The Advanced Multimodality Image- Guided Operating (AMIGO) Suite

8/11/2019 The Advanced Multimodality Image- Guided Operating (AMIGO) Suite

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341F.A. Jolesz (ed.),Intraoperative Imaging and Image-Guided Therapy,

DOI 10.1007/978-1-4614-7657-3_24, Springer Science+Business Media New York 2014

Why the AMIGO

On May 4, 2011, Brigham and Womens Hospital (BWH)

unveiled the Advanced Multi-modality Image Guided

Operating (AMIGO) Suite, the first suite in the world to give

surgeons and interventional specialists immediate access

to a full array of imaging modalities for use during proce-

dures. This cutting-edge operating room/interventional suite

enables treatments that are less invasive and more effective.

The AMIGO suite represents the next major step in Image

Guided Therapy (IGT).

The AMIGO Suite is an innovative surgical and interven-

tional environment that is the clinical translational test bed

of the National Center for Image-Guided Therapy (NCIGT)

at the Brigham and Womens Hospital (BWH) at Harvard

Medical School. The AMIGO is an integrated, 5,700 square

foot area divided into three sterile procedure rooms in which

a multi-disciplinary team will treat patients with the ben-

efit of intra-operative imaging using multiple modalities.

The space is designed so that teams can move effortlessly

throughout to access any of the advanced imaging and surgi-

cal technologies.

The AMIGO Suite is one of the first surgical environments

in the world to integrate the use of this wide variety of

advanced imaging technologies, including CT and MRI

cross-sectional imaging systems; x-ray and ultrasound real-

time imaging systems; and molecular imaging systems such

as a hand-held beta probe, PET, and targeted optical

imaging.

Molecular image-guided therapy will be pioneered with

the use of multiple molecular probes, such as PET, optical

imaging, and targeted mass spectrometry, to increase the

sensitivity and specificity of cancer detection. Application

of these technologies is expected to improve the ability to

define tumor margins to more completely excise or ther-

mally ablate tumors. In addition to multi-modality imag-

ing, the AMIGO has various navigational devices, robotic

devices, and therapy delivery systems that help physicians

to localize and treat tumors and other targeted abnormali-

ties. The AMIGO represents and encourages multi-disci-

plinary cooperation and collaboration among teams of

surgeons, interventional radiologists, imaging physicists,

computer scientists, biomedical engineers, nurses and

technologists to reach the common goal of delivering the

safest and the most effective state-of-the-art therapy to

patients in a technologically advanced but patient-friendly

environment.

AMIGO is the physical manifestation of the NCIGT mis-

sion. It is a not only an operating suite, but the test bed for

research and the proving ground for this vision. Above all,

the AMIGO will provide a sophisticated, fully integrated

image-guided therapy infrastructure that will lead to disrup-

tive changes in procedural paradigms of surgery and inter-

ventional radiology.

The NCIGT is focused on the multidisciplinary devel-

opment of innovative image-guided intervention technolo-

gies to enable effective, less invasive clinical treatments

that are not only more economical, but also produce better

results for patients. It is now becoming apparent that the

use of multiple modalities can enhance procedures by

calling upon the strength of an individual modality to

The Advanced Multimodality Image-Guided Operating (AMIGO) Suite

Daniel F. Kacher, Brendan Whalen,

Ahin Handa, and Ferenc A. Jolesz

24

D.F. Kacher, MS (*) F.A. Jolesz, MD

National Center for Image Guided Therapy,

Department of Radiology, Brigham and Womens Hospital,

Harvard Medical School, Boston, MA, USA

e-mail: [email protected]; [email protected]

B. Whalen, Barch

Partners HealthCare, Boston, MA, USA

A. Handa , Barch

Payette Associates Inc, Boston, MA, USA


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ameliorate the weakness of any complementary modality.

In response, comprehensive environments, multi-modality

operating suites, are emerging. Multi-modality image-

guided therapies utilize information derived from different

physical and biological properties of the tissues, obtained

by measurements with diverse underlying physical

principles.

AMIGO Suite Components

The central operating with its ceiling mounted single plane

x-ray machine is flanked by a PET/CT room on the left and a

MRI room on the right. Sliding doors adjoin the three rooms.

Each room has a separate entrance to the control corridor and

support spaces (Fig. 24.1).

Fig. 24.1 (a) Floor plan imparting the size of each room and itsrespective control room as well as the equipment in each room and its

maneuverability (Courtesy of Payette Architects). (b) The panoramic

cutaway rendering (Courtesy of Balazs Lengyel MD). (c) Building

section (Courtesy of Payette Architects)

a

b

c

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MRI Room: The Magnetic Resonance Imaging (MRI)

room is centered around a high-field (3 Tesla) wide bore

(70 cm) MRI scanner integrated with full OR-grade medical

gases, MRI-compatible anesthesia delivery and monitoring

system, view screens, lighting, and therapy delivery equip-

ment. Here, the clinical team uses image-guidance principles

for many oncology applications. With the familiar in-out

paradigm, patient is imaged and then withdrawn from thebore of the scanner for intervention. In some procedures, the

doctor can reach into the scanners short/wide bore to access

the patient. The room is designed to be used independently

for interventional procedures or in conjunction with the

Operating Room. The ceiling mounted MRI scanner can tra-

verse on rails to a fully draped patient on the OR table. With

this innovation, surgical patients do not need to be trans-

ferred between tables for imaging. These features enable

flexibility in workflow to tailor procedures to the needs of

the doctor and patient.

