The Concept of a Hybrid Operating Room: Applications
in Cerebrovascular Surgery
Javier Fandino, Philipp Taussky, Serge Marbacher, Carl Muroi, Michael Diepers, Ali-Reza Fathi, and Luca Remonda
Abstract The use of intraoperative digital substraction
angiography (iDSA) is a tool in cerebrovascular surgery.
According to recent studies, iDSA has been shown to alter
surgical treatment in approximately 12% of cases. Moreover,
it has been demonstrated that even experienced cerebrovascular surgeons might not accurately predict the need for
iDSA. Intraoperative DSA prevents unnecessary surgical
manipulations after occlusion of aneurysms and accurately
demonstrates occlusion rates. We present our preliminary
experience using routine iDSA within the concept of a
hybrid operating room for cerebrovascular surgery. A total
of 99 patients underwent iDSA in our hybrid operating
room. Indications included intraoperative evaluation of
occlusion rate of clipped aneurysms and patency of vicinity
vessels (n = 82), chemical angioplasty with papaverin
(n = 4), and balloon angioplasty (n = 1). In four (5%) patients,
a reposition of the clip was needed due to neck remnant and
perfusion of the aneurysm sack after clipping. A total of
five cases underwent combined microsurgical and endovascular treatment of ruptured aneurysms and arteriovenous
malformations (AVMs). The concept of a hybrid operating
room has been considered in the planning and design of
operation rooms dedicated to cerebrovascular surgery.
Hybrid procedures combining endovascular with microsurgical strategies within the same surgical session are feasible
and safe. These procedures are associated with cost-benefit
advantages.
Keywords Intraoperative angiography • Cerebrovascular
surgery • Hybrid operation room
J. Fandino, M.D. (), P. Taussky, M.D., S. Marbacher, M.D.,
C. Muroi, M.D., M. Diepers, M.D., A.-R. Fathi, M.D.,
and L. Remonda, M.D.
Department of Neurosurgery and Institute of Neuroradiology
(MD, LR), Kantonsspital Aarau,
Tellstrasse, 5001 Aarau, Switzerland
e-mail: javier.fandino@ksa.ch
Introduction
Intraoperative digital subtraction angiography (iDSA) is still
a rarely applied tool in cerebrovascular surgery. In recent
studies, iDSA has been shown to alter surgical treatment in
approximately 12% of cases [1–4]. It prevents unnecessary
surgical manipulations after occlusion of aneurysms and
accurately demonstrates occlusion rates. The introduction of
iDSA within a hybrid operation room enables the combinations of endovascular and microsurgical techniques in cerebrovascular surgery. We present our experience and concept
of a hybrid operating room for interdisciplinary treatment of
cerebral aneurysms and arteriovenous malformations
(AVMs).
Materials and Methods
The hybrid operating room is defined as a surgical theater
that enables the combination of endovascular and surgical
treatment of cerebrovascular pathologies and the use of
interventional tools such as temporary occlusion during clipping in a single procedure. In our experience, the combination of mono- or biplanar angiography apparatus with
standard surgical tables is crucial to allow standard positioning of the patient during surgery. The surgical table
(Alphamaquet 1150, Maquet AG, Switzerland) and C-arm
(Xper FD20, Philips, Netherlands) are coupled, and a collision alarm system prevents independent or uncontrolled
movements of the table or C-arm. The carbon fiber top of the
table is 360 radio translucent. Radiolucent head pins and
head holders are required for optimal acquisition of angiograms and intraoperative CT scans. Surgical personnel have
been trained to assist endovascular procedures. Neurosurgeons
are responsible for all technical issues during the procedures.
This setting allows the utilization of the operating room by
vascular surgeons and other surgical specialties with or without performance of angiograms (Fig. 1).
M. Zuccarello et al. (eds.), Cerebral Vasospasm: Neurovascular Events After Subarachnoid Hemorrhage,
Acta Neurochirurgica Supplementum, Vol. 115, DOI 10.1007/978-3-7091-1192-5_24, © Springer-Verlag Wien 2013
113
114
J. Fandino et al.
Fig. 1 The hybrid operating room allows combined microsurgical and
endovascular approaches in cerebrovascular surgery. Radiolucent head
pins and head holders are necessary for high-quality intraoperative
imaging, which includes intraoperative digital substraction angiography (iDSA) and three-dimensional computed tomographic angiography
(3D-CTA)
Results
occlusion of an aneurysm (anterior communicating aneurysm) could be documented. In this case, reposition of the
clip was unsuccessful in reaching a total occlusion of the
aneurysm, and the postoperative follow-up conventional
angiogram and coiling of the remnant aneurysm were
uneventfully performed. All endovascular aneurysm embolizations were successful; in two cases, coiling of ruptured
aneurysms was performed after emergency craniotomy for
evacuation of an intracerebral hematoma. A total of five
cases underwent combined microsurgical and endovascular
treatment of ruptured aneurysms and AVMs. Three illustrative cases are presented (Figs. 2, 3, and 4).
