Hybrid Operating Room Research Articles

Endovascular Management of an Aortacaval Fistula in Penetrating Trauma

We report the case of a 16-year-old boy who had presented after sustaining a gunshot wound to the abdomen. He was brought on arrival to the operating room for damage control laparotomy. The next morning, he underwent postoperative computed tomography, which demonstrated an aortocaval fistula (ACF) with an aortic pseudoaneurysm measuring 3.2 × 4.3 × 3.7 cm (Fig). The computed tomography scan was also notable for an accessory left renal artery. We took the patient expeditiously to the hybrid operating room for aortic stent-graft repair using a 16 × 45-mm Ovation iliac limb stent-graft (Endologix Inc, Irvine, Calif). The use of an endovascular approach to his traumatic aortic injury allowed for expedient repair without further hemodynamic compromise. We have reported this case because endovascular repair of traumatic ACFs has not been well reported, with only four other cases in the literature from 1992 to 2017. A retrospective medical record review was performed. The patient's parents had provided written informed consent for the medical record review and the report of his case. A literature review was performed using PubMed and the search terms “aorto-caval fistula” and “traumatic aorto-caval fistula.” From our literature review, we found only four other reports of the use of endovascular stent-graft repair for the treatment of traumatic ACFs. Only one other case had used an iliac limb for repair, and in that case, it was to address a complication after an open repair. Thus, we have reported our case as an infrequently reported method to manage a devastating traumatic injury. Although endovascular management has been previously reported in the setting of aortic aneurysm repair with a concomitant ACF, it has not been well described in the management of traumatic ACFs. In our review of the literature, we found only four cases reported from 1992 to 2017. Also, to the best of our knowledge, our patient is the youngest reported. Our patient's young age added a layer of difficulty in sizing the stent-graft. With the novel use of an ovation iliac limb stent-graft, we were able to appropriately size the stent-graft for our young patient and obtain successful repair of his ACF. The present case adds to the literature on the endovascular management of traumatic ACFs.

Intraoperative support with three-dimensional holographic cholangiography in hepatobiliary surgery.

This study was performed to investigate the potential of intraoperative three-dimensional (3D) holographic cholangiography, which provides a computer graphics model of the biliary tract, with mixed reality techniques. Two patients with intraductal papillary neoplasm of the bile duct were enrolled in the study. Intraoperative 3D cholangiography was performed in a hybrid operating room. Three-dimensional polygon data using the acquired cholangiography data were installed into a head mount display (HoloLens; Microsoft Corporation, Redmond, WA, USA). Upon completion of intraoperative 3D cholangiography, a hologram was immediately and successfully made in the operating room using the acquired cholangiography data, and several surgeons wearing the HoloLens succeeded in sharing the same hologram. Compared with usual two-dimensional cholangiography, this 3D holographic cholangiography technique contributed to more accurate reappearance of the bile ducts, especially the B1 origination site, and moving the hologram from the respective operators' angles by means of easy gesture-handling without any monitors. Intraoperative 3D holographic cholangiography might be a new next-generation operation-support tool in terms of immediacy, accurate anatomical reappearance, and ease of handling.

Intraoperative Cone Beam CT in Hybrid Operation Room for Pediatric Scoliosis Patients: Comparison of Pedicle Screw Violation Rate at Normal and Low Radiation Doses.

Retrospective observational study. This study aimed to determine the effect of reducing the radiation dose of intraoperative cone beam computed tomography (CBCT) during posterior spinal fusion (PSF) for pediatric scoliosis on the rate of pedicle screw (PS) violation. Intraoperative CBCT for pediatric scoliosis improves the accuracy of PS insertion in PSF. However, few reports have addressed the PS perforation rate from reduced radiation doses in hybrid navigation. We evaluated 855 PSs inserted into 58 pediatric scoliosis patients (11 male and 47 female, mean age: 16.6 yr) who underwent PSF using CBCT. A radiation dose of 1/3 or 1/5 of the normal dose (ND) was defined as a low dose (LD). After PS insertion, intraoperative CBCT images were reviewed to assess the degree of PS perforation. G2-3 (i.e., perforations of 4 mm or more) was defined as a violation. The PS violation rate was compared between the groups, and factors associated with violations were examined. A total of 567 and 288 screws were inserted in the ND group and LD group, respectively. The PS violation rate was comparable at 1.8% in the ND group and 1.7% in the LD group. Multiple logistic regression analysis showed that distance from the upper instrumented vertebra (UIV) was an independently associated factor of PS violation (+1 vertebra, operation room 0.73, P = 0.038). In addition, the mean height of patients with PS violations (148.8 ± 3.6 cm) was significantly shorter than that of patients without violations (157.9 ± 1.2 cm) ( P = 0.034). There was no increase in PS violation rate with lower doses of radiation for intraoperative navigation CBCT. Extra care is warranted for vertebrae close to the UIV and patients of shorter stature.Level of Evidence: 3.