Operating Room: The heart of the suite is the operating

room (OR), integrated with the flanking rooms. The room is

equipped with MRI-compatible anesthesia delivery and

monitoring systems; surgical microscope with near-infrared

capability; surgical navigation systems which track handheld

tools, probes, and the surgical microscope, to display images

corresponding to the tool location; a ceiling-mounted single

plane x-ray system; 2D and 3D ultrasound imagers; and a an

armamentarium of surgical support equipment. The surgical

table has a floating table top for angio acquisition and pivots

to face the MRI scanner, PET scanner, or x-ray system. All

images and data related to the procedure are collected and

prioritized by using video integration technology and can be

recorded or displayed on large view screens at the point of

care, enabling surgical teams to select and view all applica-

ble patient information at a glance.

PET/CT Room: One of the most innovative features of

the AMIGO is the inclusion of Positron Emission

Tomography (PET) in the surgical environment. Similar to

the MRI room, the PET/CT room can be used for stand-

alone interventional procedures. Unlike the MRI scanner,

the PET/CT scanner is fixed to the floor and does not move.

Patients can be transferred on a shuttle system between the

PET/CT table for imaging and the OR table for surgery. At

the time of writing, the AMIGO Suite is unique in the world

with its direct connectivity between a PET/CT room and an

operating room.

PET produces images elucidating the bodys functional

and metabolic interaction with molecular biomarkers.

The combined use of MRI and CT with PET capabilities

enables clinicians to combine anatomical, functional, and

metabolic information to enhance intra-procedural deci-

sion-making. BWHs on-site cyclotron enables the inves-

tigation of novel molecular imaging agents to localize and

target viable tumor tissue and verify complete removal or

therapeutic destruction.

AMIGO is a resource-rich environment. Table 24.1lists

the current equipment and infrastructure vendors as well as

the design and construction teams that made the project a

success.

AMIGO Suite Design and Construction

This section is intended to be a resource for institutions join-

ing the future of image-guided therapy and surgery. The real-

ization of a space like AMIGO will demand a full team of

extraordinary thinkers: designers, builders, clinicians, tech-

nical personnel, and administrators coming to a consensus

of vision to make such a project a reality. Previous publica-

tions describe the facets of architecture for diagnostic and

therapeutic suites [1] and more specifically intraoperative

MRI facilities [2]. The specifics of AMIGOs design and

construction process are presented here in stages and describe

the teams interaction.

Understanding the Technology and Its Use: It is impera-

tive to fully understand the systems being introduced into the

project and how they will be employed by the end users. The

design team worked diligently with stakeholders in the hos-

pital and industry to understand user requirements and sys-

tem capabilities. Previous installations of similar technology

were designed to support only neurosurgery. The team part-

nered with the integrator (IMRIS Inc., Winnipeg, CA) to

expand the capability of the space to support percutaneous

intervention, endovascular intervention, minimally invasive

surgery, and open surgery throughout the body.

The impact of hanging a moving MRI scanner from the

ceiling is central and pervasive throughout the entire pro-

cess. A Siemens 3-T magnet was retrofitted and integrated

by IMRIS. A considerable no fly zone was necessitated

for the travel of the scanner, and nothing could be placed on

the ceiling in its path. In the OR, the surgical table position

and boom layout were critical for enabling multiple services

to work in the space while being constrained by the no fly

zone. The x-ray c-arm travels on ceiling tracks perpendicu-

lar to the MRI tracks. Unlike conventional single-purpose

ORs, the room setup must be drastically altered to accom-

modate a given procedure. The table is nominally pivoted

towards the MRI scanner but pivots 90 for x-ray-guided

procedures and 180 for PET/CT-guided procedures. The

x-ray c-arm also travels on the ceiling. Point of care view

screens are installed at several locations to accommodate dif-

ferent procedure-specific room configurations. The ceiling-

mounted navigation system was located to enable its use in

all three table locations. Provisions were made for a work in

progress to develop patient flow between the OR and PET/

CT room. Demands for circulating space were considered

for mobile equipment and personnel to move about while

maintaining a sterile field. All these factors were considered

in designing the space.

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Design Within the Shell Space: The AMIGO Suite encom-

passes an area of 5,700 ft2. The east side of the suite is dedi-

cated to the three procedure rooms including control stations

and equipment rooms. An 8-ft-wide corridor is the central

spine that serves to spatially open up and connect the control

areas with a centralized nursing and flow coordinator station.

The west side of the suite supports services: a decontamina-

tion room, a clean assembly room, a sterile storage, and two

large equipment storage rooms, as illustrated in Fig. 24.2.

