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On May 4, 2011, Brigham and Women’s Hospital (BWH)
unveiled the Advanced Multi-modality Image Guided
Operating (AMIGO) Suite, the fi rst suite in the world to give
surgeons and interventional specialists immediate access
to a full array of imaging modalities for use during procedures.
This cutting-edge operating room/interventional suite
enables treatments that are less invasive and more effective.
The AMIGO suite represents the next major step in Image
Guided Therapy (IGT).
The AMIGO Suite is an innovative surgical and interventional
environment that is the clinical translational test bed
of the National Center for Image-Guided Therapy (NCIGT)
at the Brigham and Women’s Hospital (BWH) at Harvard
Medical School. The AMIGO is an integrated, 5,700 square
foot area divided into three sterile procedure rooms in which
a multi-disciplinary team will treat patients with the benefi
t of intra-operative imaging using multiple modalities.
The space is designed so that teams can move effortlessly
throughout to access any of the advanced imaging and surgical
technologies.
Originaltitel
The Advanced Multimodality Image- Guided Operating (AMIGO) Suite
On May 4, 2011, Brigham and Women’s Hospital (BWH)
unveiled the Advanced Multi-modality Image Guided
Operating (AMIGO) Suite, the fi rst suite in the world to give
surgeons and interventional specialists immediate access
to a full array of imaging modalities for use during procedures.
This cutting-edge operating room/interventional suite
enables treatments that are less invasive and more effective.
The AMIGO suite represents the next major step in Image
Guided Therapy (IGT).
The AMIGO Suite is an innovative surgical and interventional
environment that is the clinical translational test bed
of the National Center for Image-Guided Therapy (NCIGT)
at the Brigham and Women’s Hospital (BWH) at Harvard
Medical School. The AMIGO is an integrated, 5,700 square
foot area divided into three sterile procedure rooms in which
a multi-disciplinary team will treat patients with the benefi
t of intra-operative imaging using multiple modalities.
The space is designed so that teams can move effortlessly
throughout to access any of the advanced imaging and surgical
technologies.
On May 4, 2011, Brigham and Women’s Hospital (BWH)
unveiled the Advanced Multi-modality Image Guided
Operating (AMIGO) Suite, the fi rst suite in the world to give
surgeons and interventional specialists immediate access
to a full array of imaging modalities for use during procedures.
This cutting-edge operating room/interventional suite
enables treatments that are less invasive and more effective.
The AMIGO suite represents the next major step in Image
Guided Therapy (IGT).
The AMIGO Suite is an innovative surgical and interventional
environment that is the clinical translational test bed
of the National Center for Image-Guided Therapy (NCIGT)
at the Brigham and Women’s Hospital (BWH) at Harvard
Medical School. The AMIGO is an integrated, 5,700 square
foot area divided into three sterile procedure rooms in which
a multi-disciplinary team will treat patients with the benefi
t of intra-operative imaging using multiple modalities.
The space is designed so that teams can move effortlessly
throughout to access any of the advanced imaging and surgical
technologies.
), Intraoperative Imaging and Image-Guided Therapy,
DOI 10.1007/978-1-4614-7657-3_24, Springer Science+Business Media New York 2014 Why the AMIGO On May 4, 2011, Brigham and Womens Hospital (BWH) unveiled the Advanced Multi-modality Image Guided Operating (AMIGO) Suite, the rst suite in the world to give surgeons and interventional specialists immediate access to a full array of imaging modalities for use during proce- dures. This cutting-edge operating room/interventional suite enables treatments that are less invasive and more effective. The AMIGO suite represents the next major step in Image Guided Therapy (IGT). The AMIGO Suite is an innovative surgical and interven- tional environment that is the clinical translational test bed of the National Center for Image-Guided Therapy (NCIGT) at the Brigham and Womens Hospital (BWH) at Harvard Medical School. The AMIGO is an integrated, 5,700 square foot area divided into three sterile procedure rooms in which a multi-disciplinary team will treat patients with the ben- et of intra-operative imaging using multiple modalities. The space is designed so that teams can move effortlessly throughout to access any of the advanced imaging and surgi- cal technologies. The AMIGO Suite is one of the rst surgical environments in the world to integrate the use of this wide variety of advanced imaging technologies, including CT and MRI cross-sectional imaging systems; x-ray and ultrasound real- time imaging systems; and molecular imaging systems such as a hand-held beta probe, PET, and targeted optical imaging. Molecular image-guided therapy will be pioneered with the use of multiple molecular probes, such as PET, optical imaging, and targeted mass spectrometry, to increase the sensitivity and specicity of cancer detection. Application of these technologies is expected to improve the ability to dene tumor margins to more completely excise or ther- mally ablate tumors. In addition to multi-modality imag- ing, the AMIGO has various navigational devices, robotic devices, and therapy delivery systems that help physicians to localize and treat tumors and other targeted abnormali- ties. The AMIGO represents and encourages multi-disci- plinary cooperation and collaboration among teams of surgeons, interventional radiologists, imaging physicists, computer scientists, biomedical engineers, nurses and technologists to reach the common goal of delivering the safest and the most effective state-of-the-art therapy to patients in a technologically advanced but patient-friendly environment. AMIGO is the physical manifestation of the NCIGT mis- sion. It is a not only an operating suite, but the test bed for research and the proving ground for this vision. Above all, the AMIGO will provide a sophisticated, fully integrated image-guided therapy infrastructure that will lead to disrup- tive changes in procedural paradigms of surgery and inter- ventional