Impact of radiation to the eye of operators during endo-cardiovascular surgery and the importance of protection

To verify the amount of radiation exposure to the eye of operators during endocardiovascular surgery (ECVS) in hybrid operating room (HOR), which increases the risk of cataracts in surgeons. Fifty cases of ECVS (including 36 transcatheter aortic valve implantation and 14 thoracic endovascular repair) using the transfemoral approach performed from February 2020 to July 2020 were included. A measurement device was attached to the left side of the head of the operators and their assistants to measure the cumulative dose (CD) of intraoperative radiation exposure. The subjects were divided into the control group (Group C, n = 26), received conventional protection using the protective curtain in HOR and the protected group (Group R, n = 24), received conventional protection and protection sheet. The normalized CD by dose area product (CD/DAP) was evaluated. The CD/DAP of the surgeons was significantly decreased in Group R, averaging at 5.97 μSV/Gycm2 in Group C group and 4.40 μSV/Gycm2 in Group R (p < 0.01). Moreover, CD/DAP of the assistant was significantly reduced in the Group R, with an average of 1.87 μSV/Gycm2 in the Group C and 1.01 μSV/Gycm2 in Group R (p < 0.01). The radiation exposure to the surgeon's eye could be significantly reduced by protection sheet.

Clinical outcomes of procedures combining endovascular embolization with a direct surgical approach in a hybrid operating room for the treatment of refractory dural arteriovenous fistulas.

Background: We reviewed the clinical outcomes of a procedure that combines endovascular embolization and a direct surgical approach in a hybrid operating room (OR) for the treatment of refractory dural arteriovenous fistulas (dAVFs).Methods: All patients with intracranial dAVFs who underwent a procedure combining endovascular embolization and direct surgical approach with biplane angiography or a robotic C-arm system in a hybrid OR between February 2004 and June 2020 were considered. Borden grading, occlusion rate, pre-and post-operative modified Rankin Scale (mRS) scores, and complications were retrospectively investigated. The pre-and postoperative mRS scores were compared using the Wilcoxon signed-ranks test.Results: We evaluated 14 arteriovenous fistulas (AVFs) in consecutive 13 patients. Of these, ten AVFs were previously treated with endovascular embolization, ten were located in the transverse-sigmoid sinus, and four in the cortical vein. The Borden grade was II in two AVFs and III in 12 AVFs. Immediate occlusion of the AVF was achieved in 13 AVFs, and gradual occlusion was observed in one case. The median preoperative mRS was 1 (0–3), whereas the median postoperative mRS was 0 (0–1) which indicated marked improvement (P = 0.006). Complications including postoperative transient visual disturbance and intraprocedural extravasation were observed in only two cases.Conclusion: The combination of endovascular embolization and direct surgical approach in a hybrid OR could achieve sufficient occlusion of refractory AVFs with acceptable complication rates and improved symptoms.

Transvenous Lead Extraction without Procedure-Related Deaths in 1000 Consecutive Patients: A Single-Center Experience.

