Surgical equipment
The dream machine

Patients in the Middle East have access to the world’s most sophisticated neurosurgical operating room, one is operational in Dubai and another under construction in Riyadh. Callan Emery finds out more about this futuristic OR.



There is good reason why the phrase “brain surgery” has found it way into colloquial English language to mean “very intelligent” or “highly skilled”. Brain surgery, or neurosurgery, of necessity requires a deft hand and absolute precision. Any slip of the scalpel or incorrect incision can have disastrous consequences for the patient.

Over the past few years there have been some remarkable advances in technology, which now enable the neurosurgeon to achieve extremely fine precision during surgery. As with all advances in medicine, the benefits for the patient are significant and include improved safety, fewer complications following surgery, shorter time in the operating room and quicker recovery.

In a move which is taking neurosurgery into the 21st Century, BrainLab  (www.brainlab.com), a Munich, Germany-based company has integrated key technologies to produce an extremely powerful and sophisticated neurosurgical operating suite — the BrainSuite iMRI.

The BrainSuite iMRI is at the cutting edge of this field of medicine. There are currently only five in operation around the world. These are at Friedrich-Alexander University, Erlangen, Germany; Ospedale Sant Andrea, Rome, Italy; Staten Island University Hospital, New York, United States; Neuro Spinal Hospital, Dubai, United Arab Emirates; and BrainLAB AG, Headquaters, Munich. There are seven other suites being constructed at leading hospitals in the United States, Japan, Saudi Arabia and India, according to BrainLab.

“It is the dream of all neurosurgeons to be able to work with it,” Dr Karim Msaddi, neurosurgeon at Dubai’s Neuro Spinal Hospital, told Middle East Health.

The BrainSuite iMRI is the only completely compatible neurosurgical OR that fully integrates advanced imageguided surgery and all the necessary diagnostic tools, including high-field intraoperable MRI and powerful surgical microscopes, to treat complicated neurosurgical cases, such as brain tumours and vascular abnormalities.



BrainLab points out that this suite improves the efficiency and standard of care for established procedures and offers excellent research opportunities for creating new approaches.

Julia Glimmann, the product manager for BrainLab’s integrated OR solutions, told Middle East Health that the key components of the BrainSuite iMRI include:

VectorVision sky iMRI Navigation System

Vector Vision software including Automatic Image Registration

Zeiss OPMI Neuro NC4 MultiVision microscope

BrainSuite Data Billboard and Data Management System

BrainSuite iMRI system: high-field MRI scanner (1.5 Tesla Siemens Magnetom Espree)

Rotating OR table with integrated head clamp and coil

OR lights with integrated video camera, ceiling supply unit, anaesthesia equipment

BrainSuite iMRI RFshielded OR cabin

She said the BrainSuite iMRI was first launched at the AANS (American Association of Neurological Surgeons) trade show in Chicago in April 2002. “Around the same time, the first installation of BrainSuite iMRI was at the University of Erlangen, Germany.”

Integration

Dr Msaddi stressed that it is the seamless integration of its components that results in such a powerful neurosurgical OR.

He explained that images from the iMRI are transferred in realtime to the navigation system, which acts like a global positioning system for the human body.

“This enables target volumes of brain tumours, for example, to be localised with submillimetric accuracy. “It also enables the neurosurgeon to decide what trajectory to take to access the tumour and to avoid highly functional areas of the brain.”

Dr Msaddi explained that the VectorVision sky navigation system guides the neurosurgeon’s surgical instrument with an infrared laser, while the surgeon simultaneously follows the procedure under microscope, where the full volume of the tumour can be seen.

“What makes this system special is the high-field iMRI. Intra-operable MRI has been around for a while, but they have been low-field MRIs. The 1.5 Tesla and higher field MRI is in effect a functional-MRI (fMRI) enabling instant and continual updating of the tumour position.

“This is particularly important in neurosurgery, as there is what we call ‘brainshift’. The brain changes shape during surgery and it is essential the co-ordinates of the tumour are continually updated” to ensure precise and accurate surgery.

“This is also necessary for tracking other important centres of the brain.”

Dr Msaddi said that the high-field MRI and new software from BrainLab enables diffusion tensor magnetic resonance imaging (DTI) with fibre tracking. “This enables the neurosurgeon to follow, for example, the pyramidal tracts – motor nerve pathways in the brain and spinal cord – to see how their position changes during surgery and how to avoid damaging them.”

The Data Billboard

The BrainSuite’s Data Billboard provides the entire OR team clear access to all clinical data through an advanced visualisation design to enhance surgical decision-making processes.

Glimmann explained: “The central device for controlling all instruments in the BrainSuite is the touch screen. In order to avoid incorrect information we chose not to use voice control in the BrainSuite.

“On the touch screen you can follow your navigation, display the images of the microscope, control the data billboard and room control system as well as the OR lights. All these features can also be controlled from a wall mounted touch screen outside the sterile field or from the control room outside the BrainSuite,” she said.

With neurosurgeons operating in such close proximity to the MRI scanner, one of the obvious questions is: how can they do it? How can they use metal surgical instruments in such close proximity to the powerful MRI magnet? BrainLAB says standard surgical instruments can be used as the operating field is situated outside the 5 Gauss line.

