29 views 0 likes

Dr. CCHMC Pediatric Surgery

GCMD Space · View profile →

Update Course Rewind: Highlighting Collaboration from Surgery & Interventional Radiology in the OR 2024

Video Published 2025-03-26 Updated 2026-08-01

Timestops (6)

Hybrid OR and Image-Guided Surgery Overview

Cone Beam CT Technology and Integration

Ultrasound Applications in Pediatric Surgery

Lung Nodule Localization Techniques

Augmented Reality and 3D Visualization

Summary of Image-Guided Surgical Applications

Topic Overview

A panel discussion on image-guided surgery collaboration between pediatric surgeons and interventional radiologists, recorded at the 12th annual Cincinnati Children's update course in August 2024. The session covers practical applications of real-time imaging techniques (ultrasound, cone beam CT, fluoroscopy) for procedures including lymph node localization, foreign body removal, pulmonary nodule localization, and vascular malformation management. Speakers emphasize that effective collaboration does not require a hybrid operating room and describe both routine applications and emerging technologies including augmented reality surgical guidance.

Key Takeaways

Hybrid OR not required—bring ultrasound to regular OR or use CT then transfer for image-guided collaboration (2:17)
Cone beam CT on C-arm provides excellent bony visualization for maxillofacial/ENT/spine cases; many institutions already have it (2:45)
Ultrasound in OR localizes supraclavicular nodes, foreign bodies, and monitors vessel patency during neuroblastoma excision (4:44)
Pulmonary nodule localization uses coil (avoids wire displacement) or methylene blue with cone beam CT and Kopans wire placement (6:19)
Program manager liaison and leadership engagement from both surgery and radiology chiefs critical for adoption success (3:54)

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Speaker 1
Em Goddy — host
Speaker 3 — guest
Speaker 4 — guest
Speaker 5 — guest
Amanda Bellingford — guest

Chapters

0:01Introduction and Course Classification — Introduction to the update course recap series and classification of image-guided surgery as 'blue square' promising newer practice. Overview of collaboration between surgery and interventional radiology.
1:32Image Guidance Fundamentals and Hybrid OR — Definitions of image-guided surgery techniques and hybrid operating rooms. Discussion of cone beam CT technology and clarification that hybrid ORs are not required for collaborative image-guided procedures.
3:24Program Structure and Cross-Training — Description of Cincinnati Children's 7-year collaborative program including cross-training, program management role, leadership support, and multi-divisional use of hybrid OR facilities.
4:40Routine Clinical Applications — Practical use cases including lymph node localization, foreign body removal, critical structure identification during neuroblastoma excision, vessel patency confirmation, and pulmonary nodule localization techniques.
7:38Advanced Applications — Vascular malformation management combining sclerotherapy and resection, and transbronchial biopsy guidance using cone beam CT with 3D segmentation and live fluoroscopy overlay.
8:35Emerging Technologies and Summary — Demonstration of augmented reality holographic imaging using MRI-derived overlays in a hydrocephalic sheep model, with summary of key collaboration principles and techniques.