BackgroundTransvenous lead extraction (TLE) is now a first-line technique for the treatment of complications related to cardiac implantable electronic devices. The aim of the study was to demonstrate that it is possible to safely perform difficult TLE procedures with a maximum reduction of peri-procedural major complications.MethodsA total of 1000 consecutive patients undergoing TLE in a single high-volume center from 2016 to 2019 were studied. All procedures were performed in a hybrid room or operating room by a specialized TLE team. TLE was performed under general anesthesia and monitored by transesophageal echocardiography, and the operating room was suitably equipped for immediate surgical intervention. The effectiveness and safety of the procedures were assessed, with particular emphasis on major complications.ResultsIn all, 1952 leads with the mean implant duration of 111.7 ± 77.6 months had been extracted. Complete procedural success of patients was achieved in 95.9% and clinical success in 99.1%. Major complications, predominantly cardiac tamponade (63.3%), occurred in 22 patients (2.2%). Rapid diagnosis and immediate intervention were the key to a 100% survival in patients with this complication.ConclusionPerforming procedures in a hybrid operating room under general anesthesia in the presence of a cardiac surgeon and with the use of transesophageal echocardiography significantly improves the safety of transvenous lead extraction.

Combined Endovascular and Surgical Treatment for Brain Arteriovenous Malformations in Biplanar Hybrid Operating Room.

Combined surgical and endovascular treatment for vascular disorders has become prevalent in recent years. However, reports on one-session hybrid surgery for arteriovenous malformations (AVMs) are relatively rare. The safety and efficiency of combined treatment for brain AVMs were analyzed in biplanar hybrid operating room (OR) at one stage. We retrospectively analyzed 20 patients with AVMs undergoing combined surgical and endovascular treatment from October 2015 to June 2018. The data for resection rate, microcatheter adhesion, surgical position and postoperative outcomes were analyzed. Total resection or near-total resection was achieved in all cases. A total of 13 patients were under combined endovascular and surgical procedures, and 7 experienced surgery with intraoperative digital subtraction angiography. Sitting position was applied in 3 of them; 2 niduses in cerebellum, and 1 in parietal lobe. Compared with admission modified Rankin Scale (mRS) in all patients, postoperative 12-month mRS showed a significant decline. Besides, 3 patients experienced microcatheter adhesion after endovascular embolization, thereafter underwent surgical adhesion removal while nidus resection was done. Combined endovascular and surgical modality in a hybrid OR at one stage provides a safe strategy for the treatment of AVMs. The biplanar hybrid neurointerventional suite is endowed with unconstrained operating angle which enables combined endovascular and surgical treatment in sitting position. It also reduces the risk of microcatheter adhesion, which enables interventional radiologists to perform aggressively.

"Intraoperative Cone Beam CT in Hybrid Operating Room Set-Up as An Alternative to Postoperative CT for Pedicle Screw Breach Detection"

Accurately positioned pedicle screws offer optimal biomechanical fixation, making them a well-accepted treatment choice for a variety of spine pathologies [1,2]. However, up to 42% of pedicle screws were reported to be malpositioned

A 5-YEAR RETROSPECTIVE ANALYSIS OF IONIZING RADIATION DOSE TO HYBRID OPERATING ROOM PERSONNEL IN SAUDI ARABIA.

The annual average effective dose (ED) for operating room personnel (ORP) in Saudi Arabia was estimated from the period of 2015-2019 using thermoluminescent dosemeters. A retrospective analysis was conducted on annual EDs for 7530 ORP working across 52 hospitals. These workers were only exposed to radiation in the operating room. The annual average ED over the period of 5years was found to be 0.59mSv with no incidence of a dose above the annual dose limit of 20mSv. The maximum annual ED reported was 15mSv for an operating room worker in 2019. More than 88% of the workers received an annual ED of <1mSv. The study concluded that the work environment in hybrid operating rooms across Saudi Arabia is safe. However, it is always recommended that workers take every protective measure when dealing with ionization radiation.

Single-step localization and excision of small pulmonary nodules using a mobile 3D C-arm.

