Hybrid Operating Room Research Articles

Trauma Hybrid Operating Room (THOR) shortened procedure time in abdominopelvic trauma patients requiring surgery and interventional radiology procedures

IntroductionAbdominopelvic injuries are common, and bleeding occurring in both cavities requires various bleeding control techniques i.e., laparotomy, angiographic embolization (AE), and orthopedic fixation. Hence, the use of Trauma Hybrid Operating Room (THOR) in abdominopelvic injuries has theoretical advantages including rapid bleeding control and minimizing patient transportation. The objective of the present study is to evaluate the impact of THOR in abdominopelvic injuries. MethodA pre-post intervention study of abdominopelvic injury patients requiring both surgery and interventional radiology (IR) procedures for bleeding control from January 2015 to May 2020 was conducted. The patients were divided into 2 groups, pre-THOR group (received surgery in OR and scheduled for IR procedures in a separate IR suite, before December 2017) and THOR group (received all procedures in THOR, after December 2017). The primary outcomes were procedure time (including transit time in the pre-THOR group) and mortality. ResultsNinety-one abdominopelvic trauma patients were identified during the study period, 56 patients in pre-THOR group and 35 patients in THOR group. Distribution of injuries was similar in both groups (59 abdominal injuries, 25 pelvic fractures, and 7 combined injuries). The bleeding-control interventions in both groups were 79 laparotomies, 10 preperitoneal pelvic packings, 12 pelvic fixations, 45 liver AEs, and 21 pelvic AEs. THOR group underwent significantly less thoracotomy (1 vs. 11, p = 0.036), more resuscitative endovascular balloon occlusion of the aorta (REBOA, 0 vs. 5, p = 0.014), and more pelvic AE (13 vs. 9, p = 0.043). The procedure time was significantly shorter in THOR group (153 min vs. 238 min, p = 0.030). Excluding the transit time in the pre-THOR group, procedure time was not significantly different (153 vs. 154 min, p = 0.872). Both groups had similar mortality rates of 34%, but the mortality due to exsanguination was significantly lower in THOR group (11% vs. 34%, p = 0.026). ConclusionsTHOR eliminated transit time, resulting in shorter procedure time in abdominopelvic trauma patients requiring bleeding-control intervention. Although overall mortality reduction could not be demonstrated, the mortality due to exsanguination was reduced in THOR group.

Responsive neurostimulation device therapy in pediatric patients with complex medically refractory epilepsy.

Pediatric epilepsy is characterized as drug resistant in 20%-30% of patients and defined as persistent seizures despite adequate treatment with two first-line antiepileptic medications. The American Academy of Neurology advocates surgical options earlier in the treatment of epilepsy to provide long-term seizure reduction. The new development of minimally invasive approaches has recently allowed for surgical options to patients not previously deemed surgical candidates. These may include patients with bilateral, deep, eloquent, or poorly localizing epileptogenic foci. To this end, responsive neurostimulation (RNS) is an FDA-approved closed-loop neuromodulation device for adjuvant treatment of adults with medically intractable epilepsy arising from one or multiple foci. In this study, the authors describe their initial institutional experience with the use of RNS in pediatric patients with drug-resistant epilepsy. An IRB-approved retrospective review was conducted of 8 pediatric patients who underwent RNS implantation at Cincinnati Children's Hospital Medical Center between 2019 and 2021. Eight patients met the inclusion criteria for the study. The average age at the time of surgery was 14.7 years (range 8-18 years) with a mean follow-up of 16.5 months. All patients underwent invasive monitoring with stereo-EEG, subdural grid placement, or a combination of both. All patients had either bilateral or eloquent cortex targets. Trajectories were based on noninvasive (phase 1) and invasive (phase 2) seizure onset zone localization data. Four (50%) of the 8 patients underwent surgical intervention for epilepsy prior to RNS placement. RNS electrodes were placed with robot-assisted guidance in a hybrid operating room with intraoperative CT and electrocorticography. The authors demonstrated individualized RNS electrode trajectory and placement with targets in the amygdala/hippocampus, bilateral insula, bilateral parietal and occipital targets, and frontoparietal regions for a total of 14 implanted electrodes. One adverse event occurred, a wound infection requiring return to the operating room for removal of the RNS implant. All patients demonstrated a reduction in seizure frequency. All patients achieved > 50% reduction in seizure frequency at last follow-up. RNS implantation in carefully selected pediatric patients appears safe and efficacious in reducing seizure burden with a low rate of operative complications.

