Hybrid Operating Room Research Articles

Role of requests and communication breakdowns in the coordination of teamwork: a video-based observational study of hybrid operating rooms

ObjectivesThis study investigated the functional role of ‘requests’ in the coordination of surgical activities in the operating room (OR). A secondary aim was to describe, closely, instances of potential miscommunication...

The need for a rapid transfer to a hybrid operating theatre: Do we lose benefit with poor efficiency?

PurposeRecent studies on hybrid operating rooms (ORs) have mainly reported their applications in orthopaedic surgery and interventional radiology (IR); there are few studies assessing severely injured patients who underwent IR or surgery in hybrid ORs for haemostasis. Therefore, this study aimed to evaluate our early experience with the use of hybrid OR to control haemorrhage in severe trauma patients. MethodsMedical charts of patients who underwent an emergency surgery or IR for haemostasis were analysed retrospectively between January and December 2015. ResultsOf the 95 patients directly transported to the general or hybrid OR, 69 (73%) were transported to the non-hybrid OR and underwent emergency surgeries, whereas 26 (27%) were transported to the hybrid OR and underwent emergency IR or surgery on-site. Patients transported to the hybrid OR had a higher median Injury Severity Score (median: 29, interquartile range[IQR]: 21–36.5 vs median: 21, IQR: 16–27) and lower median initial systolic blood pressure (median: 96, IQR: 82.75–128.75 vs median: 114, IQR: 95–151.5) than those transported to the non-hybrid OR. The median time from the emergency room (ER) arrival to the start of the emergency procedure in the hybrid OR group was similar with that in the non-hybrid OR group (median: 80, IQR: 62.75–91.5 vs median: 75, IQR: 56.5–99). Seven patients underwent IR and surgery concurrently in the hybrid OR because of a haemodynamically unstable pelvic fracture, severe liver injury, and severe brain haemorrhage. The median time from the ER arrival to the start of the haemostatic procedure or operation was 64(43–97) minutes. ConclusionsAlthough the hybrid OR may be used for haemostasis in severely injured patients, the long median time from ER arrival to the start of a haemostatic procedure in hybrid OR indicates the need for a new workflow to reduce this time and to facilitate hybrid OR use.

Real-Time Streaming of Surgery Performance and Intraoperative Imaging Data in the Hybrid Operating Room: Development and Usability Study.

BackgroundThe trend of quick evolution and increased digital data in today’s operating rooms (ORs) has led to the construction of hybrid ORs. There is often a main control room with monitors for integrating intraoperative data from multiple devices in the hybrid OR. However, there is no adequate solution for communicating the data with people outside the OR.ObjectiveThe objective of this study was to design an intelligent operating room (iOR) system, augmented onto the existing information technology (IT) infrastructure of hybrid ORs, to stream surgery performance and intraoperative imaging data.MethodsIn this study, an all-in-one device with synergetic encoder and decoder was used. The device was able to stream multiple sources to one display. The lossless video and images from specific surgical workflows were streamed outside the hybrid OR through network protocols and were further managed by a streaming server and wireless control system. The steps of this study included the following: (1) defining the requirements and feasibility of an iOR system in the hybrid OR, (2) connecting multiple sources, (3) setting up equipment across the hybrid OR and a conference room, (4) designing a video management system, and (5) real-time streaming under specific surgical workflows.ResultsThe wired streamed video was shown simultaneously on the display in the hybrid OR and the display in the conference room with near-zero latency. Additionally, an interactive video between the hybrid OR and the conference room was achieved through the bidirectional wireless control system. The functions of recording, archiving, and playback were successfully provided by the streaming server. The readily available hardware components and open-access programming reduced the cost required to construct this streaming system.ConclusionsThis flexible and cost-effective iOR system not only provided educational benefits, but also contributed to surgical telementoring.