Structure: AMIGO is advantageously located two floors

below grade on the hospitals subgrade foundation. The

larger and stronger reinforced concrete columns on this level

support the ceiling-mounted MRI scanners structural steel,

causing less concern from vibration than placing the suite on

an upper floor. The greatest structural challenge was meeting

the steel beam deflection tolerance specification that IMRIS

required to support the weight of the MRI as it transits: no

more than 1/8 deflection of steel beam for every 8 ft of

beam length. The specific challenge was to maintain this

requirement while limiting the dimensions of the steel beam

in order to allow infrastructure to fit overhead. The unique

design, shown in Fig. 24.3, kept the steel support simple and

allowed for maximum flexibility for infrastructure to fit

within the ceiling plenum.

Another concern was vibration from outside the hospital

that might impact the image quality from the MRI. A major

source of vibration is the plant that provides supplemental

electricity to the six hospitals in the surrounding Longwood

Medical area, located adjacent to the end of the hospital

housing AMIGO. To mitigate the effects, large pre-

compressed vibration isolation pads were designed for all

beam and column connections (Fig. 24.3).

Shielding and Penetration: Along with the shielding ven-

dor (ETS-Lindgren, Glendale Height, IL) and IMRIS, the

team designed the shielding efficiently to enclose the two

impacted rooms. Both the OR and MRI rooms are six-sided

copper RF-shielded boxes to prevent electromagnetic inter-

ference from impacting MR image quality. Both the OR and

PET/CT rooms are lead shielded. The sliding doors and con-

trol room doors in the OR were designed with additional

Table 24.1 Equipment andindustrial partners in AMIGO

Imaging equipment, patient table, and room integrator IMRIS, Inc.

Designer Payette Architecture, Inc (Boston, MA)

Build, general contractor Barry Construction /Suffolk Construction

RF enclosure, sliding doors ETS-Lindgren

Booms and lights Trumpf GmbH

Video integrator Black Diamond Video

3-T Verio MRI scanner Siemens Healthcare

Artis zee single plane angiography/fluoroscopy x-ray system Siemens HealthcareBiograph mCT PET/CT Siemens Healthcare

Acuson S2000 ultrasound system Siemens Healthcare

568-megapixel display Siemens Healthcare

Pro Focus Ultra View ultrasound system BK Medical

Nonferrous metal detector Kopp Development

VectorVision sky navigation system (neuro procedures) BrainLab, Inc.

Pentero Surgical Microscope Carl Zeiss, Inc.

EnSite NaxX navigation system (EP procedures) St. Jude Medical

Cardio lab electrophysiology recording (EP procedures) GE Healthcare

Stockert 70 RF generator (EP procedures) Biosense Webster

IMROC MRI-compatible wireless headset OptoAcoustics

CUSA NXT ultrasonic tissue ablation system Intregra

Force Triad electrosurgical unit Covidien

Malis CMC bipolar electrosurgical unit Codman

Bair Hugger patient warmers Arizant Healthcare

Alaris IV infusion pumps CareFusion

MRI, CT, x-ray power injectors Medrad, Inc.

Aegis navigation system (interventional radiology procedures) Hologic/Sentinelle Medical

Aegis MRI-guided pelvic intervention solution (patient

positioning, MRI coil, targeting device, software)

Hologic/Sentinelle Medical

Symbow Medical navigation system

(interventional radiology procedures)

Symbow Medical

Ablative laser Visualase, Inc.

Endoscout MRI navigation system Robin Medical, Inc.

MRI-compatible task light and view screens Aadcomed, Inc.

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structural reinforcement to support the weight of the copper

and lead.

The viewing windows into the OR, MRI, and PET/CT

rooms (Fig. 24.4) are oversized and comprised of polarizing

privacy glass, lead glass, and RF copper mesh glass. The pri-

vacy glass when turned off turns opaque and meets the laser

safety requirements to allow laser operation inside the room

without additional laser safety measures being installed.Silicon rolled steel for magnetic shielding was located

only on the rear of the MRI room to prevent the MRI scan-

ners fringe field from extending into the hallway adjoining

the EP labs, to protect patients, personnel, and equipment

outside the suite.

Another unique detail in AMIGO is the inclusion of an

independent RF-shielded equipment cabinet inside the larger

RF-shielded enclosure. This feature allows clinicians and

researchers to stage non-MRI-compatible equipment into the

interventional environment via waveguides and filtered con-

nectors without affecting image quality (Fig. 24.5).Additional pen panels were added under each control win-

dow as well as the MRI equipment room to allow for addi-

tional connections with equipment placed outside the RF

a

Fig. 24.2 Suite floor plan. (a) Procedure space is to the right of thecentral corridor and support space is to the left. The red arrowshows

the pathway for entry into the suite and the orange arrows show the

pathways into the procedure rooms (Courtesy of Payette Architects).

(b) Axiometric view of suite (Courtesy of Balazs Lengyel MD)



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rooms. All subpanels are modular and can be retrofitted to

meet future user requirements (Fig. 24.5).

Location of all filters and waveguides required for all

infrastructure (electrical conduits, HVAC ducts, med gas

piping, etc.) penetrating the shielded rooms was carefully

coordinated to ensure a clean plenum space above the ceil-

ing. Boom mounts were designed to obviate the requirement

for kicker supports, a space saving method that allowed for

much needed above ceiling space (Fig. 24.6).