Efficacy of a Protective Sheet for Reducing Ocular Radiation Exposure During Transcatheter Aortic Valve Implantation.

The use of hybrid operating rooms (HOR) for transcatheter aortic valve implantation (TAVI) has increased, so radiation exposure during procedures that use X-ray fluoroscopy is a fundamental problem not only for patients but also for surgeons and interventional cardiologists, increasing the risk of cataracts among operators. We investigated the efficacy of leaded glasses and protective sheets for ocular radiation protection.Methods and Results: Between January 2020 and February 2021 we enrolled 54 TAVI procedures using the transfemoral approach. The subjects were divided into a curtain protection group (Group C, n=20), glass protection group (Group G, n=17), and sheet protection group (Group S, n=17). The cumulative dose (CD) of the operators showed a decreasing trend in Group S compared with the other two groups. The CD normalized by dose area product (CD/DAP) of the operators was significantly reduced in Group S compared with Group C. However, Group G showed no significant difference compared with Group C. Regarding the distribution of CD/DAP, Group S had a significantly lower distribution than that in groups C and G. Protective sheets provide more stable radiation protection than conventional curtains or leaded glasses.

Fixed compared to mobile imaging arms for transcarotid artery revascularization.

Transcarotid artery revascularization (TCAR) is a new surgical option for carotid artery stenosis. While this procedure is optimally performed in hybrid operating rooms (OR), it is currently unclear whether it could be safely performed using portable, C-arm fluoroscopy with equivalent results. The aim of this study is to determine whether there are differences in intraoperative and perioperative outcomes stratified by imaging modality. A retrospective review of all TCAR procedures attempted within our health system was performed, capturing all cases between September 2017 and May 2022. Procedures were divided into 2 cohorts, based on whether they were performed in a hybrid OR or with portable, C-arm in a standard OR. Patient demographics, intraoperative results, and postoperative outcomes were compared using univariate strategies. A total of 503 patients were included for review, of which 422 were performed in a hybrid OR (84%) and 81 were performed using a portable C-arm (16%). Intraoperatively, an increased estimated blood loss (47.7 ± 54.7 vs 26.1 ± 26.9mLs, p < 0.01) and operative time was found in the cases performed in a hybrid OR. However, the fluoroscopy time was lower (4.0 ± 2.6 vs 5.2 ± 5.8min, p = 0.01) in the setting of advanced intraoperative imaging. Postoperatively, we found no differences with respect to myocardial infarction (0.2% vs. 0%, p > 0.99), stroke (2.4% vs. 2.5%, p = 0.96), or death (0.7% vs. 2.5%, p = 0.15) between groups. While there are some intraoperative variabilities between TCAR performed in hybrid versus standard ORs, postoperative outcomes are comparable. Therefore, the lack of a hybrid room should not be a deterrent to the adoption of TCAR.

Adhered ECMO cannula in COVID-19 related severe acute respiratory failure

BackgroundCrescent cannula adhesion in the setting of COVID-19 respiratory failure requiring extracorporeal membrane oxygenation (ECMO) support is a novel complication. The objective of this case presentation is to highlight this rare complication and to explore potential predisposing factors and our management strategies.Case presentationWe present the case of a 25 y.o. patient with COVID-19 respiratory failure requiring ECMO support for 16-days in which a 32 Fr crescent cannula became adherent to the SVC and proximal jugular vein. Attempts to remove the cannula at the bedside failed due to immobility of the cannula. Ultrasound of the right neck was unremarkable, so he was taken to the hybrid OR where both TEE and fluoroscopy were unrevealing. An upper sternotomy was performed, and the superior vena cava and proximal jugular vein were dissected revealing a 2 cm segment of the distal SVC and proximal jugular vein that was densely sclerosed and adherent to the cannula. The vessel was opened across the adherent area at the level of the innominate vein and the cannula was then able to be withdrawn. The patient suffered no ill effects and had an unremarkable recovery to discharge.ConclusionsTo date, there have been no reports of crescent cannula adhesion related complications. In patients with COVID-19 respiratory failure requiring ECMO, clinicians should be aware of widespread hypercoagulability and the potential of unprovoked, localized venous sclerosis and cannula adhesion. We report our technique of decannulation in the setting of cannula adhesion and hope that presentation will shed further light on this complication allowing clinicians to optimize patient care.