The use of a hybrid operating room equipped with robotic C-arm cone-beam computed tomography for single-step localization and excision of small pulmonary nodules finds high cost barriers. The new generation of 3D C-arm system not only depicts soft tissues with high contrast but also offers a more affordable and sustainable solution. This approach has been chiefly applied in the field of orthopedic surgery. In this case series, we describe the use of a mobile 3D C-arm system for localizing and removing small pulmonary nodules. Between July and September 2020, we identified 14 patients who underwent localization and removal of small pulmonary nodules with a 3D C-arm system. We retrospectively reviewed clinical records to document the feasibility and safety of the procedure. The median tumour size was 7.5 mm [interquartile range (IQR): 5 - 9.75 mm], with a median distance from the pleural surface of 4.2 mm (IQR: 0.5 - 6.45 mm). We successfully visualized all of the pulmonary lesions by intraoperative CT imaging. Localization was achieved in 13 patients, who subsequently underwent complete thoracoscopic resection. The median time required to localize lesions was 41.5 min (IQR: 33.75 - 53.25 min), with a median radiation exposure (expressed through the skin absorbed dose) of 143.45 mGy (IQR: 86.1 - 194.6 mGy). Failure to localize occurred in 1 patient because of pneumothorax caused by repeated needle puncture. All patients were successfully discharged and the median length of stay was 2.5 days (IQR: 2 - 3 days). This case series demonstrates the feasibility of single-step localization and excision of small pulmonary nodules using a mobile 3D C-arm.

Neuroendovascular Training Using Multisource Video-Recording System in a Hybrid Operating Room

Increasing restrictions over trainees' working hours and the recent coronavirus disease 2019 pandemic warrant new educational methods of surgical skills. We assessed a novel video-recording system for neuroendovascular skill education, developed with the installation of a hybrid operating room (OR) at our institution. A single-plane angiography unit with a large flat display (FlexVision XL; Philips Medical Systems) was installed in our OR. All media sources in the OR, including live fluoroscopy and ceiling-mounted camcorders, were connected to a video switcher. This video switcher laid up to 8 video images into one big image, which was transferred to the large display and the professional-use Blu-ray recorder. The recording was performed continuously during the procedure. This recording system was evaluated retrospectively with a questionnaire administered to the 5 trainees. Using this system, 68 interventional procedures were recorded. Among the potential merits, the trainees assigned the greatest value to the simultaneous recording of the operator's hand motions and the fluoroscopy images. Among the potential limitations of the system, the prolonged time and the increased volume of the video data bothered the trainees the most. The recorded video looked like a live demonstration. Our "selfie" video recording system was useful for skill training of neuroendovascular interventions.

Accuracy of screw stabilization of the dorsal pelvic ring using a hybrid operating room: 5 Year experience in a level 1 trauma center

IntroductionAccuracy for screw placement in the dorsal pelvic ring can be enhanced using intraoperative 3D navigation. Advances in intraoperative imaging lead to benefits for pelvic surgery. New c-arms are equipped with flat panel detectors, which have a larger detector and assure higher image quality with accompanying dose reduction. A hybrid OR is defined by a fixed imaging system in an operating room providing the benefit of the surgical environment in combination with advanced intraoperative imaging. Aim of our investigation was to analyze the accuracy of navigated sacroiliac (SI) and transsacral transiliac (TSTI) screws in the dorsal pelvic ring, which were implanted with a hybrid OR in the first five years of use. Material and methodsAll percutaneous SI or TSTI screws implanted in the hybrid OR using intraoperative navigation in the first 5 years of utilization (between June 2012 to June 2017) were included. Intraoperative 3D-scans and postoperative computed tomography were examined for screw perforation. Results210 SI and TSTI screws were implanted in 187 patients using intraoperative navigation in the hybrid-OR. 90.6 % of SI screws showed no cortical perforation. 6,3 % had a grade 1, 2.4 % a grade 2 and 0.8 % a grade 3 perforation. In 80.7 % of TSTI screws no perforation and in 13.3 % a grade 1 perforation was detected. 3.6 % showed a grade 2 and 2.4 % a grade 3 perforation. No significant difference between both screw types regarding the grade of cortical perforation could be seen. No significant relation between perforation rate and year of operation could be detected. ConclusionIntraoperative navigation in a hybrid OR ensures a high accuracy for SI screws. Due to the large field of view and high image quality TSTI screws can be safely implanted in S1 and S2. Utilization of a hybrid-OR is accompanied with a steep learning curve.

