Der Hybridoperationssaal

Comparison of the Effective Radiation Dose in the Region of the Facial Skull Between Multidetector CT, Dental Conebeam CT and Intraoperative 3D C-Arms

Study Design

Experimental single-centre study of X-ray absorption using a phantom skull.

Objective

This experimental study aimed to compare the radiation doses of different 3D imaging devices used in maxillofacial surgery, including one Multidetector CT (MDCT), two Conebeam CT (CBCT) and four intraoperative 3D C-arms.

Methods

Thermoluminescent dosimeters (TLD) were used to determine the absorbed radiation in an Alderson-Rando phantom skull. The phantom skull was positioned in the before mentioned seven devices and a defined 3D facial skull image was acquired. Subsequently, the TLD'S were read out and the effective doses (ED) and the organ doses (OD) were calculated and compared.

Results

OD varied significantly between tissues as well as between the 3D X-ray devices. The OD of the 3D C-arms were significantly lower than those of all other devices. The OD of the CT, especially in the standard setting, was the highest. Only by special adjustments of the scan protocol regarding CMF requirements for traumatology, the MDCT could achieve almost equivalent doses as the two tested CBCT-scanners. The calculated effective doses were also lowest for the 3D C-arm devices (11.2 to 129.9 μSv). The ED of the MDCT were significant higher (284.52-844.97 μSv) than in all other devices. The ED of the CBCTs (173.7-184.9) were lower than for MDCT but still higher than those of the 3D C-arms.

Conclusions

Intraoperative imaging using 3D C-arm devices is an effective method to verify reduction results in maxillofacial surgery intraoperatively with significantly lower ED than postoperatively CBCT and MDCT imaging.

Mandibular Fractures: Diagnosis and Management

Accurate evaluation, diagnosis, and management of mandibular fractures is essential to effectively restore an individual's facial esthetics and function. Understanding of surgical anatomy, fracture fixation principles, and the nuances of specific fractures with respect to various patient populations can aid in adequately avoiding complications such as malocclusion, non-union, paresthesia, and revision procedures. This article reviews comprehensive mandibular fracture assessment, mandibular surgical anatomy, fracture fixation principles, management considerations, and commonly encountered complications. In addition, this article reviews emerging literature examining 3-dimensional printing and intraoperative imaging.

Comparison of a ceiling-mounted 3D flat panel detector vs. conventional intraoperative 2D fluoroscopy in plate osteosynthesis of distal radius fractures with volar locking plate systems

Objectives

To compare intraoperative 3D fluoroscopy with a ceiling-mounted flat panel detector in plate osteosynthesis of distal radius fractures (AO/OTA 2R3C1.2) with volar locking plate systems to conventional 2D fluoroscopy for detection of insufficient fracture reduction, plate misplacement and protruding screws.

Methods

Using a common volar approach on 12 cadaver forearms, total intraarticular distal radius fractures were induced, manually reduced and internally fixated with a 2.4 distal radius locking compression plate. 2D (anterior-posterior and lateral) and 3D (rotational) fluoroscopic images were taken as well as computed tomographies. Fluoroscopic images, Cone Beam CT (CBCT), 360° rotating sequences (so called “Movies”) and CT scans were co-evaluated by a specialist orthopedic surgeon and a specialist radiologist regarding quality of fracture reduction, position of plate, position of the three distal locking screws and position of the three diaphyseal screws. In reference to gold standard CT, sensitivity and specifity were analyzed.

Results

“Movie” showed highest sensitivity for detection of insufficient fracture reduction (88%). Sensitivity for detection of incorrect position of plate was 100% for CBCT and 90% for “Movie.” For intraarticular position of screws, 2D fluoroscopy and CBCT showed highest sensitivity and specifity (100 and 91%, respectively). Regarding detection of only marginal intraarticular position of screws, sensitivity and specifity of 2D fluoroscopy reached 100% (CBCT: 100 and 83%). “Movie” showed highest sensitivity for detection of overlapping position of screws (100%). When it comes to specifity, CBCT achieved 100%. Regarding detection of only marginal overlapping position of screws, 2D fluoroscopy and “Movie” showed highest sensitivity (100%). CBCT achieved highest specifity (100%).

