Update Course Rewind: Highlighting Collaboration from Surgery & Interventional Radiology in the OR 2024

Globalcast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello pediatric surgery family. I'm M. Goddy from Cincinnati Children's Hospital Medical Center. In this video series, we'll be recapping the sessions and sharing the key highlights from our 12th annual update course in pediatric surgery, which was held in August 2024. This year, we introduced a new approach to classify practice changing ideas at our update course. Presentations now fall into three categories: green circle for established practice, blue square for promising newer practice, and black diamond for early adopter practice only. In this session, Amanda Wallingford, an interventional radiology technologist, and doctors Dan von Allmen, John Ricardio, and Timothy Lotz, will talk about the use of image guidance, surgery, and the importance of collaboration between departments. Information from this session classifies as a blue square for promising newer practice. This session is really about combining the expertise of surgeons with the expertise of our interventional radiologists and ultimately impacting the patient. So you keep the focus on what's right for the patient, put the egos aside and you can do really great things. Image guided surgery is a technique that uses real time imaging to help surgeons navigate during procedures with greater precision. This can involve techniques like CT, MRI, ultrasound or fluoroscopy to provide detailed views of internal structures, improving accuracy and safety. Um and even when we talk about image guidance, I think sometimes surgeon and interventional radiologist may be speaking different languages. Some surgeons may not know what's possible with image guidance, so they don't know what to ask for. And interventional radiologist may not know what the surgeons need. So they might not even know what to offer. A hybrid operating room is a specialized surgical suite that integrates both advanced imaging technology and traditional surgical setup. Some institutions like Cincinnati Children's build hybrid operating rooms so that patients do not need to be transported between separate radiology and surgical areas, which can enhance efficiency, reduce complications and improve patient outcomes. While a hybrid operating room is a valuable asset, it is not required for image guided surgery. So it's important to understand that you don't have to have a hybrid OR to be able to do this type of collaboration. It can occur in your regular OR by just bringing an ultrasound machine. It can occur in a hybrid OR if you're lucky enough to have that. Or it can occur in sort of dual settings where you go to interventional radiology, maybe you go to the CT scanner for a coil or a wire localization and then roll the patient up to the OR. Let's talk about an important part of hybrid OR. A cone beam CT. What is it really? So, it's a CT scan that's performed on a C-arm fluoroscopy unit. Basically, it's positioned over the patient's point of interest and it rotates around the patient, collecting multiple images which are then stacked together to create a CT. It provides excellent visualization of bony structures, making it valuable for maxilo facial, ENT, spine and orthopedic surgeries. Cone beam CT can be integrated into the operating rooms for real-time guidance, improving accuracy and minimally invasive procedures. And I think this is technology that many people have and don't realize that they have available at their institutions even if they're not doing it within a hybrid OR space. As I mentioned at at Cincinnati, we are fortunate, we are very collaborative with the surgeons. We share know-how, working together in our hybrid OR, which we've had open for about seven years now. There's also cross training. Interventional radiologists at Cincinnati Children's help train some of the pediatric surgery fellows who had ultrasound guidance for vascular access. Important part of the program is having someone that can really champion the efforts of the surgeons and the interventional radiologist and combine everyone working together. I'm the program manager at Cincinnati over image guided surgery. And my job is really to help be the liaison between the surgeons and the interventional radiologist because we all know nobody's going to want to try something new if it's going to be more complicated and take a longer time than their normal practice. And it is also a huge help is just having our leadership engaged in this program. Dr. von Allman is a huge support of the collaborations and so is the chief of radiology and that has really helped. Our hybrid OR was built so that any division can come in and use the room. It is not just sitting idle. We're doing collaborative cases with neurology, neurosurgery, pulmonary, gynecology, and we're doing multiple procedures on these patients when they're in there. So moving on, let's talk about some routine and widely available use cases. So, simple things, lymph node localization. You've got that supraclavicular lymph node that you can't really feel very well. You know it needs to come out. It needs more than just a core biopsy. You work together. So with ultrasound guidance, we'll just localize that with the Copan's needle wire. You know, even if you don't have a hybrid hour, the ultrasound machine rolls up to the OR, it's one prep and