Comparing Mobile C-Arm with a Hybrid Operating Room for Imaging in Fenestrated Stent-Graft Endovascular Abdominal Aortic Aneurysm Repair

To evaluate the advantages of a hybrid operating room (OR) (group 2) compared with a fluoroscopic mobile C-arm (group 1) during fenestrated stent-graft endovascular aneurysm repair (f-EVAR). This single-center study retrospectively analyzed prospectively collected data of consecutive patients treated with f-EVAR for short-necked, juxtarenal, and suprarenal aortic aneurysms between January 2006 and July 2016. Primary end points were technical success and perioperative complications. Secondary end points included 30-day and 1-year mortality as well as target vessel patency. About 96 patients were treated (85 men; 74.1±6.3years); 46 patients (48%) belonging to group 1 and 50 (52%) patients belonging to group 2. Technical success was achieved in 92.7% of the procedures (group 1 91.3% vs. group 2 94%, P=0.72). Significantly more complex interventions were performed in group 2 (n=38 of 50) compared with group 1 (n=14 of 46; P<0.001), in which primarily renal f-EVAR interventions were performed. In group 2, significantly less contrast was used (median 150mL vs. 100mL; P<0.001). The 30-day mortality in group 1 was 9% and 2% in group 2 (P=0.14), and 1-year survival was also not significantly different between both groups. Target visceral vessel primary patency was significantly higher in group 1 (87.6% vs. 85.5% [P=0.006] and 83.8% vs. 78.3% [P=0.03]) at 6 and 12months, respectively). There was no significant difference in renal artery primary patency at 6 and 12months. Immediate and 1-year outcomes after f-EVAR for abdominal aortic aneurysm were comparable using a hybrid OR compared with a mobile C-arm, despite the use of significantly more complex stent grafts in the patients treated in the hybrid OR. The use of a hybrid OR may assist in achieving satisfying results in complex f-EVAR.

Thoracic aggressive vertebral hemangiomas: multidisciplinary management in a hybrid room.

Vertebral hemangiomas (VH) account for 2-3% of all spinal tumors. The majority is incidentally found on radiographic studies: 1% present with pain and/or neurologic deficits. We report our experience with the multidisciplinary management of aggressive symptomatic thoracic VH by concomitant intraoperative sclerotization with sodium tetradecyl sulfate (STS), vertebroplasty, posterior decompression (with/without fusion) and surgical resection in a hybrid operating room (HR) equipped with a rotational scanner and a radiolucent operating table. Patients admitted with aggressive spinal VH between 2007 and 2018 were included. Data regarding demographics, presenting symptoms, location of the lesion, preoperative embolization, length of the surgery, estimated blood loss (EBL) as well as follow-up (FU) were retrieved. Five patients were included (three females, mean age 65years; range 59-75). Three patients presented with a myelopathy and two mechanical thoracic pain. All patients underwent a single-stage percutaneous sclerotization and vertebroplasty followed by a surgical decompression associated with epidural intralesional injection of STS and subtotal resection of the epidural lesion. Two patients had preoperative embolization. Mean procedural duration was 338min (range 210-480min). Four patients had marginal EBL, one patient had 500ml EBL. Patients had no evidence of lesion recurrence or progression at the end of the follow-up. The single-stage multimodal management of aggressive symptomatic VH is safe and effective. It allows for a direct intraoperative sclerotherapy combined with maximal tumor resection, resulting in reduced blood loss. The use of STS as a direct intraoperative sclerotizing agent is safe and reliable.

Teamwork and Safety Attitudes in Complex Aortic Surgery at a Dutch Hospital: Cross-Sectional Survey Study

BackgroundImproving teamwork in surgery is a complex goal and difficult to achieve. Human factors questionnaires, such as the Safety Attitudes Questionnaire (SAQ), can help us understand medical teamwork and may assist in achieving this goal.ObjectiveThis paper aimed to assess local team and safety culture in a cardiovascular surgery setting to understand how purposeful teamwork improvements can be reached.MethodsTwo cardiovascular surgical teams performing complex aortic treatments were assessed: an endovascular-treatment team (ETT) and an open-treatment team (OTT). Both teams answered an online version of the SAQ Dutch Edition (SAQ-NL) consisting of 30 questions related to six different domains of safety: teamwork climate, safety climate, job satisfaction, stress recognition, perceptions of management, and working conditions. In addition, one open-ended question was posed to gain more insight into the completed questionnaires.ResultsThe SAQ-NL was completed by all 23 ETT members and all 13 OTT members. Team composition was comparable for both teams: 57% and 62% males, respectively, and 48% and 54% physicians, respectively. All participants worked for 10 years or more in health care. SAQ-NL mean scores were comparable between both teams, with important differences found between the physicians and nonphysicians of the ETT. Nonphysicians were less positive about the safety climate, job satisfaction, and working climate domains than were the physicians (P<.05). Additional education on performed procedures, more conjoined team training, as well as a hybrid operating room were suggested by participants as important areas of improvement.ConclusionsNonphysicians of a local team performing complex endovascular aortic aneurysm surgery perceived safety climate, job satisfaction, and working conditions less positively than did physicians from the same team. Open-ended questions suggested that this is related to a lack of adequate conjoined training, lack of adequate education, and lack of an adequate operating room. With added open-ended questions, the SAQ-NL appears to be an assessment tool that allows for developing strategies that are instrumental in improving quality of care.