radiology. The NCIGT is focused on the multidisciplinary devel- opment of innovative image-guided intervention technolo- gies to enable effective, less invasive clinical treatments that are not only more economical, but also produce better results for patients. It is now becoming apparent that the use of multiple modalities can enhance procedures by calling upon the strength of an individual modality to The Advanced Multimodality Image- Guided Operating (AMIGO) Suite Daniel F. Kacher , Brendan Whalen, Ahin Handa, and Ferenc A. Jolesz 24 D. F. Kacher , MS (*) F. A. Jolesz , MD National Center for Image Guided Therapy, Department of Radiology , Brigham and Womens Hospital, Harvard Medical School , Boston , MA , USA e-mail: kacher@bwh.harvard.edu; jolesz@bwh.harvard.edu B. Whalen , Barch Partners HealthCare , Boston , MA , USA A. Handa , Barch Payette Associates Inc , Boston , MA , USA 342 ameliorate the weakness of any complementary modality. In response, comprehensive environments, multi-modality operating suites, are emerging. Multi-modality image- guided therapies utilize information derived from different physical and biological properties of the tissues, obtained by measurements with diverse underlying physical principles. AMIGO Suite Components The central operating with its ceiling mounted single plane x-ray machine is anked by a PET/CT room on the left and a MRI room on the right. Sliding doors adjoin the three rooms. Each room has a separate entrance to the control corridor and support spaces (Fig. 24.1 ). Fig. 24.1 ( a ) Floor plan imparting the size of each room and its respective control room as well as the equipment in each room and its maneuverability (Courtesy of Payette Architects). ( b ) The panoramic cutaway rendering (Courtesy of Balazs Lengyel MD). ( c ) Building section (Courtesy of Payette Architects) a b c
D.F. Kacher et al. 343 MRI Room : The Magnetic Resonance Imaging (MRI) room is centered around a high-eld (3 Tesla) wide bore (70 cm) MRI scanner integrated with full OR-grade medical gases, MRI-compatible anesthesia delivery and monitoring system, view screens, lighting, and therapy delivery equip- ment. Here, the clinical team uses image-guidance principles for many oncology applications. With the familiar in-out paradigm, patient is imaged and then withdrawn from the bore of the scanner for intervention. In some procedures, the doctor can reach into the scanners short/wide bore to access the patient. The room is designed to be used independently for interventional procedures or in conjunction with the Operating Room. The ceiling mounted MRI scanner can tra- verse on rails to a fully draped patient on the OR table. With this innovation, surgical patients do not need to be trans- ferred between tables for imaging. These features enable exibility in workow to tailor procedures to the needs of the doctor and patient. Operating Room : The heart of the suite is the operating room (OR), integrated with the anking rooms. The room is equipped with MRI-compatible anesthesia delivery and monitoring systems; surgical microscope with near-infrared capability; surgical navigation systems which track handheld tools, probes, and the surgical microscope, to display images corresponding to the tool location; a ceiling-mounted single plane x-ray system; 2D and 3D ultrasound imagers; and a an armamentarium of surgical support equipment. The surgical table has a oating table top for angio acquisition and pivots to face the MRI scanner, PET scanner, or x-ray system. All images and data related to the procedure are collected and prioritized by using video integration technology and can be recorded or displayed on large view screens at the point of care, enabling surgical teams to select and view all applica- ble patient information at a glance. PET/CT Room : One of the most innovative features of the AMIGO is the inclusion of Positron Emission Tomography (PET) in the surgical environment. Similar to the MRI room, the PET/CT room can be used for stand- alone interventional procedures. Unlike the MRI scanner, the PET/CT scanner is xed to the oor and does not move. Patients can be transferred on a shuttle system between the PET/CT table for imaging and the OR table for surgery. At the time of writing, the AMIGO Suite is unique in the world with its direct connectivity between a PET/CT room and an operating room. PET produces images elucidating the bodys functional and metabolic interaction with molecular biomarkers. The combined use of MRI and CT with PET capabilities enables clinicians to combine anatomical, functional, and metabolic information to enhance intra-procedural deci- sion-making. BWHs on-site cyclotron enables the inves- tigation of novel molecular imaging agents to localize and target viable tumor tissue and verify complete removal or therapeutic destruction. AMIGO is a resource-rich environment. Table 24.1 lists the current equipment and infrastructure vendors as well as the design and construction teams that made the project a success. AMIGO Suite Design and Construction This section is intended to be a resource for institutions join- ing the future of image-guided therapy and surgery. The real- ization of a space like AMIGO will demand a full team of extraordinary thinkers: designers, builders, clinicians, tech- nical personnel, and administrators coming to a consensus of vision to make such a project a reality. Previous publica- tions describe the facets of architecture for diagnostic and therapeutic suites [ 1 ] and more specically intraoperative MRI facilities [ 2 ]. The specics of AMIGOs design and construction process are presented here in stages and describe the teams interaction. Understanding the Technology and Its Use : It is impera- tive to fully understand the systems being introduced into the project and how they will be employed by the end users. The design team worked diligently with stakeholders in the hos- pital and industry to understand user requirements and sys- tem capabilities. Previous installations of similar technology were designed to support only neurosurgery. The team part- nered with the integrator (IMRIS Inc., Winnipeg, CA) to expand the capability of the space to support percutaneous intervention, endovascular