drape, put the Copan wire in. And then as the surgeon, you follow it down, you find that lymph node easily. And it takes what could be a big dissection and turns it into a nice and easy one. Sometimes there's a foreign body that's hard to feel. Sometimes it's a piece of glass. Ultrasound in the OR can be a great tool for this case. And often times surgeons will do this themselves. But sometimes it can be more challenging. Maybe give your IR colleague a call and we'll go ahead and localize it before there's introduction of some of that error. Just makes things virtually invisible. You can also use it for identifying and protecting critical structures during surgery. So, we all know during those terrible neuroblastoma excisions when you're creeping up the aorta and you're trying to see where the celiac takeoff is, I'm looking with the ultrasound every five minutes during that case and re-reorienting myself with the ultrasound. And then you can use it at the end of the case to confirm vessel patency. The transplant surgeons have been doing this forever, whether it's looking at the flow in the kidney transplant at the end of a case or looking at portal flow after a mex bypass. Again, you can use it at the end of a challenging neuroblastoma excision where you've really skeletonized the renal hilum, just reassuring yourself that the renal flow looks good at the end of the case is an easy and great use of these tools. There are all sorts of different ways to do pulmonary nodule localization and many of them involve collaboration between surgery and interventional radiology. You can do it with a wire, you can do it with a coil, you can do it with dye. Do it with whatever you're most comfortable with at your institution. The way we do it at Lurie is we actually make use of two different locations. First, they go to the pre-op CT and interventional radiologist use CT guidance and leave a coil right next to the nodule. And then in the OR, we'll use fluoroscopy under two different orthogonal planes. So you got to look at one angle and then move it 90 degrees to make sure you really have the nodule and remove it. I like this approach um sometimes combined with a dye because you're not at risk for wire um displacement. At Cincinnati Children's, they have a similar approach for these cases, but with a hybrid operating room, which obviates the need for patient transportation between radiology and surgical areas. We use a combination of methylene blue blood patch as we're going in. We'll do a cone beam CT, ideally with the patient in thoscopy position. This is just one draping and one prepping and it will be in the hybrid OR. We'll do a methylene blue blood patch tattooing of the visceral plura as we're going through it with the Copan's needle. And then we'll deploy the Copan's wire. What are the other use cases? Vascular malformations. These things are often managed in a multi-disciplinary VLC clinic. Interventional radiologist can offer sclerotherapy, pediatric surgeons can offer resection, but sometimes a combination is just the best. So if you have something where it's not really amenable to sclerotherapy, they can still do angiogram essentially and directly inject it and get a contrast study and then put glue in it so that if you have these little out pouching, these little legs, you can make sure that you're getting those fully resected at the time. But collaboration does not end here. There are so many use cases. Here, Dr. Ricardio explains how they work together with the pulmonology team to help them with transbronchial biopsies. We'll do a beam CT, we'll segment out the 3D anatomy, it takes about one minute and then our live fluorol will be superimposed over the this nodule. So in AP and a lateral view, they always know where they're going to be uh performing the transbronchial biopsy. Virtual reality, augmented reality, those are the things that are going to be a part of the future for sure. Here, we can see the IR research lab, which mirrors the clinical hybrid OR. It's just a holographic display superimposed over your patient on the table. So you take either pre-procedure CT MR imaging, segment that out and actually co-register it to your patient and the technology can track instruments. But that's definitely coming along. Let's watch this short video demonstrating a hydrocephalic sheep model about a one day old. In this example, Dr. Ricardio and his team used MRI imaging to create a holographic overlay of the anatomy. By aligning key reference points or fiducials, the hologram matches perfectly with the actual anatomy. Using hand gestures, you can virtually slice through the holographic image to view the dilated ventricles, helping in precise placement of a drain. In summary, collaboration between surgeons and interventional radiologist, even outside hybrid ORs, enhances patient care by integrating tools like ultrasound and cone beam CT for precise localization and guidance. Routine and innovative image guided techniques such as lymph node localization, pulmonary nodule marking, and vessel patency checks, simplify complex surgeries and reduce invasiveness. Emerging technologies like virtual and augmented reality are paving the way for more accurate, interactive surgical planning and execution, demonstrated by tools like holographic imaging in experimental models. Thank you for watching this video. Globalcast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.