The Center for Surgical Innovation (CSI) combines, in one facility, interoperative imaging capabilities that give surgeons unprecedented ability to see, in real time, the tissue and organs involved in procedures. Designed and built by the Minnesota-based technology firm IMRIS, the CSI configuration combines computed-tomography (CT), magnetic resonance imaging (MRI) and traditional fluoroscopy (x-ray) technology, and is the only hybrid operating suite in the world where both CT and MRI can scan a patient on the OR table with either or both modalities — without moving the patient. The advantages in operating efficiency and patient safety are immense, says Dr. Sohail K. Mirza, Medical Director of CSI and Chair of Orthopaedics at Dartmouth-Hitchcock.

“CSI began as an idea — a dream, really — about a facility that could dramatically accelerate and improve surgery. CSI allows us to perform procedures in ways that are significantly better than conventional surgery. We’re looking very carefully at how the technology we use and the procedures we develop will improve the lives of patients.”

In 2010, the National Institutes of Health awarded a $9.3 million grant to support development of the $19 million CSI. The project leverages the research strengths and interests of Dartmouth-Hitchcock and Dartmouth College, including the Geisel School of Medicine and Thayer School of Engineering, in a multi-disciplinary approach to advancing population health. Construction began in June, 2011; the first surgeries in CSI were neurosurgery procedures performed by Dartmouth-Hitchcock Chief of Neurosurgery Dr. David Roberts in the spring of 2014.

“We offer services for very complex, high-risk cases like pediatric spine surgery, like Amanda’s, as well as certain types of brain tumor surgery and spine cancer surgery, that we wouldn’t be able to offer without the technology in the CSI,” says Mirza, who is also a professor of orthopedic surgery at Geisel. “This will allow us to directly contribute to improving the health of local patients and the population we serve in Northern New England.”

Seeing below the surface

Surgeons are too often limited by what they cannot see, including anatomy that is difficult to reach or medical conditions that are not visible to the naked eye. “While advances in imaging such as real-time x-rays during surgery and MRI and CT scans prior to surgery have helped to advance many surgical procedures, further innovation is needed,” Mirza explains. “An example would be the fractures of the second vertebrae in older adults, where a millimeter too long or too much to one side can mean catastrophe if a blood vessel is injured. But with 3D imaging during procedures and things like robotic surgery, we’ll be able to be much more precise and overcome a lot of human limitations.”

CSI enhances Dartmouth-Hitchcock’s nationally-recognized research programs in neurosurgery and orthopedic surgery; leverages research in neuro-imaging and breast imaging to spawn innovative new programs in interventional psycho-therapeutics and intraoperative biomarkers for surgical resection guidance; and augments emerging research programs in prostate surgery, intraoperative oximetry imaging, and in vivo optical microscopy. CSI offers advanced imaging, image-guidance and data collection tools, which will be used to substantiate and/or validate medical discoveries, clinical hypotheses and procedural innovations.

“CSI consists of two operating rooms and two procedure rooms in a long, linear set of suites that will provide intraoperative CT and MRI scanning,” explains Keith Paulsen, PhD, the Robert A. Pritzker Professor of Biomedical Engineering at Thayer School of Engineering and CSI Scientific Director. “The scanners are mounted on ceiling rails, allowing them to move in and out of the ORs. The MRI can go into either OR and the CT can go into one of the ORs, which we call OR 2. That makes OR 2 the only operating room in the world at this time that has both MRI and CT scanning.”