SINGLE ARTERIAL ACCESS FOR TRANSFEMORAL TRANSCATHETER AORTIC VALVE IMPLANTATION WITH THE ACURATE NEO SELF-EXPANDING AORTIC BIOPROSTHESIS: INSIGHTS FROM THE LONDON HEALTH SCIENCES CENTRE HEART TEAM

SINGLE ARTERIAL ACCESS FOR TRANSFEMORAL TRANSCATHETER AORTIC VALVE IMPLANTATION WITH THE ACURATE NEO SELF-EXPANDING AORTIC BIOPROSTHESIS: INSIGHTS FROM THE LONDON HEALTH SCIENCES CENTRE HEART TEAM

Role of hybrid operating room in management of low-velocity penetrating brain injury

Penetrating brain injuries (PBIs) are a severe subtype of traumatic brain injuries (TBIs), where an object pierces the cranium and meninges. Based on the speed of penetration, it can be classified into high and low-velocity penetration. Low-velocity penetrating injury (LVPBI) cause lacerations to the scalp, depressed skull fractures as well as localized brain tissue and blood vessel damage along the object's path of travel. There have been many case reports and small case series published describing these events. However, there is no standardized guideline for general management to improve patient outcomes. In this report we discuss our experience of using the hybrid theatre to manage such cases. We present the clinical management of a 10-year-old boy who was shot in the head with a harpoon. Computed Tomography Angiography (CTA) demonstrated that the harpoon punctured through the jugular foramen and had a high probability of internal jugular vein (IJV) and internal carotid artery (ICA) involvement. The surgery was performed seven days after injury in a hybrid operating room (OR). We used intraoperative digital subtraction angiogram (DSA) to guide our decision to permanently occluded the IJV and ICA. The patient had a good postoperative recovery and was sent home after three weeks of observation in the hospital. Despite the high cost, intraoperative cerebral angiography in hybrid theatre for selected patients with penetrating brain injury where major blood vessel damage is anticipated might benefit overall patient outcome.

Localization of small peripheral pulmonary nodules for surgical resection: a new intraoperative technique in hybrid operating room

ObjectiveThe purpose of this study was to introduce a new feasible and effective intraoperative localization technique for small peripheral pulmonary nodules in hybrid operating room.MethodsBetween June 2020 and June 2021, the intraoperative localization was performed in 27 patients for 35 small pulmonary nodules at our institution. The procedure was undergone under thoracoscopic observation. After making the VATS ports, a titanium clip was clipped at the visceral pleura as near the pulmonary nodule as possible to be a marker for the nodule. VATS resection was performed next.ResultsA total of 27 patients were included in this study, including 6 males and 21 females. The median age was 58 years (range 34–78 years). All surgeries were performed by two-port VATS. A total of 35 pulmonary nodules underwent intraoperative localization. The mean diameter of nodules was 10.6 ± 3.7 mm. The distance of nodules to visceral pleura was 8.3 ± 8.7 mm. The mean localization time was 23.3 ± 3.3 min. The median time of C-arm scanning was 3 (range 2–4) times. The median times for clipping were 2 (range 1–3) times. All the nodules were localized successfully and resected precisely. No VATS were converted to thoracotomy. There were no complications related to localization procedures.ConclusionsThis new intraoperative localization technique was feasible, safe and effective. And also the intraoperative procedure could avoid extra suffering for patients.

