**4. Planning the hybrid room**

Careful planning and professional expertise is a key factor for every hybrid room project. Before planning a hybrid operating room a clear vision for the utilization should be established (Benjamin, 2008).

Today's operating rooms require concepts that address the requirements and needs of different surgical specialties and procedures. Workflow efficiency is a key success factor for the hospital and the surgical program. Minimal turnover times and optimal processes throughout the entire surgical workflow and the actual surgical procedure are required (Tomaszewski, 2008). Therefore, a hybrid operating room should ideally be integrated into an existing OR suite. All aspects and steps starting with patient transfer from the ward to anesthesia and operating room preparation are important. Addiontional aspects for planning are material supply processes, i.e. of materials necessary for the procedure, and postoperative intensive care surveillance and treatment.

Due to high cost, OR facilities are commonly shared by different disciplines. A very flexible room layout and design allow for the necessary repositioning of devices and changes of the

The Hybrid Operating Room 89

Nursing staff (circulating and scrub nurses) Working positions, patient and material logistics Surgical technicians (i.e. perfusionist) Working positions, equipment requirements Anesthetist Working positions, equipment requirements Anesthesia nurses Working positions, equipment requirements,

OR manager Scheduling, general workflow management

Equipment planners, Architects Technical room planning, construction,

Vendors Installation requirements and schedule

Expert consensus rates the performance of mobile C-arms in hybrid ORs as insufficient and recommends floor-mounted systems for hygienic reasons (Bonatti et al., 2007). In fact, some hospitals do not allow operating parts directly above the surgical field, because dust may fall in the wound and cause infection. Since any ceiling-mounted system includes moving parts above the surgical field and impairs the laminar airflow, such systems are not the right option for hospitals enforcing highest hygienic standards. Ceiling-mounted systems require substantial ceiling space and, therefore, reduce the options to install surgical lights or booms. Nonetheless, many hospitals choose ceiling-mounted systems because they cover the whole body with more flexibility and – most importantly – without moving the table. The latter is sometimes a difficult and dangerous undertaking during surgery with the many lines and catheters that must also be moved. Moving from a parking to a working position during surgery, however, is easier with a floor-mounted system, because the C-arm just turns in from the side and does not interfere with the anesthesiologist. The ceiling-mounted system, by contrast, during surgery can hardly move to a parking position at the head end without colliding with anesthesia equipment. In an overcrowded environment like the OR, biplane systems add to the complexity and interfere with anesthesia, except for neurosurgery, where anesthesia is not at the head end. Monoplane systems are therefore clearly recommended for rooms mainly used for cardiac surgery. There are certainly exceptions: especially if pediatric cardiologists or electrophysiologists are important stakeholders in room usage, a biplane

Biomedical engineers Technical room planning

system may also be considered (Bonatti et al., 2007; Tomaszewski, 2008).

opts for a large detector (Nollert & Wich, 2008).

operating room.

3D imaging may become more and more important for OR planning and postoperative evaluation of the operative site. Therefore, a large detector would offer greater options, including portrait imaging. The preference for a detector may vary, although the majority

In summary, mobile C-arms are generally considered insufficient for cardiovascular imaging and do not comply with international standards for cardiac imaging (Bonatti et al., 2007). For hybrid rooms, fixed monoplane and biplane angiographic systems are available which are either mounted on the ceiling or on the floor. Beside conventional C-arm systems, a dedicated robotic surgical C-arm is available, which allows maximal flexibility in the

Table 1. Team members of an OR and the issues they care about

requirements

material logistics

drawings, project management

procedural descriptions, imaging and equipment

**Team member Topics**  Surgeon(s) Working positions, clinical applications,

OR configuration (Tomaszewski, 2008). This is especially important with the increasing utilization of novel technologies and with space limitations in most OR suites. Layout and design should be ergonomic and workflow driven. For the hybrid OR with the addition of an angiography system to the room it becomes even more important, because this oftenly involves non-standard installations, or non-standard functionality, or non-standard products. During the entire planning and implementation process clear, frequent and comprehensive communication of all parties involved is vital.

