Everything is for the “safest” surgeries:
Hybrid Operating Room

The most widely seen types of cancer in the world are lung, breast, bowel, prostate and skin cancers respectively. In Turkey, women generally suffer from breast, lung, thyroid and bowel cancers whereas men suffer more from lung, prostate and colorectal cancers. Anadolu Medical Center Medical Oncology Specialist Prof. Dr. Şeref Kömürcü has indicated that on average 200,000 new cancer diagnoses are made every year. Here are his tips for cancer patients to protect themselves against coronavirus:

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• Less surgical traumas
• Smaller incisions
• Shorter operation times
• Less blood loss
• Less complications
• Fewer duration of stay in hospital
• Less cost

Anadolu Medical Center
Director, Department of Neurosurgery
Professor Dr. Serdar Kahraman
"Hybrid operating room is a term used for the new types of operating rooms in which advanced medical imaging systems and medical devices can be used together simultaneously..."

Anadolu Medical Center
Neurosurgery Specialist
Assoc. Dr. Selçuk Göçmen
"Thanks to the special operating microscope combined with Neuro-navigation, we can remove the tumor with a smaller incision to minimize mistakes."

One of the areas most benefited from the advances in technology is medicine. Therefore, we are come across more comfortable and more reliable treatments every day. We are indebted to the advancements in science and medical technology, especially in recent years, such as intelligent diagnosis and treatment methods, imaging devices or robotic surgery, which is one of the most important milestones in surgery. These technologies are now an integral part of operating rooms, and introduces us to a completely different format of the operating room: “Hybrid Operating Room”. We asked the specialists about hybrid operating rooms, which draw attention with their advanced technological equipment and the advantages brought by this equipment to both surgeons and patients and to share those with you in our Vital magazine. Director of Department of Neurosurgery of Anadolu Medical Center, Prof. Dr. Serdar Kahraman and Neurosurgery Specialist Assoc. Dr. Selçuk Göçmen have provided an insight for hybrid operating rooms…

EVERYTHING IS TOGETHER IN THIS ROOM!

“Hybrid Operating Room” is a concept for the new operating room type where advanced medical imaging systems and medical devices can be used together. In fact, it started in 1970s with the use of mobile x-ray devices (C-arm fluoroscopy) in the operating rooms, but today it has reached to a whole new level. Today, following the introduction of mobile computed tomography (CT) and magnetic resonance (MR), today with the introduction of neuro-navigation which determines the operation target and neuro-monitorization device (monitoring the operation processes in the brain and nerve function), we can say that it has fully reached the hybrid concept. With the addition of the operating microscopes with special fluorescent filter integrated and navigation systems, the separation of tumors from normal nerve tissues is now easier. In other words, microscopes are now also included in the concept of “hybrid”. Apparently, with the advances in medical technology of the near future, hybrid operating rooms may have new guests with the technological patient comfort they provide…

When we look to previous years, we see that the development of minimally invasive surgical techniques and the development of hybrid operating rooms are parallel to each other in Turkey and in the world. Therefore, the most difficult and problematic complex operations have become more secure. This means significant advantages for both patient and doctor such as less surgical trauma, smaller incision, shorter operation duration, less blood loss, less complications, less duration of stay, less cost.

HYBRID OPERATING ROOM IN BRAIN SURGERY

In brain, spinal cord and spine surgeries, hybrid operating rooms are used for many disease groups and trauma surgery. Some examples are; Aneurysm (bubble), Arteriovenous neurovascular surgery of brain or spinal cord diseases such as malformation (AVM), brain tumor or functional stereotactic surgery and spinal implantation surgery. Now, let us take a look at the next generation technology devices in hybrid operating rooms used by brain and spinal cord surgeons and what they provides for patients and surgeons.

O-ARM CT (O-ARM TOMOGRAPHY)

Mobile tomography allows immediate filming during operation

Computed tomography can be filmed during the operation with the mobile tomography device which is a new generation imaging system. With this technology, 2 or 3-dimensional imaging can be performed in both brain and spine-spinal surgery. Moreover, in a three-dimensional 360 ° angle it takes less than 13 seconds. The system also has robotic positioning. By this way, the device can be brought closer to the patient and tomography can be imaged very quickly in the operating room. An important advantage of this can be described as follows: since it takes only one image at a time, the images with the same image quality can be viewed throughout the surgery with one third radiation amount when compared with other standard tomography devices. It is especially used in surgeries including;

• Spinal deformities due to aging
• Pressures in the spinal canal
• Spine tumors
• Childhood and youth spine curvatures
• Some developmental diseases of the spine
• Screwing in fractures and dislocations due to trauma (platinum placement)

The place where the screw should be placed in the spine varies according to the anatomical region but should be determined with 1-2 mm accuracy. Until recently, spine screwing operations were performed with a C-arm and 2-dimensional X-ray machine called “scopy”. In these surgeries, the patient could be re-operated due to the possibility of the screws going into an undesirable area, which increased the risk of infection and length of hospitalization. However, the success rate of screwing operations performed with O- Arm CT technology, increases with 3-dimensional tomography image and the margin of error is reset. O-Arm-CT is compatible with all targets highly neuronavigation system and can have a precision operation which can further increase the chance of success. Therefore, with a sensitivity of 1-2 mm, the risk of injury to the spinal cord and nerve roots is almost eliminated and a safer operation is performed.