intervention, minimally invasive surgery, and open surgery throughout the body. The impact of hanging a moving MRI scanner from the ceiling is central and pervasive throughout the entire pro- cess. A Siemens 3-T magnet was retrotted and integrated by IMRIS. A considerable no y zone was necessitated for the travel of the scanner, and nothing could be placed on the ceiling in its path. In the OR, the surgical table position and boom layout were critical for enabling multiple services to work in the space while being constrained by the no y zone. The x-ray c-arm travels on ceiling tracks perpendicu- lar to the MRI tracks. Unlike conventional single-purpose ORs, the room setup must be drastically altered to accom- modate a given procedure. The table is nominally pivoted towards the MRI scanner but pivots 90 for x-ray-guided procedures and 180 for PET/CT-guided procedures. The x-ray c-arm also travels on the ceiling. Point of care view screens are installed at several locations to accommodate dif- ferent procedure- specic room congurations. The ceiling- mounted navigation system was located to enable its use in all three table locations. Provisions were made for a work in progress to develop patient ow between the OR and PET/ CT room. Demands for circulating space were considered for mobile equipment and personnel to move about while maintaining a sterile eld. All these factors were considered in designing the space. 24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite 344 Design Within the Shell Space : The AMIGO Suite encom- passes an area of 5,700 ft 2 . The east side of the suite is dedi- cated to the three procedure rooms including control stations and equipment rooms. An 8-ft-wide corridor is the central spine that serves to spatially open up and connect the control areas with a centralized nursing and ow coordinator station. The west side of the suite supports services: a decontamina- tion room, a clean assembly room, a sterile storage, and two large equipment storage rooms, as illustrated in Fig. 24.2 . Structure : AMIGO is advantageously located two oors below grade on the hospitals subgrade foundation. The larger and stronger reinforced concrete columns on this level support the ceiling-mounted MRI scanners structural steel, causing less concern from vibration than placing the suite on an upper oor. The greatest structural challenge was meeting the steel beam deection tolerance specication that IMRIS required to support the weight of the MRI as it transits: no more than 1/8 deection of steel beam for every 8 ft of beam length. The specic challenge was to maintain this requirement while limiting the dimensions of the steel beam in order to allow infrastructure to t overhead. The unique design, shown in Fig. 24.3 , kept the steel support simple and allowed for maximum exibility for infrastructure to t within the ceiling plenum. Another concern was vibration from outside the hospital that might impact the image quality from the MRI. A major source of vibration is the plant that provides supplemental electricity to the six hospitals in the surrounding Longwood Medical area, located adjacent to the end of the hospital housing AMIGO. To mitigate the effects, large pre- compressed vibration isolation pads were designed for all beam and column connections (Fig. 24.3 ). Shielding and Penetration : Along with the shielding ven- dor (ETS-Lindgren, Glendale Height, IL) and IMRIS, the team designed the shielding efciently to enclose the two impacted rooms. Both the OR and MRI rooms are six-sided copper RF-shielded boxes to prevent electromagnetic inter- ference from impacting MR image quality. Both the OR and PET/CT rooms are lead shielded. The sliding doors and con- trol room doors in the OR were designed with additional Table 24.1 Equipment and industrial partners in AMIGO Imaging equipment, patient table, and room integrator IMRIS, Inc. Designer Payette Architecture, Inc (Boston, MA) Build, general contractor Barry Construction /Suffolk Construction RF enclosure, sliding doors ETS-Lindgren Booms and lights Trumpf GmbH Video integrator Black Diamond Video 3-T Verio MRI scanner Siemens Healthcare Artis zee single plane angiography/uoroscopy x-ray system Siemens Healthcare Biograph mCT PET/CT Siemens Healthcare Acuson S2000 ultrasound system Siemens Healthcare 56 8-megapixel display Siemens Healthcare Pro Focus Ultra View ultrasound system BK Medical Nonferrous metal detector Kopp Development VectorVision sky navigation system (neuro procedures) BrainLab, Inc. Pentero Surgical Microscope Carl Zeiss, Inc. EnSite NaxX navigation system (EP procedures) St. Jude Medical Cardio lab electrophysiology recording (EP procedures) GE Healthcare Stockert 70 RF generator (EP procedures) Biosense Webster IMROC MRI-compatible wireless headset OptoAcoustics CUSA NXT ultrasonic tissue ablation system Intregra Force Triad electrosurgical unit Covidien Malis CMC bipolar electrosurgical unit Codman Bair Hugger patient warmers Arizant Healthcare Alaris IV infusion pumps CareFusion MRI, CT, x-ray power injectors Medrad, Inc. Aegis navigation system (interventional radiology procedures) Hologic/Sentinelle Medical Aegis MRI-guided pelvic intervention solution (patient positioning, MRI coil, targeting device, software) Hologic/Sentinelle Medical Symbow Medical navigation system (interventional radiology procedures) Symbow Medical Ablative laser Visualase, Inc. Endoscout MRI navigation system Robin Medical, Inc. MRI-compatible task light and view screens Aadcomed, Inc. D.F. Kacher et al. 345 structural reinforcement to support the weight of the copper and lead. The viewing windows into the OR, MRI, and PET/CT rooms (Fig. 24.4 ) are oversized and comprised of polarizing privacy glass, lead glass, and RF copper mesh glass. The pri- vacy glass when turned off turns opaque and meets the laser safety requirements to allow laser operation inside the room without additional laser safety measures being installed. Silicon rolled steel for magnetic shielding was located only on the rear of the MRI room to prevent the MRI scan- ners fringe eld from extending into the hallway adjoining the EP labs, to protect patients, personnel, and equipment outside the suite. Another unique detail in AMIGO is the inclusion of an independent RF-shielded equipment cabinet inside the larger RF-shielded enclosure. This feature allows clinicians and researchers to stage non-MRI-compatible equipment into the interventional environment via waveguides and ltered con- nectors without affecting image quality (Fig. 24.5 ). Additional pen panels were added under each control win- dow as well as the MRI equipment room to allow for addi- tional connections with equipment placed outside the RF a Fig. 24.2 Suite oor plan. ( a ) Procedure space is to the right of the central corridor and support space is to the left. The red arrow shows the pathway for entry into the suite and the orange arrows show the pathways into the procedure rooms (Courtesy of Payette Architects). ( b ) Axiometric view of suite (Courtesy of Balazs Lengyel MD)
