Hybrid operating room - Knowledge (XXG)

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procedure speeds up recovery and potentially reduces complications, the loss of natural vision and tactile sensing makes it difficult for the surgeon to locate the nodules, especially in cases of non-superficial, ground-glass opaque, and small lesions. The yield rate for nodules < 1 cm can be below 40% as studies show. As a consequence sometimes more healthy tissue is resected than actually necessary in order to avoid missing (parts of) the lesion. Using advanced intra-operative imaging in the operating rooms helps to precisely locate and resect the lesion in a potentially tissue-sparing and quick fashion. In order to be able to use image guidance during video-assisted thoracoscopic surgery, rotational angiography has to be performed before the introduction of ports, thus before the lobe in question deflates. This way the lesion is visible through the natural contrast of air. In a second step, hook wires, thread needles, or contrast agent (lipiodol, iopamidol) are introduced into or next to the lesion to ensure visibility on the angiogram after lung deflation. Then, the conventional part of video-assisted thoracoscopic surgery starts with the introduction of thoracoscopes. The imaging system is used in fluoroscopic mode now, where both the inserted instruments and the previously marked lesion are well visible. A precise resection is now possible. In case contrast agent has been used to mark the lesion, it will also drain into the regional lymph nodes, which then can be resected within the same procedure.

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released which support the surgeon in selecting this optimal fluoroscopy angulation or even drive the C-arm automatically into the perpendicular view to the aortic root. Some approaches are based on pre-operative CT images, which are used to segment the aorta and calculate optimal viewing angles for valve implantations. CT images must be registered with C-arm CT or fluoroscopic images to transfer the 3D volume to the actual angiographic system. Errors during the registration process might result in diversification from the optimal angulations of the C-arm and must be manually corrected. Additionally, anatomical variations between the acquisition of the pre-operatively CT image and surgery are not accounted for. Patients are generally imaged with hands-up in a CT scanner while surgery is performed with arms aside the patient, which leads to substantial errors. Algorithms purely based on C-arm CT images acquired in operating rooms by the angiographic system are inherently registered to the patient and show the present anatomy structures. With such an approach, the surgeon does not rely on pre-operative CT images acquired by the radiology department, which simplifies the workflow in the operating room and reduces errors in the process.

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approach is expanding. The image quality, the possibility of imaging the patient in the surgical position and the guidance of the instruments facilitate this approach.(Efficacy of DynaCT for surgical navigation during complex laparoscopic surgery: an initial experience. Partial resection of the kidney, leaving as much healthy tissue, meaning kidney function to the patient has been described.). The challenges the surgeons face is the loss of natural 3D vision and tactile sensing. Through small ports he/she has to rely on the images provided by the endoscope and is unable to feel the tissue. In a hybrid operating room the anatomy can be updated and imaged in real time. 3D images can be fused and/or overlaid on live fluoroscopy or the endoscope. (Real-time image guidance in laparoscopic liver surgery: first clinical experience with a guidance system based on intraoperative CT imaging.) Crucial anatomy like vessels or a tumor can be avoided and complications reduced. Further investigations are under trial at the moment. (Surgical navigation in urology. European perspective)

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However, the risk of malpositionins, revisions and nerval damage cannot be underestimated (Malposition and revision rates of different imaging modalities for percutaneous iliosacral screw fixation following pelvic fractures: a systematic review and meta-analysis). The possibility of the use of an angio system with a spatial resolution of 0.1 mm, the large field of view to image the entire pelvis in one image and the high kW rate allows the surgeon high precision images while not impairing hygiene (floor mounted systems) or access to the patient (CT). Degenerative spine surgery, traumatic spinal fractures, oncologic fractures or scoliosis surgery are other types of surgery that can be optimized in a hybrid OR. The large field of view and the high kW rate allow to optimally image even obese patients. Navigations systems or the use of integrated laser guidance can support and improve the workflow.

