Historically, surgeons have relied primarily on
their direct vision of open surgical sites to perform procedures. The
open incision surgical procedures are generally followed by long
recovery periods for patients.
Dr. Kurst Semm, a German gynecologist, invented the
automatic insuffolator in 1960 that led to the development of minimally
invasive surgical techniques in 1980s. In 1987, Dr. Phillipe Mouret,
performed the first video-laparoscopic cholecystectomy in Lyons,
France.
By the 1990s, minimally invasive surgery had become
a common occurrence. An increasing number and type of procedures are
now being performed with minimally invasive techniques. This leads to
better outcomes such as enhanced patient safety, less pain, shorter
recovery periods, and reduced system wide costs. Advancements in
communication, information technology, digital imaging, and robotics
have also aided the development of new surgical techniques for surgeons
to perform procedures with greater patient comfort, safety, and
accuracy.
The following is a brief overview of current and
anticipated future surgical techniques that are having an impact on the
operating room (OR) design.
Minimally invasive surgery (MIS)
Surgeons perform a procedure by inserting surgical
instruments, a light source, and endoscopic video camera through
keyhole incisions in the body near the surgical site and by
manipulating the instruments while viewing on video monitors. The
minimally invasive surgery procedures require ergonomic location of
video monitors and electronic equipment in the OR, as well as the
ability to control lighting for optimum viewing of video monitors.
Image guided and computer aided surgery
Modern computer aided surgery techniques utilize
radiography, fluoroscopy computed tomography, sonography, and magnetic
resonance imaging devices as navigation systems for greater accuracy.
Three-dimensional image-guided systems are being
utilized for neuro-surgical procedures that require precision. Portable
imaging systems are generally used for these procedures, which require
parking spaces in or adjacent to the OR.
Robotic assisted surgery
Robotic surgery has two main components: the
surgeon's console and a robotic arm above the patient table. The
surgeon sits in a console and manipulates the master controls while
looking into a viewer that displays images obtained from an endoscopic
camera inside the patient's body. A slave robotic arm holds the
surgical instruments inserted inside the patient's body.
This master-slave manipulator allows surgeons to
perform more precise surgical procedures than those possible with
conventional endoscopic surgery. Future minimally invasive gene therapy
may utilize a combination of surgical robots and navigation systems.
Impact of new surgical techniques on operating room design
New surgical techniques bring new technologies into
the OR. This has been a challenge due to limited access for new wiring
and the lack of structural support in conventional hard ceiling
construction in operating rooms. Often, ad-hoc solutions are found,
such as placing the new equipment on another cart, which results in
operating rooms that are crowded with carts, monitors, and electronic
equipment with wires across the floor. This can create unsafe working
conditions for the staff.
A fresh approach is needed to integrate various
technologies into the physical layout of the OR. Details of the OR
design should facilitate optimal workflow to support new surgical
techniques, maintain a sterile environment, and provide flexibility to
accommodate new technology over longer periods of time.
Specific design considerations for OR include:
• Operating room size. A typical response to
equipment crowded ORs is a request for increasingly larger ORs.
However, experience has shown that the most valuable space in an OR is
the space immediately surrounding the patient table. The prime space
around the patients should be as free of carts as possible to provide
work area for staff. Utilization of ceiling supported utilities and
equipment booms allows ergonomic organization of equipment around the
patient. The space along the walls can be utilized for parking supply
carts. This concept frees up floor space from the impact of wires,
hoses and carts on staff circulation enhancing patient safety and
workflow efficiency for the staff. An efficiently organized OR with an
area of 600 to 650 square feet and a width of 24 to 25 feet provides
adequate space for most procedure types.
• Operating room layout. The orientation of patient
table and placement of doors is important for maintaining a sterile
field and efficient workflow in the OR.
• Ceiling layout and design. Ceiling design is
critical to a functional OR and for flexibility to accommodate current
and future needs for ceiling mounted booms and utilities.
• Accommodation of imaging technology. Placement of
support rooms between Ors provides future flexibility. These adjoining
rooms could be used as specialty supply or equipment storage for ortho,
neuro, or cardiac procedures, and could also be converted into control
rooms or storage space for portable imaging devices. ORs should also be
constructed with lead shielding to provide safety measures for current
and future imaging technology. PACS monitors mounted on the patient's
foot-side wall can provide the ability to view high quality digital
images during procedures.
• Data and communication systems. Wide multitudes of
standalone data systems, communication, and voice recognition
technologies have been developed for ORs. Efforts are under way to
develop an open-system infrastructure that will integrate all
technologies in the operating room. Such a system would provide instant
access to patient history, lab tests, and digital imaging with
touch-screen, wireless, or voice-activated controls, and would enhance
operational efficiencies and patient safety. A dedicated equipment room
within the surgery suite would be the hub for connectivity for the
various technologies.
Conclusion
The next generation OR will be based on successful
integration of the emerging technologies to provide an efficient and
safe work environment for staff, better patient outcomes, and reduction
in overall costs.
The Center for Integration of Medicine and
Innovative Technology (CIMIT), based in Cam-bridge, MA, is currently
working on an “Operating Room of The Future” project. The project will
examine the impact of individual technologies and systems integration
on the safety and efficiency of patient care with a year 2008 vision of
delivering a new way of managing the surgical patient from check-in to
discharge.