Cost Analysis of Hybrid Operation Room versus Non-Hybrid use in General Thoracic Surgery

Cost Analysis of Hybrid Operation Room versus Non-Hybrid use in General Thoracic Surgery

Application of hybrid operating rooms for treating spinal dural arteriovenous fistula.

BACKGROUNDA hybrid operating room (hybrid-OR) is a surgical space that combines a conventional operating room with advanced medical imaging devices.AIMTo explore and summarize the technical features and effectiveness of the application of a hybrid-OR in dealing with spinal dural arteriovenous fistulas (SDAVFs).METHODSEleven patients with SDAVFs were treated with the use of a hybrid-OR at the Department of Neurosurgery of our hospital between January 2015 and December 2018. The dual-marker localization technique was used in the hybrid-OR to locate the SDAVFs and skin incision, and the interoperative digital subtraction angiography (DSA) technique was used before and after microsurgical ligation of the fistulae in the hybrid-OR to verify the accuracy of obliteration. The patients were followed for an average of 2 years after the operation, and the preoperative American Spinal Cord Injury Association (ASIA) score and postoperative ASIA score at 6 mo after the operation were compared.RESULTSThe location and skin incision of the SDAVFs were accurately obtained by using the dual-marker localization technique in the hybrid-OR in all patients, and there were no cases that required expansion of the range of the bone window in order to expose the lesions. Intraoperative error obliteration occurred and was identified in two patients by using the intraoperative DSA technique; therefore, the findings provided by the intraoperative DSA system significantly changed the surgical procedure in these two patients. With the assistance of the hybrid-OR, the feeding artery was correctly ligated in all cases, and the intraoperative error obliteration rate decreased from 18.2% (2/11) to 0%. All 11 patients were followed for an average of 2 years. The ASIA score at 6 mo after the operation was significantly improved compared with the preoperative ASIA score, and there were no patients with late recurrence during the follow-up.CONCLUSIONCompared with intra-arterial embolization for the treatment of SDAVFs, hybrid-ORs can solve the problem of a higher incidence of initial failure and late recurrence. Compared with direct occlusion of SDAVFs in microsurgery, hybrid-ORs can take advantage of the intraoperative DSA system for locating the shunt and verifying the obliteration of fistulae in order to reduce the error obliteration rate. At this point, our experience suggests that the safety and ease of use make hybrid-ORs combined with microsurgery and intraoperative DSA systems an attractive modality for dealing with SDAVFs.

Image-guided video-assisted thoracoscopic resection (iVATS): Translation to clinical practice-real-world experience.

ObjectiveWe developed a novel approach for localization and resection of lung nodules, using image‐guided video‐assisted thoracoscopic surgery (iVATS). We report our experience of translating iVATS into clinical care.MethodsMethodology and workflow for iVATS developed as part of the Phase I/II trial were used to train surgeons, radiologists, anesthesiologists, and radiology technologists. Radiation dose, time from induction to incision, placement of T‐bar to incision and incision to closure, hospital stay, and complication rates were recorded.ResultsFifty patients underwent iVATS for resection of 54 nodules in a clinical hybrid operating room (OR) by six surgeons. Fifty‐two (97%) nodules were successfully resected. Forty‐two (84%) patients underwent wedge resection, four (7%) lobectomies, and two (4%) segmentectomy all with lymph node dissection. Median time from induction to incision was 89 minutes (range: 13‐256 minutes); T‐bar placement was 14 minutes (10‐29 minutes); and incision to closure, 107 minutes (41‐302 minutes). Average and total procedure radiation dose were: median = 6 mSieverts (range: 2.9‐35 mSieverts). No deaths were reported and median length of stay was 3 days (range: 1‐12 days).ConclusionsTranslation of iVATS into clinical practice has been initiated using a safe step‐wise process, combining intraoperative C‐arm computed tomography scanning and thoracoscopic surgery in a hybrid OR.