Infrastructure: HVAC ducts and vents, medical gas pip-

ing, electrical conduits, and sprinkler lines were tightly coor-

dinated into the available plenum space inside, above, and

around the RF shield, 3D infrastructure modeling (Fig. 24.7),

to ensure precision and effective layering was critical.

The location of the suite, two floors below grade, caused

design and constructability issues with the quench vent and

purge exhaust ducts for the MRI scanner. Welded stainless

steel ducts were run 500 linear feet from AMIGO through an

existing OR space directly above, to a five-story exterior

vertical shaft, to a point on the roof safely away from the

adjacent patient bed tower air intakes. The infrastructure ris-

ers to house the large ducts and other mechanical hardware

were carefully designed and constructed to ensure minimal

disruption to the hospital infrastructure or interference with

the existing imaging systems.

Airflow: All three procedure rooms were designed to

exceed air turnover specification for full-grade operating

rooms set forth by the FGI Guidelines and the MA

Department of Public Health (DPH). In an ideal OR

environment, laminar downward airflow is provided by a

10 10-wide array of diffusers around the patient table to

prevent airborne debris from entering the surgical field. Due

to the orthogonal tracks for the MRI scanner travel and x-ray

c-arm travel, in addition to demand for ceiling real estate for

grid lighting and boom mounts, ideal placement of diffusers

was not possible (Fig. 24.8).

To receive project approval, the DPH required a 3D com-

putational fluid dynamics model of the space to be created to

illustrate adequate airflow. The modeling showed optimal

quantity and location of supply and returns air diffusers to

achieve necessary airflow speeds and contaminated air dilu-

tion around the patient table. The design yields negligible

difference in the movement of airborne particles compared to

an ideal OR.

Booms: AMIGO is intended to enable multiple surgical

and interventional services, each with their unique needs.

The OR is designed to have two central procedure positions:

a surgical field placed in the direction of the MR room and a

second field for x-ray-based procedures. The boom layout is

intended to meet current needs and offer flexibility for the

future unforeseen needs. Separate equipment booms for sur-

gical support equipment and cardiac ablation (EP) equipment

were necessary. In a typical EP lab, equipment is placed

below or attached to rails on the side of the patient table. This

setup is incompatible with operating room standards and not

possible with the moving MRI scanner due to magnetic

attraction on the devices. Lights and view screens are posi-

tioned with left-right symmetry when the patient table is

bFig. 24.2 (continued)

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pivoted with the head towards the MRI scanner. Patient posi-

tion dictates where the surgeon stands and which view

screens are used for a given procedure. A 568-megapixel

display is mounted on the same tracks as the x-ray c-arm and

can be used for both surgical and x-ray-based procedures.

The x-ray boom arm holding the lead shield was made long

enough to reach and protect a clinician standing on the distal

side, away from the boom mounts. The navigation system

camera and touch screen were positioned to enable naviga-

tion in either table position. All mounts for the booms were

positioned such that the booms could be pivoted towards the

walls of the room, outside the 5-G line, where they would not

be magnetically attracted to the MRI scanner when it enters

the OR.

The operating room is approximately 700 ft2, creating a

deficit compared to the recommended 850 ft2. The ceiling

space occupied with two sets of ceiling rails at different

ceiling heights for x-ray and MRI, HVAC diffusers, general

2 2 surgical lighting fixtures, and LED MRI-compatible

lighting presented an optimization problem for locating the

five boom mounts, each supporting as many as three arms.

Drawings of boom travel and 3D rendering with kinematic

models of the booms were critical for determining final loca-

tions. Figure 24.9illustrates some of the techniques employed

to achieve desired boom reach and clearances and prevention

of conflicts and collisions.

Power and Power Shutdown: The three procedure rooms

were powered with critical power and isolated power with

W14x193

PRE-COMPRESSED VIBRATION ISOLATION PADS

BEAM MOUNTING PLATE AT COLUMN

SEISMIC SNUBBER

a

b

Fig. 24.3 (a) Constructionphotograph of the steel structure

(Courtesy of Payette Architects).

(b) Design and construction

photograph of the structural

isolation damper (Courtesy of

Payette Architects & Cavanaugh

Tocci Associates)



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emergency backup. Critical power breached the RF shield-

ing via electrical filters. Since isolated power could not

cross the shielding without losing its isolation, the isola-

tion transformer panels were located inside the RF shield.

A product was identified that did not put out electromag-

netic interference (EMI) in the band used by the MRI scan-

ner and installed outside the 5-G line. Many clinical

devices and infrastructure elements in use during the pro-

cedure, however, do release EMI and must be powered off

prior to imaging. Such items were powered by circuits

controlled by a relay panel. Room integration touch

screens enable shutdown of all devices with a single com-

mand. Outlets are color coded, and signage is installed to

inform users if the outlets remain powered during

imaging.

The PET/CT scanner and x-ray system are backed up by

universal power supplies (UPS). A UPS was not supplied for

the MRI; after careful consideration it was determined that

Fig. 24.4 PET/CT and OR control room (Courtesy of Warren Jagger Photography)

a b

Fig. 24.5 (a) RF-shielded cabinet inside MRI room and penetration panels and waveguides (Courtesy of Payette Architects). (b) Drawing detailof shielded window and under counter penetration panel (Courtesy of Payette Architects)

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UPS was not required based on the need, the considerable

space requirements, and added project costs.