Thanks to the O- Arm CT system, undesirable situations that require re-operation of the patient (for example, screw entering the wrong place in spine screwing operations, blood accumulation in the operation area in brain surgeries) are minimized by taking tomography under sterile conditions at the final stage of the surgery.

To summarize the advantages of spine screwing operations performed with O- Arm device:

• It gives the surgeon critical information at every stage, reducing the risk of recurrence.
• The patient is exposed to less amount of radiation.
• With a smaller surgical incision, patients have a faster recovery time and bleeding decreases.
• The system minimizes the great risks of complex operations.
• Reduces the risk of infection. The risk of screw-related stroke is reduced to the lowest rate.

NEURO-NAVIGATION SYSTEM

Navigation that recognizes all the pathways of the brain

It calculates the coordinates of the surgical site and reaches the target with minimal deviation. Thus, the risk of death or injury is minimized. The new generation of neuronavigation, the which is “direction finding or orientation” system, calculates the coordinates with a system similar to GPS technology for a target within the brain or spinal cord surgery and enables the surgeon to see the 3-dimensional scanned images. Neuronavigation, which is a high-end computer technology, approaches the targeted lesion in neurosurgery with a high degree of accuracy (less than 1 mm). This, of course, can minimize the damage to healthy tissue during surgery. In this method, the patient's MRI and/or CT is taken and transferred to the navigation device before surgery. Thus, during surgery, real-time navigation of the patient's brain and spine can be visualized and planning is made accordingly.

This method can be used together with other technologies or it can be used by itself only. Stereotaxic biopsy can be performed in all cases with small and deeply located tumors and with the help of a small entrance hole. In other words, a thin needle reaches directly to the region in millimeters and tissue samples are taken. And, of course, the pathological examination of this tissue sample determines which treatment method will be used for the treatment of patient.

Advantages

• It moves perfectly on sensitive anatomy and avoids critical structures.
• Surgery is performed at a more minimally invasive margin (with a small surgical incision, the operation time is shorter).
• It provides safer surgery without disrupting the patient's healthy anatomy.

NEW GENERATION FLUORESCENT FILTER MICROSCOPE

Removing tumor tissue from normal tissue

As it is known, the treatment of brain and spinal cord tumors is microsurgery. The major difficulty in this surgery is the separation of tumor tissue from normal tissue. Achieving this by using a standard normal surgical microscope can sometimes be problematic. However, with new generation microscopes, special light filters, eg fluorescent stains, tumor tissue can easily be distinguished from normal nerve tissue. Therefore, a special surgical microscope combined with neuronavigation allows a small incision to maximize tumor removal with minimal error.

This system is present only in certain hospitals within Turkey and it is used for cerebrovascular operations in addition to tumor operations. For example, a special substance is given to the patient intravenously during surgery and the microscope filter can be adjusted so that the vessels of the brain can be seen, that is, angiography of the brain. In this way, the vascular network of the brain is monitored before the end of the surgery. This increases the chance of a more secure surgical treatment of cerebrovascular disorders.

INTRAOPERATIVE NEUROMONITORIZATION

Critical points of the brain are broadcast live on the screen!

It is a system that provides continuous monitoring of the brain, spinal cord, nerve roots and reflex pathways by electrodes placed on the muscles of the patient's scalp during the surgery in order to minimize the damage (risk of stroke) of the nerves that may develop due to brain tumor and spine surgeries. The system warns the surgeon when there is a change in the values ​​followed by the neurologist throughout the surgery. Thus, the patient is prevented from developing irreversible damage (such as paralysis), thus also preventing the reducing the quality of life. The patient can return home and work in a short time.

What will happen in the near future?

Robotic surgery, which has already been activated in some branches, will spread more in the future. Thus, the concept of minimally invasive surgeries will become more and more effective with the advanced technology. The concept of hybrid operating room includes not only emerging technologies, but also advances in artificial intelligence applications. Therefore, we can foresee that artificial intelligence applications will maximize patient safety and treatment success in the near future in the process from diagnosis to treatment.