341 F.A. Jolesz (ed.

), Intraoperative Imaging and Image-Guided Therapy,

DOI 10.1007/978-1-4614-7657-3_24, Springer Science+Business Media New York 2014
Why the AMIGO
On May 4, 2011, Brigham and Womens Hospital (BWH)
unveiled the Advanced Multi-modality Image Guided
Operating (AMIGO) Suite, the rst suite in the world to give
surgeons and interventional specialists immediate access
to a full array of imaging modalities for use during proce-
dures. This cutting-edge operating room/interventional suite
enables treatments that are less invasive and more effective.
The AMIGO suite represents the next major step in Image
Guided Therapy (IGT).
The AMIGO Suite is an innovative surgical and interven-
tional environment that is the clinical translational test bed
of the National Center for Image-Guided Therapy (NCIGT)
at the Brigham and Womens Hospital (BWH) at Harvard
Medical School. The AMIGO is an integrated, 5,700 square
foot area divided into three sterile procedure rooms in which
a multi-disciplinary team will treat patients with the ben-
et of intra-operative imaging using multiple modalities.
The space is designed so that teams can move effortlessly
throughout to access any of the advanced imaging and surgi-
cal technologies.
The AMIGO Suite is one of the rst surgical environments
in the world to integrate the use of this wide variety of
advanced imaging technologies, including CT and MRI
cross-sectional imaging systems; x-ray and ultrasound real-
time imaging systems; and molecular imaging systems such
as a hand-held beta probe, PET, and targeted optical
imaging.
Molecular image-guided therapy will be pioneered with
the use of multiple molecular probes, such as PET, optical
imaging, and targeted mass spectrometry, to increase the
sensitivity and specicity of cancer detection. Application
of these technologies is expected to improve the ability to
dene tumor margins to more completely excise or ther-
mally ablate tumors. In addition to multi-modality imag-
ing, the AMIGO has various navigational devices, robotic
devices, and therapy delivery systems that help physicians
to localize and treat tumors and other targeted abnormali-
ties. The AMIGO represents and encourages multi-disci-
plinary cooperation and collaboration among teams of
surgeons, interventional radiologists, imaging physicists,
computer scientists, biomedical engineers, nurses and
technologists to reach the common goal of delivering the
safest and the most effective state-of-the-art therapy to
patients in a technologically advanced but patient-friendly
environment.
AMIGO is the physical manifestation of the NCIGT mis-
sion. It is a not only an operating suite, but the test bed for
research and the proving ground for this vision. Above all,
the AMIGO will provide a sophisticated, fully integrated
image-guided therapy infrastructure that will lead to disrup-
tive changes in procedural paradigms of surgery and inter-
ventional radiology.
The NCIGT is focused on the multidisciplinary devel-
opment of innovative image-guided intervention technolo-
gies to enable effective, less invasive clinical treatments
that are not only more economical, but also produce better
results for patients. It is now becoming apparent that the
use of multiple modalities can enhance procedures by
calling upon the strength of an individual modality to
The Advanced Multimodality Image-
Guided Operating (AMIGO) Suite
Daniel F. Kacher , Brendan Whalen,
Ahin Handa, and Ferenc A. Jolesz
24
D. F. Kacher , MS (*) F. A. Jolesz , MD
National Center for Image Guided Therapy,
Department of Radiology , Brigham and Womens Hospital,
Harvard Medical School , Boston , MA , USA
e-mail: kacher@bwh.harvard.edu; jolesz@bwh.harvard.edu
B. Whalen , Barch
Partners HealthCare , Boston , MA , USA
A. Handa , Barch
Payette Associates Inc , Boston , MA , USA
342
ameliorate the weakness of any complementary modality.
In response, comprehensive environments, multi-modality
operating suites, are emerging. Multi-modality image-
guided therapies utilize information derived from different
physical and biological properties of the tissues, obtained
by measurements with diverse underlying physical
principles.
AMIGO Suite Components
The central operating with its ceiling mounted single plane
x-ray machine is anked by a PET/CT room on the left and a
MRI room on the right. Sliding doors adjoin the three rooms.
Each room has a separate entrance to the control corridor and
support spaces (Fig. 24.1 ).
Fig. 24.1 ( a ) Floor plan imparting the size of each room and its
respective control room as well as the equipment in each room and its
maneuverability (Courtesy of Payette Architects). ( b ) The panoramic
cutaway rendering (Courtesy of Balazs Lengyel MD). ( c ) Building
section (Courtesy of Payette Architects)
a
b
c

