RENE JOHNSTON / TORONTO STAR
Dr. Jonathan Irish, head of surgical oncology at the Princess Margaret Cancer Centre, shows the Artis Zeego robotic fluoroscopy machine in the new high-tech operating room. The scanner can be moved over anesthesized patients as they lie down.
Toronto General Hospital’s ‘operating room of the future’
Cancer surgeons will soon begin operating in high-tech $10-million suite, which features sophisticated scanning equipment to help guide instruments.
O.R. Number 19 at the Toronto General Hospital is as fine a working surgical suite as you’re liable to find on Earth.
A bit shopworn, jumbled and rank with disinfectants, sure. Yet it’s crammed with some of the most sophisticated gadgetry in the cutting trade today.
But Dr. Jonathan Irish — a childlike eagerness in his voice — is anxious to move next door.
“Wait until you see it,” the head of surgical oncology at the affiliated Princess Margaret Cancer Centre says as he heads down the hall. “Just wait.”
To the sucking sound caused by the positive pressure on the other side, Irish swings open the door to O.R. Number 20 and raises his hands with a “ta-dah” flourish.
“This technology elevates an excellent surgeon to be able to do things that we weren’t able to do before.”
DR. JONATHAN IRISH
HEAD OF SURGICAL ONCOLOGY AT PRINCESS MARGARET CANCER CENTRE
“Welcome to the operating room of the future.”
The future of surgery that Irish reveals here appears to be bright. Gleaming even.
Indeed, futuristic is as apt a word as any to describe the suite — known as the GTx, for “guided therapeutics.” Surgeons will begin performing operations here in the coming weeks.
“This is big tech, big space . . . and certainly the cutting edge,” says Irish, as he launches a tour of the $10-million facility at the General’s University Ave. plant.
The first thing he points to is the obvious — the room’s size. At roughly 160 square metres, it is about three times larger than a standard operating room in most modern hospitals.
That space is far from a luxury, however. It’s needed to house the starship array of imaging equipment that whirs into motion around a central operating table.
These computed tomography (CT) scanners have been deployed to capture tumors and other surgical targets with unmatched precision — and to guide physicians to them via the safest and most optimal routes.
As such, the GTx, which will be used extensively for cancer surgeries, fits in well with Princess Margaret’s current $1-billion fundraising campaign.
One of the key goals of that effort is to fund and support research into the early detection of tumours, when they are at their smallest and most treatable stages.
However, while tiny tumours present optimal treatment targets, they also make for elusive ones.
“So the concept of using new technologies to target (things like tumours) in surgery is something that is a huge platform for our billion dollar challenge,” says Irish.
“The eyes of the future surgeon, the hands of the future surgeon, the knife of the future surgeon is all part of that package,” says Irish.
The room’s new CT tools can create, in real time, a GPS-like guidance system through the perilous interior of the human body.
Such aids will be invaluable to surgeons like Irish, who specializes in head and neck cancers.
Often using the nasal cavity as a point of attack, Irish must guide his tiny drills — mounted at the end of flexible tubes — through a fraught landscape, jammed up against brains and arteries and optic nerves.
But now it will be more than just his eyes in the room. “We can also use this technology to be our eyes,” he says.
The first-line set of prying electronic eyes will be provided by the room’s Artis Zeego robotic fluoroscopy machine.
This impressive, C-shaped scanner — about 1.5 metres in diameter — is the newest generation of a device that was pioneered over the past decade by Toronto General and Princess Margaret researchers to peer inside bodies.
The machine — its C-ends capped with the actual CT scanning plates — can be moved over anesthetized patients as they lie on the operating table.
A hinged attachment to its base then allows the scanners to revolve around the patient and create a three-dimensional image of the surgical site as the operation progresses.
The machine, which had to be manoeuvred to the table manually during its previous, experimental usage, has offered a powerful tool for surgeons like Irish, who have long used other types of CT images to direct their instruments during operations.
The pictures they had available, however, were often days old, Irish says.
The major advance with the new GTx-based device is its robotic arm mount — similar to those used in auto assembly plants — which can easily and quickly move the scanner in and out as often as a surgeon desires.
“This gives us real time, on-the-table imaging, allowing us to update the (pictures) whenever we want,” he says.
“So we can get essentially GPS guidance with an image we’ve done seconds ago. And this is important, because during an operation, things can move. Things can change.”
