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Technology: Integrated operations

Kathleen Armstrong explores how new developments in surgical technology and procedures are changing the face of the operating theatre

Professor Erik Fosse has a vision. As head of the Interventional Centre at Norway’s Rikshospitalet, he is leading the way in new surgical and interventional techniques that are changing not only the face of surgery but also the face of the operating theatre itself.

Maquet's Variop modular operating theatre
MRI and CT scanning are known to most of us only as tests whose high-tech images have transformed the way disease is diagnosed. But advances in technology are bringing these technologies more and more into the operating theatre, creating new opportunities for interventional radiology and a new breed of ‘hybrid’ operating theatre. “In the future we will see more and more multiple-modality rooms in which technologies such as MRI and CT scanners are integrated into the rooms,” Fosse says.  For example, he and his colleagues are looking at how MRI can be used for targeted drug delivery, helping to monitor the ultrasonic release of drugs – a development that will be particularly beneficial for cancer treatment.

Fosse foresees a separation between interventional radiology and diagnostic radiology as these developments take hold. “Within five years, cath labs could be used for intervention and not for diagnostics,” he predicts. But for the design of the operating theatre, such developments throw up a number of challenges, not least of which is the size of the room required to accommodate such equipment. In addition, as new technology is developed, the operating theatre may need to change to adapt to its use. Since the first hybrid room was built at the Interventional Centre in 1996, Fosse says it has changed four times – the latest rebuild taking place in late 2008.

The room is built using a ‘box-in-box’ principle, Fosse says, using double walls and ceiling so that cabling can be incorporated but also enabling walls to be easily removed in order to change the size of the room. An outer wall with floor to ceiling windows also means changes can be made with as little disruption as possible to the rest of the facility.

Future-proofing
Bill Rostenberg from Anshen + Allen agrees that building flexibility into the design of operating theatres is essential. Taking a ‘universal room approach’ to create an integrated interventional platform with layouts that can accommodate interventional processes would ensure that operating theatres can adapt to the needs of the future.

The key is building an infrastructure that enables flexibility. For example, fixed, vertical elements such as lift shafts and stairs should be placed along the perimeter of the building to create a flexible clinical zone that can be modified without the vertical elements compromising workflow or spatial configuration.

Building two or three operating theatres next to each other also creates a simple solution for expansion, enabling walls to be removed to make a large hybrid suite. Understanding workflows is also essential and it is here that the challenges of bringing two different fields of work together becomes more apparent. Standards that apply to surgical suites, for example the Association of periOperative Registered Nurses (AORN) standards, do not have the same applicability for interventional radiology.

There is a different culture for sterile control. While surgeons have long operated behind a ‘red line’ in which everything must be sterile, “interventional cardiologists may prefer to walk in and out of the control area without having to scrub down”, Rostenberg says.

“In the US, there is a lot of competition between specialists but what is needed here is multidisciplinary collaboration as complex procedures are becoming multidisciplinary,” he adds. “Good operating theatre design requires clinical input and strong vision – not just from clinical leaders but also from the administrative side. If collaboration doesn’t come from the clinicians, it needs to come from management.”

A 'universal room approach' with layouts that can accommodate interventional processes
(courtesy of Anshen + Allen)

Humanistic response

Anshen + Allen has created a number of integrated interventional platforms in the US and in the UK. Palomar Pomerado Health in California incorporates a series of adjacent operating theatres, a section of which is designated for interventional radiology / cath lab use and which can therefore be adapted to different clinical needs and standards. The deep floor plate is ‘daylighted’ with borrowed light from external windows and interior courtyards and flowing into procedure rooms from corridors.

“Humanising the deep floor plate” is something that Rostenberg sees as important. “In the US in the last 30 years there has been a lot of development of supertechnology-driven hospital departments that are almost factory-like. Floor plans are driven by clinical adjacencies bringing departments together. What it has yielded has been hospital buildings that may be clinically effi cient but are deep, dark, confusing buildings and you often can’t see outdoors. This is now changing.”

Plan of a CT-Cath operating theatre
(courtesy of Anshen + Allen)
Maquet is currently developing a fully integrated hybrid operating theatre with the flexibility to perform both open surgery and minimally invasive surgery. “The operating table in the cath lab is not designed for surgical procedures, so it is limited to minor surgery,” says product manager, operating table systems, Bernhard Kulik. “The customer needs to be able to have the flexibility to perform all kinds of surgery for a more efficient workflow in the room.”

The new system, controlled through the imaging system, will use synchronic articulation to enable the system to rotate without the risk of colliding with the operating table. The company plans to launch its integrated hybrid operating theatre at Medica in Frankfurt in November. Maquet has experience in flexible operating theatre design. Its Variop modular operating theatre is designed with its walls in three parts so that it can be easily changed and/or new installations integrated. The company has also developed a glass wall that has foil between two layers of glass, enabling the hospital to choose to have the wall transparent or opaque or designed with colours or images to suit the individual operating theatre environment.