Integrating Endovascular and Operative Intervention in Trauma

Patterns of utilization of the hybrid operating room (hybrid-OR) in trauma have not been described. The aim of this study was to describe the sequencing and integration of endovascular and operative interventions in trauma using a hybrid-OR. This is a single-center, retrospective cohort study of trauma patients who underwent both endovascular and operative intervention (2013-2019). Patients were separated into four groups based on procedure patterns: concomitant-linked (C-L), concomitant-independent, serial-linked (S-L) and serial-independent (S-I). The groups were defined as follows: C-L - related endovascular and operative interventions in the same OR; concomitant-independent - unrelated interventions in the same OR; S-L - related interventions in separate ORs; S-I - unrelated interventions in separate ORs. Patient characteristics, procedures performed and time to angiography in each group were analyzed. Out of 202 patients, most procedures utilizing the hybrid-OR were for hemorrhage control (84.1%) and were performed in a C-L manner (36.1%). Patients in the C-L group were most likely to undergo lower extremity revascularization and received the most transfusions. Patients in the S-L and S-I groups were more severely injured, had greater severe abdominal injury and were more likely to undergo damage control surgery and solid organ interventions, respectively. The C-L group had the highest percentage of patients to undergo angiography within 12 h (77%, P=0.053). The hybrid-OR is an ideal space for hemorrhage control in trauma, but there is room for improvement in the triage of patients with non-compressible torso hemorrhage. Current practice patterns prioritize the hybrid-OR for management of lower extremity injury and are not optimal. Use of the hybrid-OR could be improved by concomitant management of patients with severe abdominal injury requiring damage control surgery.

Open Balloon Tamponade and Hepatic Angiography for Hemorrhage Control of Transhepatic Gunshot Wounds in a Hybrid Trauma Operating Room Environment

The management of high-grade liver trauma is challenging and mortality rates are high. Balloon tamponade is a valuable tool for control of transhepatic penetrating injuries. We report three cases of hybrid management of penetrating liver trauma with balloon tamponade and hepatic angiography in a hybrid operating room environment. The combination of balloon tamponade with hepatic angioembolization provides an enhanced approach for the management of these injuries.

Open Balloon Tamponade and Hepatic Angiography for Hemorrhage Control of Transhepatic Gunshot Wounds in a Hybrid Trauma Operating Room Environment

The management of high-grade liver trauma is challenging and mortality rates are high. Balloon tamponade is a valuable tool for control of transhepatic penetrating injuries. We report three cases of hybrid management of penetrating liver trauma with balloon tamponade and hepatic angiography in a hybrid operating room environment. The combination of balloon tamponade with hepatic angioembolization provides an enhanced approach for the management of these injuries.

Protected and unprotected radiation exposure to the eye lens of vascular surgeons during endovascular procedures in hybrid operating rooms

Abstract Objective Radiation induced cataract has been observed at lower threshold doses than expected. Therefore, the annual limit for equivalent dose to the eye lens has been reduced from 150 to 20 mSv. We aimed to evaluate radiation exposure to the eye lens of vascular surgeons working in a hybrid operating room before and after a dose reduction program was established. Methods Prospective non-randomized trial with a historic control group. From April – October 2019, radiation exposure to the operator was measured during all endovascular procedures performed in the hybrid operating room using BeOSL Hp(3) eye lens dosimeters placed outside the 0.75mm lead equivalent glasses on the side of the radiation source and behind the lead glasses. Measured values were compared to data from a prospective study performed at the same center in the years of 2012 and 2013 before a dose reduction program had been implemented. Results A total of 181 consecutive patients underwent an endovascular procedure in the hybrid operating room. The mean unprotected eye lens dose of the main operator was 0.119 mSv for EVAR (n = 30), 0.118 mSv for TEVAR (n = 23), 0.312 mSv for more complex aortic procedures (F/BrEVAR; n = 15) and 0.046 mSv for peripheral interventions. Compared to the control period, EVAR had 75% lower, TEVAR 79% lower and more complex aortic procedures 55% lower radiation exposure unprotected eye lens of the operator. The 0.75 mm lead equivalent glasses led to a median reduction of the exposure to the eye lens by the factor 3.43. Behind the lead glasses at the level of the eye lens, radiation exposure exceeding the detection limit of 0.042 mSv was measured only in 22 of 181 cases. There was a significant correlation between DAP between both protected and unprotected eye lens dose (p &amp;lt; 0.0001, r2 = 0.512 and 0.282). DAP correlated significantly with patients’ body mass index, operating time, fluoroscopy time and digital subtraction angiography time. Conclusion The dose reduction program at our institution has led to a relevant reduction of the radiation dose to the head and the eye lens of the main operator in endovascular procedures. With optimum radiation protection measures including a ceiling-mounted shield and 0.75 mm lead equivalent glasses, more than 440 EVARs, 280 TEVARs or 128 FEVARs could be performed per year until the dose limit for the eye lens of 20 mSv would be reached.

