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Inside Room 1 at Dartmouth's Center for Surgical Innovation, or CSI, Dr. David Roberts performs delicate brain surgery. He's removing a small, low-grade tumor deep inside his 50-year-old patient's brain. Medical advances, like computer guidance and fluoroscopy, help guide him to the tumor. It can be here on monitors in the control room just outside the OR.

"If you didn't have these kinds of guidance technologies the risk of getting lost would be too great," Roberts said. "It further confirms where you are, one of the most important things in tumor surgery. It can provide confirmation that you've accomplished what you set out to do."

And here, what he's set out to do is completely remove the tumor. It can mean the difference between life and death for the patient. But it's not uncommon for patients to need a second surgery once an MRI — hours or days after the first operation — shows tumor remains.

But now at Dartmouth, the need for a second shot at removing the tumor is a thing of the past. When surgery wraps up, the OR team straps down equipment, counts tools and does an all-hands-on-deck safety check before an MRI moves right into the operating room. It's an intra-operative MRI. The scan done while the patient is still asleep and before her head is closed. The doctor steps out into the control center to carefully analyze his work. Is the tumor completely gone?

"The MRI looks very good," Roberts said.

Intra-operative MRIs are available at the most sophisticated hospitals in the country. But at Dartmouth, there's even more. The CSI has an intra-operative CAT scanner as well, in addition to traditional X-rays.

"As far as I'm aware, it is the only operating room in the world at this time that has both magnetic resonance imaging, MRI, and computer tomography, or CT scanning, that can be used in the same procedure," said [Robert A. Pritzker Professor of Biomedical Engineering] Keith Paulsen, the scientific director of the CSI.

One shows bones, the others also show soft tissue, like muscle and the body's organs. They're technologies helpful in complicated procedures.

Today, the Center for Surgical Innovation is being used for neurosurgery, but it's already being used in other specialties, as well.

"In orthopedics it's really been fluoroscopy, or plain film X-rays, that are taken because you can see bones, but you can't appreciate the soft tissue at all, nor the three dimensionality of the area that we're operating on," Paulsen said. "So we think using MRI and CT, where you can get three-dimensional visualization, can really radically change some of the procedures that are done."

Complex spine surgery for one. But it's not just about the clinical work at the CSI; it's research. The $19 million center was funded in large part by the National Institutes for Health, so that Dartmouth's clinicians, engineers and scientists can develop new tools and techniques.

For patients, the goal is to lower costs through fewer surgeries and other medical procedures, but most importantly for improved patient safety.

"It's a safety issue," Roberts said. "And again, the risk of going back in, re-exposing the patient to the risk of infection. It's hard going back in for a variety of reasons."

But that's not expected to happen at Dartmouth anymore, not for the complicated procedures now being done at its Center for Surgical Innovation, a state-of-the-art facility now in a worldwide league of its own.

Construction of Dartmouth's surgical center was funded by a $9.3 million grant from the NIH. The remainder came from the hospital itself, and Dartmouth's medical and engineering schools.