A number of concepts have been advocated for the next generation operating room based on some inadequacies of the current systems. Most have focused on removing excess tubes and wiring, others on information systems or robotics. An analysis of other industries, a projected direction of current technologies, a focus on the importance of integrated information systems, and a serious consideration of emerging basic technologies suggest a significantly different approach.

Most minimally invasive surgical procedures are now performed in operating rooms that were originally designed for traditional open surgery. Laparoscopic instrumentation such as insufflators, light sources, and camera control units must be placed on one or more equipment carts. After the cart has been moved into place, insufflation tubing, video cables, light cords, cautery lines, and foot controls must be positioned and connected. This cart-based paradigm restricts the ergonomic configuration of the operating room and creates potential mechanical, electrical, and biological hazards to the patient and operating room staff. In order to decrease clutter, ease personnel movement, improve ergonomics, maintain the sterile field, and facilitate the use of advanced imaging, communication, and display devices, an appropriately designed operating environment is essential. Herein we detail both the theoretical and practical aspects of the design and describe the implementation and utilization of such a suite in our hospital. These design elements may prove to be critical to the next generation of minimally invasive surgical suites and will facilitate future advanced laparoscopic procedures.

Recent technological advances have made possible the introduction of the magnetic resonance imaging (MRI) system into the operating room to guide neurosurgical interventions. We review the possibilities and limitations associated with various open-configuration magnet designs, including systems from the Phillips, Siemens, General Electric, Odin and IMRIS designs. This technology has been shown to be a feasible adjunct to current neurosurgical management of intracranial brain tumors for both biopsy and resection procedures and shows significant potential applications for epilepsy surgery, spine surgery and for minimally invasive interventional techniques. Combined with other surgical planning modalities, intra-operative MRI scanners provide an evolutionary influence on the design of today's operating room.

The future development of the neurosurgical operative environment is driven principally by concurrent development in science and technology. In the new millennium, these developments are taking on a Jules Verne quality, with the ability to construct and manipulate the human organism and its surroundings at the level of atoms and molecules seemingly at hand. Thus, an examination of currents in technology advancement from the neurosurgical perspective can provide insight into the evolution of the neurosurgical operative environment. In the future, the optimal design solution for the operative environment requirements of specialized neurosurgery may take the form of composites of venues that are currently mutually distinct. Advances in microfabrication technology and laser optical manipulators are expanding the scope and role of robotics, with novel opportunities for bionic integration. Assimilation of biosensor technology into the operative environment promises to provide neurosurgeons of the future with a vastly expanded set of physiological data, which will require concurrent simplification and optimization of analysis and presentation schemes to facilitate practical usefulness. Nanotechnology derivatives are shattering the maximum limits of resolution and magnification allowed by conventional microscopes. Furthermore, quantum computing and molecular electronics promise to greatly enhance computational power, allowing the emerging reality of simulation and virtual neurosurgery for rehearsal and training purposes. Progressive minimalism is evident throughout, leading ultimately to a paradigm shift as the nanoscale is approached. At the interface between the old and new technological paradigms, issues related to integration may dictate the ultimate emergence of the products of the new paradigm. Once initiated, however, history suggests that the process of change will proceed rapidly and dramatically, with the ultimate neurosurgical operative environment of the future being far more complex in functional capacity but strikingly simple in apparent form.

Although modern operative neurosurgery is a complex technical undertaking requiring an amalgam of technologies and instrumentations, few reported efforts have dealt with the definition and development of suitable and optimal dedicated operating environments. This report presents the first detailed description of a dedicated, self-contained neurosurgical operating suite incorporating major surgical instrumentation and visualization technologies to provide an "idealized" environment for stereotactic, microscopic, and microstereotactic procedures. Advanced computer technology for visualization to augment, simulate, document, and facilitate all aspects of neurosurgery is described. The architectural and functional design of the operating suite is itself an integral surgical instrument as well as a laboratory for development of new dimensions of neurosurgery.