D.F. Kacher et al.
343
MRI Room : The Magnetic Resonance Imaging (MRI)
room is centered around a high-eld (3 Tesla) wide bore
(70 cm) MRI scanner integrated with full OR-grade medical
gases, MRI-compatible anesthesia delivery and monitoring
system, view screens, lighting, and therapy delivery equip-
ment. Here, the clinical team uses image-guidance principles
for many oncology applications. With the familiar in-out
paradigm, patient is imaged and then withdrawn from the
bore of the scanner for intervention. In some procedures, the
doctor can reach into the scanners short/wide bore to access
the patient. The room is designed to be used independently
for interventional procedures or in conjunction with the
Operating Room. The ceiling mounted MRI scanner can tra-
verse on rails to a fully draped patient on the OR table. With
this innovation, surgical patients do not need to be trans-
ferred between tables for imaging. These features enable
exibility in workow to tailor procedures to the needs of
the doctor and patient.
Operating Room : The heart of the suite is the operating
room (OR), integrated with the anking rooms. The room is
equipped with MRI-compatible anesthesia delivery and
monitoring systems; surgical microscope with near-infrared
capability; surgical navigation systems which track handheld
tools, probes, and the surgical microscope, to display images
corresponding to the tool location; a ceiling-mounted single
plane x-ray system; 2D and 3D ultrasound imagers; and a an
armamentarium of surgical support equipment. The surgical
table has a oating table top for angio acquisition and pivots
to face the MRI scanner, PET scanner, or x-ray system. All
images and data related to the procedure are collected and
prioritized by using video integration technology and can be
recorded or displayed on large view screens at the point of
care, enabling surgical teams to select and view all applica-
ble patient information at a glance.
PET/CT Room : One of the most innovative features of
the AMIGO is the inclusion of Positron Emission
Tomography (PET) in the surgical environment. Similar to
the MRI room, the PET/CT room can be used for stand-
alone interventional procedures. Unlike the MRI scanner,
the PET/CT scanner is xed to the oor and does not move.
Patients can be transferred on a shuttle system between the
PET/CT table for imaging and the OR table for surgery. At
the time of writing, the AMIGO Suite is unique in the world
with its direct connectivity between a PET/CT room and an
operating room.
PET produces images elucidating the bodys functional
and metabolic interaction with molecular biomarkers.
The combined use of MRI and CT with PET capabilities
enables clinicians to combine anatomical, functional, and
metabolic information to enhance intra-procedural deci-
sion-making. BWHs on-site cyclotron enables the inves-
tigation of novel molecular imaging agents to localize and
target viable tumor tissue and verify complete removal or
therapeutic destruction.
AMIGO is a resource-rich environment. Table 24.1 lists
the current equipment and infrastructure vendors as well as
the design and construction teams that made the project a
success.
AMIGO Suite Design and Construction
This section is intended to be a resource for institutions join-
ing the future of image-guided therapy and surgery. The real-
ization of a space like AMIGO will demand a full team of
extraordinary thinkers: designers, builders, clinicians, tech-
nical personnel, and administrators coming to a consensus
of vision to make such a project a reality. Previous publica-
tions describe the facets of architecture for diagnostic and
therapeutic suites [ 1 ] and more specically intraoperative
MRI facilities [ 2 ]. The specics of AMIGOs design and
construction process are presented here in stages and describe
the teams interaction.
Understanding the Technology and Its Use : It is impera-
tive to fully understand the systems being introduced into the
project and how they will be employed by the end users. The
design team worked diligently with stakeholders in the hos-
pital and industry to understand user requirements and sys-
tem capabilities. Previous installations of similar technology
were designed to support only neurosurgery. The team part-
nered with the integrator (IMRIS Inc., Winnipeg, CA) to
expand the capability of the space to support percutaneous
intervention, endovascular intervention, minimally invasive
surgery, and open surgery throughout the body.
The impact of hanging a moving MRI scanner from the
ceiling is central and pervasive throughout the entire pro-
cess. A Siemens 3-T magnet was retrotted and integrated
by IMRIS. A considerable no y zone was necessitated
for the travel of the scanner, and nothing could be placed on
the ceiling in its path. In the OR, the surgical table position
and boom layout were critical for enabling multiple services
to work in the space while being constrained by the no y
zone. The x-ray c-arm travels on ceiling tracks perpendicu-
lar to the MRI tracks. Unlike conventional single-purpose
ORs, the room setup must be drastically altered to accom-
modate a given procedure. The table is nominally pivoted
towards the MRI scanner but pivots 90 for x-ray-guided
procedures and 180 for PET/CT-guided procedures. The
x-ray c-arm also travels on the ceiling. Point of care view
screens are installed at several locations to accommodate dif-
ferent procedure- specic room congurations. The ceiling-
mounted navigation system was located to enable its use in
all three table locations. Provisions were made for a work in
progress to develop patient ow between the OR and PET/
CT room. Demands for circulating space were considered
for mobile equipment and personnel to move about while
