Recent Advances in Surgery 33 Colin D Johnson, Irving Taylor
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Advances in Technologies in Operating TheatersCHAPTER ONE

Shirish G Ambekar,
Patrick G Magee
Surgery in its early days was limited to the drainage of abscesses, amputations of gangrenous limbs, extraction of decaying teeth and the treatment of trauma. Operations were carried out usually on kitchen tables in the candlelight by a person who had limited knowledge of the anatomy and physiology of the human body. Lack of anesthesia meant that they had to be performed swiftly without any consideration of asepsis, blood loss, analgesia or cosmesis. Mortality was high due to infections and shock. During the nineteenth and early part of the twentieth centuries, famous surgeons from the US and Western Europe performed surgery with an audience of medical students and even the general public. There would be a central table with galleries around it for the public to stand and watch. Hence, the name operating theater was coined (Figs 1.1 and 1.2).
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Fig. 1.1: Sir W MacCormac, a senior surgeon at St. Thomas' Hospital, London, about to perform an operation in Bellevue Hospital, New York in 1891 at the request of Prof Sayre(Courtesy: Wellcome Library, London).
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Fig. 1.2: An operation at St Bartholomew's Hospital, London. In 1910, the anesthetist, Charles Hadfield, is using a Vernon Harcourt apparatus(Courtesy: Wellcome Library, London).
In the last few decades various surgical specialties evolved. There was exponential growth in the knowledge and understanding of the working of the human body. Asepsis, antibiotics, anesthesia and transfusion services helped to reduce the mortality and morbidity due to surgery. Technology also played an immense role in improving surgical results.
Depending on the types of surgical work undertaken in the operating room (OR), the workload and the need for multiple specialties working together, different types of ORs can be built.
Purpose Built Operating Rooms
Purpose built ORs for cardiac surgery, for example, will have space for cardiopulmonary support systems like a cardiopulmonary bypass machine, intra-aortic balloon pump and ventricular assist device. Those for gastrointestinal (GI) and urological surgery will need facilities for multiple scopes and monitors to display the operative field. Neurosurgery and ophthalmic ORs will have the facilities for operating microscopes, laser and magnetic resonance imaging (MRI).
Hybrid Operating Rooms
Hybrid ORs can facilitate the working together of different specialties at the same time and place. Interventional radiologists and vascular surgeons can perform stenting of aneurysms or injured vessels together and if the 5need arises, the patient can be operated upon in the same hybrid OR by the vascular surgeon. Cardiologist and cardiac surgeons can work in unison in such hybrid ORs and can perform various procedures like closure of congenital defects, percutaneous implantation of degenerated valves and angioplasty and bypass surgeries. Urologists and radiologists can treat conditions like renal stones with minimal access in the hybrid ORs with the facilities of C-arm, fluoroscopy and laser.
Mobile Operating Rooms
Mobile operating facilities can carry staff, OR and all other support systems that are needed to run such a service to an area, which may be remote from the permanent facility. Mobile ORs are very useful in battlefields (Fig. 1.3), remote villages in the developing world (Fig. 1.4) and also in other situations, such as outer space or at sea.
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Fig. 1.3: Chemical and biological protective shelter, which can be inflated in 15 minutes and used as an operating room.1
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Fig. 1.4: Even today, surgical facilities in certain parts of the developing world are primitive and in such areas mobile ORs can make a big difference(Courtesy: Wellcome Library, London).
A large lorry, carrying a mobile OR, can go from place to place and doctors can perform basic surgical operations, and provide general health care services. In developing countries such mobile ORs can also be used for conducting camps for cataract removal, sterilization procedures, etc. In some countries, attempts have been made to use a cruise liner converted into a mobile OR facility that can be docked offshore. In this ultra modern facility, all sorts of major operations can be performed by highly trained staff coming from all over the world.
