Photo courtesy of
Philips Healthcare

Special report: The case for the hybrid OR

August 15, 2011
by Olga Deshchenko, DOTmed News Reporter
This report originally appeared in the August 2011 issue of DOTmed Business News

To build its hybrid operating room, Cooper University Hospital knocked down a wall.

The Camden, N.J.,-based facility removed a partition that separated two brand new ORs to create a single, approximately 1,000-square-foot space. The resulting hybrid room, which opened about a year ago, also consists of a fairly large supply room and a control room.

“You can access all of these rooms freely through motion-activated doors,” says Dr. Joseph Lombardi, head of the hospital’s division of vascular and endovascular surgery. “They slide open like in Star Trek.”

And that’s only the beginning of the OR’s futuristic feel. At the heart of any hybrid suite environment is a sophisticated imaging system that marries the capabilities of radiology with the sterility of surgery.

In the case of Lombardi’s OR, it’s the C-shaped Axiom Artis from Siemens Healthcare that enables physicians to precisely visualize small vessels, stents and catheters during cases.

Coupled with the traditional aspects of an OR, the imaging system allows surgeons to simultaneously perform open surgery and minimally invasive procedures in the same space.

But a hybrid room doesn’t come cheap – a hospital must be ready to shell out millions for the project. (Cooper University Hospital spent $3 million on its hybrid room.)

Still, industry research suggests that hospitals are tapping their piggybanks to embed high-end imaging systems into their ORs.

Why go hybrid?
Interest in hybrid rooms has notably grown in the last couple of years. Today, The Advisory Board Company, a consulting, research and technology services firm, regularly advises hospitals on the intricacies of hybrid OR projects. “We definitely get asked about this investment on a weekly basis,” says Ashley Ford, a research consultant with the company’s technology insights division.
And given the spike in interest among providers, it’s no surprise competition for hybrid OR customers is fierce. According to a recent report by Millennium Research Group, the hybrid OR market is projected to grow by about 15 percent per year through 2015.

Varying forms of hybrid room environments have been around since the 1990s and as a relatively new space, the term itself often ignites a debate about its definition.

“The simplest way for us to define a hybrid OR is an environment that enables both catheter-based interventional procedures and open surgical procedures to be performed in the same room,” says Greg McIff, director, cardiovascular strategic marketing, with GE Healthcare’s Surgery unit.
Photographed by
Leonard Myszynskim
sOlar eye communications

It’s possible for specialties like urology, neurology and orthopedics to claim a stake in a hybrid OR. But because of a convergence of current health trends and device innovation, the dominant users of today’s hybrid ORs are vascular surgeons, cardiothoracic surgeons and interventional cardiologists.

As the global rate of cardiac disease continues to rise, so does the trend of minimally invasive interventions that improve patient care and control costs.
Surgical advancements are allowing a growing number of patients who were traditionally managed only through open procedures to undergo minimally invasive procedures, according to Robert Popilock, senior manager, alliances, with Steris Coporation. There is also a bigger focus on managing more challenging patients, such as those with concomitant disease and surgical risk factors, using noninvasive techniques.

“Making it possible to meet both of these needs is the ability to perform less invasive surgeries under image guidance while at the same time performing more invasive and challenging interventional procedures under the safety net of a sterile surgical environment,” Popilock wrote in an e-mail to DOTmed News.
The core procedures driving the interest in hybrid ORs are abdominal aneurism therapy, thoracic aneurism and dissection therapy and aortic valve replacements and repairs, according to GE’s McIff.

And within one year, industry experts anticipate new transcatheter valves to hit the market -devices that will greatly expand the opportunities for minimally invasive procedures in cardiac cases.

Today, the majority of clinical trial sites where transcatheter valve procedures are being performed are hybrid rooms, according to The Advisory Board’s Ford. Clinical investigators deem hybrid ORs to be the ideal spaces for the newest techniques, as surgeons and interventionalists must work side by side, Ford explains.

In addition to improved patient care and expanded clinical procedures, access to the high-end equipment of a hybrid OR also serves as a magnet for surgical talent. “In order to attract quality vascular surgeons, you’re going to need to have a hybrid operating room, there’s no question about it,” says Cooper’s Lombardi.

