Growth in minimally invasive surgical (MIS) procedures over the past decade has resulted in a corresponding increase in surgical suites dedicated to such procedures. Endoscopic video equipment has migrated from cumbersome floor carts to ceiling-mounted equipment booms, with the ultimate goal of streamlining staff workflow, improving operating room safety and resolving poor ergonomics.

While we can infer that eliminating the jumble of electrical cables, connecting wiring, and suction/irrigation tubing associated with the use of floor carts will improve safety and workflow, and that moving display monitors to adjustable ceiling mounts will promote better ergonomics, have any studies actually demonstrated these benefits?

Generally, we can evaluate the benefit of a new medical technology by conducting an evidence-based technology assessment of its safety, effectiveness, clinical benefit, and cost-effectiveness. Such an assessment involves a comprehensive search and review of relevant, published, peer-reviewed studies. However, in the case of ceiling-mounted surgical booms — and other technologies that are not used directly for patient care — published evidence is scant; in the case of surgical booms, the evidence consists of a prospective operational study and staff survey, a small retrospective analysis of room preparation time, and a simulation study. There are no published studies addressing safety or cost-effectiveness relative to the use of conventional video equipment carts.

How then, can we determine whether ceiling-mounted booms can, in fact, improve safety, ergonomics and workflow efficiency, and whether the relatively high cost of creating dedicated minimally invasive surgical suites (up to $300,000 per room) is justified?

The answer to this question is not an easy one. A review of the limited evidence suggests that making the change to ceiling-mounted booms may decrease room preparation and turnover times. A prospective study (Wong et al.) of 640 cases performed in a new dedicated minimally invasive operating room (O.R.) with ceiling-mounted booms found that room set-up and turnover times were reduced by approximately five minutes. Surveyed surgical staff participating in this study rated overall improvements in efficiency and workload as "much better" or "better." During the 10-month study period, no accidents or safety incidents were reported. However, the two surveyed anesthesiologists reported concerns regarding potential collisions with ceiling-mounted equipment.

A retrospective study (Hsiao et al.) of 40 patients found that pre-anesthesia set-up time was approximately six minutes faster in a dedicated minimally invasive surgery suite than a conventional room using cart-based laparoscopy equipment, but overall average total room preparation time was not significantly faster. A simulation study (Kenyon et al.) involving five R.N.s found significant differences in mean video equipment set-up and put-away times between dedicated MIS suites and standard O.R.s.

This review of the limited evidence complicates the answer to our initial questions and raises additional questions. Does a five- or six-minute reduction in room preparation and decreased turnover time translate to actual improved efficiency in surgical services? Do the benefits of ceiling-mounted booms outweigh the cost of installation and associated facility structural modifications that may be necessary before installation?

In the absence of relevant, well-designed published studies comparing ceiling-mounted booms with existing floor carts to answer these questions, technology decision-makers may instead have to consider factors that are more specific to their individual facilities, including:

Anecdotal reports from other users of the technology and safety reports (available on the U.S. Food and Drug Administration’s Web site) may also contribute to a technology decision that weighs the benefits of moving equipment from the floor to the ceiling.

While the hazards of cables, tubing, and wiring on the O.R. floor are eliminated with ceiling-mounted booms, new safety issues have arisen. The FDA has documented a few reports of collisions between the booms, other equipment and staff members, as well as reports of equipment falling from ceiling mounts. Some facilities that jumped on the surgical boom bandwagon early have informally reported problems with boom placement and movement relative to other new technologies in the operating room, such as robotic surgery systems and additional display monitors for radiology images.

Technology in the O.R. will only continue to advance, creating more opportunities for equipment integration — and interference. Increasing use of image guidance in surgical procedures has led to the need for access to the picture archiving and communication system (PACS). Therefore, PACS display monitors are replacing the traditional film-based viewboxes in O.R.s. Now, O.R.s commonly have dedicated mobile C-arms or floor- or ceiling-mounted fluoroscopy systems. A few facilities have rooms with intraoperative magnetic resonance imaging (MRI) for more advanced neurointerventional procedures.

In the future, intraoperative imaging may expand to include computed tomography (CT), MRI, positron emission tomography (PET), and MRI-guided focused ultrasound. This complete integration of multiple imaging modalities in the O.R. environment has been dubbed an "advanced multimodality image-guided O.R." (Reijnen et al.). Three-dimensional visualization systems for surgical planning, computer-assisted robotic surgery systems, digital pathology systems, and teleconferencing/telesurgery systems are also predicted to become the norm in the "O.R. of the future."

Growing up in the age of the Internet has led to the expectation of instant access to information, and this mindset has affected healthcare delivery as well. Surgical staff will want — and expect — access to the patient’s medical record, including diagnostic images, laboratory test results, and complete medical history before, during and after surgical procedures.

What does all this technology integration mean for the future of surgical boom technology? The ceiling has now become as crowded as the floor once was. And ceiling-mounted surgical boom technology has begun to evolve into a "surgical equipment management solution," with options for wall-mounting and/or floor pedestals with more positioning capabilities. With O.R. space at a premium, an essential feature for surgical equipment management systems will be manipulability —retractable arms, easily movable booms, adaptable display monitor configurations and other features that will allow the ongoing integration of new technologies.

For those planning renovation of existing O.R.s or new construction, flexibility is the key to the future. O.R. space, infrastructure, and equipment management technology will have to be able to accommodate future technological advances, not only in surgery, but also in patient records management, imaging, laboratory, and telecommunications. And technology cannot be the only consideration. The integration of intraoperative multimodality imaging will require appropriately trained imaging technologists that are available to staff surgical procedures. HPN

References:

1. Hsiao KC, Machaidze Z, Pattaras JG. Time management in the operating room: an analysis of the dedicated minimally invasive surgery suite. Journal of the Society of Laparoendoscopic Surgeons. 2004; 8:300-303.

2. Kenyon TAG, Urbach DR, Speer JB, et al. Dedicated minimally invasive surgery suites increase operating room efficiency. Surgical Endoscopy. 2001; 15:1140-1143.

3. Reijnen M, Zeebregts CJ, Meijerink W. Future of operating rooms. Surgical Technology International. 2005;14:21-27.

4. Wong JCH, Yau KK, Chung CCC, et al. Endo-Lap OR: an innovative "minimally invasive operating room" design. Surgical Endoscopy. 2006:20:1252-1256.