24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite 346 rooms. All subpanels are modular and can be retrotted to meet future user requirements (Fig. 24.5 ). Location of all lters and waveguides required for all infrastructure (electrical conduits, HVAC ducts, med gas piping, etc.) penetrating the shielded rooms was carefully coordinated to ensure a clean plenum space above the ceil- ing. Boom mounts were designed to obviate the requirement for kicker supports, a space saving method that allowed for much needed above ceiling space (Fig. 24.6 ). Infrastructure : HVAC ducts and vents, medical gas pip- ing, electrical conduits, and sprinkler lines were tightly coor- dinated into the available plenum space inside, above, and around the RF shield, 3D infrastructure modeling (Fig. 24.7 ), to ensure precision and effective layering was critical. The location of the suite, two oors below grade, caused design and constructability issues with the quench vent and purge exhaust ducts for the MRI scanner. Welded stainless steel ducts were run 500 linear feet from AMIGO through an existing OR space directly above, to a ve-story exterior vertical shaft, to a point on the roof safely away from the adjacent patient bed tower air intakes. The infrastructure ris- ers to house the large ducts and other mechanical hardware were carefully designed and constructed to ensure minimal disruption to the hospital infrastructure or interference with the existing imaging systems. Airow : All three procedure rooms were designed to exceed air turnover specication for full-grade operating rooms set forth by the FGI Guidelines and the MA Department of Public Health (DPH). In an ideal OR environment, laminar downward airow is provided by a 10 10-wide array of diffusers around the patient table to prevent airborne debris from entering the surgical eld. Due to the orthogonal tracks for the MRI scanner travel and x-ray c-arm travel, in addition to demand for ceiling real estate for grid lighting and boom mounts, ideal placement of diffusers was not possible (Fig. 24.8 ). To receive project approval, the DPH required a 3D com- putational uid dynamics model of the space to be created to illustrate adequate airow. The modeling showed optimal quantity and location of supply and returns air diffusers to achieve necessary airow speeds and contaminated air dilu- tion around the patient table. The design yields negligible difference in the movement of airborne particles compared to an ideal OR. Booms : AMIGO is intended to enable multiple surgical and interventional services, each with their unique needs. The OR is designed to have two central procedure positions: a surgical eld placed in the direction of the MR room and a second eld for x-ray-based procedures. The boom layout is intended to meet current needs and offer exibility for the future unforeseen needs. Separate equipment booms for sur- gical support equipment and cardiac ablation (EP) equipment were necessary. In a typical EP lab, equipment is placed below or attached to rails on the side of the patient table. This setup is incompatible with operating room standards and not possible with the moving MRI scanner due to magnetic attraction on the devices. Lights and view screens are posi- tioned with left-right symmetry when the patient table is b Fig. 24.2 (continued) D.F. Kacher et al. 347 pivoted with the head towards the MRI scanner. Patient posi- tion dictates where the surgeon stands and which view screens are used for a given procedure. A 56 8-megapixel display is mounted on the same tracks as the x-ray c-arm and can be used for both surgical and x-ray-based procedures. The x-ray boom arm holding the lead shield was made long enough to reach and protect a clinician standing on the distal side, away from the boom mounts. The navigation system camera and touch screen were positioned to enable naviga- tion in either table position. All mounts for the booms were positioned such that the booms could be pivoted towards the walls of the room, outside the 5-G line, where they would not be magnetically attracted to the MRI scanner when it enters the OR. The operating room is approximately 700 ft 2 , creating a decit compared to the recommended 850 ft 2 . The ceiling space occupied with two sets of ceiling rails at different ceiling heights for x-ray and MRI, HVAC diffusers, general 2 2 surgical lighting xtures, and LED MRI-compatible lighting presented an optimization problem for locating the ve boom mounts, each supporting as many as three arms. Drawings of boom travel and 3D rendering with kinematic models of the booms were critical for determining nal loca- tions. Figure 24.9 illustrates some of the techniques employed to achieve desired boom reach and clearances and prevention of conicts and collisions. Power and Power Shutdown : The three procedure rooms were powered with critical power and isolated power with W14x193 PRE-COMPRESSED VIBRATION ISOLATION PADS BEAM MOUNTING PLATE AT COLUMN SEISMIC SNUBBER a b Fig. 24.3 ( a ) Construction photograph of the steel structure (Courtesy of Payette Architects). ( b ) Design and construction photograph of the structural isolation damper (Courtesy of Payette Architects & Cavanaugh Tocci Associates)