Hybrid OR equipment options
Hospitals able to set aside $3 to $5 million to build a hybrid OR have plenty of opportunities to shop around for vendors.

First, facilities must decide on a particular imaging system, the priciest and largest device to inhabit the hybrid room. (The clinical goals of the specialists who will be using the OR dictate the requirements of the device.)

With the intended procedures in mind, surgeons will need to consider whether they need a biplane or a single plane angiography system and determine the best detector size.

And since the imaging device is only one piece of the hybrid OR puzzle, it’s important to consider how the staff will work with and around the system.

Hanneke Naus, business development manager, hybrid OR, with Philips Healthcare, says the company’s most popular imaging solution has been a device with a large detector, the Allura Xper FD20.

Choosing a system with a large detector is driven by the desire to create an OR environment that can accommodate a range of procedures by different specialists, Naus says.

A recent innovation by Philips for the hybrid OR environment is its FlexMove option for the Allura Xper FD product line. With FlexMove, the ceiling mounted X-ray system can be moved to either side of the table during procedures. When not in use, it can be “parked” in the corner of the OR to free up space.

Hospitals can also look to Siemens Healthcare for hybrid room imaging options. The company’s Artis zee product line includes floor and ceiling-mounted interventional imaging systems, as well as the Artis zeego, a multi-axis system based on robotic technology to enable greater control and positioning.

According to Sudhir Kulkarni, segment manager, hybrid OR with Siemens, the zeego system is ideal for the hybrid room environment because of its flexibility. The device’s various angulations provide unobstructed access to the operating table without disrupting the staff’s workflow.

Another player in this sector is GE Healthcare. At the high-end of the company’s imaging solutions for hybrid rooms is the Innova 4100-IQ system, currently indicated for catheter-based interventional procedures. The system is equipped with 3D reconstruction capabilities and the company’s flat panel detector.

GE also markets the OEC 9900 Elite MD motorized C-Arm for hybrid environments. “This is a mobilized C-Arm with a cath lab-like control panel,” GE’s McIff explains. “It can be attached to a surgical table that allows the surgeon to have full control of all orbital locations of the C-Arm.”

But choosing an imaging solution is only the first step of equipping a hybrid room. It will also require a table, lights, booms and video integration devices – and that’s just some of the necessities.

Devices that can be easily modified when needed are important for hybrid rooms, a requirement manufacturers are well aware of when designing equipment management systems.

Last year, Trumpf Medical Systems launched its latest boom product called TruPort, a ceiling mounted system with a completely modular head. The design allows for an easy configuration of the system when say, new equipment comes into the OR, says Steve Palmer, the company’s director of marketing.

Palmer describes TruPort as a “plug-n-play” boom, since repositioning of services can be done without having to call in a service tech.

And in March, Berchtold Coporation introduced its new Teletom boom with an exchangeable module design. Matthew Weismiller, the company’s president, says the boom can be easily reconfigured to accommodate changes in gases and services when necessary.

To ease the equipment selection process, many vendors, including leading surgical companies such as Skytron, Steris, Stryker, Trumpf and Berchtold, are forming unprecedented strategic partnerships with imaging giants like GE, Philips, Siemens and Toshiba to offer comprehensive equipment solutions for hybrid suites. These partnered imaging and surgical equipment companies create and share sample hybrid room layouts, enabling hospitals to see how all the equipment can work together. “It’s very comfortable for customers who have to start from scratch,” says Philips’ Naus. “They have a starting point.”

For instance, Toshiba worked with Maquet to make the company’s ceiling mounted Infinix-i X-ray systems compatible with the Maquet Magnus OR table. And last spring, Stryker and Intuitive Surgical formed an alliance to integrate the daVinci Si surgical robot with the Stryker iSuite.

Because many institutions choose to work with multiple companies, vendor partnerships can also save time.

Brian Grant, assistant product manager with Skytron, says hospitals have no direct experience with hybrid rooms, so showing them feasible models – which have been preapproved in terms of design, fit and ergonomics of all the equipment thanks to vendor collaboration – can speed up the planning process.

The path to hybrid
While hybrid suite portfolios differ among vendors, they share a goal of meeting the needs of the multidisciplinary specialists within the OR.