Conclusion

As for assessment of quality of fracture reduction and detection of incorrect position of plate as well as overlapping position of the three diaphyseal screws CBCT and “Movie” are comparable to CT – especially when combined. Particularly sensitivity is high compared to standard 2D fluoroscopy.

The value of intraoperative angiography in the time of indocyanine green videoangiography in the treatment of cerebrovascular lesions: Efficacy, workflow, risk-benefit and cost analysis A prospective study

INTRODUCTION

Intraoperative digital subtraction angiography (ioDSA) allows early treatment evaluation after neurovascular procedures. However, the value and efficiency of this procedure has been discussed controversially. We have evaluated the additional value of hybrid operating room equipped with an Artis Zeego robotic c-arm regarding cost, efficiency and workflow. Furthermore, we have performed a risk-benefit analysis and compared it with indocyanine green (ICG) angiography.

METHODS

For 3 consecutive years, we examined all neurovascular patients, treated in the hybrid operating theater in a risk-benefit analysis. After using microdoppler and ICG angiography for best operative result, every patient received an additional ioDSA to look for remnants or unfavorable clip placement which might lead to a change of operating strategy or results. Furthermore, a workflow-analysis reviewing operating steps, staff positioning, costs, technical errors or complications were conducted on randomly selected cases.

RESULTS

54 patients were enrolled in the risk-benefit analysis, 22 in the workflow analysis. The average duration of a cerebrovascular operation was 4 h 58 min 2 min 35 s accounted for ICG angiography, 46 min 4 s for ioDSA. Adverse events occurred during one ioDSA. In risk-benefit analysis, ioDSA was able to detect a perfusion rest in 2 out of 43 cases (4,7%) of aneurysm surgery, which could not have been visualized by ICG angiography before. In arterio-venous-malformation (AVM) surgery, one of 11 examined patients (7,7%) showed a remnant in ioDSA and resulted in additional resection. The average cost of an ioDSA in Ulm University can be estimated with 1928,00€.

CONCLUSION

According to our results ioDSA associated complications are low. Relevant findings in ioDSA can potentially avoid additional intervention, however, due to the high costs and lower availability, the main advantage might lie in the treatment of selected patients with complexes neurovascular pathologies since ICG angiography is equally safe but associated with lower costs and better availability.

A systematic review on the application of the hybrid operating room in surgery: experiences and challenges

The hybrid operating room has been widely applied in different surgery sub-specialties. We aim to identify the advantages of hybrid operating rooms by focusing on intraoperative imaging and explore what to do for further improving its application. We searched related literature in websites including Pubmed, MEDLINE, Web of science, using the keywords ("hybrid operating room" or "integrated operating room" or "multifunctional operating room") and ("surgery" or "technique" or "intervention" or "radiology"). All the searched papers were screened and underwent quality evaluation. A total of 30 literature was eventually identified after full-text screening. These articles covered 10 countries and presented data for 15,558 individuals. The median sample size was 536 (range 8-12,804). Application of the hybrid operating room in general surgery, neurosurgery, thoracic surgery, urology, gynaecologic and obstetrics surgery, cardiovascular surgery, was summarized. Four different operative indicators were applied (operative duration, mortality rate, operation success rate and complication rate). A hybrid OR could significantly increase the operation success rate and reduce operative duration, mortality rates, and complication rates. Further efforts could be made to reduce radiation exposure in the hybrid operating room and increase its cost-effectiveness ratio.

[Hybrid operating room : Application in trauma surgery and orthopaedics]

BACKGROUND

For some years now, more and more hospitals in Germany have acquired so-called hybrid operating rooms. In these operating rooms it is possible to produce three-dimensional imaging during the operation. Originally developed for cardiovascular surgery, these rooms are increasingly being used for interdisciplinary purposes. Previous experiences in the use for trauma surgery and orthopedics has shown that three-dimensional imaging can have a positive effect on the success of surgery.

