Hello, listeners. We have a brand new series for you today, starting with our first episode. This is on image guided surgery, and we thought, who better to help us to guide us through this path as surgery residents than a radiology resident as well. So, I'm Rod Gerardo. I'm Ellen In Cisco. I'm M Tombach. My name is Denise Fam, one of the residents in radiology at University of Toledo. And we're joined today by a couple experts. I'm John Racadio, and I'm a pediatric interventionist radiologist at Cincinnati Children's Hospital. Hi, I'm Dan von Allman. I am a pediatric general surgeon and have the privilege of being the surgeon in chief here at Cincinnati Children's Hospital Medical Center. Hi, my name is Nicole Helbert, and I am an interventional radiology technologist, and I run our image guided surgery program. Our our initial question was a basic question. What is image guided surgery? Well, I've had a long-standing interest in image guided surgery, and when I came to Cincinnati Children's, I I found a colleague with a similar interest in uh, Dr. Racadio from interventional radiology. Potentially, if you combine those two skill sets, you would be able to do things in a better way that would provide for better outcomes for the patients. So, for example, when I struggle in the operating room trying to figure out where an artery is when I'm taking out a neuroblastoma, Dr. Racadio can wheel in his ultrasound machine and say, well, it's right there. Those are the kinds of things that are the basis for this um, collaboration to try to leverage the expertise of both radiologists and surgeons in a single case. So, I will say when when people say hybrid uh, procedure rooms, it's uh, it's confusing because initially when you said hybrid procedure rooms, in my mind it is in radiology there's hybrid procedure rooms, right? Where there's CT scanners, there's fluro, there's pet scanners, kind of all in the same room and you have a big room with four different corners where you can just roll the patient in to do whatever, uh, including MRI. But this hybrid OR is more of a conventional OR with interventional radiology. Sometimes the word hybrid is misunderstood. There's probably a concept of what this room is to a radiologist. There's a concept of what this is to the general surgeon and maybe they don't overlap and we're trying to show our audience what this overlap or this partnership could potentially be. And it's not quite what general surgery thinks. I don't think it's quite what radiology thinks, it's somewhere in the middle here and I think that's what we're trying to show off. By having uh, uh, the opening of this hybrid OR that we recently opened about three years ago, uh, we're really able to take that to another level. So, interventional radiology overall is using imaging guidance to do procedures, mostly percutaneous procedures. And there are times that combining the percutaneous nature of interventional radiology with more of an open or conventional surgery will result in the greater or maximize the uh, efficacy of the procedures that we provide uh for patients. So, what is a hybrid operating room and how is the hybrid operating room at Cincinnati Children's different from others? Typically a hybrid operating room historically has involved single surgical subspecialties, such as cardiothoracic surgery, neurosurgery or even trauma surgery. Well, a hybrid operating room is designed to leverage both the capabilities of the surgeon and the interventional radiologist and incorporates a standard uh operating room that then is supplemented with radiology equipment present in advanced interventional radiology suite. And by doing that, we're able to combine surgical techniques in a sterile environment with imaging uh that we would only be able to obtain in a advanced imaging setting such as the interventional radiology suite. One of the differences about our hybrid operating room is the collaborative spirit. From the early room design meetings to the actual clinical cases, we have involved staff from different levels and services. One unique thing about Cincinnati Children's is that in addition to having the hybrid OR with the radiology and surgical capabilities, they also have a lab so that we can study the different procedures and translate them to use in patients. That component is what brought Nicole into the team. You know, she's the research side that kind of bridges the the gaps between all these different specialties. I think the next question is who all is involved in in the hybrid operating room. It's a big team. We've seen the pictures. They said sometimes there's like dozens of people in the room for a specific procedure. So you're talking about a hybrid OR. Um, obviously you have the usual or typical calf lab staff member including nurse or radtech, IR physician and any trainees that may be involved in that. There's a scrub tech as well as a circulating tech. And depending on how well they know the hybrid OR setup, they may need one for surgery as well. In terms of operating the radiographic equipment and CT scanner, whether that's the CT scanner or the fluoro machine, uh, the radtech or the IR physician will be the one um operating those. And then obviously anesthesia, um, if needed, and usually they are for pediatric cases, uh, will be set up at the head of the table. To me, this seems like a very complex setup that they have. So within that, Nicole sent us an example of like a rundown. It's like a play by play plan of how they're going to do a case and it's like GI is going to move here, surgery is going to move here, IR is going to move here, the anesthesia just got to do this. The scrub tech is going to move to this side. It's like a dance how they come up with that plan. equipment. There are a lot of booms overhead, the lights, the monitors, and then when you bring in other equipment from other subspecialists for their particular procedures, there's even more of a an issue with where exactly to place things. It's really been key and and Nicole Hilbert has driven that with these pre-procedural walkthroughs where we position everything uh where we know it needs to be. And by planning that, we want to be more organized and since there're going to be a lot of people in that room, we need them to be less frustrated with the process because surgery is also complicated and we need to be organized to see what people are going to do at the time. Space is very valuable. So you put the IVIS machine in, you put the ultrasound machine in and then you have, you know, whatever else machine that you need. So all of that take up space. So location is uh is very valuable. One thing that physically different in the hybrid OR on the as far as the C arm uh setup is, in a typical interventional radiology lab, the C arm is fixed