maintaining a sterile eld. All these factors were considered
in designing the space.
24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite
344
Design Within the Shell Space : The AMIGO Suite encom-
passes an area of 5,700 ft
2
. The east side of the suite is dedi-
cated to the three procedure rooms including control stations
and equipment rooms. An 8-ft-wide corridor is the central
spine that serves to spatially open up and connect the control
areas with a centralized nursing and ow coordinator station.
The west side of the suite supports services: a decontamina-
tion room, a clean assembly room, a sterile storage, and two
large equipment storage rooms, as illustrated in Fig. 24.2 .
Structure : AMIGO is advantageously located two oors
below grade on the hospitals subgrade foundation. The
larger and stronger reinforced concrete columns on this level
support the ceiling-mounted MRI scanners structural steel,
causing less concern from vibration than placing the suite on
an upper oor. The greatest structural challenge was meeting
the steel beam deection tolerance specication that IMRIS
required to support the weight of the MRI as it transits: no
more than 1/8 deection of steel beam for every 8 ft of
beam length. The specic challenge was to maintain this
requirement while limiting the dimensions of the steel beam
in order to allow infrastructure to t overhead. The unique
design, shown in Fig. 24.3 , kept the steel support simple and
allowed for maximum exibility for infrastructure to t
within the ceiling plenum.
Another concern was vibration from outside the hospital
that might impact the image quality from the MRI. A major
source of vibration is the plant that provides supplemental
electricity to the six hospitals in the surrounding Longwood
Medical area, located adjacent to the end of the hospital
housing AMIGO. To mitigate the effects, large pre-
compressed vibration isolation pads were designed for all
beam and column connections (Fig. 24.3 ).
Shielding and Penetration : Along with the shielding ven-
dor (ETS-Lindgren, Glendale Height, IL) and IMRIS, the
team designed the shielding efciently to enclose the two
impacted rooms. Both the OR and MRI rooms are six-sided
copper RF-shielded boxes to prevent electromagnetic inter-
ference from impacting MR image quality. Both the OR and
PET/CT rooms are lead shielded. The sliding doors and con-
trol room doors in the OR were designed with additional
Table 24.1 Equipment and
industrial partners in AMIGO
Imaging equipment, patient table, and room integrator IMRIS, Inc.
Designer Payette Architecture, Inc (Boston, MA)
Build, general contractor Barry Construction /Suffolk Construction
RF enclosure, sliding doors ETS-Lindgren
Booms and lights Trumpf GmbH
Video integrator Black Diamond Video
3-T Verio MRI scanner Siemens Healthcare
Artis zee single plane angiography/uoroscopy x-ray system Siemens Healthcare
Biograph mCT PET/CT Siemens Healthcare
Acuson S2000 ultrasound system Siemens Healthcare
56 8-megapixel display Siemens Healthcare
Pro Focus Ultra View ultrasound system BK Medical
Nonferrous metal detector Kopp Development
VectorVision sky navigation system (neuro procedures) BrainLab, Inc.
Pentero Surgical Microscope Carl Zeiss, Inc.
EnSite NaxX navigation system (EP procedures) St. Jude Medical
Cardio lab electrophysiology recording (EP procedures) GE Healthcare
Stockert 70 RF generator (EP procedures) Biosense Webster
IMROC MRI-compatible wireless headset OptoAcoustics
CUSA NXT ultrasonic tissue ablation system Intregra
Force Triad electrosurgical unit Covidien
Malis CMC bipolar electrosurgical unit Codman
Bair Hugger patient warmers Arizant Healthcare
Alaris IV infusion pumps CareFusion
MRI, CT, x-ray power injectors Medrad, Inc.
Aegis navigation system (interventional radiology procedures) Hologic/Sentinelle Medical
Aegis MRI-guided pelvic intervention solution (patient
positioning, MRI coil, targeting device, software)
Hologic/Sentinelle Medical
Symbow Medical navigation system
(interventional radiology procedures)
Symbow Medical
Ablative laser Visualase, Inc.
Endoscout MRI navigation system Robin Medical, Inc.
MRI-compatible task light and view screens Aadcomed, Inc.
D.F. Kacher et al.
345
structural reinforcement to support the weight of the copper
and lead.
The viewing windows into the OR, MRI, and PET/CT
rooms (Fig. 24.4 ) are oversized and comprised of polarizing
privacy glass, lead glass, and RF copper mesh glass. The pri-
vacy glass when turned off turns opaque and meets the laser
safety requirements to allow laser operation inside the room
without additional laser safety measures being installed.
Silicon rolled steel for magnetic shielding was located
only on the rear of the MRI room to prevent the MRI scan-
ners fringe eld from extending into the hallway adjoining
the EP labs, to protect patients, personnel, and equipment
outside the suite.
Another unique detail in AMIGO is the inclusion of an
independent RF-shielded equipment cabinet inside the larger
RF-shielded enclosure. This feature allows clinicians and
researchers to stage non-MRI-compatible equipment into the
interventional environment via waveguides and ltered con-
nectors without affecting image quality (Fig. 24.5 ).
Additional pen panels were added under each control win-
dow as well as the MRI equipment room to allow for addi-
tional connections with equipment placed outside the RF
a
Fig. 24.2 Suite oor plan. ( a ) Procedure space is to the right of the
central corridor and support space is to the left. The red arrow shows
the pathway for entry into the suite and the orange arrows show the
pathways into the procedure rooms (Courtesy of Payette Architects).
( b ) Axiometric view of suite (Courtesy of Balazs Lengyel MD)