OBJECTIVE

Can minimally invasive operations on the spine benefit intraoperatively from three-dimensional imaging with respect to operating times and results?

METHODS

Minimally invasive operations on the spine performed at the UKSH Campus Kiel between 2015 and 2018 in the hybrid operating room were considered. These were compared to minimally invasive spinal surgery performed in conventional operating rooms.

RESULTS

As is usual with the establishment of a new procedure, there are initially longer operating times. With regular use and appropriate training and experience of the personnel, the processes can be optimized.

CONCLUSION

Due to the accuracy of the three-dimensional imaging, errors can be detected and eliminated at an early stage during the operation. Revisions are less frequent. In contrast, there is increased radiation exposure and sometimes longer operation and anesthesia times.

Feasibility of laser-guided percutaneous pedicle screw placement in the lumbar spine using a hybrid-OR

PURPOSE

Innovations in intraoperative imaging lead to major changes in orthopaedic surgery. In our setting, a 3D flat-panel c-arm (Artis zeego) is mounted on a robotic arm offering an integrated aiming tool (Syngo iGuide). Our aim was to investigate the feasibility of Syngo iGuide for pedicle screw placement in comparison with fluoroscopic screw implantation.

METHODS

In 10 lumbar models, 100 screws were implanted. In 5 models, a standard fluoroscopic technique was used. Syngo iGuide was used in all other models. Afterwards, CT-scans were performed and screw accuracy was investigated.

RESULTS

The procedure time for the new technique was significantly longer in comparison with the standard technique. The post-operative CT showed the same accuracy in both groups.

CONCLUSIONS

Syngo iGuide proofed feasible for percutaneous implantation of pedicle screws in anatomic models. Syngo iGuide can be a help for screw implantation in difficult anatomic regions without the need of an additional navigation system.

The parturient in the interventional radiology suite: New frontier in obstetric anaesthesia

The anaesthesiologist's presence during interventional radiology (IR) is increasing due to increasingly ill patients and intricate procedures. The management of a parturient in IR suite is complex in terms of logistics of an unfamiliar procedure in an unfamiliar area. The literature available is largely written by radiologists with little attention paid to anaesthetic details and considerations. In the Indian scenario, in the absence of hybrid operating rooms (ORs), logistics involve transport of a parturient back and forth between the IR suite and the OR. As members of a multidisciplinary team, anaesthesiologists should utilise their expertise in fluid management, transfusion therapy and critical care to prevent and treat catastrophic events that may accompany severe peri-partum bleeding. Ensuring familiarity with the variety of IR procedures and the peri-procedure requirements can help the anaesthesiologist provide optimum care in the IR suite.

[Intraoperative 3D imaging in spinal surgery]

BACKGROUND

Intraoperative imaging during spinal interventions has experienced significant developments over the last two decades. By the introduction of flat screen detectors, 3D imaging has been made possible and easier and by developing compact and mobile systems computed tomography can even be used in the operating theater.

OBJECTIVE

Presentation of modern intraoperative 3D imaging and navigation in spinal surgery.

MATERIAL AND METHODS

The techniques of intraoperative 3D imaging and navigation during spinal procedures are presented based on the currently available literature and own experiences at a German national spine and trauma center.

RESULTS

The use of flat panel detectors and the possibility of 3D visualization nowadays substantially facilitate the use of navigation and allow certain control of surgical results even during the intervention. Radiation exposure of the whole team in the operating theater can be significantly reduced by the new techniques.

CONCLUSION

The advantages of intraoperative 3D imaging with a clear improvement of visualization for spinal surgeons and the certain control of materials at the end of the operation are obvious. Even the use of navigation has been greatly simplified and can therefore lead to an even greater precision and less radiation exposure. There are even more sophisticated developments, such as operation suites and intraoperative computed tomography but these are initially reserved for selected centers.