A total of 99 patients underwent operations in our hybrid
operating room. Indications included intraoperative evaluation of occlusion rate of clipped aneurysms and patency of
vicinity vessels (n = 82), chemical angioplasty with papaverin
(n = 4), balloon angioplasty (n = 2), and primarily endovascular coiling with option of neurosurgical intervention (n = 4).
In four (5%) patients, a reposition of the clip was needed due
to neck remnant and perfusion of the aneurysm sack after
clipping. In one case, the clip was repositioned due to occlusion of a vessel near the aneurysm. In one case, a suboptimal
The Concept of a Hybrid Operating Room: Applications in Cerebrovascular Surgery
115
Fig. 2 Illustrative case 1. Acute
subdural hematoma after
aneurysm rupture of a left
posterior communicating artery
aneurysm (arrow). The patient
underwent emergency craniotomy for evacuation of the
hematoma followed by coiling of
the aneurysm. The duration
between hospital admission and
final angiogram was 4 h
Fig. 3 Illustrative case 2. Combined endovascular and microsurgical
treatment of a right temporal arteriovenous malformation (AVM). After
embolization of two main feeders, complete resection of the AVM
could be achieved. Postinterventional angiogram and computed tomography (CT) showed no remnant of the AVM
116
J. Fandino et al.
Fig. 4 Illustrative case 3. Combined endovascular and microsurgical
treatment of a complex recurrent right internal carotid artery (ICA)
aneurysm treated in the 1970s (a–c). Primary endovascular occlusion
was not possible (d). The aneurysm was clipped using a left-sided pte-
rional approach under endovascular temporary occlusion of the right
anterior communicating artery (ACA) (e–g). The remnant aneurysm
could be coiled (h, i). No postoperative neurological deficit could be
documented
Discussion
combined procedures and facilitate the surgical processes.
Finally, we consider it crucial that the neurosurgeon be trained
for operating all the equipment installed in the hybrid operating room, including the angiogram apparatus and software
for the acquisition and evaluation of three-dimensional rotational angiography.
Intraoperative imaging in neurosurgery allows the early
identification of complications and optimizes the treatment
objectives. Intraoperative DSA [1–4] and near-infrared indocyanine green video angiography for the assessment of vascular flow during cerebrovascular surgery have contributed
to safety and the prevention of severe complications during
cerebrovascular procedures [5]. The concept of a hybrid
operating room not only allows the performance of routine
iDSA in all cerebrovascular procedures but also opens the
possibility for combined approaches in a sterile environment.
Both microsurgical and endovascular techniques can be
applied to achieve excellent results and prevent complications, whose possible causes might be detected during surgery. From our point of view, the following important issues
have to be included in planning for a hybrid operation room
for cerebrovascular procedures: location, table, multidisciplinary application, operating room technicians, and surgeon’s capability for operating the equipment. The hybrid
operating room should be planned within the concept of a
conventional surgical environment that allows sterile procedures and personnel flexibility. According to our experience,
a surgical table that allows all standard positions is crucial not
only for neurosurgeons but also for other surgical specialties;
this can contribute to optimal utilization of the operation
room during the slots when neurosurgical procedures are not
planned. In our concept, operating room technicians have to
be trained for endovascular techniques to integrate them in
Conclusion
The concept of a hybrid operating room should be considered in the planning and design of operating rooms dedicated
to cerebrovascular surgery. Hybrid procedures combining
endovascular with microsurgical strategies in the same
surgical session are feasible and safe and have cost-benefit
advantages.
Conflicts of Interest Statement The authors do not have financial
interests with the manufacturing companies of the equipment mentioned in this manuscript.
References
1. Alexander TD, Macdonald RL, Weir B, Kowalczuk A (1996)
Intraoperative angiography in cerebral aneurysm surgery: a prospective study of 100 craniotomies. Neurosurgery 39:10–17,
discussion 17–18
The Concept of a Hybrid Operating Room: Applications in Cerebrovascular Surgery
2. Barrow DL, Boyer KL, Joseph GJ (1992) Intraoperative angiography in the management of neurovascular disorders. Neurosurgery
30:153–159
3. Klopfenstein JD, Spetzler RF, Kim LJ, Feiz-Erfan I, Han PP,
Zabramski JM, Porter RW, Albuquerque FC, McDougall CG, Fiorella
DJ (2004) Comparison of routine and selective use of intraoperative
angiography during aneurysm surgery: a prospective assessment.
J Neurosurg 100:230–235
117
4. Chiang VL, Gailloud P, Murphy KJ, Rigamonti D, Tamargo RJ
(2002) Routine intraoperative angiography during aneurysm surgery.
J Neurosurg 96:988–992
5. Raabe A, Beck J, Gerlach R, Zimmermann M, Seifert V (2003)
Near-infrared indocyanine green video angiography: a new method
for intraoperative assessment of vascular flow. Neurosurgery
52:132–139, discussion 139