Room to Operate
Dartmouth’s new Center for Surgical Innovation makes space for research in clinical care.
By Anna Fiorentino
Imagining what life would be like if medical technologies never advanced is not hard. “We would be dying sooner and of many more diseases if we hadn’t put money and effort into research,” says Keith Paulsen, Thayer’s Robert A. Pritzker Professor of Biomedical Engineering.
The value of medical research is why Paulsen and Dr. Sohail Mirza, chair of Dartmouth-Hitchcock’s Department of Orthopaedics, have worked together to create the Center for Surgical Innovation (CSI), the nation’s first surgical facility dedicated to translational research.
Paulsen, CSI scientific director, and Mirza, CSI medical director, will oversee research that combines Thayer expertise in biomedical engineering, imaging, and computation with clinical expertise at Dartmouth-Hitchcock Medical Center and Geisel School of Medicine—research that uses the CSI to test new approaches in the operating room, such as complex real-time image-guided surgical procedures.
The CSI mitigates a major limitation for researchers: a lack of operating room time and space for the clinical studies on animals and humans that must be carried out before any new technique or technology becomes standard practice. While various hospitals, including those affiliated with Duke and Johns Hopkins universities, have surgical centers dedicated to imaging research and innovation, the CSI is the only one where research won’t have to compete with clinical care. Completely separate from Dartmouth-Hitchcock’s busy operating rooms, the 12,000-square-foot CSI is largely free from the scheduling and financial realities that drive high-volume clinical surgical units. “The pressure to make this a profit center where patients need to get in and out won’t be prevalent,” says Paulsen.
Although most of the research will benefit patients in the future, Paulsen says the CSI gives Dartmouth-Hitchcock surgeons access to the most advanced surgical environment for handling complex cases that would otherwise end up elsewhere. “If we didn’t build this center, all of our patients would go to Boston,” Paulsen says. “If you want to do research, you have to create your own space.”
THE $20-MILLION CSI BEGAN TO TAKE shape in 2010 when Thayer, Geisel, and Dartmouth-Hitchcock matched $10-million in federal stimulus money. Adjoining Dartmouth-Hitchcock’s Advanced Imaging Center—which Paulsen, an imaging expert, also directs—the CSI occupies space below a new clinical radiology unit, which factored into the project planning.
The CSI features two operating rooms that are large enough to accommodate multiple researchers and equipment. Computed tomography (CT) scanning and magnetic resonance imaging (MRI) systems can be moved from one operating room to the other along ceiling-mounted tracks. Two diagnostic imaging rooms can be used for nonsurgical or minimally invasive procedures. Windows overlook the operating and diagnostic rooms so researchers and students—from undergraduates to graduate and medical students—can observe surgeries, imaging sessions, and other research activities. The CSI also includes ancillary offices, patient holding spaces, control rooms, and labs, including a small wet lab for tissue studies.
Carefully planned elements of the CSI will allow researchers to use the same operating room for either animal or human procedures. Animals enter the operating room through a separate entrance. A state-of-the-art ventilation system minimizes the risk of cross-contamination between human patients and animal subjects. Differential pressurization sensors maintain positive pressure with laminar airflow over the table during human surgeries and negative pressure during animal procedures. If the pressure isn’t at the correct level, the doors to the operating room won’t even open. “We wanted to get the floor as clean as possible,” says CSI managing director John Peiffer.
The CSI will leverage previously funded research in brain and breast imaging and also roll out new programs in interventional psychotherapeutics and intraoperative biomarkers for guiding surgical resections. The CSI will introduce emerging research programs in prostate surgery, intraoperative oximetry imaging, and in vivo optical microscopy.
Paulsen expects the facility to lend itself to employing and refining image-guided technology used in the da Vinci robotic surgical system, which the surgeon manipulates from a console outside the operating room. Paulsen says that research conducted in the CSI may help bring to life a machine with vision sharper than the human eye. The day may come, he says, when “we can let images obtained by scanners drive the surgery, especially in orthopaedics, where not a lot of soft tissue is moving around.”
Another project Paulsen and his team will take to the CSI explores fluorescence imaging to guide neurosurgeons as they resect brain tumors. In research that began in 2008, Paulsen’s lab group is among the first to harness fluorescence to prevent tissue damage during brain surgery. German doctors had discovered that if a patient is given an oral dose of a 5-aminolevulinic acid solution before brain surgery, a chemical reaction causes certain cells, including cancer cells, to fluoresce—illuminating tumors so they can be removed during surgery. Paulsen and his team, along with doctors from the Ontario Cancer Institute in Toronto, took even more of the guesswork out of fluorescence-guided brain surgery by creating a fiber-optic probe that can detect early-stage, low-grade tumors via fluorescence not visible to the naked eye. With the probe already sharpening the accuracy of fluorescence-guided tumor detection from 64 to 94 percent, Paulsen’s group will further assess how to use fluorescence more precisely so neurosurgeons can consistently perform safer and more complete resections.
The work may well open new treatment options for deadly tumors. “By the end of this next phase of research we plan to conduct at the Center for Surgical Innovation, we will have implemented and evaluated wide-field techniques in human surgeries,” says Paulsen. “We expect to demonstrate that these innovations improve surgical outcomes when added to visually detected fluorescence imaging in a prospective enrollment of patients with malignant glioma.”
Thayer students and graduates are among the many people who will be conducting research in the CSI. For example, Ph.D. candidate Kolbein Kolste will continue to improve the fluorescence-detection probe for neurosurgery. In another project, research associate and Ph.D. graduate Xiaoyao Fan Th’12 is working with Dr. David Roberts, a Dartmouth-Hitchcock neurosurgeon, on a noninvasive, ultrasound-based registration method for guiding surgery, a technique used last year at Dartmouth-Hitchcock for the first time. According to Fan, the CSI will magnify the scope and outcomes of their work. “The intraoperative MRI and CT can be used together with the navigation system to update information during a partial or complete tumor resection to ensure all tumor tissue has been resected,” she says.
“The CSI will make Thayer the magnet school for students and faculty interested in improving surgical technology,” says Mirza. “In return, Thayer faculty and students will change surgery in meaningful ways that benefit patients by developing technology to make surgery safer and more effective for patients.”
The CSI will also be open to researchers beyond the Upper Valley, including companies that need to conduct preclinical trials en route to securing FDA approval for new technologies, products, and procedures. “My goals for the CSI is to have enough resources and personnel to allow maximal use of the facility, and provide easy access to any student or faculty member anywhere in the world to bring their ideas here,” says Mirza.
“The CSI will be a national destination for patient care and innovation,” he says. “We want outside engineers, biomedical scientists, and physician-researchers to bring their ideas to the CSI because it will have the very best capabilities.”
According to imaging specialist and Thayer adjunct professor John Weaver, the CSI will be a vital means to a critical end: saving lives. “The CSI provides a unique opportunity to improve surgical practice. The intersection of excellent engineers and surgeons makes the prospects so promising,” he says. “Professor Paulsen and Dr. Mirza know how to improve the surgical process so the entire system can be optimized and the right innovations can be incorporated in effective ways.”
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