Key claims

0:13The 12th annual update course in pediatric surgery was held in August 2024 — Em Goddy
0:56Image-guided surgery session classifies as blue square for promising newer practice — Em Goddy
1:15Image-guided surgery uses real-time imaging including CT, MRI, ultrasound, or fluoroscopy to provide detailed views of internal structures — Em Goddy
1:39Surgeons may not know what is possible with image guidance so they don't know what to ask for — Em Goddy
1:44Interventional radiologists may not know what surgeons need so they might not know what to offer — Speaker 4
2:17A hybrid operating room is not required for image-guided surgery collaboration — Speaker 5
2:23Image-guided collaboration can occur in regular OR by bringing an ultrasound machine, in a hybrid OR, or in dual settings using CT scanner for localization then moving to OR — Speaker 5
2:45Cone 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 — Amanda Bellingford
2:59Cone beam CT provides excellent visualization of bony structures making it valuable for maxillofacial, ENT, spine, and orthopedic surgeries — Em Goddy
3:15Many institutions have cone beam CT technology available and don't realize it even if not in a hybrid OR space — Speaker 5
3:28Cincinnati Children's hybrid OR has been open for about 7 years — Speaker 4
3:36Interventional radiologists at Cincinnati Children's help train pediatric surgery fellows including guidance for vascular access — Em Goddy
3:54Having a program manager as liaison between surgeons and interventional radiologists is important because nobody wants to try something new if it will be more complicated and take longer than normal practice — Amanda Bellingford
4:11Leadership engagement from both surgery and radiology chiefs has helped the collaborative program — Amanda Bellingford
4:24The hybrid OR at Cincinnati is used by multiple divisions including urology, neurosurgery, pulmonary, and gynecology for collaborative cases with multiple procedures — Amanda Bellingford
4:44For lymph node localization of difficult-to-palpate supraclavicular nodes, ultrasound guidance with Kopans needle wire can be used in one prep and drape — Speaker 5
5:15Ultrasound in OR can localize foreign bodies like glass, and IR colleagues should be called before air introduction makes things virtually invisible — Speaker 4
5:40During neuroblastoma excisions, ultrasound can be used every 5 minutes to identify celiac artery takeoff while dissecting along the aorta — Speaker 5
5:52Ultrasound can confirm vessel patency at end of case including renal flow after challenging neuroblastoma excision where renal hilum has been skeletonized — Speaker 5
6:19Pulmonary nodule localization can be done with wire, coil, or dye depending on institutional preference — Speaker 5
6:35At one institution, CT-guided coil placement by IR is followed by fluoroscopy in OR under two orthogonal planes to localize and remove pulmonary nodules — Speaker 5
6:56Coil approach for pulmonary nodule localization avoids risk of wire displacement — Speaker 5
7:14At Cincinnati Children's, pulmonary nodule localization uses methylene blue blood patch with cone beam CT in thoracoscopy position, tattooing visceral pleura with Kopans needle then deploying Kopans wire — Speaker 4
7:38Vascular malformations are often managed in multidisciplinary VLC clinic with IR offering sclerotherapy and surgeons offering resection — Speaker 5
7:52For vascular malformations not amenable to sclerotherapy, IR can do angiogram with direct contrast injection and glue placement to ensure complete resection of outpouchings — Speaker 5
8:20For transbronchial biopsies, cone beam CT with 3D anatomy segmentation taking about 1 minute allows live fluoroscopy to be superimposed over nodule in AP and lateral views — Speaker 4
8:46Augmented reality uses holographic display superimposed over patient on table by taking pre-procedure CT or MRI imaging, segmenting it out, and co-registering it to the patient — Speaker 4

Cases discussed

9:03Hydrocephalic sheep model demonstration of augmented reality surgical guidance

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Ultrasound-Guided Neuroblastoma Resection: Protecting the Celiac Axis in Real Time

The patient case from this episode, retold from presentation to outcome with the decisions made along the way. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Case narrative · AI-written, human-reviewed

The Presentation

A child with neuroblastoma required tumor excision along the aorta. 5:40 The mass encased the celiac artery origin, and the surgical plane required dissection millimeters from this critical vessel. 5:40 The anatomy was distorted, the tissue planes obliterated by tumor, and visual landmarks unreliable. 5:40

The Decision Point

Dissecting a neuroblastoma off the aorta is slow work. 5:40 You advance in small increments, never certain how close you are to the celiac takeoff until you see it — or injure it. The traditional approach relies on anatomic memory and tactile feedback, but neither is trustworthy when tumor has remodeled the retroperitoneum.

The question was whether real-time imaging could change that. 5:40 Ultrasound can identify the celiac artery through overlying tissue, but using it effectively during an open abdominal case requires more than pointing a probe at the field. It requires knowing when to stop dissecting and reorient, and it requires someone who can interpret the images while the surgeon's hands are occupied.

