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Hybrid ORs set the stage for cutting-edge care

Publish Date: 8/15/2012

A hybrid OR is a state-of-the-art surgical suite with advanced imaging capabilities that integrates traditional surgery options with complex minimally invasive surgical techniques. While their unique requirements have typically limited them to select facilities, hybrid ORs are becoming more common throughout the U.S. and are transforming the standard of care.

Hybrid procedures are opening doors to new treatment options for conditions that previously could only be treated through open surgery and are providing high-risk patients who once had few to no treatment options with viable, lower risk surgical procedures. Less invasive hybrid interventions reduce the number of procedures and the length of a procedure required to treat a condition. In addition, the ability to perform high-quality imaging studies along with open surgery and minimally invasive procedures in the same room helps to eliminate the need to transfer patients to another department, thereby shortening the duration of hospitalization and reducing the risk of infection.

Multidisciplinary approach 

Planning, designing, and implementing a hybrid OR is no small endeavor. On average, a hybrid OR costs approximately $3-5 million and requires approximately a 1,000-square-foot space. Nearly double the size of a traditional OR, the space is needed to accommodate high-end imaging equipment, which may include ceiling- or floor mounted C-arm systems or a multi-axis system with a robotic arm. The additional space is also needed for the number of team members who may need to be in the room at the same time. “Staff calculations have shown that in hybrid procedures eight to 20 people are needed, including anesthesiologists, surgeons, nurses, technicians, perfusionists, experts from device companies, and so forth.”1

Since the room will be used by an interdisciplinary team, all stakeholders should be involved in the planning of a hybrid OR. A collaborative team approach is needed to weigh in on everything from the design of the room to vendor selection to the staffing model. Often, a formal committee is required to reach a consensus on the kind of equipment that will be used in the room and the types of procedures that will be done.

Once the room is operational, the complexity of the technologically advanced hybrid techniques requires multidisciplinary expertise and intensive collaboration among team members, including surgeons, interventional cardiologists, and interventional radiologists.

“We are using more of the interventional procedures to augment the open procedures that weren’t done before, and from cross pollination of ideas of what interventional cardiologists can do, what interventional radiologists can do…we’ve learned a lot more from each other than we ever expected,” said T. Brett Reece, MD, assistant professor at the University of Colorado School of Medicine. “All of us bring something a little different to the table, whether it is perspective or skill sets. We’ve gone a long way in terms of improving the procedures, doing what’s safe and what we can do best for the patient by these collaborations.”

Types of procedures 

Hybrid procedures are used across several disciplines, with new developments rapidly transforming cardiac, vascular, and cardiothoracic care. New treatment options for conditions such as peripheral vascular disease, abdominal aneurysms, and thoracic aortic aneurysms are commonly employed in hybrid ORs.

Access to high-resolution, real-time images of the heart within a sterile operating suite allows for innovative, customized heart procedures, including a new technique to treat aortic stenosis. For those suffering from aortic valve disease, the transcatheter aortic valve replacement (TAVR) procedure provides a treatment option to replace heart valves without open surgery. The TAVR involves a small incision in the leg to implant a valve in the heart known as the SAPIEN valve, which was approved by the U.S. Food and Drug Administration in November 2011.

“The Sapien valve is the only catheter-based treatment option for people with severe aortic valve disease who are not eligible for surgery, and an estimated 40% of people with severe aortic stenosis do not undergo valve surgery and may benefit from this new treatment option.”2 The TAVR is an innovative technique that eliminates the need for certain patients to undergo open heart surgery and be placed on heart-lung machines, and it offers those who have undergone the procedure considerable improvements in quality of life.

Minimally invasive catheter-based procedures can also treat a variety of congenital heart defects. The Congenital Heart Center at New York-Presbyterian Morgan Stanley Children’s Hospital is one of a few facilities in the United States to offer a hybrid program for infants and children who require surgery but could benefit from a minimally invasive catheter-based interventions.3 At the Congenital Heart Center, surgeons have been using a less invasive hybrid technique to treat a defect in newborns called hypoplastic left heart syndrome.

In February 2012, a team of UCLA adult congenital cardiologists and cardiac surgeons performed a unique hybrid procedure that stopped a softball-sized aneurysm from growing in a 49-year-old woman. The hybrid surgery was performed to repair the aneurysm in her pulmonary artery. A balloon-mounted ‘melody valve’ was used to replace her pulmonary valve and close the hole in her heart, an approach that shortened the time needed on the heart-lung machine by more than an hour.4

Patient care benefits 

Hybrid ORs offer significant advantages to patients, with one of the primary benefits being reduced risk. The combined setting, which offers exceptional imaging capabilities during surgical procedures, reduces delays and infection risk associated with having to move patients to different areas of the hospital.

New hybrid techniques allow a patient’s condition to be treated with a single procedure rather than a combination of surgeries and help to avoid the need for open surgery or a heart-lung machine, resulting in quicker recovery times and shorter hospitalizations. Most importantly, hybrid surgeries provide the capability to treat conditions that were previously inoperable for high-risk patients.

The University of Colorado Hospital opened a hybrid OR in April 2012 and its team has already performed thoracic endovascular aortic repair, endovascular aneurysm repair, and the TAVR, among many other procedures. “The benefits of having a hybrid OR are in relation to patient safety,” said Katherine Halverson-Carpenter, MBA, RN, CNOR, patient care services director of obstetrical and perioperative services at University of Colorado Hospital. “As we do more of the complex procedures that were being done in the cath lab or interventional, by having that in the OR, it provides the resources more closely at hand.”

Hybrid ORs provide a new level of safety and efficiency that reduces risk, improves the quality of patient care, and helps to produce optimal patient outcomes. As technology and hybrid interventions continue to evolve and offer an advanced standard of care, hybrid ORs are anticipated to become a more common surgical setting.

“I think hybrid ORs are going to become more commonplace,” Halverson-Carpenter said. “As technology develops, hybrid ORs will be used in other services than current traditional cardiology, vascular surgery, cardiothoracic surgery, neurosurgery, and so on. It will be used by other specialties, that haven’t begun to realize the advantages.”

This article was featured in the August issue of AORN Connections.


References 

  1. The cardiovascular hybrid OR—clinical & technical considerations. The Cardiothoracic Surgery Network.   Accessed July 11, 2012. http://www.ctsnet.org/portals/endovascular/nutsbolts/article-9.html 
  2. Newark Beth Israel performs heart valve replacement without surgery.  NJToday.net.  Accessed July 11, 2012. http://njtoday.net/2012/06/04/newark-bethisrael-performs-heart-valve-replacementwithout-surgery/#ixzz1zULsm5YB. Accessed July 11, 2012.
  3. Frontiers in medicine: hybrid and catheter based surgery for babies with congenital heart defects. Columbia University Department of Surgery.  Accessed July 11, 2012. http://www.columbiasurgery.net/2012/02/09/frontiers-in-medicine-hybridand-catheter-based-surgery-for-babies-withcongenital-heart-defects/ 
  4. ‘Hybrid’ surgery saves UCLA patient from softball-sized aneurysm. UCLA Today.  Accessed July 11, 2012. http://today.ucla.edu/portal/ut/hybrid-surgerysaves-ucla-patient-231606.aspx.

 

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