Combined with some potent computer graphics programming, these fresh images can be presented in several ways as they flash up on two massive flat screens suspended above the operating table.
Most notable of these imaging options is one that will be uniquely available to GTx surgical teams.
In it, the nerves, vessels or brain bits that press in around the target tumours will be sheathed in computer-generated fencing — a virtual chain-link protection that keeps surgeons away from these critical tissues.
And as the tube-mounted scalpels — miniature drills or pulsing lasers — move in on the cancers, real-time imaging tracks their progress through this graphically protected anatomy, with the surgeon able to watch the motions on screen.
If any of these protected spaces are approached too closely, he says, an alarm will sound. If they are breached, the electronic scalpel will shut down.
“It creates no-fly zones to prevent collateral damage,” Irish says.
The thought of ceding such operational control to a computer might not sit well with many surgeons.
But Irish says most will simply accept such restrictions on their surgical autonomy as sensible and helpful advancements.
“This technology elevates an excellent surgeon to be able to do things that we weren’t able to do before,” he says. “I don’t see it as a challenge; I see it as a great opportunity.”
And, in the end, Irish says, surgeons can always turn the technology off if they want.
For even sharper images during operations, GTx surgeons will also have access to a more powerful CT machine, the nearby Siemens dual-energy CT Flash scanner to the table’s right.
This O-shaped scanner can plumb images at smaller resolutions and in deeper parts of the body than its robotic counterpart, Irish says.
Because of its size and weight, however, patients must move to the machine and be fed through its circular aperture.
This would be an immensely complex and disruptive undertaking in traditional operating rooms, with much of the surgical team being required to physically hoist the table, patient and attendant wires and tubing over to the scanner.
But in the new room, this entire operation is performed automatically, with the table swinging over and being fed through the scanner at the press of a button.
The amped-up and automated imaging systems provided by the room’s scanner tandem will become increasingly important at the hospital, as research to detect smaller and smaller tumours bears fruit.
“Let’s say we now can detect a very, very small lung cancer . . . often the standard of care is to repeat a CT scan in a few months to see if it’s grown,” Irish says.
But with the GTx’s real-time guidance capacity, surgeons can go in right away with an increased confidence of finding and removing the cancer, he says.
Its advanced equipment and plush space, however, will not be the only things that separate the GTx from other operating rooms.
Its signature feature will be its role as the world’s first research-based operating room, Irish says.
Patients wheeled into O.R. Number 20 will automatically enter medical trials — research projects meant to compare its surgical procedures and equipment with those used in standard operating facilities.
“It’s a research operating room; you can’t actually be a patient in this operating room unless you’re part of a research trial,” Irish says.
“The other 19 operating rooms are for the everyday stuff. This operating room is for the use of innovative technologies.”
Surgery has traditionally been a discipline apart from other branches of medicine, where rigorous, randomized trials of new medications and procedures must prove out their worth and value scientifically over older treatments.
“But the concept of developing (surgical) technologies . . . was ‘this is interesting, let’s just try it,’ ” Irish says.
After trials in animal models and cadavers, surgical procedures and equipment were brought into clinical settings, but were not necessarily matched systematically against older techniques and technologies to prove their superiority.
Irish says the GTx will change that.
“The first in-human technologies will be used here . . . and evaluated here,” Irish says.
The success of the new equipment and techniques deployed in the room — now and in the future — will be evaluated based on comparisons with the outcomes of surgeries preformed by the same physicians in the hospital’s older suites.
The high-tech cutting room will also be used to evaluate some purely human factors, such as alternative nursing roles and new concepts in surgical team configurations.
But because most of the research projects will be testing new scanners, guidance systems and the like, engineers and physicists will often join the standard roster of surgeons, nurses and anesthetists around its operating table.
Irish points, for example, to Michael Daly, whose role as a biomedical engineer would have typically seen him toil exclusively in laboratories, helping to create improved scanning and radiation devices.
“In our new O.R. of the future . . . an engineer like Michael, will be right in there to help design new technologies to develop the new eyes of the surgeon, or hands of the surgeon or new knife,” Irish says.
For Daly, the idea that his career would take him into an active O.R. never crossed his mind.
“I did applied math and electrical engineering (at school), but I spend many days . . . in the operating room, seeing the clinical challenges and learning about anatomy,” he says.
“So I get a better idea of what technology is feasible and what can be effective.”
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