The team chose to use intraoperative ultrasound not once at the start of the case, but repeatedly — every few minutes — as the dissection advanced along the aorta. 5:40 This was not a one-time localization. It was continuous spatial awareness, updated as the anatomy changed.

What They Did

An ultrasound machine was brought into the operating room. 5:40 As the surgeon dissected along the aorta, an interventional radiologist used the ultrasound probe to identify the celiac artery takeoff and communicate its position relative to the surgical plane. 5:40 The imaging was repeated at regular intervals throughout the dissection. 5:40

The rationale was straightforward: if you know where the vessel is before you reach it, you can adjust your approach rather than discovering it by proximity or injury. 5:40 The ultrasound provided a map that updated faster than the tissue could be divided.

At the end of the case, after the renal hilum had been skeletonized during the tumor excision, the team used ultrasound again — this time to confirm renal artery patency. 5:52 The vessel had been manipulated extensively, and direct visualization of flow answered the question of whether the kidney remained perfused without waiting for delayed signs of ischemia. 5:52

The Outcome

The discussants did not report the postoperative course or long-term outcome of this case.

What the Case Changes

This case demonstrates a principle that applies beyond neuroblastoma: when critical structures are obscured by pathology, intermittent imaging can substitute for the anatomic clarity you have lost. 5:40 The value is not in confirming what you already see — it is in revealing what you cannot.

Three transferable judgments emerge. First, ultrasound in the OR does not require a hybrid suite or specialized equipment. 2:17 A standard ultrasound machine and a colleague trained in its use are sufficient. 2:17 Second, the utility of intraoperative imaging scales with the frequency of use. 5:40 Checking once at the beginning of a case is less useful than checking repeatedly as the dissection evolves. 5:40 Third, end-of-case vessel patency checks are simple and informative. 5:52 Transplant surgeons have used this approach for decades to confirm portal flow after mesocaval shunts and renal flow after kidney transplants. 5:52 Extending the same logic to complex tumor resections where vascular structures have been extensively manipulated is a low-cost, high-yield practice. 5:52

The broader lesson is about collaboration. 1:39 1:44 As one of the discussants noted, surgeons may not always know what is possible with image guidance, and interventional radiologists may not always know what surgeons need. 1:39 1:44 The gap is not technical — it is conversational. Closing it requires surgeons to articulate the moments of uncertainty in their cases and interventional radiologists to translate imaging capabilities into surgical solutions.

For the trainee, the question to ask is not whether your institution has a hybrid OR. The question is whether you have identified the colleague who can bring an ultrasound machine into your next difficult case and tell you what you are looking at while your hands are still in the field.

Takeaways from this story

Intraoperative ultrasound at regular intervals during aortic dissection provides updated spatial awareness as anatomy changes.
End-of-case ultrasound confirms vessel patency after extensive hilar manipulation without waiting for delayed ischemia signs.
Image-guided collaboration requires no hybrid OR—just an ultrasound machine and a trained colleague in the room.
Surgeons often don't know what imaging can offer; radiologists often don't know what surgeons need—closing that gap is conversational.

Keywords

hydrocephalus neuroblastoma vascular malformations pulmonary nodules lymph node localization foreign body removal pulmonary nodule localization sclerotherapy transbronchial biopsy kidney transplant Mesorex bypass thoracoscopy methylene blue Cincinnati Children's Hospital Medical Center GlobalCastMD

Hashtags

#pediatricsurgery #interventionalradiology #imageguidedsurgery #hybridOR #collaboration #conebeamCT #cincinnatichildrens #InterdisciplinaryTeam #InterdisciplinaryCollaboration

