multidisciplinary use (microsurgery, stereotactic surgery, trauma surgery, thoracic surgery), increases the utilization rate and does not prolong patient turnover times. The simultaneous, multidisciplinary use with unchanged turnaround times may improve cost-effectiveness.
The agenda is subject to change.