24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite
346
rooms. All subpanels are modular and can be retrotted to
meet future user requirements (Fig. 24.5 ).
Location of all lters and waveguides required for all
infrastructure (electrical conduits, HVAC ducts, med gas
piping, etc.) penetrating the shielded rooms was carefully
coordinated to ensure a clean plenum space above the ceil-
ing. Boom mounts were designed to obviate the requirement
for kicker supports, a space saving method that allowed for
much needed above ceiling space (Fig. 24.6 ).
Infrastructure : HVAC ducts and vents, medical gas pip-
ing, electrical conduits, and sprinkler lines were tightly coor-
dinated into the available plenum space inside, above, and
around the RF shield, 3D infrastructure modeling (Fig. 24.7 ),
to ensure precision and effective layering was critical.
The location of the suite, two oors below grade, caused
design and constructability issues with the quench vent and
purge exhaust ducts for the MRI scanner. Welded stainless
steel ducts were run 500 linear feet from AMIGO through an
existing OR space directly above, to a ve-story exterior
vertical shaft, to a point on the roof safely away from the
adjacent patient bed tower air intakes. The infrastructure ris-
ers to house the large ducts and other mechanical hardware
were carefully designed and constructed to ensure minimal
disruption to the hospital infrastructure or interference with
the existing imaging systems.
Airow : All three procedure rooms were designed to
exceed air turnover specication for full-grade operating
rooms set forth by the FGI Guidelines and the MA
Department of Public Health (DPH). In an ideal OR
environment, laminar downward airow is provided by a
10 10-wide array of diffusers around the patient table to
prevent airborne debris from entering the surgical eld. Due
to the orthogonal tracks for the MRI scanner travel and x-ray
c-arm travel, in addition to demand for ceiling real estate for
grid lighting and boom mounts, ideal placement of diffusers
was not possible (Fig. 24.8 ).
To receive project approval, the DPH required a 3D com-
putational uid dynamics model of the space to be created to
illustrate adequate airow. The modeling showed optimal
quantity and location of supply and returns air diffusers to
achieve necessary airow speeds and contaminated air dilu-
tion around the patient table. The design yields negligible
difference in the movement of airborne particles compared to
an ideal OR.
Booms : AMIGO is intended to enable multiple surgical
and interventional services, each with their unique needs.
The OR is designed to have two central procedure positions:
a surgical eld placed in the direction of the MR room and a
second eld for x-ray-based procedures. The boom layout is
intended to meet current needs and offer exibility for the
future unforeseen needs. Separate equipment booms for sur-
gical support equipment and cardiac ablation (EP) equipment
were necessary. In a typical EP lab, equipment is placed
below or attached to rails on the side of the patient table. This
setup is incompatible with operating room standards and not
possible with the moving MRI scanner due to magnetic
attraction on the devices. Lights and view screens are posi-
tioned with left-right symmetry when the patient table is
b
Fig. 24.2 (continued)
D.F. Kacher et al.
347
pivoted with the head towards the MRI scanner. Patient posi-
tion dictates where the surgeon stands and which view
screens are used for a given procedure. A 56 8-megapixel
display is mounted on the same tracks as the x-ray c-arm and
can be used for both surgical and x-ray-based procedures.
The x-ray boom arm holding the lead shield was made long
enough to reach and protect a clinician standing on the distal
side, away from the boom mounts. The navigation system
camera and touch screen were positioned to enable naviga-
tion in either table position. All mounts for the booms were
positioned such that the booms could be pivoted towards the
walls of the room, outside the 5-G line, where they would not
be magnetically attracted to the MRI scanner when it enters
the OR.
The operating room is approximately 700 ft
2
, creating a
decit compared to the recommended 850 ft
2
. The ceiling
space occupied with two sets of ceiling rails at different
ceiling heights for x-ray and MRI, HVAC diffusers, general
2 2 surgical lighting xtures, and LED MRI-compatible
lighting presented an optimization problem for locating the
ve boom mounts, each supporting as many as three arms.
Drawings of boom travel and 3D rendering with kinematic
models of the booms were critical for determining nal loca-
tions. Figure 24.9 illustrates some of the techniques employed
to achieve desired boom reach and clearances and prevention
of conicts and collisions.
Power and Power Shutdown : The three procedure rooms
were powered with critical power and isolated power with
W14x193
PRE-COMPRESSED VIBRATION ISOLATION PADS
BEAM MOUNTING PLATE AT COLUMN
SEISMIC SNUBBER
a
b
Fig. 24.3 ( a ) Construction
photograph of the steel structure
(Courtesy of Payette Architects).
( b ) Design and construction
photograph of the structural
isolation damper (Courtesy of
Payette Architects & Cavanaugh
Tocci Associates)

