HYBRID OPERATING THEATER ROOM

1. Prepared by: Dr.Eng. Walid Tarawneh
What is Hybrid OT room?;
It is an Operating Theater (OT) room environment that enables both imaging systems and open surgery procedure to be
performed in the same room. Simply it is the ability to perform less invasive surgeries under image guidance tools and systems
Why Hybrid OT are needed?;
The imaging system allows surgeons to simultaneously perform open surgery, and minimally invasive procedures in the same
space, which mean that hybrid OT rooms are allowing a growing number of patients, who were traditionally managed only
through open procedures to undergo minimally invasive procedures. There is also a bigger focus on managing more challenging
patients, such as those with concomitant disease and surgical risk factors, using noninvasive techniques.
Therefore the Hybrid OT Room is the ideal space where both surgeons and interventionists can perform multi surgical tasks
with minimally invasive procedures.
In addition Hybrid OT allows physicians to perform procedures using real-time image guidance, and to assess effectiveness and
manage perioperative complications, all in a single encounter.
Main Approaches for Imaging Systems Location in the OT rooms;
I. Movable standalone imaging system from Outside the OT Room
II. Movable standalone imaging system from inside the OT Room parking area
III. Movable Imaging system from a dedicated parking area (ceiling mounted /floor mounted) - fig.1 CT/Angio Hybrid OT
room.
IV. Fixed location for the Imaging system inside the OT Room – (MRI Operative Hybrid Room-fig2).
The most simple utilization of imaging systems in OT rooms is the use of Ultrasound scanner, mobile X-Ray unit and C-Arm X-Ray
Mobile (such systems can be located the outside/inside the OT room) . These rooms cannot be considered as Hybrid OT rooms.
The performed procedures in these rooms are not minimally invasive, while the minimally invasive procedures carried in the
Hybrid OT require imaging techniques that can visualize smaller body parts and thin vessels and can be facilitated through
intraoperative 3D imaging.

2. Fig.1 - Hybrid CT /Angio OT room
Fig. 2 - Hybrid MRI OT room
Clinical Application:
Hybrid OT Rooms are currently used mainly in Cardiac, Vascular and Neurosurgery, but could be suitable for a number of other
surgical disciplines.
Dr.Eng. Walid Tarawneh
Dr.Eng. Walid Tarawneh

3. What are the main Challenges need to be considered for Hybrid OT Rooms? ;
1. Environmental conditions - Sophisticated imaging system that marries the capabilities of radiology with the sterility of
surgery.
2. Spaces required - Additional spaces to OT room to allocate the imaging system , control, store the imaging system
equipment & components, and screening /holding the patient (especially in Hybrid MRI OT)
3. Protection - Sterility requirements combined with radiation/ radio-frequency protection
4. Medical Procedure (Operation) - Wide range of specialized Medical Staff needed to work side by side and to perform the
required OT room Medical/Surgical procedures.
5. Integration and compatibility – The integration between the imaging system and OT room Systems/equipment is highly
required.
6. Systems flexibility: The imaging system configuration should provide unobstructed access to the operating table without
disrupting the staff’s workflow.
7. Cost - A Hybrid OT room doesn’t come cheap (Space, Medical Equipment, Environmental, Protection, Staff, Materials,
Software, Navigations and Image Guidance Tools /Systems … etc.
Most used Hybrid OT rooms:
I. Hybrid OT with Angiography Imaging System (for cardio & endovascular surgery) ,
II. Hybrid OT with Computerized Tomography system (CT- scanner)
III. Hybrid OT with combined CT- scanner and angiography system called CT/A Hybrid OT
IV. Hybrid OT with Magnetic Imaging System (MRI) called also intraoperative magnetic resonance imaging (IMRI)
Basic Design considerations:
1. Determination of the medical /surgical procedures (utilization plan).
In this phase a protocols should be developed for how the new space will be used by various specialties: cardiology,
surgery, and interventional radiology. These specialties will require specific procedures, room layouts, and budgets—
elements that will have the most influence on equipment selection, a defining factor for a hybrid OT. Bringing
everyone’s needs to the table early will ensure the most effective outcome for staff and personnel. It will also shorten
the equipment selection process.[1]
2. Selection of the imaging modality/system and all the needed equipment.
By using the planned utilization many of the required equipment shall be determined. For example; single-plane
installation meets the needs for cardiology and vascular cases, but neurosurgery and electrophysiology physicians prefer
biplane configurations. In addition ceiling-mounted imaging equipment can be more easily “parked” out of the surgical
field than floor-mounted equipment. However, floor-mounted equipment with a robotic arm helps move the C-Arm out
of field and offers additional benefits like better 3-D imaging.