Also, the MRI magnet is actively shielded. In other words, within the magnet, a secondary magnetic coil of opposite polarity is positioned outside of the main magnetic coil. The secondary coil greatly reduces the magnetic fringe field that extends into the area surrounding the magnet.

Glimmann explained what the 5 Gauss line is: “Around the magnet there is a magnetic fringe field which becomes weaker the further you move away. The 50 Gauss line indicates the distance to the magnet from which things can be actively pulled to the magnet.

The 5 Gauss line is further away from the magnet and is called the pace-maker line. People wearing pace makers should not come closer to the magnet than this line, which is marked on the OR floor. “Operating in the BrainSuite takes place outside the 5 Gauss line since the head of the patient on the OR table is positioned outside this line.

Therefore regular surgical instruments can be used. The instruments will not be attracted to the magnet and sensitive electronic devices work properly.”

Workflow

The sophisticated design of the BrainSuite iMRI is complemented by an efficient workflow system, starting with BrainLab’s iPLAN treatment planning software to markerless patient registration and navigation-ready surgical instruments.

The iPLAN software enables doctors and treatment centres to effectively use the massive amount of information available to them as well as giving them remote, multi-user access so that data can be viewed from outside the OR, at home or at the patient’s bedside where 3D renderings can be used to refine or explain a surgical approach.

BrainLab’s Z-Touch markerless patient registration offers a fast, reliable and accurate solution for patient registration. The company says more than 70% of its VectorVision navigation procedures are registered with Z-Touch.

BrainLab says it has created a combination of navigation-ready instruments to ensure faster setup and optimised surgical workflow. With an operational BrainSuite iMRI at Dubai’s Neuro Spinal Hospital and one currently being installed at the Neurosciences Centre at King Fahd Medical City (KFMC) in Riyadh, Saudi Arabia, patients requiring neurosurgery in the Middle East are very fortunate to have such cutting-edge equipment within their reach.

In fact, patients from much further afield have been using the facility at the Neuro Spinal Hospital, which actually has two units – one for neurosurgery and one for spinal surgery, according to Dr Msaddi.

“We get patients from all over – the Middle East, India, Pakistan, Algeria,” he said. “We’ve even had a patient from the United States who came here for spinal surgery.” “For neurosurgery we have two operating rooms, which can both make use the of MRI component of the BrainSuite.

“We also use the MRI a lot for diagnostic purposes,” he said. This point was made by BrainLab at a press conference in Dubai in January to announce KFMC’s purchase of the BrainSuite iMRI. The company pointed out that hospitals can offset some of the costs of the BrainSuite iMRI by also using it as a MRI diagnostic facility for services such as MR-angiography or MR spectroscopy.

“It is expensive,” Dr Mahmoud Al Yamani, director of Neurosciences Centre at KFMC, said at the press conference, without divulging how much KFMC had paid for the system. “But after a lot of research we found the BrainSuite iMRI to be the most advanced neurosurgery OR available.”

He said, with their investment in BrainSuite, KFMC wanted to set a new standard in healthcare for the region. Dr Yamani added that with BrainSuite’s functional- MRI capabilities “we also plan to carry out advanced neurological research”.

Robot-assisted surgery proves more accurate than conventional surgery

A new study from Imperial College London shows that robot assisted knee surgery is significantly more accurate than conventional surgery.

The team of surgeons tested whether Acrobot, a robotic assistant, could improve surgical outcomes for patients undergoing partial knee replacement. Acrobot works by helping the surgeon to line up the replacement knee parts with the existing bones.

The surgeons looked at 27 patients undergoing unicompartmental knee replacement. The patients were separated into two groups as part of a randomised controlled trial, with 14 having conventional surgery, and the remaining 13 having robot assisted surgery.

Although the operations took a few minutes longer using the robotic assistant, the replacement knee parts were more accurately lined up than in conventional surgery. All of the robotically assisted operations lined up the bones to within two degrees of the planned position, but only 40% of the conventionally performed cases achieved this level of accuracy.

The team found there were no additional side effects from using robotassisted surgery, and recovery from surgery was quicker in most cases. Professor Justin Cobb, from Imperial College London, who led the research team, said: “These robots are designed to hold the surgeon’s hand in the operating theatre, not take over the operation. This study shows they can be an enormous help, preventing surgeons from making mistakes.

More importantly, by showing how the increased accuracy makes a difference to how well a knee works after surgery, we will be able to develop a new generation of less invasive procedures without the risks of error, providing faster recovery and better functional outcomes for patients.”

The study involved both surgeons and engineers from Imperial College, with medical robotics engineers designing the Acrobot prototype, and surgeons testing it. Professor Cobb added: “This study could have important implications for not just surgery, but also for health economics. By improving the accuracy of surgery, and ultimately improving the outcome for patients, we can make sure the knee replacements work better and last longer, preventing the need for additional surgery.”

The study – Hands on robotic unicompartmental knee replacement – A prospective randomised controlled clinical investigation of the Acrobat system, Journal of Bone and Joint Surgery, February 2006 – was funded by The Acrobot Company, a spin out of Imperial College London. http://www.acrobot.co.uk/

                                  
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