In medicine, the better the infrastructure, the more precise the diagnoses are and the more effective the treatment is. That is why we continuously make major investments in medical devices. For example, Hirslanden uses the state-of-the-art da Vinci technology. We also perform operations with the CyberKnife and TrueBeam linear accelerators, which were developed for use in radiosurgery. We also are among the leading providers of x-ray diagnostics. Our specialist institutes for radiology and nuclear medicine offer the full range of radiological examinations: magnetic resonance imaging (MRI), computed tomography (CT), as well as PET-CT scans, conventional radiology, mammography, ultrasound and nuclear medicine.
In addition to conventional operating theatres, Clinique Cecil in Lausanne and our Zurich hospitals Klinik Hirslanden and Klinik Im Park each feature one of the most modern theatres in Europe – a hybrid operating theatre for innovative, interdisciplinary and minimally invasive procedures, particularly in the areas of neurosurgery and heart surgery.
Read on to find out more about some of these cutting-edge technologies.
Brachytherapy (internal radiation) is a form of radiotherapy; it is subdivided into seeds and the afterloading therapy. Brachytherapy with seeds is a minimally invasive procedure during which tiny capsules with radioactive substances, so-called “seeds” (approximately the size of a grain of rice), are inserted into the area to be treated by means of a thin needle. They radiate the cancer internally in a very targeted manner. The inserted seeds are so small that the patient does not feel them. Depending on the circumstances, either radioactive iodine (I-125) or palladium (PD-103) is used.
The advantage of this method is that the radiation works directly within the malignant tissue. Due to the proximity of the area to be treated to the radiation source, the fall-off of the radiation dose in the surrounding tissue is much higher than with teletherapy. That’s why a higher radiation dose can be applied in a very short amount of time with brachytherapy. The entire duration of the treatment is generally reduced from six weeks to approximately one week.
A further advantage is the significantly lower radiation exposure for the patient compared with other radiotherapies. Even with an advanced tumour or with the recurrence of a tumour following normal radiotherapy, brachytherapy on its own or in connection with normal radiotherapy and/or chemotherapy has considerable advantages.
A special x-ray procedure used to produce cross-sectional images of selected parts of the body
The CyberKnife is the only non-invasive, robot-operated radiosurgical system for the treatment of tumours anywhere in the body. The CyberKnife system combines several modern technologies: an image-guided tumour tracking system, a high-precision computer-operated robot arm and a modern patient positioning system. These technologies make it possible to carry out radiotherapy on tumours with an extremely high degree of accuracy.
High-precision robot technology
The high-precision robot can manoeuvre the radiotherapy unit along six axes, making it possible to treat every region of the body from the best possible angle. In combination, these modern technologies ensure exceptional accuracy with deviations of less than one millimetre, and deliver the ideal dose of radiation – all of which makes the treatment less physically demanding for the patient.
The CyberKnife system can be used to treat tumours in all regions of the body, even areas that previously could not be treated with radiosurgical therapy. This includes tumours in the lungs and abdomen, which can change position due to the patient’s breathing or movements in the digestive tract. Tumours located near tissues that are particularly sensitive to radiation, such as the spinal cord and the optic nerve, can also be treated using the CyberKnife.
There are, however, a few situations where the CyberKnife is not suitable:
- very extensive tumours
- tumours that cannot be easily defined
- pronounced infiltration
- multiple organ metastases
- adjuvant ‘add-on’ radiation after surgery
- emergency situations
A telemanipulator (surgical robot) transmits the operator’s hand movements to instruments that have been positioned inside a small incision in the patient’s abdomen (keyhole surgery). The operator controls the movements of the instruments and is guided by a three-dimensional video display, which is capable of tenfold magnification for exceptional precision and reliable results. In the case of prostate cancer, for instance, this combination of advanced technology and experienced operators delivers excellent oncological results, as well as very good outcomes in relation to continence and sexual function.