634:, in general, have less complex positioning needs, but based on their interventional experience in angiography may be used to having fully motorized movements of the table and the tabletop. For positioning patients on non breakable tabletops, positioning aids are available, i.e. inflatable cushions. Truly floating tabletops are not available with conventional operating room tables. As a compromise, floatable angiography tables specifically made for surgery with vertical and lateral tilt are recommended. To further accommodate typical surgical needs, side rails for mounting surgical equipment like retractors or limb holders should be available for the table. 529:. For the surgical lights it is most important that they cover the complete area across the operating room table. Moreover, they must not interfere with head heights and collision paths of other equipment. The most frequent mounting position of OR-lights is centrally above the operating room table. If a different position is chosen, the lights usually are swivelled in from an area outside the operating room table. Because one central axis per light head is necessary, this may lead to at least two central axes and mounting points in order to ensure sufficient illumination of the surgical field. The movement range of the 251:

much higher than using pre-operative data. Rotational angiography visualizes the bronchial tree in 3D during the procedure. The air thereby serves as a ‘natural’ contrast agent, thus the nodules are well visible. On this 3D image, using dedicated software, the nodules can be marked, along with a planned needle path for the biopsy (endobronchially or trans-thoracically). These images can then be overlaid on live fluoroscopy. This gives the pulmonologist improved guidance towards the nodules. Yield rates of 90% in nodules of 1–2 cm, and 100% in nodules > 2 cm have been reported with this approach.

694:: High frame rates (images acquired per second) are needed to visualize fast motion without stroboscopic effects. However, the higher the frame rate, the higher the radiation dose. Therefore, the frame rate should be chosen according to the clinical need and be as low as reasonably possible. For example, in pediatric cardiology, frame rates of 60 pulses per second are required compared to 0.5 p/s for slowly moving objects. A reduction to half pulse rate reduces dose by about half. The reduction from 30 p/s to 7.5 p/s results in a dose saving of 75%. 313:

reporting or diagnostic purposes. In particular, when contrast media is injected, a data acquisition is mandatory, because the stored sequences can be replayed as often as required without re-injection of contrast media. To achieve a sufficient image quality for diagnoses and reporting, the angiographic system uses up to 10 times higher x-ray doses than standard fluoroscopy. Thus, data acquisition should be applied only when truly necessary. Data acquisition serves as a base for advanced imaging techniques such as DSA and rotational angiography.

642:, or with a universal breakable tabletop that provides enhanced patient positioning, but restricts 3D imaging. The latter are particularly suited for neurosurgery or orthopedic surgery, and these integrated solutions recently also became commercially available. If it is planned to share the room for hybrid and open conventional procedures, these are sometimes preferred. They provide greater workflow flexibility because the tabletops are dockable and can be easily exchanged, but require some compromises with interventional imaging. 78: 665:, thus lower their dose. Awareness is one critical issue, otherwise the available protection tools might be neglected. Among these tools is protective clothing in the form of a protective apron for the trunk, a protective thyroid shield around the neck and protective glasses. The later may be replaced by a ceiling-suspended lead glass panel. Additional lead curtains can be installed at the table side to protect the lower body region. Even more restrictive rules apply to pregnant staff members. 534:

lights a critical item in the planning and design process. Other aspects in the planning process of operating room lights include avoidance of glare and reflections. Modern operating room operating room lights may have additional features, like built-in camera and video capabilities. For the illumination of the wound area, a double-arm OR-light system is required. Sometimes even a third light may be required, in cases where more than one surgical activity takes place at the same time, e.g.

564:. Expert consensus rates the performance of mobile C-arms in hybrid ORs as insufficient, because the limited power of the tube impacts image quality, the field of view is smaller for image-intensifier systems than for flat-panel detector systems and the cooling system of mobile C-Arms can lead to overheating after just a few hours, which can be too short for lengthy surgical procedures or for multiple procedures in a row, that would be needed to recover the investment in such a room. 503:

perfusionists, support staff from device companies etc. can work in such an OR. Depending on the imaging system chosen, a room size of 70 square meters including a control room but excluding a technical room and the preparation areas is recommended. Additional preparations of the room necessary are 2-3mm lead shielding and potentially enforcement of the floor or ceiling to hold the additional weight of the imaging system (approximately 650–1800 kg).

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patient can be performed. For example, the tension in the brain due to a severe haemorrhage can be relieved and the aneurysm can be coiled. The concept of placing the emergency patient on an operating table as soon as he/she enters the hospital, if stable perform a trauma scan in the CT or if unstable immediate procedure in the hybrid operating room without having to reposition the patient can save valuable time and reduce risk of further injury.

688:: X-ray radiation consists of hard and soft particles, i.e. particles with a lot of energy and particles with little energy. Unnecessary exposure is mostly caused by soft particles, as they are too weak to pass through the body and interact with it. Hard particles, by contrast, pass through the patient. A filter in front of the x-ray tube can catch the soft particles, thus hardening the beam. This decreases dose without impacting image quality. 208:

acquisition of a cone beam computed tomography image can also be used to reconstruct three dimensional CT-like images. This may be useful for the applications above and also for confirmation of targeting for placement of ventricular catheters, biopsies, or deep brain stimulation electrodes. Intra-operative MRI is used to guide brain tumor surgery as well as placement of deep brain stimulation electrodes and interstitial laser thermal therapy.