Digital Footprint of Vascular Surgery Training Programs in the United States and Canada

The digital footprint of vascular residency and fellowship programs may have an impact on an applicant's likelihood of selecting a given program. This may include content and accessibility of a particular program's website as well as its social media presence. The goal of this study is to evaluate the online presence of all accredited vascular surgery training programs in the United States and Canada. A list of accredited vascular surgery training programs in the United States was obtained from the Accreditation Council for Graduate Medical Education and the Society for Vascular Surgery websites. Canadian program websites were sourced from the Canadian Society for Vascular Surgery website. Each program website was individually queried. A systematic Google search of each program was carried out to determine website accessibility. Thirty-one individual content and quality metrics were used to appraise the websites. Three major social media platforms (Twitter, Facebook, and Instagram) were individually searched for program profiles. A total of 105 independent vascular surgery fellowship programs in the 5+2 paradigm and 55 integrated vascular surgery residency programs in the 0+5 paradigm were identified in the United States. An additional 10 Canadian programs were also identified, including 10 integrated residency programs and 4 independent fellowships. Ninety-nine percent of integrated residency and fellowship programs were accessible through Google search. Program description was also almost universally available. Significant differences between US and Canadian programs were observed including the mention of salary information (43% vs. 10%, P=0.039), clinic responsibilities (38% vs. 90%, P=0.001), teaching responsibilities (34% vs. 100%, P<0.0001), program director contact information (47% vs. 80%, P=0.045), mention of journal club (52% vs. 100%, P=0.003), research requirements (50% vs. 90%, P=0.014), and past and current research (30% vs. 70%, P=0.009 and 37% vs. 80%, P=0.008, respectively). Additionally, there were significant differences in mention of institutions from which trainees came from (48% vs. 10%, P=0.021), mention of hybrid operating room (42% vs. 100%, P=0.0003), advertised medical student rotations (25% vs. 90%, P<0.0001), and finally social media presence (13% vs. 70%, P<0.0001). The overall digital footprint of the majority of training programs in the United States was small, unlike their Canadian counterparts. Although the vast majority of websites for vascular surgery training programs were accessible via simple internet searches, they lacked information that could have been important to applicants. Additionally, the significant underuse of social media platforms by American vascular surgery programs indicated a potential missed opportunity to target the millennials who make up most of the applicant pool to these programs.

Percutaneous Pulmonary Artery Venting via Jugular Vein While on Peripheral Extracorporeal Life Support.

Peripheral extracorporeal membrane oxygenation (ECMO) setting remains a valid option to treat cardiogenic shock (CS). We investigated a percutaneous approach to unload the left ventricle (LV) while on veno-arterial (v-a) peripheral ECMO support. Between 2017 and 2018, eight patients (three females, mean age: 49.6 years old, and five males, mean age: 58 years old, respectively) suffered refractory CS due to acute myocardial infarction (n = 4), acute myocarditis (n = 2), acute decompensation on chronic heart failure (n = 1), and primary graft failure after heart transplantation (Htx) (n = 1), respectively. After a multidisciplinary CS team discussion, it was decided to proceed with peripheral v-a ECMO placement and percutaneous LV venting via right internal jugular vein access to drain the pulmonary artery (PA), in the hybrid operating room. In a single postcardiotomy case, the PA trunk was vented centrally. Mean ECMO support time was 8.5 days. Seven (87.5%) patients were successfully weaned from ECMO and one (12.5%) successfully bridged to Htx. All patients were successfully discharged after treatment except for a single case who died due to sepsis. In case of not recommended usage of LV apical venting, the adoption of v-a peripheral ECMO support associated with percutaneous PA drainage enables the rapid onset of extracorporeal life support with an effective biventricular unloading.

Early and mid-term results of endovascular treatment of thoracic aorta diseases: a single-center experience

We conducted an analysis to assess early and mid-term outcomes of patients after thoracic endovascular aortic repair (TEVAR) for type B thoracic aorta dissection, descending thoracic aneurysm, or traumatic aortic transection. From January 2016 through December 2018, twenty-seven patients (23 male, 4 female, mean age of 57 years) affected by type B dissection (n = 13 [48.2%]), thoracic aneurysm (n = 9 [33.3%]), and post-traumatic aortic isthmus rupture (n = 5 [18.5%]) were treated using TEVAR with and without left subclavian artery revascularization. All procedures were performed in a hybrid operating room using general (n = 12) or regional (n = 15) anesthesia. A combined brachial artery and bilateral femoral artery access was used in all patients. To achieve adequate proximal thoracic aorta landing zone length, coverage of the left subclavian artery with proximal endovascular plug occlusion was performed in 17 patients (62.9%); including 4 patients undergoing carotid–subclavian artery bypass before TEVAR stent-graft deployment. Primary procedural success rate was 96.3%; 1 patient had a Type Ib endoleak that was treated by distal stent graft extension. Four adverse outcomes occurred in the immediate postoperative period, including 2 cases of left upper arm acute ischemia (7.4%), ischemic stroke (3.7%), and asymptomatic iliac artery dissection (3.7%). During a mean follow-up of 18 months, no graft-related deaths or endoleak occurred. One patient developed symptomatic subclavian steal syndrome 1 month after operation and underwent a left carotid–subclavian artery bypass with symptom resolution. One patient died 6 months after TEVAR due to neoplasm. Our experience indicates TEVAR is a safe and less invasive alternative to open surgery for a spectrum of thoracic aorta diseases, especially for urgent conditions and in patients with high-risk surgical comorbidities.