Wide range of applications
This technology is particularly well suited for performing radical prostectomies (with minimal damage to the patient’s blood vessels and nerves), removing malignant and benign tumours while saving the affected organ, the complete removal of the kidneys in the case of very large tumours or kidneys that no longer function, the plastic correction of ureteropelvic junction obstructions, lymph node removal and the radical removal and replacement of urinary bladder with an artificial bladder in patients with bladder cancer.
Robot-aided da Vinci technology delivers such excellent precision for complex kidney, bladder and prostate surgery, that it is increasingly also being used for heart operations.
da Vinci technology offers patients numerous advantages over open surgical techniques:
• minimally invasive surgery
• ‘microscopic’ operations with tenfold magnification
• minimal tissue damage
• less blood loss during surgery
• less pain after surgery
• possibility of retaining continence and sexual function after prostate and bladder operations
• wound heals faster
• very good cosmetic results
• faster recovery (convalescence)
Hybrid operating theatres combine conventional surgical equipment with a high-performance imaging system that produces three-dimensional images of the patient’s body during surgery and displays them on screens inside the operating theatre.
- Imaging system: During the operation, a robot arm connected to the imaging system rotates around the patient and delivers three-dimensional images of the inside of the body.
- Team: A team of up to 20 people work inside the hybrid operating theatre – including vascular surgeons, endovascular specialists, anaesthetists, operating theatre nurses, cardiology technicians and implant experts.
- Operating table: The operating table can be rotated in all directions and communicate with the imaging system. The table’s movements are synchronised with the imaging system’s robot arm.
New techniques, greater teamwork
The key advantage of hybrid operating theatres is that they can be used to perform open and minimally invasive surgery, or a combination of both, and also provide high-precision radiological imaging during the procedure. This paves the way for entirely new interdisciplinary therapeutic concepts that are faster, safer and less traumatic for patients, because everything can be carried out simultaneously in one place. Particularly in the case of vascular emergencies, it is possible to convert a minimally invasive operation into an open operation in just a few minutes, without the patient having to be moved to another theatre at such a critical time.
Various examinations can also be incorporated into the procedure. For instance, the surgical team can measure and evaluate the patient’s blood pressure, blood flow rate, the amount of blood being transported through the heart and the elasticity of the vessels. This saves the patient from undergoing time-consuming individual examinations, or being transported to various diagnostic devices during the operation.
Setting up a hybrid operating theatre is a very challenging task: not only does the imaging unit require additional space, but such theatres are also staffed by more personnel.
Hybrid imaging techniques for optimised heart surgery
Minimally invasive treatment methods have become an established part of cardiology. These include hybrid heart operations involving the use of cardiac catheters. Ultrasound and x-ray imaging are usually used at the same time. Each technique has different strengths: x-ray images make it possible to display bones, instruments and catheters, whereas ultrasound is ideal for showing soft tissue structures, such as heart valves. Since 2014 Hirslanden has been synchronising and fusing 3D ultrasound and x-ray images in real time, so that all the elements can be displayed live and simultaneously on a screen. This approach also enables the operator to interact directly with the images, which makes it easier to plan and carry out complex surgical procedures. The image-guidance tool involved is called an Echonavigator and it ensures synchronisity and a high degree of accuracy.
Highly specialised operations
Among other things, hybrid operating theatres are used for highly specialised procedures such as aortic valve replacement, bypass operations, treatment of cardiac septum defects, aneurysms (swollen arteries) and stenosis (narrowing of blood vessels), some of which are performed using minimally invasive techniques.
With normal breast-conserving surgery of a breast carcinoma, repeated radiotherapy of the entire breast usually follows. At the end of the radiotherapy, the radiation fields are reduced to “boost fields” encompassing the previous, smaller tumour region. This standard treatment with the linear accelerator takes around six weeks.