Surgical site infection risk due to airborne bacteria is a key area of consideration in developing operating theatre ventilation design and monitoring procedures. This paper reviews the recent extensive research into operating theatre ventilation development in relation to the design concepts in operating theatre layout, pressurization and ventilation, particularly the evolvement of ultra-clean ventilation. The findings that led to the current technical standards and the developments of microbial measurements and numerical techniques are discussed. Since the late 1980s, computational fluid dynamics has been a fast developing tool used in the prediction of room air distribution and contaminant dispersion. The basic principles and current practice applying to operating theatre ventilation studies are introduced.

The objective of this report is to present and contrast the development of the different intraoperative MR systems that are currently in use. The manuscript focuses on the design and clinical experience of a 1.5 Tesla MR system, based on a movable magnet. This configuration is similar to the operating microscope and other surgical adjuncts, with MR technology moved to and from the patient as needed. The system has been used to monitor 294 neurosurgical procedures. including CNS neoplasia. epilepsy, cervical spine disorders, arteriovenous malformations, cavernomas and aneurysms. In many cases the surgical procedure was significantly altered by intraoperatively acquired MRI. Future developments include the construction of a 3 Tesla intraoperative MR system and an ambidextrous MR-compatible robot. This seamless integration of robotic technology into an intraoperative MR environment may well revolutionize neurosurgery.

The minimally invasive surgical revolution has changed the way surgery is practiced. It has also helped surgical innovators to break the tethers that anchored the practice of surgery in an early 20th century operating room environment. To some in surgery, the Operating Room of the Future will be seen as a revolution but to others, an inevitable evolution of the changes ushered in by the adoption of minimally invasive surgery. Although minimally invasive surgery has conferred considerable advantages on the patient, it has imposed significant difficulties on the surgeon, which in turn, have impacted outcomes. These difficulties were primarily human factor in nature and were poorly understood by critical groups such as device manufacturers, surgeons, and surgery educators and trainers. This article details what these human factors were, how they related to the practice of minimally invasive surgery, and how they will impact on the practice of surgery in the Operating Room of the Future. Much of the technology for the Operating Room of the Future currently exists (eg, surgical robotics, virtual reality, and telemedicine). However, for it to function optimally it must be integrated in a fashion that takes on board the human factor strengths and limitations of the surgeon. These advanced technologies should then be harnessed to optimize surgical practice. In some cases, this will involve rethinking existing technologies (ie, three-dimensional camera systems), applying technologies that currently exist in a manner that is more systematic and better managed (ie, surgical robots and virtual reality), and a reconsideration of who should be applying these technologies for the practice of surgery in the 21st century. In all cases, there will be education and training implications for the practitioner. Lastly, there must be unequivocal demonstration that these changes bring about positive benefits for patients in terms of better outcomes and for surgeons in terms of ability and ease of doing their job. After the experiences of the last decade with minimally invasive surgery, the Operating Room of the Future should be seen as a well-grounded evolution, not a revolution.

The huge changes brought about by minimal access surgery in the last 15 years tell us much about the dynamic state of surgical technology and the need for sudden accommodation to a new item or concept that has captured the public eye. The minimal access technology invites us to extrapolate improvements in ergonomics and visualization and the combination of diagnostic and therapeutic motives in the operating room. The need for proper sensors to provide haptics to our instruments is high. Smart materials, smart catheters, wireless connectivity, and integrated technology for plug-and-play use are very attractive subjects that will draw many resources toward their successful application to operating room issues. Collaboration among institutions and industry will be useful to achieve efficiency, synergy, and the critical mass of talent to solve the significant problems ahead.

The Operating Room of the Future is a construct upon which to develop the next generation of operating environments for the patient, surgeon, and operating team. Analysis of the suite of visions for the Operating Room of the Future reveals a broad set of goals, with a clear overall solution to create a safe environment for high-quality healthcare. The vision, although planned for the future, is based upon iteratively improving and integrating current systems, both technology and process. This must become the Operating Room of Today, which will require the enormous efforts described. An alternative future of the operating room, based upon emergence of disruptive technologies, is also presented.