Use of a Hybrid Operating Room to Improve Reduction of Syndesmotic Injuries in Ankle Fractures: A Case Report

Ankle fractures are one of the most common orthopedic injuries requiring operative treatment, and approximately 1 in 4 ankle fractures will have an associated distal tibiofibular syndesmosis disruption. Syndesmotic reduction is crucial to restoring ankle function and preventing the development of arthritis. The hybrid operating room provides 3-dimensional intraoperative imaging capabilities that can enable the surgeon to ensure the syndesmosis is appropriately reduced, particularly by comparing it with the contralateral ankle. By confirming the syndesmosis reduction intraoperatively, the risk of a return to the operating room for revision surgery is decreased.

One year orthopaedic trauma experience using an advanced interdisciplinary hybrid operating room

Hybrid operating rooms have been used successfully in several surgical specialties, but no data have been published for orthopaedic trauma. We present our one-year orthopaedic trauma experience using a hybrid operating room, which incorporates 3D fluoroscopic imaging as well as navigation capabilities. Data were compiled for a series of 92 cases performed in an advanced hybrid operating room at the level one trauma center in Ulm, Germany. All patients who had surgery performed using this operating room during the first year were included. Setup time and surgical complications using hybrid operating room were recorded and analysed. The hybrid operating room resulted in no higher rate of complication than expected from the same cases in a conventional operating room. The hybrid room did however allow the surgeon to confidently place implants for orthopaedic trauma cases, and was most advantageous for spine and pelvis cases, both minimally invasive and conventional. Further, appropriate reduction and implant position was confirmed with 3D imaging prior to leaving the operating room and obviated the need for postoperative CT scan. Based on our one-year experience, the hybrid operating room is a useful and safe tool for orthopaedic trauma surgery.

35 m Vertical Free Fall: How Impact Surface Influences Survival

We describe the accidental free fall of a 23-year-old construction worker, who fell 13 stories (approximately 35 meters) from a false work landing on a toilet container. On impact he broke through the roof of the container, which attenuated his fall and made his survival possible. The patient sustained a central spleen rupture, liver laceration, subdural hematoma, blunt thoracic trauma with a left-sided hematothorax and right-sided pneumothorax with serial bilateral rib fractures, and an unstable fracture of the 10th thoracic vertebra. Two thoracic drainages were inserted in the emergency department before the patient underwent emergency surgery for the management of his intra-abdominal injuries. On the third day after trauma the unstable fracture of the 10th thoracic vertebra was stabilized with an internal fixator. Following extubation on day 8 after trauma the patient did not show any peripheral neurological deficits but cerebral affection with a general slowdown. After only 21 days, the patient was discharged from the hospital to a rehabilitation center where work specific rehabilitation was started. Although the patient is not suffering from physical afflictions from the injury his daily life abilities are still limited due to cerebral damage.

Medical imaging using ionizing radiation: optimization of dose and image quality in fluoroscopy

The 2012 Summer School of the American Association of Physicists in Medicine (AAPM) focused on optimization of the use of ionizing radiation in medical imaging. Day 2 of the Summer School was devoted to fluoroscopy and interventional radiology and featured seven lectures. These lectures have been distilled into a single review paper covering equipment specification and siting, equipment acceptance testing and quality control, fluoroscope configuration, radiation effects, dose estimation and measurement, and principles of flat panel computed tomography. This review focuses on modern fluoroscopic equipment and is comprised in large part of information not found in textbooks on the subject. While this review does discuss technical aspects of modern fluoroscopic equipment, it focuses mainly on the clinical use and support of such equipment, from initial installation through estimation of patient dose and management of radiation effects. This review will be of interest to those learning about fluoroscopy, to those wishing to update their knowledge of modern fluoroscopic equipment, to those wishing to deepen their knowledge of particular topics, such as flat panel computed tomography, and to those who support fluoroscopic equipment in the clinic.