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The long halls of the Ope­rat­ing Center in Groß­hadern provide a sense of the size of this large build­ing. More than 40,000 oper­at­ions are per­formed each year here since the center opened in 2014. The Operat­ing Center, part of the clinic at Ludwig-Maximilians-Univer­sity (LMU), is consid­ered a suc­cess­ful model in pro­fes­sional circles. The influ­ence of the LMU is clear: advanced, min­i­mally inva­sive proce­dures, operat­ing in hybrid rooms, and using a sliding gantry, i.e. computed tomo­graphy equip­ment that can be moved back and forth between two oper­at­ing rooms demon­strate the close connec­tion to research.

But the stan­dard tech­nol­ogy is highly advanced as well. From patient entrance areas and proce­dures to the central sterile material supplies depart­ment and on to intra­operative imag­ing, medi­cal advances are a great priority every­where in the Operat­ion Cen­ter. For this reason, in the spinal and pelvic sur­gery sec­tion of the Depart­ment for General, Trauma and Recon­structive Sur­gery, senior physi­cian Dr. Zeckey and spe­cial­ist Dr. Weidert are plan­ning today’s proce­dures with the assis­tance of the newest imaging systems.

Both doctors work on the team of Dr. Kammerlander, the head phy­si­cian. He and Prof. Dr. Böcker, the clinic director, are known inter­na­tionally as experts in their field. That’s why, again and again, patients from all over Europe are flown to Groß­hadern to undergo a second proce­dure per­formed by profes­sion­als. Prof. Dr. Böcker’s team includes nearly fifty doctors, more than twenty of whom are head phy­si­cians or specialists. The clinic, a verified mass casualty trauma center, offers treat­ment for a wide range of sit­u­ations: from broken bones and tissue damage to athletic injuries and severely injured patients.

Today Dr. Zeckey and Dr. Weidert are performing two spinal proce­dures. The first operat­ion on the cervical spine is espe­cially chal­leng­ing: At the patient’s request, the surgeons are using an alter­native method of treat­ment. Dr. Zeckey and Dr. Weidert discuss the proce­dure in detail: because each action must be correct, advanced medi­cal tech­nol­ogy is used even in the plan­ning phase. 

For today's proce­dure, the physicians are using a new 3D C‑arm by Ziehm Imaging: the Ziehm Vision RFD 3D with pre­mium CMOSline¹ equip­ment, which will be intro­duced to the mar­ket in just a few months. As a refer­ence part­ner, the trauma sur­gery depart­ment receives the system as a loan unit much earlier in order to test the tech­ni­cal inno­va­tions in clini­cal use. A new detector, set­tings that reduce radi­ation expo­sure, and expanded user func­tions have im­proved the image quality of the 3D C‑arm. Today the new sys­tem has to demon­strate its capa­bil­ities.

Oper­at­ing on the cervico­thoracic area, the junction between the cervical spine and the thoracic spine, is difficult enough, and this, together with the anato­mical condi­tion of the patient, makes a pre­cise lateral 2D aquisi­tion of the transi­tion to the thoracic spine nearly impos­sible. But the high con­trast image of the bony struc­tures is an impor­tant require­ment for the suc­cess of the opera­tion. If the verte­bral bodies can­not be represen­ted pre­cisely with intra­opera­tive imag­ing, the spinal cord could be damaged, for example, due to the im­prop­er place­ment of screws. That’s why Dr. Zeckey and Dr. Weidert have decided to per­form the opera­tion using image-guided naviga­tion and to scan the spine with the mobile 3D C‑arm.

The C‑arm moves 180° around the patient in both linear and rota­tional motion. The 3D data set aquired in this way dis­plays even the smal­lest anato­mi­cal details of the verte­bral bodies. The physici­ans use this as a start­ing point for image-guided navi­ga­tion during the oper­a­tion. First, based on this 3D data set, they plan the exact place­ment of the screws on the monitor, and then later, during the oper­a­tion, they display the pro­gress made in set­ting the screws.

Application Specialist Nadja Baitis operates the C‑arm. She is a trained medical­technical radio­lo­gy assis­tant and is part of 3D pro­duct mana­ge­ment at Ziehm Imaging. In partic­ular, Ms. Baitis works with new C‑arm sys­tems during the test phase to ensure that all of the tech­ni­cal inno­va­tions also func­tion in prac­tical use. She trains the OR person­nel with regard to using the sys­tem and passes on her valu­able expe­ri­ence. Ms. Baitis has been in Groß­hadern for more than two weeks already and is test­ing the new sys­tem in clini­cal applica­tions. For difficult proce­dures like the one today, she controls the C‑arm her­self. The opera­tion on the cervi­cal spine takes more than four hours and the Ziehm Vision RFD 3D CMOSline is con­sulted for clini­cal guid­ance again and again. Finally, the team carries out a 3D scan.

Because the implant can be posi­tioned pre­cisely and this intra­oper­ative control scan can be per­formed, the patient does not have to wait for the results of a post-oper­ative CT scan and per­haps under­go another oper­a­tion. The final 3D image con­firms it: The screws are cor­rectly posi­tioned in the bone at the spec­i­fied anato­mical dis­tance from the arteries and spinal cord. The oper­a­tion was success­ful. The Ziehm Vision RFD 3D CMOSline is also used in the next oper­a­tion, a dor­sal instrumen­tation proce­dure in the lumbar spine.

Follow­ing train­ing by applica­tion special­ist Ms. Baitis, Dr. Weidert oper­ates the 3D C‑arm him­self from the sterile area. Once again, the intra­oper­ative 3D imag­ing pro­vides assur­ance that the implants are placed exactly where they should be to pre­vent pain and allevi­ate the need for further treat­ment. Follow­ing the proce­dure, Ms. Baitis consults with the physi­ci­ans.

How does the team rate the device’s per­for­mance? Senior phy­si­cian Dr. Zeckey is im­pressed by the quality of the Ziehm Vision RFD 3D CMOSline. And head phy­si­cian and deputy clinic director Dr. Kammerlander is also satis­fied. He uses intra­oper­a­tive naviga­tion regu­larly in his stan­dard opera­tion practice. The high-resolu­tion imag­ing together with the naviga­tion pro­vides assis­tance, particu­larly in anato­mical areas that are diffi­cult to see into, such as the cervico­thoracic transi­tion. The image-guided naviga­tion func­tion allows him to achieve the best pos­si­ble results in spinal and pelvic procedures.

The director of the Depart­ment for General, Trauma and Recon­structive Surgery, Prof. Dr. Böcker, is also very pleased with the larger volume size of the 3D C‑arm. This new option provides a larger scan­ning area, which allows more anat­omy to be dis­played in multi­planar recon­struction. For a large anato­mical region such as the pel­vis, a single 3D scan now provides ade­quate cover­age of the com­plete oper­at­ing area. Ms. Baitis values the close cooper­a­tion with the trauma sur­geons. She trusts the exper­tise of the phy­si­cians in Groß­hadern and is glad that the CMOSline version of the Ziehm Vision RFD 3D passed the first practi­cal test. She will be here at the Oper­ating Cen­ter in Groß­hadern again tomor­row for the C‑arm’s next application.