May 2017Spotlight feature

Surgery + imaging in one room = Safer, more effective procedures

New hybrid surgical suite saves time, hastens recovery

If a stripped-down term like “hybrid surgical suite” doesn’t quite convey the game-changing versatility or sophistication of the JGH’s newest operating room, here’s a suggestion: Just think of it as the Swiss army knife of surgical facilities.

“Tool” number 1 is its suitability for vascular surgery. Number 2 is the way it can handily accommodate cardiac surgery.

Yet a third—and, by far, the most important—is its ability to handle on-the-spot radiological imaging, such as x-rays. Hence the “hybrid” designation, which describes a space that can accommodate surgical as well as imaging procedures to make treatment safer and easier for patients, as well as faster and more efficient for staff.

In the hybrid surgical suite, Dr. Emmanuel Moss explains how he uses the surgical robot (at rear) to perform minimally invasive cardiac surgery. Small instruments are attached to the machine’s numbered arms, which Dr. Moss guides by manipulating the controls on a special console.

In the hybrid surgical suite, Dr. Emmanuel Moss explains how he uses the surgical robot (at rear) to perform minimally invasive cardiac surgery. Small instruments are attached to the machine’s numbered arms, which Dr. Moss guides by manipulating the controls on a special console.

Gone are the days when certain patients would have to undergo surgery in one operating theatre, only to endure the discomfort and delay of being moved to an entirely different room for imaging, sometimes as much as a day or two later.

The new $4 million suite, which received funding from the provincial government and from generous donors through the JGH Foundation (see sidebar), is now one of the few such facilities in North America. It has been active in Pavilion K since November, enabling vascular surgeons to rely on 3D imaging software to guide their movements on a giant screen and to verify their work in real time.

At the same time, says Dr. Daniel Obrand, Chief of Vascular Surgery, the surgical team has been enhanced by the arrival of Dr. Jason Bayne to develop the advanced endovascular program, which enables aneurysms (excessive enlargement of part of an artery where its wall has become weaker) to be repaired through small groin incisions, instead of large chest and abdominal incisions.

A simplified system

As for cardiac surgeons, there’s no longer any need for them to transport heart-surgery patients to a cardiac catheterization lab for the implantation of stents or for other procedures that involve imaging. Instead, as soon as surgery (including the robot-assisted variety) is completed in the hybrid suite, interventional cardiologists can position their imaging equipment at the same operating table and proceed to unblock or repair a patient’s damaged blood vessels.

Less than three weeks after undergoing a minimally invasive, robot-assisted coronary bypass in the hybrid surgical suite, Kelly Gheyara relaxes in the JGH’s Carrefour Lea Polansky and discusses his diagnosis, operation and speedy recovery.

Less than three weeks after undergoing a minimally invasive, robot-assisted coronary bypass in the hybrid surgical suite, Kelly Gheyara relaxes in the JGH’s Carrefour Lea Polansky and discusses his diagnosis, operation and speedy recovery.

“The first case we did here was a very difficult angioplasty,” Dr. Obrand recalls. “I’m convinced that if I’d had to do it with the old technology, I wouldn’t have been successful. I wouldn’t have been able to see what I needed to see.”

In fact, the adaptability of the hybrid surgical suite enabled the JGH to make history in February, becoming the first hospital in Quebec where just a single surgical session was required for a robot-assisted coronary bypass—performed by Dr. Emmanuel Moss—and the insertion of stents to prevent blockages in the patient’s coronary arteries.

“This will become a larger part of how we do things from now on,” Dr. Moss predicts. “It may not be the best fit for every patient, but wherever it’s appropriate, we intend to use it.”

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One patient’s story

It was certainly a good fit for Kelly Gheyara, the 73-year-old, history-making patient who was treated by Dr. Moss for breathlessness, caused by a blockage in his left anterior descending artery. Mr. Gheyara, a Professor of Accounting at Concordia University’s John Molson School of Business, had once enjoyed swimming two to three kilometres a day, but last year he found himself unable to climb stairs or walk more than a short distance.

“My father had a heart condition, too,” he says, “and every morning he would wake up and ask, ‘Where am I—in this world or in the one beyond?’ There were times when I had that same feeling.”

Last summer, Mr. Gheyara met with his cardiologists, Dr. David Langleben and Dr. Dominique Joyal, who suggested using the imaging capabilities of the hybrid surgical suite to insert the stents right after Dr. Moss completed the robot-assisted bypass.

