Intraoperative imaging – added benefit or high-tech gadget?

Interview with Prof. Clemens Bulitta, Director of the Institute for Medical Technology, East Bavarian Technical University of Applied Sciences Amberg-Weiden


Monitoring individual results during surgery with an angiography system? This is already an option in approximately 200 hospitals in Germany.  Thanks to intraoperative imaging, major medical procedures can be replaced by minimally invasive surgery because physicians are able to monitor the results immediately. This is gentler on patients and decreases the number of subsequent revision surgeries.

Image: Prof. Clemens Bulitta; Copyright: OTH Amberg-Weiden

Prof. Clemens Bulitta; © OTH Amberg-Weiden

In this interview with, Prof. Clemens Bulitta of the East Bavarian Technical University of Applied Sciences talks about the opportunities intraoperative imaging offers and whether the results warrant the high cost of remodeling operating rooms.

Prof. Bulitta, what opportunities does the field of intraoperative imaging currently offer?

Prof. Bulitta: There are the traditional mobile C-arm x-ray imaging, intraoperative ultrasound and the latest concepts such as intraoperative computed tomography, intraoperative MRI, and particularly intraoperative angiography. Combinations of these systems are also an option. They are summarized under the term “hybrid operating room“, which usually indicates an operating room with an angiography system. These combinations open the door to new therapy and treatment options.

To what extent does intraoperative imaging increase treatment success?

Bulitta: All in all, intraoperative imaging offers three advantages. In the case of aortic valve stenosis, for instance, numerous patients are not contenders for the conventional medical procedure based on their underlying disease. Now this group has a treatment option available that didn’t previously exist. What’s more, the treatment is also more precise. The less I can directly see and feel with minimally-invasive procedures, the more I need other options to understand the anatomical setting correctly and properly place implants for example. And ultimately the quality of the treatment success is also improved since control images are already being captured during the intervention and complications are being avoided. Surgeons are therefore able to check their results on the spot; for instance, after inserting an aortic valve or when treating a fracture. This avoids revision surgeries, which benefits the patients and avoids unnecessary costs for the hospital.

How does this impact the surgery itself?

Bulitta: All this fundamentally changes the surgical procedure. The new equipment requires a restructuring of operational procedures, and therefore also requires changes in education and staff training. In addition, major incisions are no longer necessary, which is gentler on the tissue and other structures. This is also the case with aorta surgery when treating an aortic aneurysm for instance. In the past, a vascular endoprosthesis was inserted through an abdominal incision. This major incision can be avoided with a minimally-invasive procedure via the femoral arteries. This is one example of the many possibilities this new treatment provides in the hybrid operating room.

Do you see any limits to intraoperative imaging?

Bulitta: So far, I only see technical limits at most. Depending on the type of imaging techniques, this is reflected in the area of radiation protection or construction measures in terms of costs and space.  Due to cost reasons, intraoperative imaging should primarily be used where its use makes medical sense and if the expense is justified. Having said that, each new technology also entails new risks. That’s why the interaction between the entire team and technology is very important. The system includes the entire operating room.

Image: Surgery"Hybrid-OP"; Copyright: Klinikum Weiden/private

Intraoperative imaging offers three advantages, a new treatment for example; © Klinikum Weiden/private

What measures need to be considered when it comes to renovating an operating room?

Bulitta: That depends on the imaging system that is being installed and which work processes are meant to be implemented in this room. There are few to no aspects that need to be considered in the case of mobile C-arm imaging systems for instance. In contrast, high-end systems like DTI, MRI, and angiography imaging systems have significant effects on the structural design. Of course, you need a certain amount of space and additional installed components. Radiation protection or the MRI’s magnetic field also need to be considered.

Obviously, this is expensive. Does the added benefit of these systems outweigh the cost factors?

Bulitta: I believe so. Intraoperative imaging enables surgeries with fewer complications, which makes fewer revisions necessary. This also makes the overall treatment gentler, shorter in duration and on the whole more cost-effective. It also creates new treatment options that were previously not available. From my perspective, intraoperative imaging systems have become an essential part of modern surgery. Not every regional hospital needs intraoperative MRI; however, the positive results, especially in cardiovascular surgery, speak for themselves.

Do you think intraoperative imaging will become standard in operating rooms within the next ten to 20 years?

Bulitta: As far as I know, more than 200 operating rooms in Germany already feature intraoperative imaging. Without a doubt, hybrid operating rooms will become standard in modern vascular surgery far sooner, if they aren’t already. Several minimally-invasive procedures for treating structural heart disease are also headed in this direction. How much will also depend on assessments in clinical trials and long-term studies.

Intraoperative imaging will also be used increasingly outside of the cardiovascular field, for instance, in surgical oncology or surgical procedures of the musculoskeletal system. New ideas come up thanks to the enhanced opportunities, which in turn necessitate the realization of new technologies. This generates a self-reinforcing effect.

Aspects of information consolidation will also be interesting – when you are able to show preoperative diagnostic information in an intraoperative context, with the help of images, for instance, using virtual or augmented reality.

The interview was conducted by Lorraine Dindas and Nicole Kaufmann and translated from German by Elena O'Meara.