Transcript

Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello pediatric surgery family, I'm Em Goddy from Cincinnati Children's Hospital Medical Center. In this video series, we'll be recapping the sessions and sharing the key highlights from our 12th annual update course in pediatric surgery, which was held in August 2024. This year we introduced a new approach to classify practice changing ideas at our update course. Presentations now fall into three categories green circle for established practice, blue square for. Promising newer practice and black diamond for early adopter practice only in this session, Amanda Bellingford, an interventional radiology technologist, and Doctors Dan von Alman, John Ricardo, and Timothy Lotz will talk about the use of image guidance, surgery, and the importance of collaboration between departments. Information from this session classifies as a blue square for promising newer practice. This session. It is really about combining the expertise of surgeons with the expertise of our interventional radiologists and ultimately impacting the patient, so you keep the focus on what's right for the patient and put the egos aside, and you can do really great things. Image guided surgery is a technique that uses real-time imaging to help surgeons navigate during procedures with greater precision. This can involve techniques like CT, MRI, ultrasound, or fluoroscopy to provide detailed views of internal structures, improving accuracy and safety. And even when we talk about image guidance, I think sometimes surgeon and interventional radiologists may be speaking different languages. Some surgeons may not know what's possible with image guidance, so they don't know what to ask for. And interventional radiologists may not know what the surgeons need, so that they might not even know what to offer. A hybrid operating room is a specialized surgical suite that integrates both advanced imaging technology and traditional surgical setup. Some institutions like Cincinnati Children's build hybrid operating rooms so that patients do not need to be transported between separate radiology. And surgical areas which can enhance efficiency, reduce complications, and improve patient outcomes. While a hybrid operating room is a valuable asset, it is not required for image guided surgery. So it's important to understand that you don't have to have a hybrid OR to be able to do this type of collaboration. It can occur in your regular OR by just bringing an ultrasound machine. It can occur in a hybrid OR if you're lucky enough to have that, or it can occur in sort of dual settings where you go to interventional radiology, maybe go to the CT scanner for a coil or a wire localization, and then roll the patient up to the OR. Let's talk about an important part of hybrid OR, a cone beam CT. What is it really? So it's a CT scan that's performed on a CA fluoroscopy unit. Basically, it's positioned over the patient's point of interest and it rotates around the. Patient collecting multiple images which are then stacked together to create a CT. It provides excellent visualization of bony structures, making it valuable for maxillofacial, ENT, spine, and orthopedic surgeries. Cone beam CT can be integrated into the operating rooms for real-time guidance, improving accuracy and minimally invasive procedures. And I think this is technology that many people have and don't realize that they have available at their institutions even if they're not. Do it within a hybrid OR space. Yeah, as I mentioned, at, at Cincinnati, we are fortunate. We're very collaborative with the surgeons. We share know-how, working together in our hybrid OR which we've had open for about 7 years now. There's also cross-training. Interventional radiologists at Cincinnati Children's helped train some of the pediatric surgery fellows but also some guidance for vascular access. Important part of the program is having someone that can really. Champion the efforts of the surgeons and the interventional radiologists and combine everyone working together. I'm the program manager at Cincinnati Over Image guided Surgery, and my job is really to help be the liaison between the surgeons and the interventional radiologists because we all know nobody's going to want to try something new if it's going to be more complicated and take a longer time than their normal practice. And it is also a huge help is just having our leadership engaged in this program. Doctor Vong Aman is a huge support of the collaborations and so is the chief of radiology, and that has really helped. Our hybrid OR was built so that any division can come in and use the room. It is not just sitting idle. We're doing collaborative cases with urology, neurosurgery, pulmonary, gynecology, and we're doing multiple procedures on these patients when they're in there. So moving on, let's talk about some routine and widely available use cases. So, simple things, lymph node localization. You've got that supraclavicular lymph node that you can't really feel very well. You know, it needs to come out. It needs more than just a core biopsy. You work together. So with ultrasound guidance, we'll just localize that with the Copan's needle wire. You know, even if you don't have a hybrid, the ultrasound machine rolls up to the OR, it's one prep and drape, put the Copan wire in, and then as the surgeon, you follow it down, you