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

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.