Since the newly completed suite had not yet seen active duty (except for training sessions), there was some question as to how smoothly it would run in this instance. “When I woke up from the operation, Dr. Moss came to me with a big grin, and then Dr. Joyal and Dr. Langleben, so I knew they had done it,” Mr. Gheyara says, with a broad smile of his own.

“I was relieved that I didn’t need to have open-heart surgery. And frankly, I also don’t think I would have gone through with an angiogram two or three days after the cardiac operation. It would have been too stressful for me.”

As a further bonus, Mr. Gheyara was delighted to be sent home a mere four days after the operation. By late February, about three weeks after the procedures in the hybrid suite, he was climbing stairs, walking moderate distances and preparing to resume swimming—a recovery he calls “unbelievable, like science-fiction. I’m so impressed and thankful that everybody gave me so much attention and care.”

Working in three dimensions

What is perhaps most technologically impressive about the hybrid suite is the use of 3D imaging during vascular surgery, often to repair an aneurysm. To have a vascular problem diagnosed, the patient undergoes a CT scan, which produces a conventional 2D view of the affected area. However, before the operation in the hybrid suite, special software transforms the 2D picture into a 3D image that is displayed on a giant screen alongside the operating table. Then the patient’s position on the table is exactly matched with the 3D image on the screen.

During the operation, surgeons use a highly advanced x-ray fluoroscope (known as a C-arm) to rotate in any position around the patient. This causes the 3D image on the screen to rotate in a similar fashion, clearly displaying even hard-to-see details of the patient’s anatomy.

The third dimension is especially valuable for vascular surgery, in which a thin wire sometimes needs to be threaded through the tiny branches of the arterial system, Dr. Obrand explains. During an operation, surgeons who use conventional techniques may initially think the wire has been successfully inserted, but they may discover it is actually a few centimetres away from the target. By using the reconstructed 3D image, the exact positions of the wire and the artery are clear, and this greatly simplifies the threading process.

The result, Dr. Obrand says, is a far more efficient procedure, during which patients spend less time under anesthesia and, like staff, are exposed to less of the radiation that’s needed to create the vastly superior on-screen images. As well, new images are available almost instantly, unlike previous operations that ground to a halt while the patient was transported to the cardiac catheterization lab to be x-rayed.

“Before, we basically had to pack up the whole operating room and invade the cath lab,” says Nurse Karen Williams, a Team Leader in Vascular Surgery. “Not only was it time-consuming, it was difficult for the patient and tiring for staff.

“And if we happened to be missing some tool or other piece of equipment, we had to run back to the operating room, and then back down to the cath lab—and some of us were in lead aprons!” In the current setup, surgical supplies can be acquired in a matter of seconds from a sterile storage area that’s directly accessible from the operating room.

Anticipating the unexpected

Anna Pevreal, Associate Director of Nursing for Surgery, says nurses in the hybrid suite “are now able to better anticipate any sudden changes in procedure and to deal with them more quickly.

“The room also comes with a dosimeter that monitors radiation and alerts team members if they may be exposed to unnecessary radiation. These and other factors have definitely increased job satisfaction not just in nursing, but for the entire team. I truly believe that this has a direct and positive influence on the overall experiences of our patients.”

The design and installation of the hybrid suite was a major, multi-year project within the broader construction of a series of new operating rooms in Pavilion K (which opened in January 2016). Involved in the suite’s complex planning process, which began in 2013, was a multi-disciplinary group that included vascular and cardiac surgeons, nurses, the cardiac catheterization team, anesthetists, respiratory therapists, perfusionists, radiologists, biomedical engineers, IT specialists and architects.

To determine how to best organize the suite, Ms. Williams says she and certain members of the group visited four hospitals in Canada and the United States, where they spoke to staff about what worked and what didn’t in their own suites. In addition, they incorporated useful features from the JGH’s own cardiac catheterization lab.

Particularly difficult was the positioning of the 10 ceiling booms, the carefully calibrated metal arms that hang from above, allowing staff to effortlessly swing the giant video screen and other equipment into place at the operating table.

Forging tighter links between cardiologists and cardiac surgeons

Ask yourself if this makes sense: A patient is rushed to the Emergency Department with a heart attack and is seen by a cardiologist. The cardiology team determines that the best course of action is a bypass operation. But once the patient is wheeled away for cardiac surgery, the cardiologist is out of the picture.