24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite 348 emergency backup. Critical power breached the RF shield- ing via electrical lters. Since isolated power could not cross the shielding without losing its isolation, the isola- tion transformer panels were located inside the RF shield. A product was identied that did not put out electromag- netic interference (EMI) in the band used by the MRI scan- ner and installed outside the 5-G line. Many clinical devices and infrastructure elements in use during the pro- cedure, however, do release EMI and must be powered off prior to imaging. Such items were powered by circuits controlled by a relay panel. Room integration touch screens enable shutdown of all devices with a single com- mand. Outlets are color coded, and signage is installed to inform users if the outlets remain powered during imaging. The PET/CT scanner and x-ray system are backed up by universal power supplies (UPS). A UPS was not supplied for the MRI; after careful consideration it was determined that Fig. 24.4 PET/CT and OR control room (Courtesy of Warren Jagger Photography) a b Fig. 24.5 ( a ) RF-shielded cabinet inside MRI room and penetration panels and waveguides (Courtesy of Payette Architects). ( b ) Drawing detail of shielded window and under counter penetration panel (Courtesy of Payette Architects)
D.F. Kacher et al. 349 UPS was not required based on the need, the considerable space requirements, and added project costs. Control Workstations : Available space at the control area counters prohibited placement of all computer CPUs and view screens needed for the various clinical services using the three procedure rooms. An elegant solution to this prob- lem is the IMRIS/Black Diamond Video Control Workstation. Multiple redundant control workstations were placed in the control rooms and procedure rooms. Each of these could, via a keyboard/video/mouse switching matrix, take control of the procedure-specic CPUs in the rack located in the MRI equipment room. This solution not only reduces clutter but places the computers in a controlled, conditioned, dust-free environment. Video from these computers is also routed using the control workstation to display images at the point of care and on the view screens above the control room windows. The control workstations control room power down, as well as lighting, and camera zoom/focus. A high- denition recorder enables archiving of room views and computer screens. Finishes : The design team was determined to make the space a comfortable and an enjoyable work environment that, despite being located below grade with no natural light, can utilize materials and soft colors to break the stereotypical cold and sterile environments that sometimes come to be associated with these types of spaces. Flooring materials were chosen carefully for comfort and durabil- ity. Flooring patterns were utilitarian, highlighting table rotation and iso- gauss lines of the MRI scanners fringe eld, establishing safety zones for specic equipment (Fig. 24.10 ). Colors in the ooring and throughout the suite work in harmony with the IMRIS and Siemens soft palette of cooler colors. Safety : Due to the MRI scanners magnetic eld and use of ionizing radiation for PET, x-ray, and CT, security and safety into the suite is of paramount importance. Following guidelines set by the American College of Radiology [ 4 ], four MRI safety zones were implemented. The MRI room is in Zone 4, where all staff are MRI safety trained or under direct supervision and no ferrous objects are allowed. Depending on the location of the MRI scanner, the OR shifts between Zone 3, where ferrous objects are permit- ted, and Zone 4. As a policy decision, all personnel are required to make themselves MRI safe when entering the OR no watches, pages, cell phones, wallets, etc. regard- less of the MRI scanner location. When the MRI scanner enters the OR, the MRI control room door automatically locks. The control room is Fig. 24.6 Design detail and photograph of the dielectric isolation and shielding scheme for the boom mounts (Courtesy of Payette Architects & ETS-Lindgren Shielding)
24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite 350 considered Zone 3 and is under the control of AMIGOs ow coordinator, a post that is continuously manned during business hours. The ow coordinator is responsible for con- trolling access into the suite and conrming personnel have undergone the suites rigorous safety training procedures before they can be allowed unescorted into the suite. Only staff who have undergone safety training and use the suite on a regular basis are allowed security access. Swipe card read- ers are located between the public corridor (Zone 4) and the restricted gowning area (Zone 3). All access points are on security cameras connected to the ow coordinators desk and hospital security. A nonferrous metal detector gate was installed in the Zone 3 control corridor (Fig. 24.11 ); since completion of the project, this has become a standard FGI requirement on all future MRI projects. A single gate detector services both the OR and MRI rooms; all staff and visitors must use the detec- tor prior to entering the Zone 4 rooms. Due to space a b Fig. 24.7 ( a ) Planned infrastructure above the ceiling, suite wide (Courtesy of Suffolk Construction). ( b ) Realized infrastructure above the ceiling in MRI room (Courtesy of Payette Architects)
D.F. Kacher et al. 351 Fig. 24.8 ( a ) Reected ceiling plan of the OR showing air diffusions in blue , boom mounts in green , and grid lighting in yellow (Courtesy of Payette Architects). ( b ) Red line in image depicts the cross section of the lower images. ( c ) Computational uid dynamics model of air veloc- ity vectors crossing the head of the surgical table realized in AMIGO and ( d ) for the ideal ASHRAE 170 compliant pattern a b
24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite 352 Fig. 24.9 Boom spatial layout plan. ( a ) Plan view showing booms (Courtesy of Payette Architects). ( b ) Reected ceiling view showing travel of each element of the arms (Courtesy of Payette Architects). ( c ) Kinematic 3D model used to explore boom movement (Courtesy of Trumpf Medical Systems). ( d ) Photograph of nal layout with the table in the surgical position (Courtesy of Warren Jagger Photography). ( e ) Photograph of the table in the x-ray interventional position. The EP equipment boom and surgical support equipment booms are visible (Courtesy of Warren Jagger Photography) a c d Fig. 24.8 (continued)