Control Workstations: Available space at the control area

counters prohibited placement of all computer CPUs and

view screens needed for the various clinical services using

the three procedure rooms. An elegant solution to this prob-

lem is the IMRIS/Black Diamond Video Control Workstation.

Multiple redundant control workstations were placed in the

control rooms and procedure rooms. Each of these could, via

a keyboard/video/mouse switching matrix, take control of

the procedure-specific CPUs in the rack located in the MRI

equipment room. This solution not only reduces clutter but

places the computers in a controlled, conditioned, dust-free

environment. Video from these computers is also routed

using the control workstation to display images at the point

of care and on the view screens above the control room

windows. The control workstations control room power

down, as well as lighting, and camera zoom/focus. A high-

definition recorder enables archiving of room views and

computer screens.

Finishes: The design team was determined to make the

space a comfortable and an enjoyable work environment

that, despite being located below grade with no natural

light, can utilize materials and soft colors to break the

stereotypical cold and sterile environments that sometimes

come to be associated with these types of spaces. Flooring

materials were chosen carefully for comfort and durabil-

ity. Flooring patterns were utilitarian, highlighting table

rotation and iso-gauss lines of the MRI scanners fringe

field, establishing safety zones for specific equipment

(Fig. 24.10). Colors in the flooring and throughout the

suite work in harmony with the IMRIS and Siemens soft

palette of cooler colors.

Safety: Due to the MRI scanners magnetic field and use

of ionizing radiation for PET, x-ray, and CT, security and

safety into the suite is of paramount importance. Following

guidelines set by the American College of Radiology [4],

four MRI safety zones were implemented.

The MRI room is in Zone 4, where all staff are MRI safety

trained or under direct supervision and no ferrous objects are

allowed. Depending on the location of the MRI scanner, the

OR shifts between Zone 3, where ferrous objects are permit-

ted, and Zone 4. As a policy decision, all personnel are

required to make themselves MRI safe when entering the

OR no watches, pages, cell phones, wallets, etc. regard-

less of the MRI scanner location.

When the MRI scanner enters the OR, the MRI control

room door automatically locks. The control room is

Fig. 24.6 Design detail and photograph of the dielectric isolation and shielding scheme for the boom mounts (Courtesy of Payette Architects &ETS-Lindgren Shielding)



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considered Zone 3 and is under the control of AMIGOs flow

coordinator, a post that is continuously manned during

business hours. The flow coordinator is responsible for con-

trolling access into the suite and confirming personnel have

undergone the suites rigorous safety training procedures

before they can be allowed unescorted into the suite. Only

staff who have undergone safety training and use the suite on

a regular basis are allowed security access. Swipe card read-

ers are located between the public corridor (Zone 4) and the

restricted gowning area (Zone 3). All access points are on

security cameras connected to the flow coordinators desk

and hospital security.

A nonferrous metal detector gate was installed in the

Zone 3 control corridor (Fig. 24.11); since completion of the

project, this has become a standard FGI requirement on all

future MRI projects. A single gate detector services both the

OR and MRI rooms; all staff and visitors must use the detec-

tor prior to entering the Zone 4 rooms. Due to space

a

b

Fig. 24.7 (a) Plannedinfrastructure above the ceiling,

suite wide (Courtesy of Suffolk

Construction). (b) Realized

infrastructure above the ceiling

in MRI room (Courtesy of

Payette Architects)

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Fig. 24.8 (a) Reflected ceiling plan of the OR showing air diffusionsin blue, boom mounts in green, and grid lighting inyellow(Courtesy of

Payette Architects). (b)Red linein image depicts the cross section of

the lower images. (c) Computational fluid dynamics model of air veloc-

ity vectors crossing the head of the surgical table realized in AMIGO

and (d) for the ideal ASHRAE 170 compliant pattern

a

b



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Fig. 24.9 Boom spatial layout plan. (a) Plan view showing booms(Courtesy of Payette Architects). (b) Reflected ceiling view showing

travel of each element of the arms (Courtesy of Payette Architects). (c)

Kinematic 3D model used to explore boom movement (Courtesy of

Trumpf Medical Systems). (d) Photograph of final layout with the table

in the surgical position (Courtesy of Warren Jagger Photography). (e)

Photograph of the table in the x-ray interventional position. The EP

equipment boom and surgical support equipment booms are visible

(Courtesy of Warren Jagger Photography)

a

c dFig. 24.8 (continued)

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b

c

Fig. 24.9 (continued)



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constraints, gates were not at the entrances to the OR and

MRI procedure rooms because the width of the doors would

mandate a wider gate, lowering the sensitivity of detection.

Moreover, ferrous metal (e.g., US scanner) is brought into

the OR in a controlled fashion. It was determined during

design that alarm fatigue would cause personnel to disregard

the detector alarms when a true issue arose.

In addition to the safety-related floor patterns shown in

Fig. 24.11and MRI warning posters on the doors, warning

mats were cut into the floor and labeled Stop Magnet

Always On. Indicator lights above the doors inform staff in

which room the MRI scanner is parked and when x-ray or

laser is in use (Fig. 24.13).