to a certain position and there's not much flexibility and and the ability to move it. In our hybrid OR, that C arm can move throughout the hybrid OR and move in and out as needed and and if there's a case that there's not a need for the C arm, it can be placed in a park position in the corner of the room. It really gives us a lot of added flexibility in setting up the room. The next question that we asked Dr. Racadio and Dr. von Alman was what are the components in the hybrid operating room? What are the main pieces of machinery that we need? I think there has to be buying in from the institution as a whole, and then certainly from the surgery leadership, as well as the radiology and interventional radiology leadership. a lot of pre-planning. Uh before the hybrid OR ever opened up, there was so much planning where we and we brought in uh all components from the hospital. So not just the surgeons and the interventional radiologist, uh, but the anesthesiology teams, other subspecialists, the perioperative nursing staff, the the surgical technologists, uh, to get input on what they need in a in a OR. By doing that, we were able to physically design the room to meet those needs. And then they also added there's a certification process for the surgeons and procedural, you know, radiologist who are going to come in and do things. They have to make sure that they're ready to use the OR, sign off to use the hybrid OR. Months before the hybrid OR opened up, Nicole Hilbert, myself and and Dan von Alman gave series of uh lectures or are really an an overview of what's to come. Uh we specifically went to some of to different surgical subspecialties grand rounds to explain things to them and also to get an idea from them uh start thinking about potential opportunities that they have within their own divisions. I think John brings up a really important point that is a little bit different for this hybrid um setup than for potentially an adult center. In adult centers, uh it's often times, for example, vascular surgery will use the the hybrid operating room and it's very consistent and their approach is very consistent and they have a defined patient population. When we started to pursue this technology here, as John mentioned, we went to the other divisions and said, hey, how might this help you achieve a better outcome for your patients? And the importance of that in planning the room was we had to be sure that the room would accommodate different patient setups, making this as versatile as possible so that we would allow the surgeons to come up with new ideas and new patient populations that would potentially benefit from image guided approaches. The team at Cincinnati Children's works with Philips to put together and run their hybrid operating room and it sounds like they work closely with the company to set up the hybrid OR. So before we actually designed and made the blueprints for our room in our space, we visited other sites around the country and looked at what their setups were other sites that had uh hybrid OR. And uh you know, we took the best of what we thought those sites had to offer and incorporated um that into our planning. We were one of the first hybrid operating rooms to have the Philip's Azarian Flex move C arm system. This allows the C arm to move fully around the room and support various different imaging needs of a case. As you know, an operating room is typically full of different equipment, supplies and staff. So we designed our operating room floor to be color coded with two different tiles to show the full range of the C arm movement. We have an arc on our floor that is in a green tile and the rest of the flooring is in a yellow orange tile. This allows the staff to position equipment and supplies in places that will be out of the C arm's way, but still provide adequate support to the surgical needs of the case. This hybrid operating room at Cincinnati or or elsewhere there's there are a number of different imaging modalities that we can use, whether it's fluoroscopy, CT scan, digital subtraction angiography, and a lot of other types of imaging to help with the procedures. The imaging capabilities within the room certainly are are all the capabilities of a state of the art interventional radiology suite which uh includes flat fluoroscopy, digital subtraction angiography, all the fancy road mapping, vascular applications. In addition, the C arm is able to produce uh CT scanning. So how does the patient, surgeons and the interventional radiologist benefit from a hybrid OR. I think ultimately at at at the highest level, the patient benefits from the technology that's possible in the hybrid OR, but really more importantly than that, the uh collaboration between the interventional radiologist and the surgeons in in maximizing that technology. From my perspective, I think there are multiple uh different avenues that lead to better patient outcomes, which is what we're all most interested in is doing the best thing for the patient. And along the way the surgeon and the radiologist benefit, but I think that combining those those skill sets is what ultimately will help the patient the most. We have examples of changing process that has allowed, for example, the same procedure to be done, but to be done without having to move the patient all over the hospital, uh under anesthesia, such as the lung biopsy work that we've done, where the patient can be done completely in the hybrid OR for the localization. And we're just beginning to explore all of these various different ways that this combination of both the expertise of the surgeon and the radiologist and the technology that's provided in the hybrid operating room can result in better outcomes for the patients. Certainly having live ultrasound uh allows us to uh perform real-time ultrasound guided uh navigation as well. The neuro surgeons, one of the procedures they do is placing deep electrodes for seizure evaluation and they do that a Rosa robot system. Historically, they would move patient from neurosurgical OR to main radiology to get a post procedure CT scan to assure that electrodes placed appropriately and there is no postop complications, particularly hemorrhage. What the neurosurgeons do now is they utilize the CT capabilities of the hybrid OR during the procedure. The hybrid OR was able to be incorporated with the Rosa robot as far as actually the two systems can speak to each other. And then following the electrode placement, the C arm can perform beam CT scan to evaluate electrode placement as well as for any hemorrhage. If there is anything, the surgeons any abnormality, the surgeons can act on that um immediately versus having to bring the patient back from the CT scanner back up to the OR. Our Philip's scanning CT images can be directly