Teamwork in the OR
With integrated magnetic resonance tomography and neuronavigation, the “BrainSUITE” of the Günzburg Regional Hospital is truly remarkable. Intraoperative diagnostics has become routine for the OR team and a consistent factor in the daily neurosurgery work.
Since the BrainSUITE was put into operation in September 2008, the surgical team led by Prof. Dr. Wirtz, the medical director, has done more than 550 operations. Dr. Ralf König heads the BrainSUITE hybrid OR room. He led the medical project and the installation oft he BrainSUITE together with his former colleague Dr. Thomas Schmidt, who meanwhile works at the “Evangelisches Krankenhaus” in Oldenburg, Germany. Both were satisfied by working in this hybrid OR. They report that surgical precision is significantly greater with intraoperative diagnostics than without this procedure. This is facilitated by the precision interplay of the navigation and data management system from BrainLAB and the Siemens Healthcare MAGNETOM Espree magnetic resonance tomograph (MRT), the ceiling mounted Pentero C operation microscope by Zeiss and the TRUMPF JUPITER OR table system. From the beginning, the coordination of humans and technology has functioned well. Naturally, learning continues, says Dr. Schmidt. Changes in details have improved sterile coverage, such that in spite of the theoretically increased risk in transferring patients into the MRT, there has not been a single postoperative infection to the present. Neurovascular and epileptic surgical interventions are also done in the BrainSUITE, possible in particular because of the JUPITER replaceable table top system with a column on which any other TRUMPF table top can be placed. “In spite of the higher technical requirements, we can work here exactly the way we would in any other OR," says Dr. Schmidt, “the BrainSUITE is completely integrated into the daily routine. And an operating room like this can only function if everyone, from the doctors to the nursing staff to the cleaning staff is acquainted with the special technical features."
Hand in hand with high tech
Indeed, there are features to consider in the BrainSUITE, especially with regard to safety. Because of the strong magnetic power of 1.5 Tesla, the MRT is located inside a color-marked area. Metallic objects may not cross this line. This is a challenge that is compensated by consistently applied safety procedures and the medical advantages provided by the presence of the MRT. If the brain anatomy changes during surgery, MRT images that picture functional centers or circulatory disorders provide valuable help. “Independently of the nature of the illness, intraoperative diagnostics can affect the surgical strategy,” explains Dr. Schmidt. "If a brain tumor is located next to a critical region like the speech center, we will first of all remove less tumor tissue at the border. Using the updated MRT images, we can make a new analysis of the anatomical status and remove residual tumor tissue more precisely.” This reduces the risk of permanent damage such as paralysis and can save patients a second operation. In addition, tumors can be completely resected and the reduced tumor load improves the basis for oncological aftercare.
To achieve this advantage, one component of the BrainSUITE must coordinate with another, starting from the exact positioning of the patient on the operating table and the fixation of his head in the frame with the integrated MR coil. This position must be held throughout. The TRUMPF JUPITER table design, in combination with the Miyabi design, developed in collaboration with Siemens, makes this possible. It allows the table to be turned into the transfer position manually. Using the remote control of the table, the team can position the table top exactly in the orientation of the MRT changer table and the position can be stored in advance. If a transfer is planned, the integrated so-called Bridge Board is unfolded, the table is turned, positioned and let down onto the MRT rail. As soon as the Bridge Board is lying on the table completely, the table column stops automatically and releases the rest of the transfer. This must take place quickly but safely. And this is not the only reason why the JUPITER operating table was chosen. “We are looking for a solution that will move patients as simply and gently as possible from the surgical position to the MRT,” explains Dr. Schmidt. The rotating table top provides more space between the table and the magnetic field than other designs, so that the OR team can be unhindered and safe in their work. The system performed more than 300 transfers during the first 70 operations, smoothly and without problems.
Always up to date
Depending on the indication, the MRT is used two to three times during an operation. Within a few minutes, the iPlanNet planning software from BrainLAB transforms the MRT image into a 3D image and records it in the Vector-Visionsky navigation system. This orients the patient’s head in space and makes all data for continuation of the procedure available. The BrainSUITE NET data management system allows the surgeon to use the touchscreen to control such surgical technology as navigation, microscope or illumination with the TRUMPF OR light iLed and to determine which patient images he wants displayed on which flat-panel screen. The whole thing can be compared to an automobile navigation system, according to Dr. Schmidt. “You drive and see a new road that the system doesn’t know yet. If this street were digitally photographed and stored in the navigation system, it would come up on the screen the next time. The same thing happens here.” The actual images increase the surgical precision. “Nevertheless, we cannot perform miracles – there are anatomical limits that make brain tumors inoperable,” explains Dr. Schmidt. But: with the help of intraoperative diagnostics, medicine continues to approach these limits, one step at a time. Meanwhile new projects started at the BrainSUITE: „Safety during intraoperative MRI “ und „Intraoperative MEP-Monitoring“ with Dr. Maria-Teresia Pedro and Dr. Jan Coburger.