find that lymph node easily. And it takes what could be a big dissection. And turns it into a nice and easy one. Sometimes there's a foreign body that's hard to feel. Sometimes it's a piece of glass. Ultrasound in the OR can be a great tool for this case, and oftentimes surgeons will do this themselves, but sometimes it can be more challenging. Maybe give your IR colleague a call and we'll go ahead and localize it before there's an introduction of some of that air. It makes things virtually invisible. You can also use it for identifying and protecting critical structures during. Surgery. So we all know during those terrible neuroblastoma excisions when you're creeping up the aorta and you're trying to see where the celiac takeoff is, I'm looking with the ultrasound every 5 minutes during that case and reorienting myself with the ultrasound. And then you can use it at the end of the case to confirm vessel patency. The transplant surgeons have been doing this forever, whether it's looking at the flow in a kidney transplant at the end of a case or looking at portal flow after a Mesorex bypass. Again, you. You can use it at the end of a challenging neuroblastoma excision. Where you've really skeletonized the renal hylum, just reassuring yourself that the renal flow looks good at the end of the case is an easy and great use of these tools. There are all sorts of different ways to do pulmonary nodule localization, and many of them involve collaboration between surgery and interventional radiology. You can do it with a wire, you can do it with a coil, you can do it with dye, do it with whatever you're most comfortable with at your institution. The way we do it at Laurie is we actually make use of two different locations. First, they go to the pre-op CT and interventional radiologists use CT guidance and leave a coil right next to the nodule. And then in the OR we'll use fluoroscopy under two different orthogonal planes, so you gotta look at one angle and then move it 90 degrees to make sure you really have the nodule and remove it. I like this approach, um, sometimes combined with a dye because you're not at risk for wire, um, displacement. At Cincinnati Children's, they have a similar approach for these cases, but with a hybrid operating room, which obviates the need for patient transportation between radiology and surgical areas. We use a combination of methylene blue blood patch as we're going in. We'll do a combeam CT ideally with the patient in thoracoscopy position. This is just one draping and one prepping, and it will be in the hybrid OR. We'll do a methylene blue blood patch tattooing of the visceral pleura as we're going through it with the Copan's needle. And then we'll deploy the Copan's wire. What are the other use cases? Vascular malformations. These scenes are often managed in a multidisciplinary VLC clinic. Interventional radiologists can offer sclerotherapy. Pediatric surgeons can offer resection, but sometimes a combination is just the best. So if you have something where it's not really amenable to sclerotherapy, they can still do angiogram essentially and directly inject it and get a contrast study and then put glue in it so that if you have. These little out pouchings, these little legs, you can make sure that you're getting those fully resected at the time. The collaboration does not end here. There are so many use cases here. Doctor Riccari explains how they work together with the pulmonology team to help them with transbronchial biopsies. We'll do acom beam CT. We'll segment out the 3D anatomy. It takes about 1 minute, and then our live flow will be superimposed over the, this nodule. So in AP in a lateral view, they always know. Where they're gonna be uh performing the transbronchial biopsy. Virtual reality, augmented reality, those are the things that are gonna be a part of the future for sure. Here we can see the IR research lab, which mirrors the clinical hybrid OR. It's just a holographic display superimposed over your patient on the table. So you take either pre-procedure, CT MRI imaging, segment that out and actually co-register it to your patient, and the, the technology can track instruments, but that's. Definitely coming along. Let's watch this short video demonstrating a hydrocephalic sheep model about a one day old. In this example, Doctor Ricardo and his team used MRI imaging to create a holographic overlay of the anatomy. By aligning key reference points or fiducials. The hologram matches perfectly with the actual anatomy. Using hand gestures, you can virtually slice through the holographic image to view the dilated ventricles, helping in the precise placement of a drain. In summary, collaboration between surgeons and interventional radiologists, even outside hybrid ORs, enhances patient care by integrating tools like ultrasound and comb beam CT for precise localization and guidance. Routine and innovative image guided techniques such as lymph node localization, pulmonary nodule marking, and vessel. Patency checks simplify complex surgeries and reduce invasiveness. Emerging technologies like virtual and augmented reality are paving the way for more accurate interactive surgical planning and execution demonstrated by tools like holographic imaging and experimental models. Thank you for watching this video. Globalcast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.

Comments

Loading comments…