Kershaw County Medical Center general operating room. Photo by Brian Dressler Photography, 2004

Lawrence E. Kogut, Photo by Alt-Lee Photography, 2003

Valentine A. Satko, Photo by Alt-Lee Photography, 2003
Advances in healthcare are occurring at an awesome rate. A hospital's design must keep up with changing technology, as well as the attitudes of staff and patients. One example is the design of operating rooms and their associated space as minimally invasive surgery (MIS) becomes a prevalent modality.

With an aging population demanding faster and cleaner surgeries and recoveries, hospitals must consider how to implement an MIS plan. Determining where to begin can be overwhelming, but there are some major points to consider when renovating or building an MIS Center.

What Is Minimally Invasive Surgery?

Minimally invasive surgery is performed through small incisions or existing openings in the body with the aid of computers, ultrasound, and robotic and/or endoscopic tools such as miniaturized TV cameras. The surgical outcomes are far less traumatic to the body, allowing a faster recovery at lower financial cost to both the patient and the care provider. Patients desire a fast return to active lifestyles and/or occupations, and are demanding from hospitals and other care providers that they be able to do so quickly and safely.

Patients and physicians are demanding MIS capabilities more frequently, and healthcare facilities must either keep up with the demand or risk losing valuable patients and staff to facilities that are better equipped. Medical schools, major tertiary hospitals, and research centers are already raising funds, installing equipment, and training staff to satisfy these needs.
Self Regional Healthcare Heart Center vascular operating room. Photo by Brent Silman, 2001

Planning Considerations

Operating room size. The average size of a traditional operating suite has been 400 square feet. In MIS-compatible environments, a room needs to be 650 to 700 square feet to accommodate additional equipment and staff. Such equipment includes touch screens or voice-activated systems for light, environmental, and sound control, and computer-assisted surgery equipment such as semiautonomous instruments used to perform the actual surgery while a surgeon inputs commands at a console. Additional radiographic imaging equipment is also used to guide surgeons in placing implements with a high degree of accuracy and providing a detailed view of the site. When considering which equipment to install in an operating room, it is important to realize that different manufacturers' products are not always compatible with each other. Using a single manufacturer for all equipment makes training, service, and use much easier and can provide higher-quality results.

Mechanical systems. At the beginning of surgery, temperatures must be kept low and then brought up rapidly near the end of the procedure. Traditional operating rooms require temperatures from a low of about 68°F to a high of about 80°F. Because MIS equipment operates at a higher temperature and must not overheat (steam and humidity can form, causing the equipment to malfunction), MIS operating rooms must maintain temperatures as low as 55°F. Mech-anical engineers are working with these challenges by using new control sequences and direct digital controls for temperature and humidity.
Self Regional Healthcare Heart Center operating room. Photo by Brent Silman, 2001

Because many hospitals want MRI and radiation therapy equipment adjacent to or inside operating rooms for ease of access, biomedical engineers must also develop ways to incorporate radio frequency and radiation shielding into the operating room environment. Nonferrous (nonmagnetic) metal must be used in this shielding, as with all instruments used in the same room with MRIs and high-energy radiation therapy devices. With traditional equipment and surgical instruments made of iron-based materials, this presents a significant challenge to the biomedical engineer.

Another factor to consider is how to supply and evacuate any gases needed in the operating room. Engineers have developed a new system for this by mounting an articulating boom from the ceiling to supply oxygen, nitrous oxide, nitrogen, and carbon dioxide, and to evacuate any anesthetic gases or gases caused by cauterization at the surgical site. The boom can be positioned anywhere around the patient. These booms provide a major improvement over the traditional plug-in gas induction and gas evacuation systems that could serve only a portion of the room.

Electrical systems. The increased use of scopes, computer monitors, and other minimally invasive equipment has placed higher demand on operating suite electrical systems. For example, the use of cathode-ray tube (CRT) screens has drastically changed the requirements of lighting systems. The lighting system must provide adequate light for surgical tasks but must be adjustable to allow staff to view images on CRT screens without glare or other interference.