24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite
348
emergency backup. Critical power breached the RF shield-
ing via electrical lters. Since isolated power could not
cross the shielding without losing its isolation, the isola-
tion transformer panels were located inside the RF shield.
A product was identied that did not put out electromag-
netic interference (EMI) in the band used by the MRI scan-
ner and installed outside the 5-G line. Many clinical
devices and infrastructure elements in use during the pro-
cedure, however, do release EMI and must be powered off
prior to imaging. Such items were powered by circuits
controlled by a relay panel. Room integration touch
screens enable shutdown of all devices with a single com-
mand. Outlets are color coded, and signage is installed to
inform users if the outlets remain powered during
imaging.
The PET/CT scanner and x-ray system are backed up by
universal power supplies (UPS). A UPS was not supplied for
the MRI; after careful consideration it was determined that
Fig. 24.4 PET/CT and OR control room (Courtesy of Warren Jagger Photography)
a b
Fig. 24.5 ( a ) RF-shielded cabinet inside MRI room and penetration panels and waveguides (Courtesy of Payette Architects). ( b ) Drawing detail
of shielded window and under counter penetration panel (Courtesy of Payette Architects)


D.F. Kacher et al.
349
UPS was not required based on the need, the considerable
space requirements, and added project costs.
Control Workstations : Available space at the control area
counters prohibited placement of all computer CPUs and
view screens needed for the various clinical services using
the three procedure rooms. An elegant solution to this prob-
lem is the IMRIS/Black Diamond Video Control Workstation.
Multiple redundant control workstations were placed in the
control rooms and procedure rooms. Each of these could, via
a keyboard/video/mouse switching matrix, take control of
the procedure-specic CPUs in the rack located in the MRI
equipment room. This solution not only reduces clutter but
places the computers in a controlled, conditioned, dust-free
environment. Video from these computers is also routed
using the control workstation to display images at the point
of care and on the view screens above the control room
windows. The control workstations control room power
down, as well as lighting, and camera zoom/focus. A high-
denition recorder enables archiving of room views and
computer screens.
Finishes : The design team was determined to make the
space a comfortable and an enjoyable work environment
that, despite being located below grade with no natural
light, can utilize materials and soft colors to break the
stereotypical cold and sterile environments that sometimes
come to be associated with these types of spaces. Flooring
materials were chosen carefully for comfort and durabil-
ity. Flooring patterns were utilitarian, highlighting table
rotation and iso- gauss lines of the MRI scanners fringe
eld, establishing safety zones for specic equipment
(Fig. 24.10 ). Colors in the ooring and throughout the
suite work in harmony with the IMRIS and Siemens soft
palette of cooler colors.
Safety : Due to the MRI scanners magnetic eld and use
of ionizing radiation for PET, x-ray, and CT, security and
safety into the suite is of paramount importance. Following
guidelines set by the American College of Radiology [ 4 ],
four MRI safety zones were implemented.
The MRI room is in Zone 4, where all staff are MRI safety
trained or under direct supervision and no ferrous objects are
allowed. Depending on the location of the MRI scanner, the
OR shifts between Zone 3, where ferrous objects are permit-
ted, and Zone 4. As a policy decision, all personnel are
required to make themselves MRI safe when entering the
OR no watches, pages, cell phones, wallets, etc. regard-
less of the MRI scanner location.
When the MRI scanner enters the OR, the MRI control
room door automatically locks. The control room is
Fig. 24.6 Design detail and photograph of the dielectric isolation and shielding scheme for the boom mounts (Courtesy of Payette Architects &
ETS-Lindgren Shielding)

24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite
350
considered Zone 3 and is under the control of AMIGOs ow
coordinator, a post that is continuously manned during
business hours. The ow coordinator is responsible for con-
trolling access into the suite and conrming personnel have
undergone the suites rigorous safety training procedures
before they can be allowed unescorted into the suite. Only
staff who have undergone safety training and use the suite on
a regular basis are allowed security access. Swipe card read-
ers are located between the public corridor (Zone 4) and the
restricted gowning area (Zone 3). All access points are on
security cameras connected to the ow coordinators desk
and hospital security.
A nonferrous metal detector gate was installed in the
Zone 3 control corridor (Fig. 24.11 ); since completion of the
project, this has become a standard FGI requirement on all
future MRI projects. A single gate detector services both the
OR and MRI rooms; all staff and visitors must use the detec-
tor prior to entering the Zone 4 rooms. Due to space
a
b
Fig. 24.7 ( a ) Planned
infrastructure above the ceiling,
suite wide (Courtesy of Suffolk
Construction). ( b ) Realized
infrastructure above the ceiling
in MRI room (Courtesy of
Payette Architects)

D.F. Kacher et al.
351
Fig. 24.8 ( a ) Reected ceiling plan of the OR showing air diffusions
in blue , boom mounts in green , and grid lighting in yellow (Courtesy of
Payette Architects). ( b ) Red line in image depicts the cross section of
the lower images. ( c ) Computational uid dynamics model of air veloc-
ity vectors crossing the head of the surgical table realized in AMIGO
and ( d ) for the ideal ASHRAE 170 compliant pattern
a
b

24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite
352
Fig. 24.9 Boom spatial layout plan. ( a ) Plan view showing booms
(Courtesy of Payette Architects). ( b ) Reected ceiling view showing
travel of each element of the arms (Courtesy of Payette Architects). ( c )
Kinematic 3D model used to explore boom movement (Courtesy of
Trumpf Medical Systems). ( d ) Photograph of nal layout with the table
in the surgical position (Courtesy of Warren Jagger Photography). ( e )
Photograph of the table in the x-ray interventional position. The EP
equipment boom and surgical support equipment booms are visible
(Courtesy of Warren Jagger Photography)
a
c d
Fig. 24.8 (continued)