Percutaneous thoraco-lumbar-sacral pedicle screw placement accuracy results from a multi-center, prospective clinical study using a skin marker-based optical navigation system

Study designProspective multi-center study.ObjectiveThe study aimed to evaluate the accuracy of pedicle screw placement using a skin marker-based optical surgical navigation system for minimal invasive thoraco-lumbar-sacral pedicle screw placement.MethodsThe study was performed in a hybrid Operating Room with a video camera-based navigation system integrated in the imaging hardware. The patient was tracked with non-invasive skin markers while the instrument tracking was via an on-shaft optical marker pattern. The screw placement accuracy assessment was performed by three independent reviewers, using the Gertzbein grading. The screw placement time as well as the staff and patient radiation doses was also measured.ResultsIn total, 211 screws in 39 patients were analyzed for screw placement accuracy. Of these 32.7% were in the thoracic region, 59.7% were in the lumbar region, and 7.6% were in the sacral region. An overall accuracy of 98.1% was achieved. No screws were deemed severely misplaced (Gertzbein grading 3). The average time for screw placement was 6 min and 25 secs (± 3 min 33 secs). The average operator radiation dose per subject was 40.3 µSv. The mean patient effective dose (ED) was 11.94 mSv.ConclusionSkin marker-based ON can be used to achieve very accurate thoracolumbarsacral pedicle screw placements.

Use of the Hybrid Operating Room for Pelvic and Acetabular Fracture Surgery

The hybrid operating room (HOR) utilizes advanced imaging technology to improve intra-operative visualization and facilitate efficient care in procedures that are relatively image dependent. The robotic C-arm provides improved 2D image quality and is capable of large volume three-dimensional fluoroscopy (3DF) that can rapidly create multiplanar CT like images. Here we discuss on the technique, utility, potential benefits, pitfalls, and complications of using the hybrid suite with and without intra-arterial balloon occlusion for pelvic and acetabular fracture surgery. We also present a case series of patient who underwent pelvic fixation using the HOR. While not advocated for routine use in all pelvic and acetabular fractures; the hybrid suite can be an effective tool in the treatment of complex cases and may facilitate efficient care of the hemodynamically unstable patient. It should be considered when resuscitative stabilization, angioembolization, intra-arterial balloon occlusion, or life-threatening bleeding is anticipated. Additionally, use of the hybrid room allows access to 3D fluoroscopy, and the associated benefits, if a mobile 3D unit is otherwise unavailable. These benefits must be weighed against the cumbersome table, the potential pitfalls with patient size and positioning, and the increased cost to the hospital.

EP02.03-007 Seeds of Gold. Triple Contrast Marking in Hybrid Operative Room for All-in One Diagnostic and Therapeutic Precision Surgery

The minimally invasive management of small lung lesions represents a quite challenging task for thoracic surgeons. As a matter of fact, video-assisted thoracic surgery (VATS) wedge resection could usually require conversion to thoracotomy when pulmonary lesions cannot be identified. Hybrid operating rooms (H-OR) can serve as a helpful tool in providing real-time lesion imaging and targeting, allowing the preoperative placement of different marking techniques to help locate non-palpable nodules. Our aim is to assess the efficacy of our triple contrast technique based on the simultaneous use of three different marking systems, including gold seed Biomarc - Vigeo S.r.l.), methylene blue (Methylthioninium Chloride - Bioindustria L.I.M.), and indocyanine green (-ICG- Verdye - Diagnostic Green Gmbh) to help locate non-palpable lung lesion.

Complications of TAVR From an Anesthesia Perspective.

Description Transcatheter aortic valve replacement (TAVR) has become the predominant technique for aortic valve replacement in the United States. Initially approved for high surgical risk patients, TAVR is now approved for most patients requiring valve therapy, including younger, lower-risk patients. The procedure is ideally performed in a hybrid operating room equipped with fluoroscopic equipment and transesophageal echocardiogram (TEE) imaging that can be viewed simultaneously by the operating team. The operating room should also be equipped to allow initiation of cardiopulmonary bypass, if necessary. Cardiac anesthesia teams are often involved with the management of these patients. This mini-review is designed to summarize potential complications that anesthesiologists may contend with during TAVR.

The Current Status in Intraoperative Image-Guided Neurosurgery Associated with Progressive Operating Rooms: A Retrospective Analysis