D.F. Kacher et al. 353 b c Fig. 24.9 (continued) 24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite 354 constraints, gates were not at the entrances to the OR and MRI procedure rooms because the width of the doors would mandate a wider gate, lowering the sensitivity of detection. Moreover, ferrous metal (e.g., US scanner) is brought into the OR in a controlled fashion. It was determined during design that alarm fatigue would cause personnel to disregard the detector alarms when a true issue arose. In addition to the safety-related oor patterns shown in Fig. 24.11 and MRI warning posters on the doors, warning mats were cut into the oor and labeled Stop Magnet Always On. Indicator lights above the doors inform staff in which room the MRI scanner is parked and when x-ray or laser is in use (Fig. 24.13 ). Construction : As the friendly name suggests, AMIGOs bedrock is the exceptional working relationship between the three key driving groups: the design team, construction team, and the client comprised of hospital leadership, clinicians, and technical personnel. The teamwork was evident from the beginning during early design that started with pre- construction services. Here, the contractor, client, and archi- tect worked in harmony to nd design and construction solutions to issues like wall assembly layering, mechanical electrical plumbing infrastructure coordination, critical dimensions that become imperative for ensuring room size is appropriate, and handling the complex approval process with regulatory agencies. The team also designed and built this suite to be exible and future proof. Figure 24.12 shows a series highlighting the construction- phased renovation process from the beginning to completion and reects the key design criteria described earlier. d e Fig. 24.9 (continued) D.F. Kacher et al. 355 a b Fig. 24.11 ( a ) Floor pattern safety mat and OR entrance. ( b ) Ferrous metal detector. The LEDs depict the location on the body where the metal was detected. Illuminated signage is seen in the background above the door to the MRI procedure room (Courtesy of Payette Architects) Fig. 24.10 ( Left ) Floor pattern plan in OR and MRI rooms. ( Right ) Photograph of nished ooring in the OR. The blue circle inside the green band represents the location of the MRI scanners isocenter when the scanner is in its imaging positio (Courtesy of Payette Architects)
24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite 356 Fig. 24.12 ( a ) Existing central processing department (Courtesy of Payette Architects). ( b ) Gutted shell space (Courtesy of Payette Architects). ( c ) Steel beam installation for MRI scanner travel (Courtesy of Payette Architects). ( d ) RF shielding and x-ray c-arm track installation (Courtesy of Payette Architects). ( e ) Infrastructure installation (Courtesy of Payette Architects). ( f ) Ceiling installation (Courtesy of Payette Architects). ( g ) Flooring installation and finishes. Bolt down points for the patient table are visible (Courtesy of Payette Architects). ( h ) Hanging of MRI scanner on tracks. The cable management system is visible (Courtesy of Payette Architects). ( i ) Completed operating room (Courtesy of Warren Jagger Photography). ( j ) Completed operating room (Courtesy of Warren Jagger Photography). ( k ) Completed operating room (Courtesy of Warren Jagger Photography). ( l ) Completed control room corridor (Courtesy of Warren Jagger Photography) a b AMIGO Suite Procedures The intention of AMIGO leadership is to seek out game- changing applications in the area of image-guided therapy and surgery and probe the limitations of use of the suite in a systematic fashion. An initial road map was developed to launch programs for various clinical services. Each idea was written up and vetted by an internal and external scientic review board to ensure it meets the mission of AMIGO and the National Center for Image Guided Therapy. Programs that are not successful would be modied or discontinued. Successful, economically viable programs would also ulti- mately be discontinued at AMIGO, with the intention of developing procedure-specic space in the hospital contain- ing the subset of needed equipment, or by simply sending the clinician back to his conventional space but with a validated,
D.F. Kacher et al. 357 c d Fig. 24.12 (continued) 24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite 358 e f Fig. 24.12 (continued) D.F. Kacher et al. 359 Fig. 24.12 (continued) g h 24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite 360 i j Fig. 24.12 (continued) D.F. Kacher et al. 361 Fig. 24.12 (continued) k l 24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite 362 hopefully disruptive tool. At this stage smaller hospitals and the public can reap the benets of the ongoing experiment, that is, AMIGO. The center is arranged according to cores: Imaging Core; Computation Core; Prostate Core; Neurosurgery Core; Focused Ultrasound Surgery Core; Administration, Training, Service, and Dissemination; and Collaborations. Activity of each core is projected onto the procedures in AMIGO, listed in Table 24.2 . Earlier phase procedures would be retired to create available room time for newer a b Fig. 24.13 ( a ) PET/CT room . Surgical lights with a high-denition camera, and view screens are use to support the procedures (Courtesy of Warren Jagger Photography). ( b ) Room view of the PET/CT-guided liver cryoablation. ( c ) 3D rendering of CT data with the cryoprobes in place. ( d ) Maximum intensity projection of the CT data showing the cryoprobes, with a pseudocolored single-slice of FDG PET data showing the metabolic activity tumor, overlayed Table 24.2 Road map of AMIGO procedures Phase I (~20112012) Phase II (~2013) Phase III (~2014) Brain open surgery Cerebro and endovascular Spine surgery Brain laser ablation Endoscopic kidney ablation Skull base surgery Transphenoidal pituitary resection Bone metastasis thermal ablation ENT sinus surgery Breast cancer lumpectomy Brain surgery through ventricle Craniofacial surgery XMR guided cardiac ablation Lung bronchoscopy, biopsy Lung thermal ablation Prostate biopsy, brachytherapy Image registered endoscopy (abdominal, thoracic) Trauma fracture correction Cervical cancer brachytherapy Joint replacement Liver, kidney biopsy, ablation