D.F. Kacher et al.
353
b
c
Fig. 24.9 (continued)
24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite
354
constraints, gates were not at the entrances to the OR and
MRI procedure rooms because the width of the doors would
mandate a wider gate, lowering the sensitivity of detection.
Moreover, ferrous metal (e.g., US scanner) is brought into
the OR in a controlled fashion. It was determined during
design that alarm fatigue would cause personnel to disregard
the detector alarms when a true issue arose.
In addition to the safety-related oor patterns shown in
Fig. 24.11 and MRI warning posters on the doors, warning
mats were cut into the oor and labeled Stop Magnet
Always On. Indicator lights above the doors inform staff in
which room the MRI scanner is parked and when x-ray or
laser is in use (Fig. 24.13 ).
Construction : As the friendly name suggests, AMIGOs
bedrock is the exceptional working relationship between the
three key driving groups: the design team, construction team,
and the client comprised of hospital leadership, clinicians,
and technical personnel. The teamwork was evident from the
beginning during early design that started with pre-
construction services. Here, the contractor, client, and archi-
tect worked in harmony to nd design and construction
solutions to issues like wall assembly layering, mechanical
electrical plumbing infrastructure coordination, critical
dimensions that become imperative for ensuring room size is
appropriate, and handling the complex approval process with
regulatory agencies. The team also designed and built this
suite to be exible and future proof.
Figure 24.12 shows a series highlighting the construction-
phased renovation process from the beginning to completion
and reects the key design criteria described earlier.
d
e
Fig. 24.9 (continued)
D.F. Kacher et al.
355
a b
Fig. 24.11 ( a ) Floor pattern safety mat and OR entrance. ( b ) Ferrous metal detector. The LEDs depict the location on the body where the metal
was detected. Illuminated signage is seen in the background above the door to the MRI procedure room (Courtesy of Payette Architects)
Fig. 24.10 ( Left ) Floor pattern plan in OR and MRI rooms. ( Right ) Photograph of nished ooring in the OR. The blue circle inside the green
band represents the location of the MRI scanners isocenter when the scanner is in its imaging positio (Courtesy of Payette Architects)


24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite
356
Fig. 24.12 ( a ) Existing
central processing department
(Courtesy of Payette
Architects). ( b ) Gutted shell
space (Courtesy of Payette
Architects). ( c ) Steel beam
installation for MRI scanner
travel (Courtesy of Payette
Architects). ( d ) RF shielding
and x-ray c-arm track
installation (Courtesy of
Payette Architects). ( e )
Infrastructure installation
(Courtesy of Payette
Architects). ( f ) Ceiling
installation (Courtesy of
Payette Architects). ( g )
Flooring installation and
finishes. Bolt down points for
the patient table are visible
(Courtesy of Payette
Architects). ( h ) Hanging of
MRI scanner on tracks. The
cable management system is
visible (Courtesy of Payette
Architects). ( i ) Completed
operating room (Courtesy of
Warren Jagger Photography).
( j ) Completed operating room
(Courtesy of Warren Jagger
Photography). ( k ) Completed
operating room (Courtesy of
Warren Jagger Photography).
( l ) Completed control room
corridor (Courtesy of Warren
Jagger Photography)
a
b
AMIGO Suite Procedures
The intention of AMIGO leadership is to seek out game-
changing applications in the area of image-guided therapy
and surgery and probe the limitations of use of the suite in a
systematic fashion. An initial road map was developed to
launch programs for various clinical services. Each idea was
written up and vetted by an internal and external scientic
review board to ensure it meets the mission of AMIGO and
the National Center for Image Guided Therapy. Programs
that are not successful would be modied or discontinued.
Successful, economically viable programs would also ulti-
mately be discontinued at AMIGO, with the intention of
developing procedure-specic space in the hospital contain-
ing the subset of needed equipment, or by simply sending the
clinician back to his conventional space but with a validated,

D.F. Kacher et al.
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c
d
Fig. 24.12 (continued)
24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite
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e
f
Fig. 24.12 (continued)
D.F. Kacher et al.
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Fig. 24.12 (continued)
g
h
24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite
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i
j
Fig. 24.12 (continued)
D.F. Kacher et al.
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Fig. 24.12 (continued)
k
l
24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite
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hopefully disruptive tool. At this stage smaller hospitals and
the public can reap the benets of the ongoing experiment,
that is, AMIGO.
The center is arranged according to cores: Imaging Core;
Computation Core; Prostate Core; Neurosurgery Core;
Focused Ultrasound Surgery Core; Administration,
Training, Service, and Dissemination; and Collaborations.
Activity of each core is projected onto the procedures in
AMIGO, listed in Table 24.2 . Earlier phase procedures
would be retired to create available room time for newer
a
b
Fig. 24.13 ( a ) PET/CT room .
Surgical lights with a
high-denition camera, and view
screens are use to support the
procedures (Courtesy of Warren
Jagger Photography). ( b ) Room
view of the PET/CT-guided liver
cryoablation. ( c ) 3D rendering of
CT data with the cryoprobes in
place. ( d ) Maximum intensity
projection of the CT data
showing the cryoprobes, with a
pseudocolored single-slice of
FDG PET data showing the
metabolic activity tumor,
overlayed
Table 24.2 Road map of
AMIGO procedures
Phase I (~20112012) Phase II (~2013) Phase III (~2014)
Brain open surgery Cerebro and endovascular Spine surgery
Brain laser ablation Endoscopic kidney ablation Skull base surgery
Transphenoidal pituitary resection Bone metastasis thermal ablation ENT sinus surgery
Breast cancer lumpectomy Brain surgery through ventricle Craniofacial surgery
XMR guided cardiac ablation Lung bronchoscopy, biopsy Lung thermal ablation
Prostate biopsy, brachytherapy Image registered endoscopy
(abdominal, thoracic)
Trauma fracture correction
Cervical cancer brachytherapy Joint replacement
Liver, kidney biopsy, ablation