Shinshu University Hospital has advanced operating rooms including a mobile computed tomography (mCT) room, Smart Cyber Operating Theater (SCOT) with intraoperative magnetic resonance imaging, hybrid operating room (hOR) with intraoperative image-guided surgery, and conventional operating rooms. We investigated the characteristics of cases assigned to each operating room. Five hundred forty neurosurgery cases from January 2018 to April 2021 were analyzed. We analyzed the selection of operating room according to pathology, surgical device requirement, and urgency, and we examined associations between operating room characteristics and these factors. Neurological surgeries were performed in an mCT room, an hOR, a SCOT, and a conventional operating room in 333 (61.7%), 64 (11.9%), 49 (9.1%), and 94 (17.4%) cases, respectively. mCT rooms were more frequently selected than other rooms for vascular/extra-axial tumors, which have a lower need for intraoperative image guidance. Spinal surgeries with segment diagnosis or intraoperative bone removal tended to be performed in the hOR. The rate of SCOT use tended to be higher for intra-axial tumors with poorly circumscribed borders than for vascular/extra-axial tumors. Endoscopic procedures were more frequently performed in the SCOT and mCT rooms than in hORs and conventional operating rooms. Emergency surgeries were often performed in the conventional operating rooms, even in cases where SCOT and hOR seemed suitable. Intraoperative image-guided surgeries were performed according to the characteristics of each operating room best suited for various diseases and operative methods. Further research is needed to prove whether operating room selection improves neurosurgical outcomes.

P120. Augmented reality navigation for percutaneous thoracolumbar pedicle screws: a prospective clinical study

<h3>BACKGROUND CONTEXT</h3> Conventional navigation systems depend on a separate imaging system and use of passive infra-red cameras with a bulky dynamic reference frame (DRF) attached to the spine and to the instruments for live tracking. This often leads to 1) issues with line of sight 2) need for an invasive procedure to attach the DRF 3) lowered accuracy due to inadvertent bumping of the DRF and when point of interest is further from the location of the DRF and 4) a need for repeated re-registrations that can affect the surgical workflow and impact the procedure time. These common issues that impede the adoption of navigation can be bypassed using an Augmented Reality Surgical Navigation system (ARSN), that combines the use of superior quality 3D intra-operative imaging and optical camera based Augmented Reality Navigation (ARN), noninvasive dynamic patient monitoring and on-shaft optical trackers on the Jamshidi needles to provide real time visual feedback of instrument location, without relying on fluoroscopy. <h3>PURPOSE</h3> To determine the accuracy of percutaneous pedicle screw placement when using ARSN. <h3>STUDY DESIGN/SETTING</h3> A single-arm, prospective multicenter clinical study. <h3>PATIENT SAMPLE</h3> A total of 211 pedicle screws were placed percutaneously in 39 patients between levels T2 and S1. The predominant indication was trauma (42%). However, patients with instability of the spine due to degenerative and neoplastic diseases were also included. <h3>OUTCOME MEASURES</h3> Accuracy of pedicle screw placement according to Gertzbein grading (Grade 0: no breach; Grade 1: 4mm breach) determined by three independent reviewers. The median time required to insert the pedicle screw in the right location when using the system was also noted. <h3>METHODS</h3> Navigation was performed in a hybrid OR including surgical table, motorized flat detector C-arm with intraoperative 2D/3D imaging capabilities, optical video cameras integrated in the detector for ARN, and patient motion tracking using skin markers. The C-arm rotated 180 degrees in 10 seconds during acquisition, creating a 3D Cone-Beam CT (CBCT) of the area of interest of 4-8 levels. A disposable Jamshidi needle with optical markers etched on the shaft was used to guide the needle to the desired location in the vertebral body using ARN. <h3>RESULTS</h3> Overall accuracy (Gertzbein 0-1) was 98.1% (95% CI 95.2-99.5). For thoracic screws (n=69), accuracy was 95.7%, for lumbar screws (n=126) 99.2%. Grade 0 screws (no breach) were 93% overall (86% in thoracic and 96% in lumbar levels). Four screws were graded as 2 (2-4 mm breach), with a medial positioning. Three of them were in the upper thoracic spine. None was associated with a neurological consequence. No screw was highly misplaced (> 4mm error). Six screws (2.7%) were intraoperatively revised. Median time per screw was 6 minutes and 25 sec (± 3.3 min). <h3>CONCLUSIONS</h3> Use of ARN leads to a high rate of accurate pedicle screw placement. The use of ARSN favorably compares to screw placement times reported in literature. <h3>FDA DEVICE/DRUG STATUS</h3> ClarifEye surgical navigation system (Philips Healthcare) (Approved for this indication)

Efficacy and Safety of Cone-Beam CT Augmented Electromagnetic Navigation Guided Bronchoscopic Biopsies of Indeterminate Pulmonary Nodules.