Construction: As the friendly name suggests, AMIGOs

bedrock is the exceptional working relationship between the

three key driving groups: the design team, construction team,

and the client comprised of hospital leadership, clinicians,

and technical personnel. The teamwork was evident from the

beginning during early design that started with pre-

construction services. Here, the contractor, client, and archi-

tect worked in harmony to find design and construction

solutions to issues like wall assembly layering, mechanical

electrical plumbing infrastructure coordination, critical

dimensions that become imperative for ensuring room size is

appropriate, and handling the complex approval process with

regulatory agencies. The team also designed and built this

suite to be flexible and future proof.

Figure 24.12shows a series highlighting the construction-

phased renovation process from the beginning to completion

and reflects the key design criteria described earlier.

d

e


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a b

Fig. 24.11 (a) Floor pattern safety mat and OR entrance. (b) Ferrous metal detector. The LEDs depict the location on the body where the metalwas detected. Illuminated signage is seen in the background above the door to the MRI procedure room (Courtesy of Payette Architects)

Fig. 24.10 (Left) Floor pattern plan in OR and MRI rooms. (Right) Photograph of finished flooring in the OR. The blue circle inside the greenbandrepresents the location of the MRI scanners isocenter when the scanner is in its imaging positio (Courtesy of Payette Architects)



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Fig. 24.12 (a) Existingcentral processing department

(Courtesy of Payette

Architects). (b) Gutted shell

space (Courtesy of Payette

Architects). (c) Steel beam

installation for MRI scanner

travel (Courtesy of Payette

Architects). (d) RF shielding

and x-ray c-arm track

installation (Courtesy of

Payette Architects). (e)

Infrastructure installation


Architects). (f) Ceiling

installation (Courtesy of

Payette Architects). (g)

Flooring installation and

finishes. Bolt down points for

the patient table are visible


Architects). (h) Hanging of

MRI scanner on tracks. The

cable management system is

visible (Courtesy of Payette

Architects). ( i) Completed

operating room (Courtesy of

Warren Jagger Photography).

(j) Completed operating room

(Courtesy of Warren Jagger

Photography). (k) Completed

operating room (Courtesy of

Warren Jagger Photography).

(l) Completed control room

corridor (Courtesy of Warren

Jagger Photography)

a

b

AMIGO Suite Procedures

The intention of AMIGO leadership is to seek out game-

changing applications in the area of image-guided therapy

and surgery and probe the limitations of use of the suite in a

systematic fashion. An initial road map was developed to

launch programs for various clinical services. Each idea was

written up and vetted by an internal and external scientific

review board to ensure it meets the mission of AMIGO and

the National Center for Image Guided Therapy. Programs

that are not successful would be modified or discontinued.

Successful, economically viable programs would also ulti-

mately be discontinued at AMIGO, with the intention of

developing procedure-specific space in the hospital contain-

ing the subset of needed equipment, or by simply sending the

clinician back to his conventional space but with a validated,

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Fig. 24.12 (continued) g

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Fig. 24.12 (continued)k

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hopefully disruptive tool. At this stage smaller hospitals and

the public can reap the benefits of the ongoing experiment,

that is, AMIGO.

The center is arranged according to cores: Imaging Core;

Computation Core; Prostate Core; Neurosurgery Core;

Focused Ultrasound Surgery Core; Administration,

Training, Service, and Dissemination; and Collaborations.

Activity of each core is projected onto the procedures in

AMIGO, listed in Table 24.2. Earlier phase procedures

would be retired to create available room time for newer

a

b

Fig. 24.13 (a) PET/CT room.Surgical lights with a

high-definition camera, and view

screens are use to support theprocedures (Courtesy of Warren

Jagger Photography). (b) Room

view of the PET/CT-guided liver

cryoablation. (c) 3D rendering of

CT data with the cryoprobes in

place. (d) Maximum intensity

projection of the CT data

showing the cryoprobes, with a

pseudocolored single-slice of

FDG PET data showing the

metabolic activity tumor,

overlayed

Table 24.2 Road map ofAMIGO procedures

Phase I (~20112012) Phase II (~2013) Phase III (~2014)Brain open surgery Cerebro and endovascular Spine surgery

Brain laser ablation Endoscopic kidney ablation Skull base surgery

Transphenoidal pituitary resection Bone metastasis thermal ablation ENT sinus surgery

Breast cancer lumpectomy Brain surgery through ventricle Craniofacial surgery

XMR guided cardiac ablation Lung bronchoscopy, biopsy Lung thermal ablation

Prostate biopsy, brachytherapy Image registered endoscopy

(abdominal, thoracic)

Trauma fracture correction

Cervical cancer brachytherapy Joint replacement

Liver, kidney biopsy, ablation

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procedures. A technical lead from the center is assigned to

each procedure.

PET/CT Room: The space has two modes of use. The first

is the familiar in-out paradigm currently used in interventional

CT for biopsies, drainages, and ablations. The 80-cm bore

offers ample space for placement of percutaneous probes and

patient positioning. As an aside, the installation of a PET/

MRI was explored, but the bore diameter of 60 cm was con-

sidered to be too great of a limitation for interventional use.