transferred to the Rosa robot. This allows the team to check the accuracy of each electrode placement by comparing the preop CT plan and the postop CT images acquired that in the hybrid OR. Yeah, it really has been enormously helpful to avoid having to have the radiology process as a secondary thing and and having it real time. So whether it's checking on the tumor reception or checking on lead placement or identifying and localizing a pulmonary nodule, and then having the surgery at the same time in the same place is just an enormous patient benefit because of the the inherent risks in moving a patient around the hospital, particularly in pediatrics where they are frequently, if not always anesthetized during that process. It just adds an element of danger that you can completely avoid uh using this hybrid OR technology. all the different modalities is to prevent that transportation and what could happen during patient transportation. A lot of times, there're just so many things that need to be taken in at the same time, especially if the patients on in ICU. I think this is great and always increases or or benefits patient safety and patient outcome. If I I put on my administrator hat, uh if you want another rationale for why this was a great thing for us to to get. When the neurosurgeons were talking about doing these uh electrode placements, they sent through a capital request for a CT scanner for the operating room that was going to cost us an additional million dollars. And yet by checking trying this in the hybrid room and refining the technique, we saved ourselves a new million dollar CT scanner. Wow, that's amazing. I also have no idea how much this stuff costs as the general surgery resident walking around and sometimes we're like, oh, they're putting a new CT scanner in the uh in the emergency department, that's pretty cool. And this first episode of this podcast series, we're lucky enough to have to hear from the IR side and the surgery side. But I think that we should keep in mind that the potential to use a hybrid OR is not just limited to general surgery and radiology, because these rooms can be used in collaboration with GI, neurosurgery, orthopedics, urology, everything I think can benefit from the technology that radiology can provide to these hybrid OR. What are the next steps for this technology? What can we look to the future for? I certainly think that as the technology continues to evolve, we will develop more and more indications for this. To your point earlier, I I think that culture of collaboration is absolutely critical to the underlying premise, which is that you can leverage the expertise of two different groups of physicians to create a better outcome for the patient. And at one point we did a case where we had 22 people with MD after their name in the room at once, including the anesthesia, the trainees, the everybody. I think that's what John and I are really excited about and that's why we keep pushing the surgical division directors. Part of the the the future growth, not only will be advances in different technologies, but really it's kind of been growing on its own as the early adopters from different subspecialties have tried things and they've been successful, then that branches off to um some of their colleagues that that have ideas. So it is that creativity and the collaboration that uh really is driving the growth. I must say, John has been a leader at sharing the stories from different successful cases. He puts together a short presentation about the case and the unique approach and shares it with the divisions who we collaborated with. This then gets the other staff in that division thinking of different potential applications to their cases and workflows. This has resulted in collaborative cases with different divisions we never predicted would be working in the hybrid OR. So overall, I think just the efficiency can be greatly increased and and all of that will be beneficial. Another point is oftentimes after transplant, to evaluate the transplant kidneys, at least from our transplant surgeons here, they always get a immediate doppler to evaluate the vessels, right? And that can be done like right there and then. I'm sure a lot of people listening are wondering are are aware that these hybrid operating rooms are expensive to put together. Dr. von Alman mentioned to us that having this hybrid actually saved him money from when the neurosurgery team requested CT scanner. And you would think, oh, a hybrid OR, that's so expensive, but really, Dr. van Alman said that it saved him in the long run. Yeah, they are expensive systems and we had to renovate an entire room to create this new operating room. Uh that for sure cost money. Uh on the other hand, I think that we are demonstrating that we can um that the result of that is improved patient outcomes, which I've said a hundred times, but that really is the bottom line of what we're trying to do. Uh but also the efficiencies in terms of not moving the patient around and shorting anesthesia times. So it is a significant institutional investment, um, but there are paybacks for it. vision and that collaborative effort that's supported by the leadership within surgery and radiology to allow us to have that time. So I think certainly probably in academic centers, it's it's more likely to be able to be successful. So that was image guided surgery in the hybrid operating room at Cincinnati Children's in a nutshell. You know, they found that with the hybrid operating room, the collaboration between the interventional radiologist and all the different specialties that they can make it more efficient. We have a lot more capabilities with different imaging modalities and ideally improve patient outcomes. I think I get caught up in all the cool fancy technology, but you're right. At the heart of this, the concept is improving the care of the pediatric patient. That's really the reason for all of this going on. But this first episode was just a taste. It was just a sample of what this series is going to be. We have so many interesting cases for you guys to hear about from different surgeons and interventional radiologist at Cincinnati Children's Hospital. And we're so happy to have us our extra host here, uh Denise to help us with kind of like the radiology side of it. If you like this episode, follow us on social media, subscribe to our YouTube channel. Download the State Current Pediatric Surgery app. It's in the Apple App Store, it's in the Google Play Store, but until next time. I'm Rod from Cincinnati Children's. I'm Ellen from Cincinnati Children's. I'm M from Cincinnati Children's. And I'm the odd man out from Denise from University of Toledo. And remember, knowledge should be free.
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