Update Course Rewind: Highlighting Collaboration from Surgery & Interventional Radiology in the OR 2024
With Dr. John Ricardo & Dr. Dan von Alman & Dr. Amanda Bellingford · hosted by Dr. Em Goddy · StayCurrentMD
Cued at 7:03 · stops at 7:48 · press play
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Surgeons and interventional radiologists may speak different languages regarding image guidance, with surgeons not knowing what's possible and radiologists not knowing what surgeons need.
A hybrid OR is not required for image-guided surgery; collaboration can occur in regular ORs with ultrasound machines or in dual settings where patients go to interventional radiology for localization then to the OR.
Cone beam CT is a CT scan performed on a C-arm fluoroscopy unit that rotates around the patient collecting multiple images which are stacked together to create a CT.
Cone beam CT technology is available at many institutions even if they don't have a hybrid OR space, though people may not realize they have it.
Cincinnati Children's hybrid OR has been open for about 7 years with collaborative work between surgeons and interventional radiologists.
Having a program manager serve as liaison between surgeons and interventional radiologists is important because nobody will try something new if it's more complicated and takes longer than their normal practice.
Leadership engagement from both the chief of surgery (Doctor von Alman) and chief of radiology has been crucial support for the collaboration program.
The hybrid OR at Cincinnati Children's was built so any division can use the room, with collaborative cases being performed with urology, neurosurgery, pulmonary, and gynecology, often doing multiple procedures on patients.
For supraclavicular lymph nodes that are difficult to palpate, ultrasound-guided localization with a Copan's needle wire allows the surgeon to follow it down and find the lymph node easily, turning what could be a big dissection into a nice and easy one.
For foreign body localization (such as glass), interventional radiologists can localize it with ultrasound before introduction of air, which makes things virtually invisible.
During neuroblastoma excisions when dissecting near the aorta, ultrasound can be used every 5 minutes to identify the celiac takeoff and reorient the surgeon.
Ultrasound can be used at the end of cases to confirm vessel patency, such as looking at flow in kidney transplants, portal flow after Mesorex bypass, or renal flow after challenging neuroblastoma excisions where the renal hilum has been skeletonized.
Pulmonary nodule localization can be done with wire, coil, or dye depending on institutional preference.
At one institution (Laurie), pulmonary nodule localization is performed in two locations: first in pre-op CT where interventional radiologists use CT guidance to place a coil next to the nodule, then in the OR using fluoroscopy under two orthogonal planes to ensure accurate nodule identification and removal.
Using coil localization combined with dye eliminates the risk of wire displacement.
At Cincinnati Children's, pulmonary nodule localization uses a combination of methylene blue blood patch with cone beam CT performed with the patient in thoracoscopy position, involving one draping and prepping in the hybrid OR, tattooing the visceral pleura with methylene blue blood patch while deploying a Copan's wire.
Vascular malformations are often managed in multidisciplinary VLC clinics where interventional radiologists offer sclerotherapy and pediatric surgeons offer resection, but sometimes a combination approach is best.
For vascular malformations not amenable to sclerotherapy alone, interventional radiologists can perform angiography, directly inject contrast, and place glue to ensure complete resection of small outpouchings or legs.
For transbronchial biopsies, cone beam CT is used to segment out 3D anatomy in about 1 minute, then live fluoroscopy is superimposed over the nodule in AP and lateral views so the pulmonology team always knows where they are performing the biopsy.
Augmented reality technology uses holographic displays superimposed over patients on the table, taking pre-procedure CT or MRI imaging, segmenting it out, and co-registering it to the patient, with the ability to track instruments.
The 12th annual update course in pediatric surgery was held in August 2024 and introduced a new classification system: green circle for established practice, blue square for promising newer practice, and black diamond for early adopter practice only.
Information from this session on image-guided surgery collaboration classifies as a blue square for promising newer practice.
Image-guided surgery uses real-time imaging (CT, MRI, ultrasound, or fluoroscopy) to help surgeons navigate during procedures with greater precision, improving accuracy and safety.
A hybrid operating room integrates advanced imaging technology and traditional surgical setup, eliminating the need to transport patients between radiology and surgical areas, which enhances efficiency, reduces complications, and improves patient outcomes.
Cone beam CT provides excellent visualization of bony structures, making it valuable for maxillofacial, ENT, spine, and orthopedic surgeries.
Interventional radiologists at Cincinnati Children's help train pediatric surgery fellows including guidance for vascular access.
In a hydrocephalic sheep model demonstration, MRI imaging was used to create a holographic overlay of anatomy, and by aligning key reference points (fiducials), the hologram matches perfectly with actual anatomy, allowing virtual slicing through the holographic image to view dilated ventricles for precise drain placement.