Modular Operating Rooms
Another new advance in operating theater technology is modular operating facility. Each module is built offsite and comes in packs, ready to be assembled on site. This module consists of a patient reception area, OR, anesthetic room, scrub area, sterile preparation room, equipment storage facility, laboratory, utility area or sluice, and changing and restrooms. These modules can be provided as a stand alone building that can be linked to an existing hospital or as a part of a multimodular facility that can be built for permanent or temporary use. These modular ORs are designed according to the needs of the health care provider and are built offsite. That means the site can be used for other purposes until the time of assembly. The time span from design to assembly can be as small as 10 weeks. Such modules can even be built from concrete where walls can withhold the weight of operating microscopes.
Digital operating technology is the development of the last decade. It is mainly used in Minimally Invasive Surgery (MIS) viewing applications. A centralized control module routes images from numerous surgical and diagnostic imaging devices, for example, endoscopes, ultrasound, CT, MRI, fluoroscopy and patient monitoring data, within or across operative suites and these are then displayed to other departments, other hospitals or even overseas. Cutting-edge image acquisition technology used in modern cameras is used on overboard mounted optics to display real time high quality, wide-angled photographs and videos. Digital imaging technology enables ORs staff to control and manage all equipment and multiple imaging modalities and deliver the appropriate image in real time to the various specialists in the field. Integration of these different media with one cross-platform software, operating room media center (ORMC) was developed for the centralized control of all the surgical informatics systems.2 Sterile touch screens provide effective barrier protection and prevent the transmission of microbial infections arising from contact with such instruments. Speech recognition software helps 7minimize the contact with the instruments. These digital technologies have enormous potential and can be a useful teaching and research tool where data can be stored electronically indefinitely. In future, when robotic surgery is likely to play a more important role, digital operating technologies are going to be the foundations of modern operating theaters.
The following points are to be taken into account during the planning and designing of a new OR facility:
  • Maintain consistency of design with other ORs
  • Avoid mirror image symmetry (Avoid people doing exactly opposite in one OR to that in another)
  • Fire safety
  • Accessibility (easy access to OR and the recovery room)
  • Noise insulation
  • Cleanability and maintainability
  • Optimal use of space taking into account mobile and static equipment
  • Safe power supply, lighting and supply of medical gases
  • Facilities for data storage and data transfer (audiovisual streaming) for research, videoconferencing and telemedicine
  • Facilities for the incorporation of robotic/minimal access surgery.
Each modern operating room is equipped with a set of high standard monitoring, diagnostic and digital equipment. The surgical side of the room has a pendant coming from ceiling, bearing a light source that is bright, shadow free and cold with a facility to either focus the light source or use it in a diffuse fashion (Fig. 1.5). Another pendant on the surgeon's side bears monitors, cameras and video equipment. There may also be another pendant for operating microscopes, but that may be wall mounted. Electrical diathermy (unipolar or bipolar) is usually placed at the foot end of the operating table. Modern diathermy machines are extremely safe and have built-in alarms to prevent patients getting burns in case of short circuiting of the electrical current. The operating table is operated electrically with a remote control that is placed on the anesthetist's side of the room. Modern tables can be tilted and folded in various angles and levels to give the surgeon optimal exposure (Fig. 1.6).
On the anesthetist's side of the room, there is a ceiling pendant that provides sources for piped medical gases, suction, electricity power supply and the supply of pressurized air for powering instruments, such as a surgical saw. On this side, there is also an anesthetic machine and other monitoring equipment. Basic monitors display electrocardiogram, arterial and central venous pressures, pulse oximetry and end-tidal CO2. More sophisticated monitors can display pulmonary artery pressure, cardiac output, central core and peripheral temperatures, evoked motor or sensory potentials, electroencephalogram, cerebrospinal fluid (CSF) pressures, arterial blood gases and thromboelastograph (TEG) to assess coagulation.8
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Fig. 1.5: Berchtold's supersuite combines bright, shadow-free CHROMOPHARE® lights, user-friendly TELETOM® equipment management systems and versatile OPERON® surgical tables to deliver the optimal surgical environment.3
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Fig. 1.6: OPERON® B 710—Surgical Table by Berchtold Corporation. When the patient is in the lateral position, the one-touch flex position provides excellent surgical site access during thoracic and kidney procedures.3
On the anesthetist's side, there is also a trolley for drugs and space to keep other relevant monitoring equipments like transesophageal echocardiogram (TOE), transcranial doppler (TCD) and multidrug syringe 9drivers that deliver various lifesaving medications, such as inotropes in accurate concentrations, calculated in micromoles per kilogram of patient's weight per minute.