D.F. Kacher et al. 363 procedures. A technical lead from the center is assigned to each procedure. PET/CT Room : The space has two modes of use. The rst is the familiar in-out paradigm currently used in interventional CT for biopsies, drainages, and ablations. The 80-cm bore offers ample space for placement of percutaneous probes and patient positioning. As an aside, the installation of a PET/ MRI was explored, but the bore diameter of 60 cm was con- sidered to be too great of a limitation for interventional use. Figure 24.13 shows a PET/CT-guided liver cryotherapy in progress. The second mode of use entails transferring the patient from the OR to the PET/CT scanner for imaging, then back again for continued surgery. The sliding doors between rooms are opened, a bridge is positioned between the OR tables and PET/CT table, and the patient is shuttled into the scanner on an MRI-/PET-/CT-/x-ray-compatible transfer board, which he/she never leaves throughout the procedure (Fig. 24.14 ). The transfer board supports head xation for neurosurgery. It is anticipated the thoracic service will also utilize this mode. Operating Room : The middle room of the suite is essen- tially a hybrid OR an x-ray intervention room with sterility measures, infrastructure, and equipment for surgery. Planned procedures include open surgery, minimally invasive surgery, endovascular interventions, and percutaneous and burr hole ablation procedures By far, the predominant use of intraoperative MRI rooms worldwide is for brain tumor resection. A major shortcoming of image-guided navigational systems is the use of preoperatively acquired image data, which does not account for intraoperative changes in brain morphology. The occur- rence of these surgically induced volumetric deformations (brain shift) has been well established [ 4 ]. Brain shift is a continuous dynamic process that evolves differently in dis- tinct brain regions. Intraoperative updates to the image- guided navigation data are a strong justication for this application, in order to ensure optimal resection. Image registration is an essential part of any neurosurgi- cal planning and navigation system because it facilitates combining images with important complementary, structural, and functional information to improve the information based on which a surgeon makes critical decisions. The registration process entails transforming images acquired at different time points, or with different imaging modalities, into the same coordinate system [ 5 ]. This is a topic of research in AMIGO and is explored in depth in other chapters of this textbook. When the surgeon calls for updated MR image to provide more accurate navigation, the procedure room must rst be transformed, to create an MRI safe environment. The pro- cess is supervised by a safety nurse, a new role created for AMIGO. Booms are pivoted outside the 5-G line and teth- ered. The surgical microscope (Carl Zeiss Jena, Germany), ultrasound unit (BK Medical, Peabody, MA and Siemens Healthcare, Erlangen, Germany), and EEG pedestal (XLTEK, San Carlos, CA) are removed from the room. Instruments are counted. The monopolar return electrode pad and patient warmer tubing are removed. All other ferromagnetic items are accounted for and safely positioned. The room is pow- ered down, including surgical support equipment, view screens, and keyboard/monitor/mouse extension hardware. The anesthesia machine (GE Healthcare, St Giles, England) and vital signs monitor (In Vivo Corp, Gainesville, FL) and MRI-compatible cameras (Sound Imaging Inc, San Diego, CA) remain on. The cavity is lled with sterile saline to eliminate the air-tissue interface, which can cause suscepti- bility artifact in the MR images. The skin is cursorily closed and the surgical wound draped. The patient table is returned to a level position and extended such that the patients head will be in the isocenter of the MRI scanner. The posterior element of the MRI head coil was positioned before incision. The anterior element is added. A template of the MRI scanner bore is used to ensure nothing will make contact with the scanner the table cantilevers into the bore. The sliding doors to the MRI room are opened, and MRI scanner is translated into the OR, with all personnel ensuring the pro- cess is safe (Fig. 24.15 ). Following imaging, the MRI scan- ner is returned to its adjacent room, and the process is reversed to continue surgery. Ultrasound is used between c d Fig. 24.13 (continued) 24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite 364 MR images, for the advantages of its immediacy, to track changes and to help determine when new MR images are necessary. The process for breast lumpectomy is similar. Images are available in a separate chapter in this text. EP cases for atrial brillation treatment require a differ- ent room setup. The table is pivoted 90. A 56 view screen is used to the endovascular navigation view based on pre- incision MR images, live and review EKG traces, and intracardiac ultrasound images. A technologist operates equipment from the control room. Cables and ber optics are introduced into the RF-shielded room via lters and waveguides, respectively, in the penetration panel below the control room window. Wireless MRI-compatible head- sets (Optoacoustics, Moshav Mazor, Israel) are under development to facilitate communication between the con- trol room and procedure room. Prior to MR imaging, all catheters are removed, leaving only a short sheath in place. The patient table is pivoted towards the MRI scanner, and a similar process for room preparation as that in neurosur- gery is executed. The contrast-enhanced MR images enable visualization of the acute effects of RF ablation. The goal of the imaging is to nd gaps in the burn used to electrically isolate the pulmonary veins to inform the cardiologist a b Fig. 24.14 The patient transfer system used to move patients from the OR table to the PET/CT table for imaging. ( a ) Staff move a patient from the angio table, across a bridge, onto the PET/CT table. ( b ) The concept is illustrated with a 3D CAD model (Courtesy of IMRIS Inc.)