Bronchoscopic biopsy results for indeterminate pulmonary nodules remain suboptimal. Electromagnetic navigation bronchoscopy (ENB) coupled with cone beam computed tomography (CBCT) for confirmation has the potential to improve diagnostic yield. We present our experience using this multimodal approach to biopsy 17 indeterminate nodules in 14 consecutive patients from April to August 2021. Demographic information, nodule characteristics, and biopsy results were recorded. Procedures were performed in a hybrid operating room equipped with a Siemens Artis Q bi-plane CBCT (Siemens, Munich, Germany). After ENB using the superDimension version 7.1 (Medtronic, Plymouth, MN, USA) to target the lesion, radial endobronchial ultrasound was used as secondary confirmation. Next, transbronchial needle aspiration was performed prior to CBCT to evaluate placement of the biopsy tool in the lesion. The average nodule size was 21.7+/−15 mm with 59% (10/17) < 2 cm in all dimensions and 35% (6/17) showing a radiographic bronchus sign. The diagnostic yield of CBCT-guided ENB was 76% (13/17). No immediate periprocedural or postprocedural complications were identified. Our experience with CBCT-guided ENB further supports the comparable efficacy and safety of this procedure compared to other mature biopsy modalities. Studies designed to optimize the lung nodule biopsy process and to determine the contributions from different procedural aspects are warranted.

Novel light delivery method for performing transbronchial photodynamic therapy ablation to treat peripheral lung cancer: A pilot study

BackgroundPhotodynamic therapy involves using a photosensitizer with l illumination and is recommended for treating early, centrally located lung cancers, but it is not a standard treatment for peripheral lung tumor.. We previously proposed a novel light delivery method, in which lipiodol is perfused into the bronchial tree to increase the scope of illumination via the fiber effect. Herein, we attempted this novel technique under electromagnetic bronchoscope guidance in a hybrid operation room where lipiodol facilitated light diffusion, and evaluated the effectiveness and feasibility of this technique for peripheral lung cancers. MethodsThis phase 0 pilot study included three patients with peripheral lung cancers (primary tumors ≤20-mm diameter). The photodynamic therapy was administered using Porfimer sodium as the photosensitizer, and an electromagnetic navigation bronchoscope in a hybrid operating room to guide the catheter to the tumor. This facilitated lipiodol infusion to encase the tumor and permit the transbronchial photodynamic therapy ablation. ResultsAdministering 630 nm 200 J/cm (400mW/500sec) energy through a 3-cm cylindrical diffusing laser fiber was safe; no significant acute complications were observed. Although the treatment outcome was unsatisfactory due to the low light dose, tumor pathology in one case revealed tumor necrosis, with no significant damage to the surrounding lung tissue. ConclusionsNovel light delivery transbronchial photodynamic therapy ablation for peripheral lung tumors is feasible and safe. Additional clinical trials may help determine the best illumination plan and light dose through multiple deliveries from multiple angles.

Treatment of acute aortic dissection type A with paraplegia and distal limb ischemia within a hybrid operating room

ObjectiveAcute aortic dissection type A is among the most lethal surgical emergencies. Patients may suffer from occlusion of the aorta or its branches causing end-organ malperfusion complicating the diagnosis and worsening the prognosis. Paraplegia is a rare manifestation that affects less than 5% of patients. If type A aortic dissection and occlusion of the downstream thoraco-abdominal aorta occur simultaneously and require acute treatment, a medical dilemma occurs; what should be treated first?Case reportWe describe a case with an extensive acute type A aortic dissection with signs of consciousness and severe malperfusion syndrome.ResultsThe treatment was successfully performed within a hybrid surgery suite with simultaneous open surgery and endovascular repair techniques supported by cardiopulmonary bypass circulation.ConclusionA hybrid operating room might offer the opportunity to simultaneously repair complicated aortic dissection with malperfusion syndrome, by open aortic surgery and endovascular techniques.

Thoracic surgery in Hong Kong.

