30.2.1 Operating Room Size

As surgical equipment grows increasingly larger, there has been a commensurate demand for adequately scaled operative suites. Historically, the standard operating room (OR) suite was approximately 400 square feet. According to Facility Guidelines Institute (FGI) guidelines published in 2014, the size requirement for general OR suites remains 400 square feet, or 600 square feet for procedures which require more staff and/or equipment. ¹ The size required for a hybrid OR, a surgical theater that is equipped with an advanced medical imaging device such as a fixed C-arm, CT scanner, or MRI, will be even higher with estimates of around 1,000 square feet. ¹ The typical spine surgery case involves numerous staff and equipment requirements including space for the anesthesia team, surgical team, nursing staff, tables for implants, vendors, a neuromonitoring team, a large C-arm, and occasionally a microscope. The FGI guidelines provide recommendations which account for the need for adequate space for personnel and equipment with minimal potential for contamination. ¹ Procedures that use navigation will require a secondary computer/image registration hub that houses the navigation software, while a surgical robot will be required for robotic-assisted cases. These products will have significant spatial requirements and the operating room must evolve to meet these demands.

30.2.2 Minimizing Contamination while Driving Technological Advancements

The modern operating suite should be set up to have ample space for all necessary equipment as contamination rates in the OR correlate with OR traffic. Implementation of new design features in the operative suite should not compromise sterility in the OR or operative efficiency. Recently, technologies have begun to be introduced and designed to minimize hand contact and potential intraoperative contamination. For example, OR 21 is a novel OR lighting system that utilizes a hands-free overhead light/laminar air flow combination system intended to ultimately replace currently used more typical lighting systems attached to a boom (Fig. 30‑1). Still under investigation, this system obviates the need for surgeon manipulation of intraoperative lighting, a potential source for contamination, and simultaneously can improve intraoperative air quality, another potential source of contamination.

Breach in sterility has been documented during intraoperative fluoroscopy as well as microscope use. Specifically, C-arm contamination has been reported to occur in as many as 56% of cases. ² Although perhaps easier to drape during room setup rather than immediately prior to use, prolonged C-arm drape time, in the setting of increased foot traffic, can lead to contamination. In the case of early draping, it is generally recommended to avoid contact with the C-arm and treat it as contaminated. ² Other more technologically advanced imaging modalities may be used with the benefit to decrease contamination and increase efficiency by obviating the need for multiple C-arm rotations and repeated imaging throughout the procedure. These modalities will be discussed in a separate chapter; they include Brainlab CT scanner, Ziehm C-arm, and the O-arm which do not require continuous use of the conventional fluoroscopy. ³

Postoperative culture of the surgical microscope (and drape) has revealed that contamination may occur anywhere from 12 to 44% of the time. ⁴ However, this contamination rate has not led to a similar increase in the infection rate. ⁴ Most commonly, contamination occurs around the optic eyepieces and the handles. Adequate OR space can allow more ideal microscope positioning and potentially less need for intraoperative handling. If the operative microscope should be handled intraoperatively, it is recommended to change outer surgical gloves to minimize contamination of the surgical wound. ⁴

30.2.3 Design of a Traditional Operating Suite

The operating suite should be designed to maximize efficiency, improving workflow for the assistive staff while simultaneously limiting traffic around the operative table. OR traffic has been implicated as a source of contamination. ² Ideally, the operative suite should include the operating table in the center of the room, a space for anesthesia at the head of the table, an area for the OR back table that is at least 2 feet from any room traffic, and a dedicated area for the circulating nurse ¹ (Fig. 30‑2). There should be access to the external corridor and a clean core from the OR, but these doors should not be able to be opened simultaneously so as not to allow turbulent air flow to cross the operative field. ⁵ An image display system (i.e., Picture Archiving and Communication System (PACS)) that projects images comfortably within the view of the operative table helps prevent surgeon traffic away from the operative table, limiting breaches in sterility. Similarly, with the introduction of robotics and navigation, a dedicated space should exist within the OR to store and use these devices without increasing the risk of contamination with their use. ³

30.2.4 Design of a Hybrid Operating Room

The design of the hybrid OR for spine surgery should maintain all the necessary components of the traditional operating suite with the addition of advanced medical imaging device such as a fixed C-arm, CT scanner, or MRI. The estimate for space needed for a hybrid OR is about 1,000 square feet. ^{1 ,​ 3} The most frequent imaging modality utilized in hybrid ORs for spine surgery has been a CT scanner. Hypothetically, with computer-assisted navigation (CAN), hybrid ORs can improve efficiency and minimize complications. CAN has already proven useful for minimizing radiation compared to conventional fluoroscopy. ^{3 ,​ 6} A radiation-safe area should be implemented into the design of all hybrid ORs for the benefit of the surgeon and all OR staff. ³

30.3.1 Preoperative Efficiency

To discuss the efficiency of an OR, one must analyze the steps taken prior to OR roll back that lead to inefficiencies and waste in the perioperative setting. OR costs are high and each minute used for unnecessary tasks adds to the enormous cost burden and perioperative budget. ^{9 ,​ 10} Several studies have evaluated the influence of preoperative checklist completion on OR day efficiency. Checklists may serve a dual purpose. Firstly, they ensure patient safety measures are taken prior to roll back. Secondly, they allow tracking of each teams’ contribution to the preoperative evaluation, ¹¹ including the roles of the surgical team, nursing team, anesthesiology team, and OR equipment team. Each team plays a unique and vital role in ensuring smooth operative flow. These checklists have been found to improve efficiency.

The flow of an OR day is often set by the first start. Being able to start the first case on time is critical in maximizing allotted block time. A recent study discussed the implementation of preoperative managers whose role was to ensure on-time first start times. They found that the addition of an OR facilitator reduced the amount of delayed first start cases by 50%. ^{9 ,​ 10} Ensuring that preoperative checklists are completed in a timely fashion is critical for patient safety and OR workflow. ¹¹

OR turnover is also important for maintaining an appropriate workflow. It minimizes patient discomfort, maximizes surgeon block time, and ultimately enhances hospital revenue. Formally educating designated leaders (surgeons, anesthesiologists, and nursing staff) on the importance of turnover has done little to improve this issue. The six-sigma initiative in 2002 identified key factors in improving OR turnover times: surgeon at scrub sink during patient preparation, setup dismantled upon wound closure, clean up prior to patient out of room, case chart completed, and the surgeon consistently notified of room readiness. Improving these factors resulted in a 32% reduction in turnover time. ¹² How applicable this study is to spine surgery can be debated, but recent literature focusing on efficiency in spine ORs has found that an initiative to consolidate trays and standardize instrumentation has a great benefit to both cost savings and decreased operative time. ¹³ This initiative was driven by communication between hospital OR staff, surgeon, and industry reps to focus only on needed equipment for any given surgery. ¹³ This allows a streamlined setup/clean-up, less chance for mistakes during surgery, and more efficient use of OR time. Our recommendation is that each surgeon streamlines the equipment needed for each case to derive maximum value and safety in the OR setting.