25: 658:, thus exposure is potentially harmful. Compared to a mobile C-Arm, which is classically used in surgery, CT scanners and fixed C-Arms work on a much higher energy level, which induces higher dose. Therefore, it is very important to monitor radiation dose applied in a hybrid operating room both for the patient and the medical staff. 407:

of interest in the 3D image, the outline as a contour onto the fluoroscopic image. This provides additional information that is not visible in the fluoroscopic image. Some software available provides landmarks automatically, more can be added manually be the surgeon or a qualified technician. One example is the placement of a

221:. Most importantly, using interventional imaging in video-assisted thoracoscopic surgery can substitute for the loss of tactile sensing. This approach also delivers the potential to spare healthy lung tissue by knowing the exact position of the nodule which increases the quality of life for the patient after the operation. 512:

equipment. This may require professional project management and several iterations in the planning process with the vendor of the imaging system, as technical interdependencies are complex. The result is always an individual solution tailored to the needs and preferences of the interdisciplinary team and the hospital.

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correction algorithms are necessary to remove movement artifacts. An advanced application of DSA is road mapping. From the acquired DSA sequence, the image frame with maximum vessel opacification is identified and assigned to be the so-called road-map mask. This mask is continuously subtracted from live

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including vertical and lateral tilt. It is important to also have proper accessories available, such as rails for mounting special surgical equipment retractors, camera holder). Free floating angiography tables with tilt and cradle capabilities are best suited for cardiovascular hybrid operating rooms.

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Small lung nodules identified on a thorax CT need to be examined for malignancy, thus a small portion of sample tissue is taken out in a needle procedure. The needle is advanced through the bronchial tree, or trans-thoracically, towards the position of the nodule. To make sure tissue is captured from

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that must also be moved. Moving from a parking to a working position during surgery, however, is easier with a floor-mounted system, because the C-arm just turns in from the side and does not interfere with the anesthesiologist. The ceiling-mounted system, by contrast, during surgery can hardly move

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There are more factors to consider when deciding between ceiling- and floor-mounted systems. Ceiling-mounted systems require substantial ceiling space and, therefore, reduce the options to install surgical lights or booms. Nonetheless, many hospitals choose ceiling-mounted systems because they cover

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is performed with continuous X-ray to guide the progression of a catheter or other devices within the body in live images. To depict even fine anatomic structures and devices, brilliant image quality is required. In particular, in cardiac interventions, imaging the moving heart requires a high frame

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To increase the yield rate, advanced interventional imaging with angiographic C-arms has proven to be beneficial. The advantage of intra-procedural imaging is that the patient and the diaphragm are in exactly the same position during 2D/3D imaging and the actual biopsy. Hence the accuracy is usually

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Steinmeier, Ralf; Fahlbusch, Rudolf; Ganslandt, Oliver; Nimsky, Christopher; Buchfelder, Michael; Kaus, Michael; Heigl, Thomas; Lenz, Gerald; Kuth, Rainer; Huk, Walter (October 1998). "Intraoperative Magnetic Resonance Imaging with the Magnetom Open Scanner: Concepts, Neurosurgical Indications, and

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Müller-Stich, Kenngott; Wagner, Martin; Gondan, Matthias; Nickel, Felix; Nolden, Marco; Fetzer, Andreas; Weitz, Jürgen; Fischer, Lars; Speidal, Stefanie; Meinzer, Hans-Peter; Böckler, Dittmar; Büchler, Markus W.; Müller-Stich, Beat P. (2013). "Real-time image guidance in laparoscopic liver surgery:

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A CT system mounted on rails can be moved into and out of an operating room to support complex surgical procedures, such as brain, spine and trauma surgery with additional information through imaging. The Johns Hopkins Bayview Medical Center in Maryland describes that their intra-operative CT usage

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the surgeon can observe device movements simultaneously with the 3D overlay of the vessel contours in the fluoroscopy image. An alternative way to add information from the workstation to the fluoroscopic image is to overlay, after either manual or automatic segmentation of the anatomical structures

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Angiographic systems provide a so-called acquisition mode, which stores the acquired images automatically on the system to be uploaded into an image archive later. While standard fluoroscopy is predominantly used to guide devices and to re-position the field of view, data acquisition is applied for

