text: Hybrid operating room: Clinical applications :Ajmer Singh, The Indian Anaesthetists' Forum EDITORIAL
  : 17 | Issue : 2 | Page : 35--36
  Ajmer Singh Department of Cardiac Anesthesia, Institute of Critical Care and Anesthesiology, Medanta-The Medicity, Gurgaon, Haryana, India
  Ajmer SinghDepartment of Cardiac Anesthesia, Institute of Critical Care and Anesthesiology, Medanta-The Medicity, Gurgaon - 122 001, Haryana India
  Singh A. Hybrid operating room: Clinical applications.Indian Anaesth Forum 2016;17:35-36
  Singh A. Hybrid operating room: Clinical applications. Indian Anaesth Forum [serial online] 2016 [cited 2017 Mar 30 ];17:35-36
  Available from: http://www.theiaforum.org/text.asp?2016/17/2/35/195950
  Full TextA hybrid operating room (OR) is a surgical theater that is equipped with advanced imaging facilities such as fixed C-arms, computed tomography (CT) scanner, or magnetic resonance imaging scanner.[1] Hybrid OR requires either an OR with a high-resolution imaging capacity or an interventional suite with appropriate OR features. An essential component of the infrastructure of a modern health-care system, hybrid OR, is increasingly being recognized by clinicians for its clinical applications and potential benefits. Clinical applications of hybrid OR are described mainly in cardiac, vascular, thoracic, neurosurgery, and trauma surgery [Table 1]. With documented improvement in patient outcome, the indications for hybrid procedures are increasing. For most cardiovascular procedures, amalgamation of interventions and surgery under a single anesthetic exposure can lead to elimination of staging between procedures, better resource utilization, reduction of cardiopulmonary bypass time, and improved patient safety and outcome.[2]{Table 1} Conventional fluoroscopy is used to guide the progression of catheters or devices and typically requires high frame rate (30 f/s, 50 Hz) and high power output (80 kW) to image a moving heart. In rotational angiography technique, C-arm is rotated around the patient to obtain CT-like three-dimensional (3D) images, and these 3D images can be overlaid on the top of the 2D fluoroscopic images. This technique is helpful during the deployment of fenestrated stent graft for abdominal aortic aneurysm to know the exact position of renal artery ostia. Similarly, for optimal implantation of transcatheter aortic valve implantation, exact perpendicular angle to the aortic root is vital to avoid possible complications such as compression of coronary ostia.Because of the size, complexity, and cost factors, all stakeholders in the hospital (surgeons, interventional cardiologists/neurologists/radiologists, anesthesiologists, and others) must plan and design the hybrid OR carefully for its optimal use. A hybrid suite should be large enough (at least 70 m2 ) to accommodate at least 8-20 people, robust enough to bear additional weight of imaging system (approximately 650-1800 kg), and should have a lead shielding of 2-3 mm. OR lights must be centrally located above the table, at least 2 or 3 in number for optimal illumination of surgical field, suspended without obstructing other equipment yet allowing independent swivel movement, and may have additional modular features such as camera or video facility. C-arm system can be fixed on the floor, the ceiling (monoplane), or both (biplane). Biplane system is the system of choice for pediatric cardiologists, electrophysiologists, and neurointerventionalists. The disadvantages of ceiling-mounted system include increased risk of infection (dust particles may fall in the wound) and obstruction of laminar airflow. Monoplane system mounted on the floor is preferred for cardiac surgery [Figure 1]. The OR table used primarily by interventionalists must be radiolucent (covered with carbon fiber tabletop), nonbreakable, and should allow coverage of the entire body. A breakable or segmented tabletop is preferred by orthopedic surgeons, urosurgeons, and neurosurgeons for flexible patient positioning. Monitors should be placed to allow surgeons, anesthesiologists, and interventionalists to visualize the angiographic images and hemodynamic parameters simultaneously.[3] All personnel working in a hybrid OR must wear thermoluminescent dosimeter badge to measure the ionizing radiation exposure. Minimum possible radiation must be used for the protection of both the patient and medical staff, and modern software technology can be used to enhance image quality postprocessing. The lead aprons protecting the thyroid, sternum, and gonads cover only 82% of the active bone marrow. The greatest protection is provided by keeping oneself at least 3 feet away from the source of ionizing radiation by wearing lead aprons that cover both front and back and by keeping lead screens in front of the source of radiation.[4] The anesthesiologist must have an unobstructed access to the patient, patient's airway, breathing circuit, intravenous/invasive lines, and resuscitation equipment.{Figure 1}In the future, the use of hybrid procedures and hybrid OR is expected to grow with the evolution of technology. Miniaturization of OR equipment will create more working space and a more efficient work environment.
  References1Georg N, Sabine W, Anne F. The Cardiovascular Hybrid OR-Clinical & Technical Considerations. CTSnet; 12 March, 2010. Available from: http://www.ctsnet.org/article/cardiovascular-hybrid-or-clinical-technical-considerations. [Last retrieved on 2014 Jan 27].
  2Singh A, Mehta Y, Parakh R, Kohli V, Trehan N. Role of hybrid operating room in surgery for the right atrial thrombus, pulmonary thrombi, and ventricular septal rupture after myocardial infarction. Ann Card Anaesth 2016;19:717-721.
  3Kaneko T, Davidson MJ. Use of the hybrid operating room in cardiovascular medicine. Circulation 2014;130:910-7.
  4Katz JD. Radiation exposure to anesthesia personnel: The impact of an electrophysiology laboratory. Anesth Analg 2005;101:1725-6.