In our hospitals , this therapy is now carried out with the IntraBeam on suitable patients with small breast carcinomas. This procedure is performed with a radiation unit that can be used in the operating theatre during surgery. After removal of the tumour, the tumour bed can be carefully radiated with a spherical applicator which contains a source of x-rays. This way, the relevant high-risk region within the breast (also the region with the highest risk for a localised recurrence of the breast cancer) is targeted with radiation, without affecting the surrounding tissue and particularly the skin.
MRI examinations are used to display soft tissues and tissue structures. They do not involve x-rays and the magnetic fields of 1.5 and 3.0 Tesla used for clinical applications have no adverse effects on the human body.
Double the magnetic field strength
Tesla is the unit of measurement quantifying the strength of a magnetic field and the usual strength used for MRI scans is 1.5 Tesla. The Hirslanden Private Hospital Group owns several 3.0 Tesla magnetic resonance imaging devices. The increased magnetic field strength has a direct effect on the strength of the signal produced during the measurements. 3.0 Tesla devices are therefore capable of producing image data with an even greater local resolution for better quality images of even the smallest anatomical structures. During dynamic examinations involving contrast agents, MRI scanners guarantee a significantly faster temporal resolution – which is particularly advantageous for the diagnosis of vascular diseases. The most delicate bodily structures, such as tendons, ligaments, nerves and blood vessels can be visualised faster and more accurately.
Wide range of examinations
MRI scanners produce cross-sectional images of the human body, including all the organs, making it possible to precisely assess any structural changes. They provide particularly detailed and accurate images for examining joints (e.g. shoulders, hips, knees), internal organs, blood vessels, bile ducts, as well as the brain, the spine and spinal cord, the prostate and the ureter.
The technology can also be used to perform full body scans, which are used to look for tumours or to create a comprehensive image of a patient’s circulatory system, for example. Even the smallest vascular abnormalities, tumours or structural causes of epilepsy or strokes can be displayed in exceptional detail.
The 3.0 Tesla MRI provides major benefits particularly in relation to breast examinations. Precursors of invasive breast cancer and various other types of cancer in the mammary gland can be precisely displayed and thereby identified early on by the radiology team.
A linear accelerator (LINAC) is a particle accelerator used to accelerate electrically charged particles. During this process, a predetermined dose of energy is released. Linear accelerators with electron beams are used in the field of radiotherapy to generate x-rays for the removal of cancerous tumours.
Our linear accelerators feature a built-in positioning control system and enable radiotherapy to be carried out with millimetre precision. Healthy tissue is protected as much as possible and harmful side effects can be reduced to a minimum. The linear accelerator is also equipped with additional functions: the breathing-dependant control system takes into consideration the movement of the tumour during respiratory movements and the intensity-modulated radiotherapy technology allows the individual fields of radiation to be adapted in accordance with the volume of the tumour.
These days, most patients are still treated using the linear accelerator.
The advantages of the linear accelerator
The main advantage of this technology is that larger volumes can be included and treated. A malignant tumour is known as cancer. Tumour cells from the main mass (lump which can be felt or seen in the CT/MRI scan) grow outwards into the surrounding tissue. They are also capable penetrating vessels and, for example, developing further within the lymph vessels. In this way, lymph nodes in the area around the tumour are also affected.
As a cure is only possible when all the tumour cells in the body are destroyed, it is often the case that much more than just the visible lump has to be treated. In such instances, the linear accelerator is superior to all other radiotherapy equipment.
The key advantages are:
- Targeted radiation, also of larger volumes
- Tried-and-tested over many years
- Can be combined with other forms of therapy such as chemotherapy (the benefits of this for certain tumours is now undisputed)
The Hirslanden private hospital is operating a true "TrueBeam" device (see image).
Positron emission tomography (PET) involves the emission of positrons from radioactively treated glucose (tracer), which is either injected, swallowed or inhaled. The tracer is absorbed more readily by tissues with an increased metabolic rate – such as rapidly growing tumours – and these areas appear as illuminated dots on the PET scan. A CT scan (computed tomography) is then required to precisely locate these areas of increased activity within the body. The two procedures are carried out immediately one after the other using the same device.