Original Title: Quirófanos híbridos

Authors' objectives: To review the evidence on the safety, efficacy, and cost-effectiveness of hybrid operating rooms (HORs) and gather data to address the following specific objectives: –  To establish which indications are backed by high-quality evidence on safety, efficacy and cost-effectiveness –  To formulate guidelines and provide evidence to allow new treatments to be incorporated into routine clinical practice, ensuring the highest standards of care.

Authors' results and conclusions: The analysis was based on 40 selected studies (1 randomised controlled trial, 34 cohort studies, 3 case-control studies and 2 economic evaluations) from 16 countries, including 19,900 patients (7,644 treated in a HOR). The quality of the evidence was variable, high for the only randomised controlled trial included, moderate for the observational studies, and low for the economic evaluations. By surgical discipline, the results were as follows: Cardiovascular surgery: for transcatheter aortic valve replacement, acute type A aortic dissection or transvenous lead extraction, no significant differences were observed in mortality rates between HORs and conventional operating rooms, though use of a HOR allowed combined procedures in a single session. On the other hand, for aortic dissection, in-hospital mortality was lower and 2-year survival was higher when the procedure was conducted in a HOR. Gynaecological and obstetric surgery: HORs were used in caesarean sections with placenta previa and cases of placenta accreta spectrum, helping reduce the risk of bleeding and allowing procedures to be performed in a central unit in a single session, although with longer surgical times. Orthopaedic surgery: The use of a HOR equipped with 3D imaging technology improved the accuracy of iliosacral screw placement compared to that achieved with standard 3D techniques. Thoracic surgery: Compared to two-step procedures, the localisation and resection of pulmonary nodules using intraoperative CT in a HOR setting was associated with better safety and accuracy, reducing complication rates and time to diagnosis. Vascular surgery: No differences in technical success or reintervention rates were observed between HORs and conventional operating theatres for the following procedures: endovascular aneurysm repair, thoracic endovascular aortic repair, fenestrated endovascular aneurysm repair, fenestrated/branched endovascular aneurysm repair or transcarotid artery revascularisation. On the other hand, HORs may be associated with longer surgical times. HORs were associated with higher rates of type II endoleaks and blood loss, but lower rates of type I and III endoleaks, ischaemia, target vessel occlusion, renal injury, and other complications. Less contrast agent was used in a HOR, while results concerning fluoroscopy time and radiation dose were inconclusive. Neurosurgery: The hybrid setting facilitated simultaneous performance of open surgery and endovascular techniques for treating posterior lumbar fusion, intracranial aneurysms and arteriovenous malformations, increasing safety and efficacy. Trauma surgery: Hybrid emergency operating rooms enable rapid bleeding control in patients with severe polytrauma, reducing mortality and time to surgery. Urological surgery: For partial nephrectomy, as well as surgery for gallstones and bile duct stones, a HOR enabled several procedures to be performed simultaneously with short-term clinical benefits. Regarding the economic implications, one study indicated that HORs cost more per minute than conventional operating theatres, mainly due to the higher construction costs and their advanced imaging systems, and also that costs were sensitive to the utilisation rate of the operating theatre. Another study reported that a new HOR-based workflow for trauma care was associated with more quality-adjusted life years and life years gained, but also higher healthcare costs, compared with the standard trauma workflow based on Advanced Trauma Life Support guidelines without an integrated CT scanner. Conclusions HORs are a significant innovation in modern surgery, integrating open and minimally invasive procedures with advanced imaging techniques in the same setting. Although limited and of varied quality, the available evidence suggests that the use of HORs improves diagnostic and therapeutic accuracy, and also patient safety. Additionally, they enable several interventions to be performed in a single session, which may decrease mortality and morbidity in certain contexts (aortic dissection, severe trauma, and lung nodule surgery). Nonetheless, HORs pose some challenges such as longer surgical times, greater radiation exposure, logistic complexity and higher costs. The cost-effectiveness of HORs depends on their utilisation rate and the type of procedures conducted. Though they may be cost-effective in some scenarios, such as severe trauma surgery, more comparative studies and robust evaluations are needed. Priority should be given to setting up HORs in referral and university hospitals, where the high volume of procedures justifies the investment. It is essential to establish usage protocols, indication criteria, and multidisciplinary training strategies to ensure their safety, cost-effectiveness, and sustainability.

Authors' methods: A systematic review was conducted using specialised databases (Cochrane, the HTA Database, MEDLINE, Embase, and Web of Science). The following types of studies published in English or Spanish between 2014 and 2024 were included: health technology assessment reports, systematic reviews, randomised controlled trials, observational studies, and economic evaluations. Study selection and critical appraisal were performed by independent reviewers, using validated tools (AMSTAR-2, RoB-2, Newcastle-Ottawa Scale, FLC 3.0). Relevant data were extracted from the studies included in the review, and the evidence was synthesised both narratively and quantitatively. The search was updated in January 2025.

Project Status: Completed

Year Published: 2025

URL for published report: https://www.euskadi.eus/contenidos/informacion/osteba_publicacion/eu_def/adjuntos/E-25-15-Quirofanos_hibridos.pdf

English language abstract: An English language summary is available

Publication Type: Mini HTA

Country: Spain

Organisation Name: Basque Office for Health Technology Assessment

Contact Address: C/ Donostia – San Sebastián, 1 (Edificio Lakua II, 4ª planta) 01010 Vitoria - Gasteiz

Contact Name: Lorea Galnares-Cordero

Contact Email: lgalnares@bioef.eus

Copyright: <p>Osteba (Basque Office for Health Technology Assessment) Health Department of the Basque Government</p>