D.F. Kacher et al.
363
procedures. A technical lead from the center is assigned to
each procedure.
PET/CT Room : The space has two modes of use. The rst
is the familiar in-out paradigm currently used in interventional
CT for biopsies, drainages, and ablations. The 80-cm bore
offers ample space for placement of percutaneous probes and
patient positioning. As an aside, the installation of a PET/
MRI was explored, but the bore diameter of 60 cm was con-
sidered to be too great of a limitation for interventional use.
Figure 24.13 shows a PET/CT-guided liver cryotherapy in
progress.
The second mode of use entails transferring the patient
from the OR to the PET/CT scanner for imaging, then back
again for continued surgery. The sliding doors between
rooms are opened, a bridge is positioned between the OR
tables and PET/CT table, and the patient is shuttled into the
scanner on an MRI-/PET-/CT-/x-ray-compatible transfer
board, which he/she never leaves throughout the procedure
(Fig. 24.14 ). The transfer board supports head xation for
neurosurgery. It is anticipated the thoracic service will also
utilize this mode.
Operating Room : The middle room of the suite is essen-
tially a hybrid OR an x-ray intervention room with sterility
measures, infrastructure, and equipment for surgery. Planned
procedures include open surgery, minimally invasive surgery,
endovascular interventions, and percutaneous and burr hole
ablation procedures
By far, the predominant use of intraoperative MRI rooms
worldwide is for brain tumor resection. A major shortcoming
of image-guided navigational systems is the use of
preoperatively acquired image data, which does not account
for intraoperative changes in brain morphology. The occur-
rence of these surgically induced volumetric deformations
(brain shift) has been well established [ 4 ]. Brain shift is a
continuous dynamic process that evolves differently in dis-
tinct brain regions. Intraoperative updates to the image-
guided navigation data are a strong justication for this
application, in order to ensure optimal resection.
Image registration is an essential part of any neurosurgi-
cal planning and navigation system because it facilitates
combining images with important complementary, structural,
and functional information to improve the information based
on which a surgeon makes critical decisions. The registration
process entails transforming images acquired at different
time points, or with different imaging modalities, into the
same coordinate system [ 5 ]. This is a topic of research in
AMIGO and is explored in depth in other chapters of this
textbook.
When the surgeon calls for updated MR image to provide
more accurate navigation, the procedure room must rst be
transformed, to create an MRI safe environment. The pro-
cess is supervised by a safety nurse, a new role created for
AMIGO. Booms are pivoted outside the 5-G line and teth-
ered. The surgical microscope (Carl Zeiss Jena, Germany),
ultrasound unit (BK Medical, Peabody, MA and Siemens
Healthcare, Erlangen, Germany), and EEG pedestal (XLTEK,
San Carlos, CA) are removed from the room. Instruments are
counted. The monopolar return electrode pad and patient
warmer tubing are removed. All other ferromagnetic items
are accounted for and safely positioned. The room is pow-
ered down, including surgical support equipment, view
screens, and keyboard/monitor/mouse extension hardware.
The anesthesia machine (GE Healthcare, St Giles, England)
and vital signs monitor (In Vivo Corp, Gainesville, FL) and
MRI-compatible cameras (Sound Imaging Inc, San Diego,
CA) remain on. The cavity is lled with sterile saline to
eliminate the air-tissue interface, which can cause suscepti-
bility artifact in the MR images. The skin is cursorily closed
and the surgical wound draped. The patient table is returned
to a level position and extended such that the patients head
will be in the isocenter of the MRI scanner. The posterior
element of the MRI head coil was positioned before incision.
The anterior element is added. A template of the MRI scanner
bore is used to ensure nothing will make contact with the
scanner the table cantilevers into the bore. The sliding
doors to the MRI room are opened, and MRI scanner is
translated into the OR, with all personnel ensuring the pro-
cess is safe (Fig. 24.15 ). Following imaging, the MRI scan-
ner is returned to its adjacent room, and the process is
reversed to continue surgery. Ultrasound is used between
c
d
Fig. 24.13 (continued)
24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite
364
MR images, for the advantages of its immediacy, to track
changes and to help determine when new MR images are
necessary.
The process for breast lumpectomy is similar. Images are
available in a separate chapter in this text.
EP cases for atrial brillation treatment require a differ-
ent room setup. The table is pivoted 90. A 56 view screen
is used to the endovascular navigation view based on pre-
incision MR images, live and review EKG traces, and
intracardiac ultrasound images. A technologist operates
equipment from the control room. Cables and ber optics
are introduced into the RF-shielded room via lters and
waveguides, respectively, in the penetration panel below
the control room window. Wireless MRI-compatible head-
sets (Optoacoustics, Moshav Mazor, Israel) are under
development to facilitate communication between the con-
trol room and procedure room. Prior to MR imaging, all
catheters are removed, leaving only a short sheath in place.
The patient table is pivoted towards the MRI scanner, and a
similar process for room preparation as that in neurosur-
gery is executed. The contrast-enhanced MR images enable
visualization of the acute effects of RF ablation. The goal
of the imaging is to nd gaps in the burn used to electrically
isolate the pulmonary veins to inform the cardiologist
a
b
Fig. 24.14 The patient transfer system used to move patients from the OR table to the PET/CT table for imaging. ( a ) Staff move a patient from
the angio table, across a bridge, onto the PET/CT table. ( b ) The concept is illustrated with a 3D CAD model (Courtesy of IMRIS Inc.)