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As in other minimally invasive surgery, not everybody in the surgical community did not believe in this technology. Today it is the gold standard for many types of surgery. Starting with a simple appendectomy, cholecystectomy, partial kidney resections and partial liver resections, the laparoscopic

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because of patient positioning and the insertion of stiff material, more precise planning is possible if the surgeon performs an intraoperative rotational angiography, takes an automatic segmentation of the aorta, places markers for the renal arteries and other landmarks in 3D and then overlays the

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The position of the table in the room also impacts surgical workflow. A diagonal position in the operating room may be considered in order to gain space and flexibility in the room, as well as access to the patient from all sides. Alternatively, a conventional surgery table can be combined with an

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The selection of the operating room table depends on the primary use of the system. Interventional tables with floating table tops and tilt and cradle compete with fully integrated flexible operating room tables. Identification of the right table is a compromise between interventional and surgical

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through the vessels under investigation. The first image is subtracted from the second to remove background structures such as bones as completely as possible and show the contrast-filled vessels more clearly. As there is a time lag between the acquisition of the first and the second image, motion

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Procedures to diagnose and treat small pulmonary nodules have also recently been performed in hybrid operating rooms. Interventional image guidance thereby offers the advantage of precisely knowing the position of the nodules, particularly in small or ground-glass opaque tumors, metastases, and/or

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are major users of the room. It is not recommended to implement a biplane system if not clearly required by these clinical disciplines, as ceiling-mounted components may raise hygienic issues: In fact, some hospitals do not allow operating parts directly above the surgical field, because dust may

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An magnetic resonance tomography system usually requires a lot of space both in the room and around the patient. It is not possible to perform surgery in a regular magnetic resonance tomography room. Thus for step 2, there are two ways to use magnetic resonance scanners interoperatively. One is a

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around the patient. The volume reconstruction is performed on a separate workstation. The C-Arm and the workstation are connected a communicate continuously. For example, when the user virtually rotates the volume on the workstation to view the anatomy from a certain perspective, the parameter of

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Video-assisted thoracoscopic surgery is a minimally-invasive technique to resect lung nodules that saves the patient the trauma of a thoracotomy. Thereby, small ports are used to access the pulmonary lobes and introduce a camera on a thoracoscope, along with the necessary instruments. While this

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Another tool for decreasing dose is collimation. It may be that from the field of view provided by the detector, only a small part is interesting for the intervention. The x-ray tube can be shielded at the parts that are not necessary to be visible by a collimator, thus only sending dose to the

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In summary, important aspects to be included considered are the position in the room, radiolucency (carbon fiber tabletop), compatibility, and integration of imaging devices with the operating table. Further aspects include table load, adjustable table height, and horizontal mobility (floating)

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determines the positioning of the operating room lights. Central axes must be outside of moving path and swivel range. This is especially important as devices have defined room height requirements that must be met. In this case, head clearance height for the OR-light may be an issue. This makes

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For the treatment of trauma patients, every minute counts. Patients with severe bleeding after car accidents, explosions, gunshot wounds or aortic dissections, etc. need immediate care due to the life-threatening blood loss. In a hybrid operating room both open and endovascular treatment of the

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Complex fractures like pelvis fractures, calcaneus or tibia head fractures, etc. need an exact placement of screws and other surgical implants to allow quickest possible treatment of the patients. Minimally invasive surgical approaches result in less trauma for the patient and quicker recovery.

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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 navigation system can further improve the workflow. Intraoperative

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Not only the usage of a hybrid operating room is "hybrid", but also its role within the hospital system. As it holds an imaging modality, the radiology department could take the lead responsibility for the room for expertise in handling, technical, maintenance, and connectivity reasons. From a

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Trans-Aortic Valve Implantation requires exact positioning of the valve in the aortic root to prevent complications. A good fluoroscopic view is essential, whereby an exact perpendicular angle to the aortic root is considered to be optimal for the implantation. Recently, applications have been

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A very effective measure of both protection to both the staff and the patient of course is applying less radiation. There is always a trade-off between radiation dose and image quality. A higher x-ray dose leads to a clearer picture. Modern software technology can improve image quality during

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Planning a hybrid operating room requires to involve a considerable number of stakeholders. To ensure a smooth workflow in the room, all parties working there need to state their requirements, which will impact the room design and determining various resources like space, medical, and imaging

385:. In the same way, if the C-arm angulation is changed, this angulation can be transmitted to the workstation which updates the volume to the same perspective as the fluoroscopic view. The software algorithm that stands behind this process is called registration and can also be done with other 520:

In general, two different light sources are needed in an operating room: the surgical (operating) lights used for open procedures and the ambient lighting for interventional procedures. Particular attention should be paid to the possibility to dim the lights. This is frequently needed during

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Installing a hybrid operating room is a challenge to standard hospital room sizes, as not only the imaging system requires some additional space, but there are also more people in the room as in a normal OR. A team of 8 to 20 people including anesthesiologists, surgeons, nurses, technicians,

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There are both technical measures taking by x-ray equipment manufacturers to reduce dose constantly and handling options for the staff to reduce dose depending on the clinical application. Among the former is beam hardening. Among the latter are frame rate settings, pulsed fluoroscopy and

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The 3D image itself can be overlaid colour-coded on top of the fluoroscopic image. Any change of the angulations of the C-arm will cause the workstation to re-calculate in real-time the view on the 3D image to match exactly the view of the live 2D fluoroscopy image. Without additional

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images to produce real-time subtracted fluoroscopic images overlaid on a static image of the vasculature. The clinical benefit is better visualization of small and complex vascular structures without distracting underlying tissue to support the placement of catheters and wires.

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the nodule as opposed to accidentally taking healthy lung tissue, imaging modalities such as mobile C-Arms, ultrasound, or bronchoscopes are used. The yield rate of biopsies in small nodules is reported to be between 33 and 50% in tumors smaller than 3 cm.

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Koreaki, Irie; Murayama, Yuichi; Saguchi, Takayuki; Ishibashi, Toshihiro; Ebara, Masaki; Takao, Hiroyuki; Abe, Toshiaki (March 2008). "Dynact Soft-Tissue Visualization Using An Angiographic C-Arm System: Initial Clinical Experience in the Operating Room".

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principle (as low as reasonably achievable) should be followed. Dose should be as low as possible, but image quality can only be reduced to the level that the diagnostic benefit of the examination is still higher than the potential harm to the patient.

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Some surgeons not only verify the placement of complex endografts intraoperatively, they also use their angiography system and the applications it offers for planning the procedure. As anatomy changes between a preoperative CT and intraoperative

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Schmal, Zwingmann; Hauschild O, Bode G, Südkamp NP (2013). "Malposition and revision rates of different imaging modalities for percutaneous iliosacral screw fixation following pelvic fractures: A systematic review and meta-analysis".

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also pushed the spread of angiographic systems in vascular operating room environments. Particularly for complex endografts, a hybrid operating theater should be a basic requirement. Also, it is well-suited for emergency treatment.

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Fixed C-Arms do not have these limitations, but require more space in the room. These systems can be mounted either on the floor, the ceiling, or both if a biplane system is chosen. The latter is the system of choice if pediatric

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Digital subtraction angiography (DSA) is a two-dimensional imaging technique for the visualization of blood vessels in the human body (Katzen, 1995). For DSA, the same sequence of a projection is acquired without and then with

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When using pulsed fluoroscopy, radiation dose is only applied in prespecified intervals of time, thus less dose is used to produce the same image sequence. For the time in between, the last image stored is displayed.

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is a technique to acquire CT-like 3D images intraoperatively with a fixed C-Arm. To do that, the C-Arm is rotated around the patient, acquiring a series of projections that will be reconstructed to a 3D data set.

444:(3D-DSA) is combined with a modified injection protocol and a special reconstruction algorithm. The blood flow can then be visualized in the course of time. This can be useful in the treatments of patients with 309:

rate (30f/s, 50 Hz) and high power output (at least 80 kW). Image quality needed for cardiac applications can only be achieved by high powered fixed angiography systems, not with mobile C-Arms.

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patient workflow perspective, the room could be run by their surgical department and should rather be situated next to other surgical facilities, to ensure proper patient care and fast transportation.

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can be circled on the 3D image and then overlaid on the live fluoroscopy. As the marking has been done in 3D, it will update with any change of the fluoroscopy angulation to match the current view.

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acquired either pre-operatively or intra-operatively. Such guidance requires that the 3D information is registered to the patient. This is done using special proprietary software algorithms.

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the whole body with more flexibility and – most importantly – without moving the table. The latter is sometimes a difficult and dangerous undertaking during surgery with the many lines and

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Bonatti, J.; Vassiliades, T.; Nifong, W.; Jakob, H.; Erbel, R.; Fosse, E.; Werkkala, K.; Sutlic, Z.; Bartel, T.; Friedrich, G.; Kiaii, B. (2007). "How to build a cath-lab operating room".