Real-time image-guided electromagnetic navigation bronchoscopy dual-marker technique to localize deep pulmonary nodules in a hybrid operating room.

Herein, we describe a Dyna-computed tomography-guided electromagnetic navigation bronchoscopy technique aimed at localizing deep pulmonary nodules. The method was implemented in a hybrid operating room and required the use of 2 markers (a near-infrared dye as a surface marker and a microcoil as a deep marker).

Transvenous lead extraction after heart transplantation: How to avoid abandoned lead fragments.

Many patients awaiting heart transplantation (HTX) have a cardiac implantable electronic device (CIED). Lead removal is often still a part of the HTX procedure. Abandoned lead fragments carry a risk for infections and prohibit magnetic resonance imaging (MRI) imaging. This study evaluated the concept of an elective lead management algorithm after HTX. Between 2009 and 2018, 102 consecutive patients with previously implanted CIED underwent HTX. Lead removal by manual traction during HTX was performed in 74 patients until December 2014. Afterward, treatment strategy was changed and 28 patients received elective lead extraction procedures in a hybridoperating room (OR) using specialized extraction tools. Total of74 patients with 157 leads underwent lead extraction by manual traction during HTX. The mean lead age was 32.3 ± 38.7 months. Postoperative X-ray revealed abandoned intravascular lead fragments in 31(41.9%) patients, resulting in a complete lead extraction rate of only 58.1%. The high rate of unsuccessful lead extractions led to the change in the extraction strategy in 2015. Since then, HTX was performed in 28 CIED patients. In those patients, 64 leads with a mean lead age of 53.8 ± 42.8 months were treated in an elective lead extraction procedure. No major or minor complications occurred during lead extraction. All leads could be removed completely, resulting in a procedural success rate of 100%. Our results demonstrate that chronically implanted leads should be removed in an elective procedure, using appropriate extraction tools. This enables complete lead extraction, which reduces the infection risk in this patient population with the necessity for permanent immunosuppressive therapy and allows further MRI surveillance.

Radiation Protection in Hybrid Operating Rooms: Who Takes Care of the Caregivers?

Radiation Protection in Hybrid Operating Rooms: Who Takes Care of the Caregivers?

Radiation Doses to Staff in a Hybrid Operating Room: An Anthropomorphic Phantom Study with Active Electronic Dosimeters

To quantify the effects of different imaging settings on radiation exposure to the operator and surgical team in a hybrid operating room (OR). Measurements to determine scatter radiation in different imaging and geometry settings using an anthropomorphic phantom were performed in a hybrid OR equipped with a robotic C arm interventional angiography system (Artis Zeego; Siemens Healthcare, Erlangen, Germany). The radiation dose (RD) was measured with seven calibrated Philips DoseAware active electronic dosimeters and a Raysafe Xi survey detector, which were placed at different locations in the hybrid OR. The evaluated set ups included low dose, medium dose, and high dose fluoroscopy for abdomen; fluoroscopy fade; roadmap; and digital subtraction angiography (DSA), all using 20s exposures. The effect of magnification, tube angulation, field size, source to skin distance, and RADPAD protection shields were assessed. Finally RD during cone beam computed tomography (CBCT) was obtained. In the operator position the initial settings with low dose fluoroscopy caused a RD of 1.03μGy. The use of fluorofade did not increase the radiation dose (1.02μGy), whereas the roadmap increased it threefold (2.84μGy). The RD with "normal fluoro" was 4.13μGy and increased to 6.44μGy when high dose fluoroscopy mode was used. Magnification or field size varying from 42cm to 11cm led the RD to change from 0.86μGy to 2.10μGy. Decreasing the field of view to 25% of the initial size halved the RD (0.48μGy). The RDs for the left anterior oblique 30° and right anterior oblique 30° were 3.26μGy and 1.63μGy, respectively. DSA increased the cumulative dose 33 fold but the RADPAD shield decreased the DSA RD to 4.92μGy. The RD for CBCT was 47.2μGy. Radiation exposure to operator and personnel can be significantly reduced during hybrid procedures with proper radiation protection and dose optimisation. A set of six behavioural rules were established.