D.F. Kacher et al. 365 Fig. 24.15 ( a ) OR prior to room preparation for imaging. ( b ) MRI scanner entering OR. ( c ) MRI images acquired pre-incision and after resection. The arrows showing the lesion in the pre- image remain in the same location in the post-image to appreciate the brain shift. The signal void with the yellow arrow head is the area where tissue was removed. ( d , left ) The navigation system showing the focal plane of the microscope. ( d , right ) The view through the microscope with image injection, showing the target tissue based on segmentation of the MR images. ( e , left ) Ultrasound probe in the surgical wound. The probe is tracked by the navigation system and the corresponding MR image is displayed. ( f , right ) Intraoperative US image a b where to target with the next round of ablation. MRI- compatible catheters to perform the procedure under MRI guidance are becoming commercially available. MRI safe navigation patches 12-lead EKG are also under investiga- tion. Another chapter in this text explores this topic in depth. MRI Room : Similar to the PET/CT room, the 3-T MRI room can be used in a stand-alone mode with the in-out para- digm. The 70-cm diameter bore permits biopsies, needle inser- tion-based procedures such as prostate and cervical cancer brachytherapy, and ablations to be supported by this space. A cryotherapy delivery system (Galil Medical, Yokneam, Israel) is integrated via the penetration panel, with critical system components at the point of care and the non-MRI- compatible control interface remaining outside the room. An in-bore track- ing system (Robin Medical, Baltimore, MD) is also available that uses the eld generated by the MRI gradients to derive the location and orientation of a probe or needle. An MRI- compatible view screen, vital signs monitor, and anesthesia machine are present in the room. The ceiling-mounted scanner pivots 180 on a turret to place the patient table at the front or rear of the room, depending on the needs of the procedure. Pelvic intervention is facilitated by either a commercially available system (Sentinelle Medical, Toronto, Canada) or a solution codeveloped with Johns Hopkins University. Figure 24.16 shows some of the methodology.
24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite 366 c d Fig. 24.15 (continued) D.F. Kacher et al. 367 Fig. 24.15 (continued) e The Future of the AMIGO Suite and Other Multi-modality Suites At this time, AMIGO is unique in that the suite has a tightly integrated PET/CT and its leadership has handed down a mandate to explore all possible applications, head to toe. AMIGO, however, is not alone in the world. Hybrid ORs (see chapter in this text) have been installed at many univer- sity hospitals. Fig. 24.17 shows a map of centers around the world using MRI to guide procedures. Vendors are making specialty products for these spaces. The trend is undeniable. Multimodality suites will become pervasive. The scalpel is increasingly being replaced by therapeutic tools. Cryotherapy, microwave ablation, radiofrequency ablation, brachytherapy, radiation therapy, inductive heating, focused ultrasound, localized stem cell injection, and more exotic therapies expand the armamentarium of the clinician. A symphony of imaging systems, navigation systems, robot- ics, and therapeutic probes create a new world for patient care. Researchers and integrators in these elds accelerate the progression from open invasive surgery to minimally invasive surgery or therapeutic intervention. Although AMIGO has a road map, it is typical that the inventor does not know entirely what he/she invention is for. Uses are worked out in collaboration with the user. Creativity is collaborative, cumulative, and interactive. Communication with sites worldwide will yield the answer to: What is AMIGO for? 24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite 368 a b Fig. 24.16 ( a ) Patient in lithotomy position in the MRI bore. A posi- tioning system is used to give the clinical access to the pelvis. Iteratively, a needle or cannula is placed, then the pelvis is scanned at isocenter to conrm accurate targeting. ( b ) Axial prostate imaging showing two needles in place. ( c ) The acrylic grid is registered to the scanner coordi- nate system to provide a framework for needle placement. This setup is used for prostate biopsy and prostate low-dose brachytherapy. ( d ) Sagittal image of the cervix and tandem and ring applicator (Nucletron BV, Veenendaal, Netherlands), which facilitates cannula placement (Courtesy of Nucletron BV). ( e ) A photograph of the ring applicator. The patient is taken out of the AMIGO Suite to a lead vault for insertion of radioactive sources into the cannulas
D.F. Kacher et al. 369 c d Fig. 24.16 (continued) Fig. 24.17 Map of sites using high-eld MRI. ( Red ) 58 sites perform- ing neurosurgery. ( Blue ) 24 sites performing interventions (epilepsy treatment, laser ablation, convective drug delivery). There are nine cen- ters that do both. This map neglects centers using low-eld system and is most likely not exhaustive
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