4. 3. Determination of room size and location.
The space required depends on the type of the Hybrid room. Typically it is in the range of (70 -120) m2
In respect to location and due to ;  Clinical and staff requirements,  Patients preparations and surgery post
procedures, and  Space environmental requirements, the mostly used location is at the surgery department (not to
forget that some Hybrid OT rooms have been successfully located in the CATH LAB area).
4. Timing and staff Training.
Are two more major aspects to be mindful of before opening the doors of a hybrid OT. In general a hospital looking to
design a hybrid OT from scratch really needs to anticipate 18 to 24 months of work. A big bulk of time is usually spent in
the planning, phase. Once the OT is completed, experts recommend that the staff get acquainted with the room and its
equipment. The hybrid OT will be a completely new environment. For instance, OT nurses might not know how to
best protect themselves from imaging radiation and radiology techs may be unfamiliar with the sterile requirements
of an OT. Thus, cross-training the staff is essential [2]. Training on equipment and systems shall require certain time,
while application training may require the medical staff to get training at similar local or external sites.
5. New Credentialing Criteria
All Hybrid OT Rooms Must be developed for all procedures to ensure quality and competency
Hybrid OT rooms planning consideration
1. Spaces & Rooms
 OT room including the parking area (if such is selected); Optimum (65-85) m2
 Control room; (12-15) m2
 Equipment room; (15-20) m2
 Schiller/Cooling systems for the imaging system; location of the cooling system can be in the equipment room, at
the top of the building or any acceptable space by the imaging system manufacturer.
 Holding area /preparation area; (14-18) m2
 Scrub station area; two to three scrubs (approx. 4 - 6 m2
)
 IT room – required in some cases (4-6 m2
)
 If a parking area is used the required space is(10 - 15 m2
)
 Store room – if required ; ( 5-7) m2
2. Ceiling height – (4.5 - 4.8)m, floor to floor
3. Radiation & Radio-frequency Protection – lead shielding in walls, doors and windows for Hybrid rooms with X-RAY
sources and RF shielding (Faraday cage) for systems Hybrid rooms with magnetic sources - MRI)
4. Doors
 Patient doors - sliding type (approx.2000 x 2000 mm), shielded wherever necessary
 Staff doors - sliding and non-sliding [ approx. (1100-1500)mm x 2000mm], shielded wherever necessary
5. Environmental Positive pressure and laminar airflow for OR-level sterility (50 to 200 ACH) via blowing this air through
a HEPA filters, which removes 99.995% of particulate matter greater than 0.3 µm

5. 6. Potential Collision Points; The Hybrid OT is full with ceiling and floor mounted equipment. The location of these
equipment and systems within the room space should be considered among the other factors to avoid any collision or
any restricted movement. A 3D planning is highly recommended in such projects.
Hybrid OT room Equipment & system
The types and quantities of the equipment depends on the type of the Hybrid OT room,
1. The Imaging system solution (the type of the room depend totally on this system)
2. The OT table
3. Surgical Light.
4. Equipment and anesthesia Booms
5. Integration System & video integration devices
6. Cameras and Monitors (wall and booms mounted)
7. 3D Navigation system
8. PACS viewers
9. Electrosurgical unit
10. Theater control panel (To
, pressure, Humidity, medical gases, time, room lights, power and leakage currents… etc.)
11. Anesthesia machine
12. Injectors
13. Physiologic / hemodynamic monitor
14. Operating Microscope (Neuro)
15. Doppler & Ultrasound scanner
16. Internal storage system (pharmaceutical & medical)
17. IV and syringe Pumps
18. Heart-lung machine
19. Voice communication & Audio / Stereo System
20. Medical light sources
21. Warmer, Contrast Media, MRI
Some examples of Hybrid OT rooms
In all the below examples the following issues must be considered
 System positioning and medical staff flow
 Patient monitoring and control (viewing from control room)
 The system weight & load
 Cables installation
 The Quench pipe for MRI
 relation with other ground, ceiling and wall mounted systems (Min interference)
 All related to safety issues.

6. 1. Hybrid OT with Ceiling mounted movable Imaging system ( MRI - fig.3)
fig.3
2. Hybrid OT with Floor mounted Fixed Imaging system (Angiography - fig.4)
fig.4
3. Hybrid OT with Multiple Imaging systems ( CT- ANGIO Hybrid OT- fig.5 )

7. fig.5
The role of the Navigation systems in Hybrid OT rooms (fig.6)
Surgical 3D navigation not only increases safety and precision, especially in minimally invasive surgery. It also reduces the
average time required for interventions and, by continuous visualization of the instruments, is an effective dose-saving measure.
fig.6
References;
1. Kevin Downey, 3 Elements to Consider When Planning and Designing a Hybrid Operating Room,
HealthcareDesignMagazine.com. February 23, 2015
2. Olga Deshchenko, The Case for the Hybrid OR, DOTmedbusiness news http://www.dotmed.com , August 2011