Figure 24.13shows a PET/CT-guided liver cryotherapy in

progress.

The second mode of use entails transferring the patient

from the OR to the PET/CT scanner for imaging, then back

again for continued surgery. The sliding doors between

rooms are opened, a bridge is positioned between the OR

tables and PET/CT table, and the patient is shuttled into the

scanner on an MRI-/PET-/CT-/x-ray-compatible transfer

board, which he/she never leaves throughout the procedure

(Fig. 24.14). The transfer board supports head fixation for

neurosurgery. It is anticipated the thoracic service will also

utilize this mode.

Operating Room: The middle room of the suite is essen-

tially a hybrid OR an x-ray intervention room with sterility

measures, infrastructure, and equipment for surgery. Planned

procedures include open surgery, minimally invasive surgery,

endovascular interventions, and percutaneous and burr hole

ablation procedures

By far, the predominant use of intraoperative MRI rooms

worldwide is for brain tumor resection. A major shortcoming

of image-guided navigational systems is the use of

preoperatively acquired image data, which does not account

for intraoperative changes in brain morphology. The occur-

rence of these surgically induced volumetric deformations

(brain shift) has been well established [4]. Brain shift is a

continuous dynamic process that evolves differently in dis-tinct brain regions. Intraoperative updates to the image-

guided navigation data are a strong justification for this

application, in order to ensure optimal resection.

Image registration is an essential part of any neurosurgi-

cal planning and navigation system because it facilitates

combining images with important complementary, structural,

and functional information to improve the information based

on which a surgeon makes critical decisions. The registration

process entails transforming images acquired at different

time points, or with different imaging modalities, into the

same coordinate system [5]. This is a topic of research in

AMIGO and is explored in depth in other chapters of this

textbook.

When the surgeon calls for updated MR image to provide

more accurate navigation, the procedure room must first be

transformed, to create an MRI safe environment. The pro-

cess is supervised by a safety nurse, a new role created for

AMIGO. Booms are pivoted outside the 5-G line and teth-

ered. The surgical microscope (Carl Zeiss Jena, Germany),

ultrasound unit (BK Medical, Peabody, MA and Siemens

Healthcare, Erlangen, Germany), and EEG pedestal (XLTEK,

San Carlos, CA) are removed from the room. Instruments are

counted. The monopolar return electrode pad and patient

warmer tubing are removed. All other ferromagnetic items

are accounted for and safely positioned. The room is pow-

ered down, including surgical support equipment, view

screens, and keyboard/monitor/mouse extension hardware.

The anesthesia machine (GE Healthcare, St Giles, England)

and vital signs monitor (In Vivo Corp, Gainesville, FL) and

MRI-compatible cameras (Sound Imaging Inc, San Diego,

CA) remain on. The cavity is filled with sterile saline to

eliminate the air-tissue interface, which can cause suscepti-

bility artifact in the MR images. The skin is cursorily closed

and the surgical wound draped. The patient table is returned

to a level position and extended such that the patients head

will be in the isocenter of the MRI scanner. The posterior

element of the MRI head coil was positioned before incision.

The anterior element is added. A template of the MRI scanner

bore is used to ensure nothing will make contact with the

scanner the table cantilevers into the bore. The sliding

doors to the MRI room are opened, and MRI scanner is

translated into the OR, with all personnel ensuring the pro-

cess is safe (Fig. 24.15). Following imaging, the MRI scan-

ner is returned to its adjacent room, and the process is

reversed to continue surgery. Ultrasound is used between

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MR images, for the advantages of its immediacy, to track

changes and to help determine when new MR images are

necessary.

The process for breast lumpectomy is similar. Images are

available in a separate chapter in this text.

EP cases for atrial fibrillation treatment require a differ-

ent room setup. The table is pivoted 90. A 56view screen

is used to the endovascular navigation view based on pre-

incision MR images, live and review EKG traces, and

intracardiac ultrasound images. A technologist operates

equipment from the control room. Cables and fiber optics

are introduced into the RF-shielded room via filters and

waveguides, respectively, in the penetration panel below

the control room window. Wireless MRI-compatible head-

sets (Optoacoustics, Moshav Mazor, Israel) are under

development to facilitate communication between the con-

trol room and procedure room. Prior to MR imaging, all

catheters are removed, leaving only a short sheath in place.

The patient table is pivoted towards the MRI scanner, and a

similar process for room preparation as that in neurosur-

gery is executed. The contrast-enhanced MR images enable

visualization of the acute effects of RF ablation. The goal

of the imaging is to find gaps in the burn used to electrically

isolate the pulmonary veins to inform the cardiologist

a

b

Fig. 24.14 The patient transfer system used to move patients from the OR table to the PET/CT table for imaging. (a) Staff move a patient fromthe angio table, across a bridge, onto the PET/CT table. (b) The concept is illustrated with a 3D CAD model (Courtesy of IMRIS Inc.)