Simultaneous endovascular aortic aneurysm repair and transcatheter aortic valve implantation in the hybrid operating room

Simultaneous endovascular aortic aneurysm repair and transcatheter aortic valve implantation in the hybrid operating room

Technical considerations and challenges in treatment of a ruptured PICA aneurysm in a morbidly obese patient

Morbid obesity presents unique challenges in the treatment of many neurosurgical conditions. In ruptured posterior circulation aneurysms, endovascular treatment has emerged as the safest and most efficacious treatment modality in the majority of cases. We present a technical report of a patient with extensive subarachnoid hemorrhage from a ruptured distal PICA aneurysm. The patient was taken to the hybrid OR with biplane fluoroscopy, utilizing a unique operative set-up to enable safe endovascular treatment. The PICA aneurysm was treated via a transradial approach with distal PICA occlusion using Onyx liquid embolysate. The patient remained neurologically intact and was discharged home after 14 days. This case illustrates a number of technical adjustments that may be made in the safe treatment of patients in whom obesity otherwise limits treatment options.

Leadership and change management in advancing hybrid operating rooms into interventional cardiology in hospitals within the National Health Service

Hybrid operating rooms (HORs) constitute a new advancement in cardiology where endovascular surgeons join cardiologists to perform more complex operations in an integrated care system.1 The adoption of this advancement is in line with the 10-year plan of the NHS where more funding is being provided for measurable improvement and commitment for enhanced service.1 Cardiac diseases continue to pose a challenge to the NHS where increased survival of chronically managed conditions continues to be more prevalent.2 This research would design a model to allow …

Clinical efficacy of parallel clipping technique in the treatment of complex middle cerebral aneurysms in hybrid operation rooms

Objective To explore the outcome of parallel clipping technique in the treatment of complex middle cerebral aneurysms in hybrid operation rooms. Methods A retrospective analysis was conducted on the clinical data of 13 patients with MCA complicated aneurysm admitted to Department of Neurosurgery, Nanfang Hospital of Southern Medical University from January 2015 to February 2019. All patients underwent a unilateral craniotomy with transpterional approach in the hybrid operating room. Multiple aneurysm clips were used to clip the aneurysm during the operation. Of the 13 patients, 7 were ruptured aneurysms, 4 were Hunt-Hess grade Ⅰ, 1 were Ⅲ, and 2 were Ⅳ; 6 were unruptured aneurysms. There were 19 aneurysms in 13 patients, of which 5 were single MCA aneurysms, 1 was bilateral MCA aneurysms, and the remaining 7 patients were single MCA aneurysms. The aneurysm embolization was evaluated by Raymond classification, and the clinical outcome was evaluated by modified Rankin Scale (mRS) criteria. Results Thirteen patients with 19 aneurysms underwent successful clipping. A total of 60 aneurysm clips were used. For each aneurysm, we used 1 to 6 (3.2 ± 1.6) clips. After aneurysm clipping, intraoperative angiographic review revealed clipping insufficiency (Raymond grade II) in 4 aneurysms, and 2 patients with parent aneurysm stenosis. After adjustment of the aneurysm clip, all aneurysms were completely occluded (Raymond grade Ⅰ) and the parent aneurysm had no stenosis. Only one patient developed postoperative cerebral infarction in the basal ganglia and slight hemiplegia resulting from occlusion of a branch emanating from the aneurysm wall. At discharge, the mRS was 0 in 10 patients, 2 in 2 patients, and 5 in 1 patient. Thirteen patients were followed up for 6 to 36 months (median: 17.3 months). The mRS was 0 in 10 cases, 1 in 2 cases, and 4 in 1 case. In 6 cases of re-examination, none of the aneurysms recurred. Conclusion The use of multiple aneurysm clips in the hybrid operating room to shape and clamp MCA complex aneurysms is effective and has few complications. Key words: Intracranial aneurysm; Middle cerebral artery; Microsurgery; Parallel clipping technique; Hybrid surgery