Fig. 10. Example of an hybrid OR highlighting relevant major equipment for planning

### **4.1 Team**

Hybrid operating rooms are used by different surgical disciplines, interventionalists, cardiologists and anesthesiologists. Further staff working in these rooms includes nurses and technicians, resulting in a multitude of requirements impacting the room design and determining various resources like space, medical, and imaging equipment. Building a hybrid operating room needs a team approach with joint effort of customers and vendors (Tomaszewski, 2008; Benjamin, 2008).

Hybrid operating rooms are always individual solutions tailored to the needs and preferences of the team and the hospital. Several planning iterations with experienced technological support from equipment and imaging vendors lead to an optimal solution. Hybrid OR projects involve renovation, new construction, or a little of both. OR equipment layout planning and implementation strategies are challenging. A clear understanding of the project scope and customer objectives is critical and qualified, multidisciplinary hospital team is needed to ensure success of this complex endeavour.

All team members should be committed to the project. To that end, a clearly defined and agreed project organization including all stakeholders with clearly defined roles and responsibilities is necessary.

### **4.2 Choosing the angiographic system**

Choosing the imaging system for a hybrid OR depends on the intended utilization of the room (Bonatti et al., 2007; Ten Cate et al., 2004).

OR configuration (Tomaszewski, 2008). This is especially important with the increasing utilization of novel technologies and with space limitations in most OR suites. Layout and design should be ergonomic and workflow driven. For the hybrid OR with the addition of an angiography system to the room it becomes even more important, because this oftenly involves non-standard installations, or non-standard functionality, or non-standard products. During the entire planning and implementation process clear, frequent and

Fig. 10. Example of an hybrid OR highlighting relevant major equipment for planning

Hybrid operating rooms are used by different surgical disciplines, interventionalists, cardiologists and anesthesiologists. Further staff working in these rooms includes nurses and technicians, resulting in a multitude of requirements impacting the room design and determining various resources like space, medical, and imaging equipment. Building a hybrid operating room needs a team approach with joint effort of customers and vendors

Hybrid operating rooms are always individual solutions tailored to the needs and preferences of the team and the hospital. Several planning iterations with experienced technological support from equipment and imaging vendors lead to an optimal solution. Hybrid OR projects involve renovation, new construction, or a little of both. OR equipment layout planning and implementation strategies are challenging. A clear understanding of the project scope and customer objectives is critical and qualified, multidisciplinary hospital

All team members should be committed to the project. To that end, a clearly defined and agreed project organization including all stakeholders with clearly defined roles and

Choosing the imaging system for a hybrid OR depends on the intended utilization of the

comprehensive communication of all parties involved is vital.

**4.1 Team** 

(Tomaszewski, 2008; Benjamin, 2008).

responsibilities is necessary.

**4.2 Choosing the angiographic system** 

room (Bonatti et al., 2007; Ten Cate et al., 2004).

team is needed to ensure success of this complex endeavour.


Table 1. Team members of an OR and the issues they care about

Expert consensus rates the performance of mobile C-arms in hybrid ORs as insufficient and recommends floor-mounted systems for hygienic reasons (Bonatti et al., 2007). In fact, some hospitals do not allow operating parts directly above the surgical field, because dust may fall in the wound and cause infection. Since any ceiling-mounted system includes moving parts above the surgical field and impairs the laminar airflow, such systems are not the right option for hospitals enforcing highest hygienic standards. Ceiling-mounted systems require substantial ceiling space and, therefore, reduce the options to install surgical lights or booms.