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Fig. 24.15 (a) OR prior to roompreparation for imaging. (b) MRI

scanner entering OR. (c) MRI

images acquired pre-incision and

after resection. The arrows

showing the lesion in the pre-

image remain in the same

location in the post-image to

appreciate the brain shift. The

signal void with theyellow arrow

headis the area where tissue was

removed. (d, left) The navigation

system showing the focal plane

of the microscope. (d, right) The

view through the microscope

with image injection, showing

the target tissue based on

segmentation of the MR images.

(e, left) Ultrasound probe in the

surgical wound. The probe is

tracked by the navigation system

and the corresponding MR image

is displayed. (f, right)

Intraoperative US image

a

b

where to target with the next round of ablation. MRI-

compatible catheters to perform the procedure under MRI

guidance are becoming commercially available. MRI safe

navigation patches 12-lead EKG are also under investiga-

tion. Another chapter in this text explores this topic in

depth.

MRI Room: Similar to the PET/CT room, the 3-T MRI

room can be used in a stand-alone mode with the in-out para-digm. The 70-cm diameter bore permits biopsies, needle inser-

tion-based procedures such as prostate and cervical cancer

brachytherapy, and ablations to be supported by this space. A

cryotherapy delivery system (Galil Medical, Yokneam, Israel)

is integrated via the penetration panel, with critical system

components at the point of care and the non-MRI-compatible

control interface remaining outside the room. An in-bore track-

ing system (Robin Medical, Baltimore, MD) is also available

that uses the field generated by the MRI gradients to derive the

location and orientation of a probe or needle. An MRI-

compatible view screen, vital signs monitor, and anesthesia

machine are present in the room. The ceiling-mounted scanner

pivots 180 on a turret to place the patient table at the front orrear of the room, depending on the needs of the procedure.

Pelvic intervention is facilitated by either a commercially

available system (Sentinelle Medical, Toronto, Canada) or a

solution codeveloped with Johns Hopkins University.

Figure 24.16shows some of the methodology.



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e

The Future of the AMIGO Suite and OtherMulti-modality Suites

At this time, AMIGO is unique in that the suite has a tightly

integrated PET/CT and its leadership has handed down a

mandate to explore all possible applications, head to toe.

AMIGO, however, is not alone in the world. Hybrid ORs

(see chapter in this text) have been installed at many univer-

sity hospitals. Fig. 24.17shows a map of centers around the

world using MRI to guide procedures. Vendors are making

specialty products for these spaces. The trend is undeniable.

Multimodality suites will become pervasive.

The scalpel is increasingly being replaced by therapeutic

tools. Cryotherapy, microwave ablation, radiofrequency

ablation, brachytherapy, radiation therapy, inductive heating,

focused ultrasound, localized stem cell injection, and more

exotic therapies expand the armamentarium of the clinician.

A symphony of imaging systems, navigation systems, robot-

ics, and therapeutic probes create a new world for patient

care. Researchers and integrators in these fields accelerate

the progression from open invasive surgery to minimally

invasive surgery or therapeutic intervention.

Although AMIGO has a road map, it is typical that the

inventor does not know entirely what he/she invention is for.

Uses are worked out in collaboration with the user. Creativity

is collaborative, cumulative, and interactive. Communication

with sites worldwide will yield the answer to: What is

AMIGO for?



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a

b

Fig. 24.16 (a) Patient in lithotomy position in the MRI bore. A posi-tioning system is used to give the clinical access to the pelvis. Iteratively,

a needle or cannula is placed, then the pelvis is scanned at isocenter to

confirm accurate targeting. (b) Axial prostate imaging showing two

needles in place. (c) The acrylic grid is registered to the scanner coordi-

nate system to provide a framework for needle placement. This setup is

used for prostate biopsy and prostate low-dose brachytherapy.

(d) Sagittal image of the cervix and tandem and ring applicator

(Nucletron BV, Veenendaal, Netherlands), which facilitates cannula

placement (Courtesy of Nucletron BV). (e) A photograph of the ring

applicator. The patient is taken out of the AMIGO Suite to a lead vault

for insertion of radioactive sources into the cannulas

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c dFig. 24.16 (continued)

Fig. 24.17 Map of sites using high-field MRI. (Red) 58 sites perform-ing neurosurgery. (Blue) 24 sites performing interventions (epilepsy

treatment, laser ablation, convective drug delivery). There are nine cen-

ters that do both. This map neglects centers using low-field system and

is most likely not exhaustive



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References

1. Rostenberg B. The architecture of medical imaging: designing

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peutic techniques. Hoboken: Wiley; 2006.

2. Kettenbach J, Kacher DF, Kanan AR, Rostenberg B, Fairhurst J,

Stadler A, Kienreich K, Jolesz FA. Intraoperative and interventional

MRI: recommendations for a safe environment. Minim Invasive

Ther Allied Technol. 2006;15(2):5364. Review.3. Kanal E, Borgstede JP, Barkovich JA, et al. American College of

Radiology white paper on MR safety: 2004 update and revisions.

AJR Am J Roentgenol. 2004;182:11114.

4. Nabavi A, Black PM, Gering DT, Westin CF, Mehta V, Pergolizzi Jr

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Kikinis R, Jolesz FA. Serial intraoperative magnetic resonance

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D.F. Kacher et al.

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The Advanced Multimodality Image- Guided Operating (AMIGO) Suite