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Sutherland, Garnette R.; Kaibara, Taro; Louw, Deon; Hoult, David I.; Tomanek, Boguslaw; Saunders, John (November 1999). "A mobile high-field magnetic resonance system for Neurosurgery".

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moveable magnetic resonance tomography scanner that can be brought in only when imaging is needed, the other is to transport the patient to a scanner in an adjacent room during surgery.

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Maene, Lieven; Beelen, Roel; Peeters, Patrick; Verbist, Jürgen; Keirse, Koen; Deloose, Koen; Callaert, Joren; Bosiers, Marc Bosiers (September 2012). "3D Navigation in Complex TEVAR".

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post-processing, such that the same image quality is reached with a lower dose. Image quality thereby is described by contrast, noise, resolution and artifacts. In general, the

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Suzuki, K.; Nagai K, Yoshida J, Ohmatsu H, Takahashi K, Nishimura M, Nishiwaki Y (1999). "Video-Assisted Thoracoscopic Surgery for Small Indeterminate Pulmonary Nodules *".

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imaging system if the vendor offers a corresponding integration. The operating room can then be used either with a radiotranslucent but not breakable tabletop that supports

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The repair of diseased heart valves and the surgical treatment of rhythm disturbances and aortic aneurysms can benefit from the imaging capabilities of a hybrid OR.

133:(MRI) scanners. These imaging devices enable minimally-invasive surgery. Minimally-invasive surgery is intended to be less traumatic for the patient and minimize 234:

If necessary, treatment of nodule through surgery/ radiotherapy/ chemotherapy (curative approach) or through chemoembolization / ablation (palliative approach)

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Ikeda, K.; Ikeda K, Nomori H, Mori T, Kobayashi H, Iwatani K, Yoshimoto K, Kawanaka K (2007). "Impalpable Pulmonary Nodules With Ground-Glass Opacity *".

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Hybrid operating rooms are currently used mainly in cardiac, vascular and neurosurgery, but could be suitable for a number of other surgical disciplines.

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ESUT expert group, Rassweiler; Rassweiler MC, Müller M, Kenngott H, Meinzer HP, Teber D (2014). "Surgical navigation in urology: European perspective".

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Modern angiographic systems are not just used for imaging, but support the surgeon also during the procedure by guiding the intervention based on

83: 1566: 218: 602:, where anesthesia is not at the head end. Monoplane systems are therefore clearly recommended for rooms mainly used for cardiac surgery. 2005: 581:

fall in the wound and cause infection. Since any ceiling-mounted system includes moving parts above the surgical field and impairs the

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equipment. In an overcrowded environment like the OR, biplane systems add to the complexity and interfere with anesthesia, except for

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Schreiber, G.; et al. (2003). "Performance Characteristics of Different Modalities for Diagnosis of Suspected Lung Cancer *".

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Hohenforst-Schmidt, W-; J. Brachmann. "Dynact-Navigation For Bronchoscopy Shows Promising Results In A First Feasibility Study".

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Fuse, Nozaki (2013). "Efficacy of DynaCT for surgical navigation during complex laparoscopic surgery: An initial experience".

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has a positive impact on patient outcomes by improving safety, decreasing infections and lowering the risks of complications.

585:, such systems are not the right option for hospitals enforcing highest hygienic standards. (see also and, both German only) 729: 702:

detector for the body parts in question. Modern C-Arms enable to navigate on acquired images without constant fluoroscopy.

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Tomaszewski, R. (March 2008). "Planning a Better Operating Room Suite: Design and Implementation Strategies for Success".

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Steinbauer, M.; I. Töpel, E. Verhoeven (2012). "Angiohybrid-OP – Neue Möglichkeiten, Planung, Realisierung und Effekte".

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Ten Cate, G.; Fosse, E.; Hol, P.K.; Samset, E.; Bock, R.W.; McKinsey, J.F.; Pearce, B.J.; Lothert, M. (September 2004).

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contours on 2D fluoroscopy. This guidance is updated with any change in C-Arm angulation/position or table position.

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Hartkens, Thomas; Riehl, Lisa; Altenbeck, Franziska; Nollert, Georg (2011). "Zukünftige Technologien im Hybrid OP".

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Nollert, G.; Hartkens, T.; Figel, A.; Bulitta, C.; Altenbeck, F.; Gerhard, V (2012). "The Hybrid Operating Room".

412: 1312:, University Hospital Um, Univ. Prof. Dr. Florian Gebhard, MD; Prof. Dr. Thomas R. Blattert, MD, July 10th, 2014 1907: 623:

tabletop, allowing full body coverage, is required. Therefore, non-breakable carbon fibre tabletops are used.