Cadolto's modular units can be easily
adapted to meet changing needs
Modular approach
Modular specialist Cadolto has responded to the need for larger operating spaces with the development of a 50m2 modular operating theatre unit. Although the company has not yet been asked to supply a hybrid operating room, director Dr Björn Werner says its modular units are able to meet its requirements. Cadolto also produces a 35m2 module, which can be combined with the 50m2 unit to accommodate the control room, laminar flow system and relevant technology.

The units are supplied with theatre lights, pendants and a built-in foundation for the operating table, whether it is mounted and fixed or moveable. “Our modular operating theatres come complete with state of-the-art laminar flow systems, hygiene systems and are adapted to meet the standards of different countries,” Werner says. “When it is delivered to the site, all that needs to be done is to connect the power, water, gases and the corridor(s) that link it to the building.” The only limitations are the size of the laminar flow system – a 3x3m system is normally supplied – and the ceiling height is limited to 4m, with a false ceiling to accommodate the laminar flow system.

Although modular units are more expensive up-front than on-site construction, Werner says there is actually an economic advantage because there is less disruption and they are erected in much less time. But even without the integration of MRI and CT technologies into an operating theatre, new audiovisual and electronic control technologies require a controlroom, situated next to the surgical suite, space in walls and ceilings for cabling and careful placement of C-arms, lights and screens.

Choice and control
Olympus’s ENDOALPHA system integrates touch-screen control, audiovisual communication and documentation for surgical and gastrointestinal procedures. It enables the surgeon to control lights, medical devices, operating table positioning, communications and imaging from a sterile touch-screen.

Monitors can be mounted on boom arms or on walls and the system also enables audiovisual streaming to other operating theatres, departments, classrooms or to people outside the hospital.

Marketing manager Frank Koenike says he tries to get in early on planning discussions when an operating theatre that includes the ENDOALPHA system is being designed or renovated. “Pipes and cabling need to be incorporated into design plans so they know which cables are required and where they need to run – between networks, to the main controller and to the control room.”

Olympus has also developed a blue light for the ENDOALPHA suite that is installed alongside the standard white light on the ceiling of the operating theatre. Surgeons can choose to switch over to the blue light during procedures, Koenike says, to help enhance both the clarity of the image on the monitor and orientation in the dimmed room.

The ENDOALPHA suite at the Amalie Sieveking Hospital in Hamburg also has blue glass walls, with an additional feature – a separate panel of glass above which uses RGB (red-green-blue) technology to enable the colours in the panel to be changed to create different scenarios. Effects such as a sunrise can be programmed in when the wall is installed and the scenarios changed using the touch panel in the control room. Koenike says the walls are easy to disinfect as well a being aesthetically pleasing.

The 'blue' Olympus ENDOALPHA suite at the Amalie Sieveking Hospital in Hamburg


Adapting to future needs
Graeme Hall, managing director of UK-based Brandon Medical, emphasises the importance of ‘future-proofing’. He says many hospitals choose technology because of its brand name without understanding whether it is really the best system for the operating theatre and its future needs. “People often buy what they call an integrated operating theatre – a minimally invasive endoscopy system that is integrated into the hospital audiovisual system. Often provided with half a dozen controls, it’s not very integrated at all,” Hall claims.

But, he adds, there are systems that offer more. Brandon Medical has developed a protocol platform, using its Symposia digital media system, that Hall says “can integrate anything”, including endoscopes, ultrasound, surgical scopes and lighting, all of which can be manipulated from a common platform. “Everything in the operating theatre that uses internet protocol technology, including radiology, can be integrated into a common platform,” he explains.

Lighting specialist Trumpf is looking into the development of anti-magnetic surgical lights
suitable for interventional radiology use
This includes lighting. “In a hybrid operating theatre, lights should be positioned laterally to the left and right of the table, with the C-arm able to slide on rails from the ceiling,” says Dirk Fritze, product manager for surgical lights at Trumpf. “The main concern for users is to be able to easily adjust the light, which is why its integration into the system is important, so that it can be controlled from the one screen.”

The advent of operating theatres using interventional radiological equipment such as MRI and CT presents a new challenge, even for a lighting specialist such as Trumpf. Surgical lights are typically kept away from the technology’s magnetic field and patients. To avoid interference with MRI and CT technologies, the surgical lights need to be made out of anti-magnetic material. The dilemma is that the lights also require heat-conducting material, which is typically metal and, therefore, magnetic.

Fritz says Trumpf is looking into the development of such lights. But technology does not come cheap. So, until operating suites using MRI and CT technology become more common, anti-magnetic surgical lights are unlikely to be economically viable for most hospitals.

The face of the operating theatre is changing and such developments will soon become commonplace, as surgery and interventional radiology and cardiology move ever closer. “The operating room of the future will look more like today’s cath lab,” predicts Bill Rostenberg. Making it all the more important to build flexibility into today’s designs.

Kathleen Armstrong is a healthcare writer









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