Nonetheless, many hospitals choose ceiling-mounted systems because they cover the whole body with more flexibility and – most importantly – without moving the table. The latter is sometimes a difficult and dangerous undertaking during surgery with the many lines and catheters that must also be moved. Moving from a parking to a working position during surgery, however, is easier with a floor-mounted system, because the C-arm just turns in from the side and does not interfere with the anesthesiologist. The ceiling-mounted system, by contrast, during surgery can hardly move to a parking position at the head end without colliding with anesthesia equipment. In an overcrowded environment like the OR, biplane systems add to the complexity and interfere with anesthesia, except for neurosurgery, where anesthesia is not at the head end. Monoplane systems are therefore clearly recommended for rooms mainly used for cardiac surgery. There are certainly exceptions: especially if pediatric cardiologists or electrophysiologists are important stakeholders in room usage, a biplane system may also be considered (Bonatti et al., 2007; Tomaszewski, 2008).

3D imaging may become more and more important for OR planning and postoperative evaluation of the operative site. Therefore, a large detector would offer greater options, including portrait imaging. The preference for a detector may vary, although the majority opts for a large detector (Nollert & Wich, 2008).

In summary, mobile C-arms are generally considered insufficient for cardiovascular imaging and do not comply with international standards for cardiac imaging (Bonatti et al., 2007). For hybrid rooms, fixed monoplane and biplane angiographic systems are available which are either mounted on the ceiling or on the floor. Beside conventional C-arm systems, a dedicated robotic surgical C-arm is available, which allows maximal flexibility in the operating room.

The Hybrid Operating Room 91

and open conventional procedures, these are sometimes preferred. They provide greater workflow flexibility because the tabletops are dockable and can be easily exchanged, but

Fig. 12. Example Siemens OR angiography table with a free floating tabletop

Fig. 13. Integrated Trumpf OR table with a radiolucent carbon fibre tabletop

Fig. 14. Integrated Trumpf OR table with breakable tabletop and metal parts that impair

image quality

require some compromises with interventional imaging.

### **4.3 Tables**

The selection of the OR table depends on the primary use of the system. Interventional tables with floating table tops and tilt and cradle compete with fully integrated flexible OR tables. Identification of the right table is a compromise between interventional and surgical requirements (Bonatti et al., 2007; Nollert & Wich, 2008).

Fig. 11. Siemens robotic surgical C-Arm system Artis zeego

Surgical and interventional requirements may be mutually exclusive. Surgeons, especially orthopedic, general and neurosurgeons usually expect a table with a segmented tabletop for flexible patient positioning. For imaging purposes, a radiolucent tabletop, allowing full body coverage, is required. Therefore, non-breakable carbon fibre tabletops are used.

Interventionalists require a floating tabletop to allow fast and precise movements during angiography. Cardiac and vascular surgeons, in general, have less complex positioning needs, but based on their interventional experience in angiography may be used to having fully motorized movements of the table and the tabletop. For positioning patients on nonbreakable tabletops, positioning aids are available, i.e. inflatable cushions. Truly floating tabletops are not available with conventional OR tables. As a compromise, floatable angiography tables specifically made for surgery with vertical and lateral tilt are recommended (Ten Cate et al., 2004). To further accommodate typical surgical needs, side rails for mounting surgical equipment like retractors or limb holders should be available for the table. The position of the table in the room also impacts surgical workflow. A diagonal position in the OR may be considered in order to gain space and flexibility in the room, as well as access to the patient from all sides.

Alternatively, a conventional surgery table can be combined with an imaging system if the vendor offers a corresponding integration. The operating room can then be used either with a radiotranslucent but not breakable tabletop that supports 3D imaging, or with a universal breakable tabletop that provides enhanced patient positioning, but restricts 3D imaging. The latter are particularly suited for neuro- or orthopedic surgery, and these integrated solutions recently also became commercially available. If it is planned to share the room for hybrid

The selection of the OR table depends on the primary use of the system. Interventional tables with floating table tops and tilt and cradle compete with fully integrated flexible OR tables. Identification of the right table is a compromise between interventional and surgical

Surgical and interventional requirements may be mutually exclusive. Surgeons, especially orthopedic, general and neurosurgeons usually expect a table with a segmented tabletop for flexible patient positioning. For imaging purposes, a radiolucent tabletop, allowing full