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patients with reduced pulmonary function. This allows for a precise navigation in biopsies, and resection in

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usually expect a table with a segmented tabletop for flexible patient positioning. For imaging purposes, a

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Central location above the operating room table (consideration in planning with ceiling mounted systems).

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is a very advanced surgical theatre that is equipped with advanced medical imaging devices such as fixed

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Novick, Uzzo (2001). "Nephron Sparing Surgery for Renal Tumors: Indications, Techniques and Outcomes".

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requirements. Surgical and interventional requirements may be mutually exclusive. Surgeons, especially

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Suspension accommodating unrestricted, independent movement and stable positioning of light heads

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Though imaging has been a standard part of operating rooms for a long time in the form of mobile

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Improvements of the C-Arm technology nowadays also enable perfusion imaging and can visualize

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Katzen, B. T. (January 1995). "Current Status of Digital Angiography in Vascular Imaging".

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A hybrid operating room supports steps 2 and 3 (if surgery is performed) of this workflow:

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Interventionalists require a floating tabletop to allow fast and precise movements during

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Biasi, L.; Ali, T.; Ratnam, L.A.; Morgan, R.; Loftus, I.; Thompson, M. (February 2009).

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of the legs. In summary, the key topics for planning the surgical light system include:

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first clinical experience with a guidance system based on intraoperative CT imaging".

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Kazuhiro, U.; Kazuyoshi S, Yoshikazu K, Tao-Sheng L, Katsuhiko U, Kimikazu, H (2004).

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Tagungsband zum Symposium "Medizintechnik Aktuell", 25.-26.10.2011 in Ulm, Germany

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on the patient and perform surgery procedure through one or several small cuts.

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Heran, N.S.; J.K. Song, K. Namba, W. Smith, Y. Niimi and A. Berenstein (2006).

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Faulkner, K (April 1997). "Radiation protection in interventional radiology".

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Shure, D.; et al. (1989). "Transbronchial biopsy and needle aspiration".

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Usually three light heads for optimal illumination of multiple surgical fields

437: 145: 1841:"Saarländische SHG-Kliniken setzen im Hybrid-OP auf höchsten Hygienestandard" 1423: 661:

There are a few simple measures to protect people in the operating room from

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Modular system with options for extension, e.g. video monitor and/or camera.

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are calculated from a set of projections acquired during a rotation of the

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Intraoperative 3D Imaging and Computer Guidance for MIS in Spinal Trauma

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During surgery to support decision making and accounting for brain shift

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this view can be transmitted to the angio system, which then drives the

730:"The Cardiovascular Hybrid OR-Clinical & Technical Considerations" 107: 1868:"Integrating surgery and radiology in one suite: a multicenter study" 1749:

Benjamin, M.E. (March 2008). "Building a Modern Endovascular Suite".

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Gefässchirurgie – Zeitschrift für Vaskuläre und Endovaskuläre Medizin

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A reference about neurosurgical hybrid operating rooms on NeuroNews

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The process for diagnosis and treatment usually comprises 3 steps:

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The most common imaging modality to be used in hybrid ORs is a

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or magnetic resonance tomography data acquired preoperatively.

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to a parking position at the head end without colliding with

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Information flow between workstation and angiographic system

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Nollert, Georg; Wich, Sabine; Figel, Anne (12 March 2010).

874:"The Utility of DynaCT in Neuroendovascular Procedures" 42: 461:

Imaging techniques with magnetic resonance tomography

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Magnetic resonance imaging is used in neurosurgery:

82:

Hybrid operating room for cardiovascular surgery at

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Fachverband Biomedizinische Technik: 25–29. 212:Thoracic surgery and endobronchial procedures 8: 1768: 1766: 1764: 1495:: CS1 maint: multiple names: authors list ( 1284:: CS1 maint: multiple names: authors list ( 1226:: CS1 maint: multiple names: authors list ( 1171:: CS1 maint: multiple names: authors list ( 1122:: CS1 maint: multiple names: authors list ( 912:: CS1 maint: multiple names: authors list ( 179:The shift towards endovascular treatment of 1510: 1508: 1506: 2023:Video of a hybrid Operating Room in Brazil 1973:"X-ray dose concept and reduction measure" 1552: 1550: 1548: 1546: 76: 1883: 1717: 1715: 1713: 1544: 1542: 1540: 1538: 1536: 1534: 1532: 1530: 1528: 1526: 1203: 889: 771: 723: 721: 719: 717: 715: 469:Before surgery to enable precise planning 228:Detection of nodules on CT or chest X-ray 432:Functional imaging in the operating room 711: 231:Biopsy of nodule to evaluate malignancy 1816:. Lübecker Nachrichten. Archived from 1488: 1277: 1219: 1164: 1115: 1055: 1044: 905: 67: 2002:IAEA Radiation Protection of Patients 475:After surgery to evaluate the outcome 296:Imaging techniques with a fixed C-Arm 7: 1843:. Innovations Report. Archived from 440:blood volume in the OR. To do that, 381:to exactly the same perspective for 219:video-assisted thoracoscopic surgery 1682:Procedures: A Preliminary Report". 1584:Radiologic Clinics of North America 103: 2048:Surgical procedures and techniques 942:10.1227/01.neu.0000317403.23713.92 878:American Journal of Neuroradiology 14: 1298:AO Foundation, AOTrauma Webcast: 853:from the original on 27 June 2014 36:to comply with Knowledge (XXG)'s 1939:The British Journal of Radiology 1696:10.1097/00006123-199810000-00006 1205:10.1016/j.athoracsur.2003.09.058 353:Fusion imaging and 2D/3D overlay 301:Fluoroscopy and data acquisition 23: 1912:Understanding Medical Radiation 329:Digital subtraction angiography 1808:Bastian Modrow und Lina Timm. 1020:10.1378/chest.123.1_suppl.115s 1: 2004:. 3 July 2017. Archived from 1977:Radiographic Technology Index 1724:Perioperative Nursing Clinics 1596:10.1016/S0033-8389(22)00559-0 1380:10.1016/s0022-5347(05)66066-1 1467:10.1097/MOU.0000000000000014 452:Imaging techniques with a CT 1872:Journal of Vascular Surgery 760:Journal of Vascular Surgery 2064: 1951:10.1259/bjr.70.832.9166065 1736:10.1016/j.cpen.2007.11.005 1660:10.3171/jns.1999.91.5.0804 1192:Annals of Thoracic Surgery 516:Lights, monitors and booms 200: 181:abdominal aortic aneurysms 131:magnetic resonance imaging 1885:10.1016/j.jvs.2004.06.005 1626:"Intraoperative CT (iCT)" 1416:10.1007/s00464-013-3249-0 1337:10.1007/s00464-012-2531-x 1256:10.1007/s00402-013-1788-4 809:10.1007/s00772-012-1021-8 773:10.1016/j.jvs.2008.09.013 498:Room size and preparation 413:abdominal aortic aneurysm 264:Orthopedic trauma surgery 154:intraoperative 3D imaging 104: 75: 1559:Cardiac Surgery / Book 2 845:Raftopoulos, Christian. 404:contrast agent injection 336:contrast agent injection 49:may contain suggestions. 34:may need to be rewritten 16:Type of surgical theatre 1648:Journal of Neurosurgery 1244:Arch Orthop Trauma Surg 1102:10.1378/chest.115.2.563 1075:Medical Hospital Coburg 1041:"APC Guidelines Chest". 985:10.1378/chest.95.5.1130 578:neurointerventionalists 484:Planning considerations 1787:10.1532/HSF98.20070709 1308:26 August 2014 at the 1054:Cite journal requires 1014:(1 Suppl): 115S–128S. 489:Location/ Organization 442:rotational angiography 409:fenestrated stentgraft 322:Rotational angiography 317:Rotational Angiography 174:Hybrid Cardiac Surgery 168:Cardiovascular surgery 1151:10.1378/chest.06-1882 160:Clinical applications 119:hybrid operating room 71:Hybrid operating room 2008:on 18 February 2011. 606:Operating room table 574:electrophysiologists 273:Laparoscopic surgery 1918:on 12 February 2012 1820:on 8 September 2012 1775:Heart Surgery Forum 654:X-ray radiation is 415:. The ostia of the 1847:on 4 November 2013 1751:Endovascular Today 1404:Surgical Endoscopy 832:Endovascular Today 656:ionizing radiation 531:angiography system 348:2D/3D registration 291:Imaging techniques 203:Intraoperative MRI 2043:Medical equipment 1839:Hartmann, BarbE. 1568:978-953-51-0148-2 663:scatter radiation 632:vascular surgeons 129:(CT) scanners or 115: 114: 64: 63: 38:quality standards 2055: 2010: 2009: 1994: 1988: 1987: 1985: 1983: 1969: 1963: 1962: 1945:(832): 325–326. 1934: 1928: 1927: 1925: 1923: 1914:. 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