Room staff radiation dose in a vascular surgery hybrid operating room and evaluation of a real-time radiation dosimeter

Abstract Objective Real-time radiation dosimeter have been shown to decrease radiation exposure of the staff. This effect is mainly explained by increased awareness of the radiation due to direct radiation exposure feedback to the operator. We aimed to measure the radiation exposure of all staff members working in a hybrid operating room and wanted to compare the equivalent doses of real-time radiation dosimeters with thermoluminescence dosimeters. Methods Prospective non-randomized comparative trial. From April – October 2019, all staff members working in a hybrid operating room were equipped with real-time radiation dosimeters (Unfors RaySafe i3). The table positions of all staff members were documented. In addition, the first operator was equipped with a thermoluminescence Hp(3) eye lens dosimeter (TLD) placed outside the lead glasses to validate the real-time radiation dosimeter. Results The median dose of the operator / the first assistant was 73.6 µSv / 21.8 µSv for EVAR (n = 30); 57.25 µSv / 18.2 µSv for TEVAR (n = 23); 207.0 µSv / 76.65 µSv for more complex aortic procedures (f/bEVAR etc.; n = 15); 14.85 µSv / 8.5 µSv for occlusive disease of the iliac arteries (n = 27) and 6.1 µSv / 3.4 µSv for occlusive disease of the peripheral arteries (n = 53). The anesthesiologist’s median dose was 0.3 µSv, with highest values in f/bEVAR (3.9µSv). The scrub nurse’s median dose was 2 µSv with highest values in f/bEVAR (24 µSv). The position of any staff member at the left arm for transbrachial cannulation in f/bEVAR was associated with higher median equivalent radiation doses compared to the right femoral position (272.5 vs. 207 µSv for the operator (p=ns), 175.3 vs. 27.8 µSv for the first assistant (p = 0.027) and 45.55 vs. 8.0 µSv for the scrub nurse (p = 0.14)). The equivalent doses of the TLD and RaySafe did not correlate well using simple lineal regression analysis (r2 0.1713, p = 0.0014). Conclusion With the RaySafe real-time radiation dosimeter, table positions with increased radiation exposure can be identified. This allows for improvement in shielding at these positions, possibly leading to lower radiation exposure of the staff.

Transcarotid artery revascularization (TCAR) – first experience

Abstract Objective In transcarotid artery revascularization (TCAR) the carotid stent used to treat carotid artery stenosis is introduced via a cut-down to the common carotid artery (CCA). Stent placement is performed during flow reversal using an external shunt to the femoral vein. The advantages compared to transfemoral carotid stenting are that the risks of embolization from the aortic arch and origin of the arch vessels are avoided and that clamping of the common carotid artery allows complete flow-reversal during stent placement. TCAR was developed in 2015 and is extensively used predominately in the USA. To our knowledge, TCAR has until now not been used in Switzerland. We present our first experience with TCAR. Methods Retrospective analysis of consecutive patients. Results We treated 4 patients with TCAR from Dec 2019 to May 2020. All patients were male, median age was 66y. All had high-grade internal carotid artery (ICA) stenosis (3 asymptomatic, 1 symptomatic). All procedures were performed in a hybrid operation room. Technical success was achieved in 3 patients. In these patients there was no peri-interventional stroke or TIA and duplex sonography 6 months postoperatively showed a patent stent without restenosis. In the fourth patient previous attempted transfemoral stenting for symptomatic ICA-stenosis had failed because of a very tortuous CCA. During TCAR, puncture of the CCA was difficult because of atherosclerotic thickening of the vessel wall, furthermore the tip of the guidewire for insertion of the dedicated sheath into the CCA needed to be placed in the CCA rather than in the external carotid artery (ECA) because of ECA occlusion. This led to inadvertent crossing of the stenosis with the guide wire. The procedure was abolished and converted to a conventional carotid endarterectomy. The patient had a perioperative minor stroke with signs of embolization into branches of the medial cerebral artery. He underwent transfemoral intracranial thrombectomy and eventually recovered with only minor deficits. Conclusion Our first experience with TCAR confirmed that patient selection is important: A combination of atherosclerotic disease of the CCA and occlusion of the ECA, both in themselves only relative contraindications to TCAR, led to technical failure and perioperative stroke. With good patient selection TCAR could be performed safely.