Laminar Flow Ventilation
Laminar flow ventilation was first pioneered by Charnley in the 1960s and 1970s, for orthopedic operations like total hip and knee replacements. It resulted in a marked reduction in a postoperative deep-seated wound infection.
In a laminar flow ventilation technique ultra clean, bacteria free air is pumped into the operating room either in a horizontal or vertical fashion. The vertical method can be employed in an enclosed, semi-enclosed or open manner. While conventional or plenum type of ventilation maintains 20 air changes per hour, laminar flow ventilation can achieve 300 air changes per hour.4 Colony forming units (CFU) are typically of the order of 150-300 cfus/m3 in a conventional ventilation method while that number drops to less than 10 cfus/m3 in the laminar flow method.5 To be optimally effective, it is suggested that the operating room staff must wear body exhaust suits while working in this ultra clean environment.6 These values were determined without considering whether prophylactic antibiotics were used or not, yet most experts feel that the use of antibiotics is the single most important factor in the reduction of the deep-seated infections. It was noted that by just increasing the air change rates there was no reduction in the clinical incidence of infections. More recent trials have tried to address this issue.7, 8 Laminar flow ventilation is currently used widely in all modern operating theaters.
Cyberknife is a new technology that is minimally invasive stereotactic robotic radiosurgery. Although it is not a conventional invasive surgical operation, it is a type of radiosurgery performed in specialized operative suits. It is used by oncologists and radiotherapists to treat deep-seated tumors in the body that were earlier thought to be untreatable due to the difficult access.9,10
With the use of robotic systems, multiple high resolution cameras and image-guidance high energy radiation beams can be delivered to the tumor with pinpoint accuracy. The “fall-off” of the radiation to the surrounding areas is rapid, giving protection to the healthy tissues (tissues that are 1 mm away from the tumor are protected). The Synchrony System is another software that can be used with the cyberknife to treat tumors that are in the vicinity of the chest and hence are moving with the respiratory cycle. A system of cameras, motion tracking software, fiber-optic sensing technology, infrared emitters and special tight-fitting elastic patient 10garments are used to track the motion of tumors and deliver the radiation accurately. This advance has revolutionized the treatment of many cancers and holds much promise for the future.
Operating room of the future (ORF), a project pioneered by the Centre for Integration of Medicine and Innovative Technology (CIMIT), is currently running at Massachusetts General Hospital, Boston, USA. It is an OR with a conceptual design to try new technologies and new methods of anesthesia and operative workflow in a real setting. Its goals are:
  1. To improve OR productivity by letting the operative and peri-anesthetic processes run in parallel rather than in sequence.
  2. To improve the effectiveness of anesthesia personnel by creating a new, perioperative nursing position and including a self-contained recovery area in the unit.
  3. To work near the limits of new technologies for the purpose of evaluating such equipment for more general deployment.11 This project has also helped to track the response of all users in terms of emotional exhaustion and personal accomplishments and identify groups at high-risk for burnout when exposed to new systems and technologies.12
Experiences gained and the knowledge learnt from such innovative projects will help us push the boundaries of science and explore new frontiers in the fields of surgical technology, thereby enabling us to perform surgery in remote access areas, such as battlefields, outer space, at sea or even underwater.
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  1. 11 Kelly AJ, Bailey R, Davies RG, Pearcy R, Winson IG. An audit of early wound infection after elective orthopaedic surgery. JR Coll Surg Edinb 1996;41:129–31.
  1. Brown WT, Wu X, Fayad F, et al. Cyberknife radiosurgery for stage I lung cancer: results at 36 months. Clin Lung Cancer 2007;8(8):488–92.
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