In the era of modernized medicine, thoracic surgery has been focusing on achieving minimally invasive surgery and providing a one-stop solution in treating thoracic diseases. Particularly in the Asia population, where patients are keen to have smaller wound and shorter hospital stay, thoracic surgery in Hong Kong has evolved from the traditional open thoracotomy approach to video-assisted thoracoscopic surgery (VATS). In our institution, uniportal VATS for major lung resection was developed in 2012. While uniportal VATS has brought advantages into managing thoracic pathologies, it also brought challenges like instrument fencing during manipulation and suboptimal visualization angle. To improve the procedure and its outcomes, novel techniques and equipment have been developed, for example, double-hinged instruments, robotic assisted technology and magnetic anchored and guided endoscopes (MAGS). With advanced medical imaging nowadays, management of small lung nodules or ground glass opacity (GGO) is in higher demand than ever before. Our hybrid operating room (HOR) can incorporate instant and real-time imaging in lesion localization, and provide treatment via VATS or electromagnetic navigated bronchoscopic (ENB) ablation in a one-stop manner. This paper will review the literature related to the historical development and clinical outcomes of thoracic surgery in Hong Kong and discuss the future perspective of ongoing development.

Surgeons' Leadership Style and Team Behavior in the Hybrid Operating Room: Prospective Cohort Study.

This study aimed to assess the relationship between surgeons' leadership style and team behavior in the hybrid operating room through video coding. Secondly, possible fluctuations possible fluctuations in leadership styles and team behavior during operative phases were studied. Leadership is recognized as a key component to successful team functioning in high-risk industries. The 'full range of leadership' theory is commonly used to evaluate leadership, marking transformational, transactional, and passive. Few studies have examined the effects of these leadership styles on team behavior in surgery and/or their fluctuations during surgery. A single-center study included patients planned for routine endovascular procedures. A medical data capture system was used to allow post hoc video coding through Behavior Anchored Rating Scales. Multilevel statistical analysis was performed to assess possible correlations between leadership style and 3 team behavior indicators (speaking up, knowledge sharing, and collaboration) on an operative phase level. Twenty-two cases were analyzed (47 hours recording). Transformational leadership is positively related to the extent to which team members work together (γ=0.20, P <0.001), share knowledge (γ=0.45, P <0.001), and speak up (γ=0.64, P <0.001). Passive leadership is significantly positively correlated with speaking up (γ=0.29, P =0.004). Leadership style and team behavior clearly fluctuate during a procedure, with similar patterns across different types of endovascular procedures. Consistent with other professional fields, surgeons' transformational leadership enhances team behavior, especially during the most complex operative phases. This suggests that encouraging surgeons to learn and actively implement a transformational leadership style is meaningful to enhance patient safety and team performance.

Hybrid surgery for coexistence of cerebral arteriovenous malformation and primitive trigeminal artery: A case report and literature review

The primitive trigeminal artery (PTA), an abnormal carotid-basilar anastomosis, forms the vascular anomaly connection between the internal carotid artery and vertebrobasilar system. Rarely, PTA can be complicated by several other cerebrovascular disease, including arteriovenous malformations (AVMs), intracranial aneurysms, moyamoya disease, and carotid-cavernous malformations. Herein, we reported a rare case of PTA combined with an AVM in a male patient. The patient was a 28-year-old male with epileptic seizures at the onset of symptoms. Magnetic resonance imaging showed abnormal signal foci and localized softening foci formation with gliosis in the right parietal temporal lobe. Furthermore, using a digital subtraction angiogram (DSA), it was found that an abnormal carotid-basilar anastomosis had developed through a PTA originating from the cavernous portion of the right internal carotid artery (ICA) and a large AVM on the surface of the right carotid artery. The lesion of AVM tightly developed and draining into superior sagittal sinus. A hybrid operating room was used for the surgery. The main feeding arteries of the AVM originating from three major arteries, including the right middle cerebral artery, the right anterior cerebral artery, and the right posterior cerebral artery, were clipped and subsequently, then the AVM was thoroughly removed. The intraoperative DSA showed that the AVM had been resected completely. Postoperative pathological examination of the resected specimen indicated the presence of an AVM. The patient recovered well after surgery and has been symptom-free for more than 3 months. In summary, the pathogenesis of the coexistence of PTA and AVM remains unknown. As highlighted in this case report, hybrid surgery can be used to remove AVMs and can improve the patients' prognosis. To our best knowledge, this is the first case in the literature of successful AVM treatment using hybrid surgery.