And experts agree that the secret to building a successful hybrid room is to involve all of the end-users from the start. “We recognize that the hybrid OR finds a blurring of specialist capabilities and benefits from a multi-discipline, procedure management [perspective],” Steris’ Popilock said. “Thus, identification and involvement of stakeholders is essential to ensure a well-vetted design.”

The presence of hospital administrators, surgeons, anesthesiologists, other physician users, OR nurses, radiology techs and even facilities staff is vital throughout the planning process for a hybrid room.

To ensure that everyone is on the same page, Siemens’ Kulkarni says the company strongly recommends having all the hospital stakeholders and vendors participate in joint planning sessions.

Cross-functional participation also helps establish the management process, according to Berchtold’s Weismiller. “When that new room is brought online, the customers really feel like they designed it, it’s their room,” he says.
Once clinical goals are established and the hospital has set aside the necessary funds, the facility must find the appropriate space for the project.
A hybrid OR requires about 750 to 1,000 square feet of space, depending on the imaging system. Hospitals often use corridors, nearby office spaces or a storage area in between two ORs to capture enough square footage. “It’s a bit of a puzzle at times,” says Jeff Saunders, a senior project engineer with Trumpf.

And they can be heavy — sometimes, the ceiling or the floor of the intended location may lack the necessary infrastructure to support the weight of the equipment.
Photographed by
Leonard Myszynskim
sOlar eye communications

Experts also highly recommend site visits to existing hybrid ORs. Visiting peers who have already built their hybrid rooms enables facilities in the planning stages to avoid potential mistakes and get a sense of how a hybrid room functions once it’s completed.

Some vendors are even working to enable potential customers to go on “virtual” site visits. For example, Berchtold will soon launch a new feature on its website that will let hospitals browse existing hybrid ORs, as well as watch video interviews with the stakeholders and project staff involved in creating the room.

Final words of advice
Timing and staff training are two more major aspects to be mindful of before opening the doors of a hybrid OR.

Some hospitals have managed to design, furnish and go live with a hybrid OR within months but such a timeline is highly unusual. “A hospital looking to design a hybrid OR from scratch really needs to anticipate 18 months to two years of work. And a big bulk of that is in the planning stages,” says GE’s McIff.

Once the OR is completed, experts recommend that the staff get acquainted with the room and its equipment. “Most of the time, when the system is supposed to go live, we request that everyone who is going to be operating the system be dedicated to attending the educational component without the patient,” says Siemens’ Kulkarni.

For many staff members, the hybrid OR will be a completely new environment. For instance, OR nurses might not know how to best protect themselves from imaging radiation and radiology techs may be unfamiliar with the sterile requirements of an OR. Thus, cross-training the staff is essential, points out Philips’ Naus.

Whether or not a hospital can embark on a hybrid OR project today is dependent on the facility’s clinical goals and budgetary considerations. But it’s hard to argue with the value a hybrid room can bring to a hospital’s patients, staff and bottom line.

Many experts also predict that new medical technology will continue to foster collaboration between various specialties and eventually lead to a new space, a universal operating room.

“While I think that [universal ORs] are several years off, the investment that enables physicians to work together in a multidisciplinary manner is definitely going to be a trend that’s here to stay, both on the surgical and interventional side,” says The Advisory Board’s Ford.

And Lombardi’s response to what he would change about Cooper University Hospital’s hybrid room in hindsight reaffirms the trend. “I would’ve built two of them,” the surgeon said.

DOTmed Registered OR Suite Companies

Names in boldface are Premium Listings.
Daniel Giesberg, American Medical Sales, CA
DOTmed Certified
Yves S Christopher Custodio Herrera, BJ'S TRADING LLC, CA
G. John Oggel, Green Cross Medical/ GOMED, CA
Richard Ojalvo, Medical Resources Inc, CA
Scott Patneaude, ACE Medical Equipment Inc., FL
DOTmed Certified
Moshe Alkalay, Hi Tech Int'l Group, FL
DOTmed Certified
Clinton Courson, Quest Medical Supply, Inc., FL
DOTmed 100
Alda Clemmey, Saffire Medical, MA
DOTmed Certified
DOTmed 100
Nicole Rasch, Seiler Instruments, MO
Gregory Wallace, H&S MEDICAL, NH
Sam Joshi, Maquet Inc., NJ
Philip Mothena, Simple Solutions, Inc., VA

Ashish Bhavsar, Wave Visions, India