Interventionalists require a floating tabletop to allow fast and precise movements during angiography. Cardiac and vascular surgeons, in general, have less complex positioning needs, but based on their interventional experience in angiography may be used to having fully motorized movements of the table and the tabletop. For positioning patients on nonbreakable tabletops, positioning aids are available, i.e. inflatable cushions. Truly floating tabletops are not available with conventional OR tables. As a compromise, floatable angiography tables specifically made for surgery with vertical and lateral tilt are recommended (Ten Cate et al., 2004). To further accommodate typical surgical needs, side rails for mounting surgical equipment like retractors or limb holders should be available for the table. The position of the table in the room also impacts surgical workflow. A diagonal position in the OR may be considered in order to gain space and flexibility in the room, as

Alternatively, a conventional surgery table can be combined with an imaging system if the vendor offers a corresponding integration. The operating room can then be used either with a radiotranslucent but not breakable tabletop that supports 3D imaging, or with a universal breakable tabletop that provides enhanced patient positioning, but restricts 3D imaging. The latter are particularly suited for neuro- or orthopedic surgery, and these integrated solutions recently also became commercially available. If it is planned to share the room for hybrid

body coverage, is required. Therefore, non-breakable carbon fibre tabletops are used.

requirements (Bonatti et al., 2007; Nollert & Wich, 2008).

Fig. 11. Siemens robotic surgical C-Arm system Artis zeego

well as access to the patient from all sides.

**4.3 Tables** 

and open conventional procedures, these are sometimes preferred. They provide greater workflow flexibility because the tabletops are dockable and can be easily exchanged, but require some compromises with interventional imaging.

Fig. 12. Example Siemens OR angiography table with a free floating tabletop

Fig. 13. Integrated Trumpf OR table with a radiolucent carbon fibre tabletop

Fig. 14. Integrated Trumpf OR table with breakable tabletop and metal parts that impair image quality

The Hybrid Operating Room 93

mandatory, as well as access sterile processing facilities for the disposal of soiled material from open procedures. Finally, clean air, air conditioning and ventilation technologies play

Today, this is mainly achieved with dedicated air-conditioning and ventilation solutions that create a limited protection zone, usually called "Laminar Airflow", even though this terminology might sometimes be technically misleading. These ventilation systems need to cover the entire aseptic environment of surgery in operating rooms, including the tables for materials and instruments. This zone allows for clean-room handovers of sterilized materials and shields the surgical team in sterilized garb, usually by a sufficiently large lowturbulence displacement air flow. Recent guidelines, e.g. in Germany, emphasize the importance of low turbulence. To meet the requirements of air cleanliness for operating theatres or other surgery rooms with strict hygienic requirements, very high volume flows of clean air are necessary. There are different solutions available to do so in an energyefficient way. Usually, low-turbulence displacement circulating air canopies are employed. Local requirements for the hygienic aspects of Heat, Ventilation, Air Conditioning (HVAC) vary significantly. Experts knowing the local requirements need to be involved in order to ensure clearance of the hybrid OR at the end of the project. This topic is to be discussed in detail with the responsible individuals and authorities in order to avoid non compliance

Fig. 15. Example for a Laminar Airflow ceiling ensuring a clean environment above the

The main objective of OR design is to improve the OR workflow and enhance safety by ensuring good access and clear walkways. This sets the stage for equipment and equipment

an important role in achieving these hygienic standards.

with local regulations.

surgical area

**4.6 Room layout** 

In summary, important aspects to be included considered are the position in the room, radiolucency (carbon fiber tabletop), compatibility, and integration of imaging devices with the operating table. Further aspects include table load, adjustable table height, and horizontal mobility (floating) including vertical and lateral tilt. It is important to also have proper accessories available, such as rails for mounting special surgical equipment (retractors, camera holder). Free floating angiography tables with tilt and cradle capabilities are best suited for cardiovascular hybrid operating rooms.