Another factor when planning MIS-compatible electrical systems is the power supply. Most of the equipment used for monitoring the patient, as well as the life support equipment, is controlled by microprocessor- and computer-based controllers. This has made clean, reliable, and distortion-free electrical service imperative. The power for this equipment must be separate from the utility delivery system so that disruptions will not affect the surgical procedure.

The capability of generating uninterruptible electrical power independent of the local electric utility service is a necessity today, not only to ensure continued use of the operating suite, but also to allow support services to function. The use of power conditioning equipment is crucial in maintaining a power supply without spikes or surges that can damage or ruin the delicate computer systems integral to the MIS process. Power demands will increase as MIS becomes more prevalent in the operating suites of the future and will necessitate designing spare capacity in the system to meet this demand.

Other Considerations

When planning to retrofit an existing operating suite for MIS, it is important to consider additional factors to those already described. For example, finishes must be selected carefully, as paint must have antimicrobial qualities and plastics must withstand rapid temperature change. Hospitals should also consider incorporating natural light sources into the operating room because, in the event of a power outage, it can take up to seven seconds for backup lights to come on. Windows admitting natural light provide backup lighting for emergency situations, and studies have shown that natural light can reduce stress among surgical staff.

Infection control is another major concern for the retrofit process. During construction, barriers must be put in place to contain debris and dust in the construction area. Negative air pressure devices augment these barriers to preclude the intrusion of infectious agents such as aspergillus present throughout the environment. Once the retrofit is complete, staff can maximize their contributions to infection control by using the equipment associated with MIS, which is designed to minimize the amount of contact between patient and staff.

New Construction Versus Retrofitting

Cost impact is a major concern when deciding between building a new operating suite and retrofitting an existing one. Many hospitals have found that, while the initial cost of a new suite can be sizable, constructing one can actually save a considerable amount of money in the long term. Use of the existing suite does not have to be disrupted. Fewer barriers to infection control are required because of the ability to isolate an entire suite of rooms. Further, electromechanical systems need not be shut down episodically to provide interconnections to new or expanded systems. Finally, the new operating suite and its equipment can be thoroughly tested on-site in advance of actual patient utilization, with all systems calibrated and balanced, and staff trained in appropriate operating protocols.

The Future of MIS

Today, minimally invasive procedures are performed at teaching and research hospitals, tertiary medical centers, and other major healthcare service providers, but soon they will likely become part of community medical centers and ambulatory surgery center offerings, resulting in more and more competition in the healthcare industry. In addition, with computer-assisted procedures taking center stage, staffing requirements in the operating room will decrease. Healthcare facilities must learn to adapt to these changes quickly to keep up with ever-increasing and changing standards. While the considerations before commencing construction are numerous, taking steps toward understanding the future of MIS enables hospitals to make the best decisions for their facilities. Facilities must weigh the costs, both monetary and intangible, of retrofitting versus total replacement of an operating suite. Feasibility studies in terms of market demand, reimbursement potential, and start-up costs-including staff training and specialized maintenance requirements prior to implementation-are crucial to the success of any proposed project. Involving all stakeholders in the planning process will optimize the chances for success of the project. HD

Lawrence E. Kogut, AIA, is Director of Architecture at GMK Associates Healthcare Design in Columbia, South Carolina. In 2000, they designed the first minimally invasive surgical suite of ten operating rooms in South Carolina, which included the first operating room in the state to incorporate Intuitive Surgical's da Vinci robotic system for cardiac surgery. Kogut and Satko develop space program requirements and alternative conceptual solutions and conduct frequent meetings with user groups, physicians, and government representatives to achieve facility solutions compatible with institutional objectives. Contact GMK at 803.256.0000 or visit http://www.gmka.com.
Valentine A. Satko, AIA, is a Principal Architect at GMK Associates Healthcare Design in Columbia, South Carolina. In 2000, they designed the first minimally invasive surgical suite of ten operating rooms in South Carolina, which included the first operating room in the state to incorporate Intuitive Surgical's da Vinci robotic system for cardiac surgery. Kogut and Satko develop space program requirements and alternative conceptual solutions and conduct frequent meetings with user groups, physicians, and government representatives to achieve facility solutions compatible with institutional objectives. Contact GMK at 803.256.0000 or visit http://www.gmka.com.