After the operation, the patient is transferred first to Intensive Care and later to a bed in a ward—and still the cardiologist is often neither consulted nor informed about the outcome. Only four to six weeks after the surgery, when the patient comes to the cardiology clinic for a follow-up exam, does the cardiologist finally learn what has happened to the patient and reassume the original, ongoing relationship with the patient.

Traditionally, this used to make sense at the JGH, and it’s still common practice elsewhere. After all, Cardiology is a specialty within the Department of Medicine, while Cardiac Surgery—with its own staff and multi-disciplinary team—is a separate division in the Department of Surgery. The two simply haven’t overlapped.

Until now.

Dr. Lawrence Rudski

Dr. Lawrence Rudski

According to Dr. Lawrence Rudski, Chief of Cardiology and Director of the JGH Integrated Cardiovascular Program, arrangements that seem reasonable administratively don’t necessarily work to the patient’s advantage in every instance.

That’s why, as Dr. Rudski’s job title suggests, the JGH is making a major push to more closely integrate the activities of heart-related healthcare professionals. The objective is to provide the patient with better, more comprehensive care through a tighter collaboration that dismantles the proverbial departmental silos.

Early adoption

“The JGH is, to my knowledge, the first place in the world that has ever survived this attempt,” he says. “A couple of other places have attempted it, but they were unable to pull it off.” The main obstacle, he explains, is resistance from various healthcare professionals who find it difficult to accommodate such a radical change to the traditional organizational structure.

However, Dr. Rudski says he embraced this concept about four years ago, when it was proposed by Dr. Lawrence Rosenberg soon after his promotion from Chief of Surgery to Executive Director of the JGH. Dr. Rosenberg, a major proponent of transformational change that improves the patient experience, is now President and CEO of CIUSSS West-Central Montreal.

“What we had previously was fragmented care,” Dr. Rudski explains. “In addition to the doctors, we had one set of nurses before the operation, and a second set afterwards. We had one physiotherapist before the operation, and a different one after. The same was true for social workers.

“I took it upon myself to lead the effort, along with our nursing partners, because this is as much about the integration of nursing staff as it is about doctors. Previously, you either became a surgical nurse or a medical nurse. Now there’s cross-training for nurses in what used to be two completely different cultures.”

Continuity of care

As a result, Dr. Rudski says, cardiologists are now more involved in patient care just before and after cardiac surgery, when complications are likeliest to arise. They also work closely with their surgical colleagues and with highly specialized nurse practitioners.

“We can invoke a multidisciplinary (heart team) approach for more complex cases to determine the best type of treatment. We can also better coordinate the timing of procedures and surgery, because we are all aware of the patients on our units.

“Our new system allows us to intervene more expeditiously and rely a little less on protocol and more on expertise. The biggest change we’ve noticed is that when we now see our patients post-operatively in our office, we know exactly what has been happening to them. We know all the nuances, so we’re much better able to give them the ongoing care they need.

“Our next step is to move beyond the hospital environment and create a seamless integration with frontline and community resources, in order to help patients make a smooth transition back to the community. This will be accomplished through the development of patient trajectories and will again utilize the full complement of health care providers at the JGH and in our CIUSSS.”

Better accident prevention

As is the case in the other new operating rooms in Pavilion K, the booms help to prevent accidents by allowing equipment to hang from the ceiling, rather than sit on the floor. However, since the hybrid suite needs extra booms to accommodate the C-arm and related imaging equipment, the design was much more complicated.

Then there was the need to harmonize the needs of the disparate teams, says Dr. Lawrence Rudski, Director of the JGH Cardiovascular Integrated Practice Unit. “It requires an arrangement that is not immediately intuitive,” he explains.

“In most instances, surgical teams and cardiac catheterization teams don’t mix their work spaces. So we had to go through a number of simulations, where the catheterization team would come to the operating room and learn exactly how to position the equipment, how to perform the angioplasty, and how to do the angiograms.

“It took—and still takes—a lot of teamwork, because it’s an integration of two full teams. Now everyone is feeling much more comfortable working in what is becoming a natural extension of their own team.”

Dr. Rudski also believes that as more such procedures are performed, “as the team-building grows, and as we use the hybrid room more and more, we’ll be developing the expertise to be a real leader in this type of treatment in Canada.”

“The new room is like night and day—like going from an old black-and-white TV to a plasma screen,” agrees Dr. Obrand. “It’s nothing short of revolutionary—that’s the only word to use.”

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