Collaboration in the Hybrid Operating Room: A Focus Group Study From the Perspective of the Nursing Staff

Technical advancements in the operating room setting continue, and the concept of the hybrid operating room is promoted and accepted worldwide. The hybrid setting means inclusion of radiology in the already complex environment of a traditional operating room. Collaboration in this type of environment becomes essential and investigating how the nursing staff experiences this collaboration in the hybrid operating room is needed. The aim of the study was to investigate how the nursing staff from the specialties of surgery, anesthesiology, and radiology experienced collaborating in a hybrid operating room. Explorative qualitative design was used. Five focus groups consisting of operating room nurses, operating room assistant nurses, nurse anesthetists, assistant nurse anesthetists, and radiographers were included in the study. Interviews using semistructured questions were conducted. Directive content analysis was used for the data analysis. The following categories revealed: (1) different patient safety perspectives; (2) responsibilities being shared and divided; (3) collaboration becoming better over time; (4) uneven division of labor in a strained work situation and different terms of employment; (5) lack of education and joint meetings; and (6) environmental constraints for satisfying collaboration. The nursing staff in the hybrid operating room highlighted they worked toward a common goal but prioritized their own specific tasks rather than the procedure as a whole. This, together with the uneven task distribution and unclear responsibilities, could create tension between the different staff categories, impacting procedures negatively. The results revealed the importance of proper preparation of the staff to work in the hybrid operating room. Having team building activities, common meetings, relevant training to meet educational needs, and adjusting the team composition could improve hybrid operating room collaboration and improve patient safety and outcomes.

Endovascular Solutions for Aortic Arch Diseases: Total and Hybrid

Although the endovascular approach is the therapeutic option of choice for thoracic and abdominal aortic diseases, open surgery is still the treatment of choice for aortic arch diseases. While open surgical repair remains the gold standard treatment for complete aortic arch replacement, it continues to be burdened by high mortality and neurologic complications, especially for patients who require redo surgery. Therefore, in the era of endovascular surgery, it is not surprising that hybrid operating rooms, new technologies, and new approaches are strongly challenging open surgery. Less-invasive endovascular procedures, when used to treat aortic arch diseases, when feasible and indicated, have clear advantages over open surgery, primarily because there is no need for cardiopulmonary bypass, hypothermic circulatory arrest, or cerebral protection. Moreover, patients who have already been treated for acute type A aortic dissection continue to have a considerable risk for future aortic reintervention, which is associated with increased risk for short- and long-term mortality. In light of these advantages, it is clear how selected high-risk patients with aortic arch disease could benefit from the endovascular approach. However, the hemodynamic and anatomic characteristics of the aortic arch make the endovascular approach in this region challenging. In fact, uncorrected stent-graft placement can have fatal consequences for the patient and increase the risk of endoleaks and stroke. To minimize these potential risks, precise and accurate preoperative planning to achieve optimal stent-graft dimensions and implantation is essential together with careful patient selection. Endovascular options for the treatment of aortic arch disease include both hybrid procedures and total endovascular solutions. This manuscript provides an overview of the current strategies for endovascular aortic arch treatment, including the most recent available series on this topic. In addition, a literature search offers insight into the current state of the art.