D.F. Kacher et al.
365
Fig. 24.15 ( a ) OR prior to room
preparation for imaging. ( b ) MRI
scanner entering OR. ( c ) MRI
images acquired pre-incision and
after resection. The arrows
showing the lesion in the pre-
image remain in the same
location in the post-image to
appreciate the brain shift. The
signal void with the yellow arrow
head is the area where tissue was
removed. ( d , left ) The navigation
system showing the focal plane
of the microscope. ( d , right ) The
view through the microscope
with image injection, showing
the target tissue based on
segmentation of the MR images.
( e , left ) Ultrasound probe in the
surgical wound. The probe is
tracked by the navigation system
and the corresponding MR image
is displayed. ( f , right )
Intraoperative US image
a
b
where to target with the next round of ablation. MRI-
compatible catheters to perform the procedure under MRI
guidance are becoming commercially available. MRI safe
navigation patches 12-lead EKG are also under investiga-
tion. Another chapter in this text explores this topic in
depth.
MRI Room : Similar to the PET/CT room, the 3-T MRI
room can be used in a stand-alone mode with the in-out para-
digm. The 70-cm diameter bore permits biopsies, needle inser-
tion-based procedures such as prostate and cervical cancer
brachytherapy, and ablations to be supported by this space. A
cryotherapy delivery system (Galil Medical, Yokneam, Israel)
is integrated via the penetration panel, with critical system
components at the point of care and the non-MRI- compatible
control interface remaining outside the room. An in-bore track-
ing system (Robin Medical, Baltimore, MD) is also available
that uses the eld generated by the MRI gradients to derive the
location and orientation of a probe or needle. An MRI-
compatible view screen, vital signs monitor, and anesthesia
machine are present in the room. The ceiling-mounted scanner
pivots 180 on a turret to place the patient table at the front or
rear of the room, depending on the needs of the procedure.
Pelvic intervention is facilitated by either a commercially
available system (Sentinelle Medical, Toronto, Canada) or a
solution codeveloped with Johns Hopkins University.
Figure 24.16 shows some of the methodology.

24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite
366
c
d
Fig. 24.15 (continued)
D.F. Kacher et al.
367
Fig. 24.15 (continued)
e
The Future of the AMIGO Suite and Other
Multi-modality Suites
At this time, AMIGO is unique in that the suite has a tightly
integrated PET/CT and its leadership has handed down a
mandate to explore all possible applications, head to toe.
AMIGO, however, is not alone in the world. Hybrid ORs
(see chapter in this text) have been installed at many univer-
sity hospitals. Fig. 24.17 shows a map of centers around the
world using MRI to guide procedures. Vendors are making
specialty products for these spaces. The trend is undeniable.
Multimodality suites will become pervasive.
The scalpel is increasingly being replaced by therapeutic
tools. Cryotherapy, microwave ablation, radiofrequency
ablation, brachytherapy, radiation therapy, inductive heating,
focused ultrasound, localized stem cell injection, and more
exotic therapies expand the armamentarium of the clinician.
A symphony of imaging systems, navigation systems, robot-
ics, and therapeutic probes create a new world for patient
care. Researchers and integrators in these elds accelerate
the progression from open invasive surgery to minimally
invasive surgery or therapeutic intervention.
Although AMIGO has a road map, it is typical that the
inventor does not know entirely what he/she invention is for.
Uses are worked out in collaboration with the user. Creativity
is collaborative, cumulative, and interactive. Communication
with sites worldwide will yield the answer to: What is
AMIGO for?
24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite
368
a
b
Fig. 24.16 ( a ) Patient in lithotomy position in the MRI bore. A posi-
tioning system is used to give the clinical access to the pelvis. Iteratively,
a needle or cannula is placed, then the pelvis is scanned at isocenter to
conrm accurate targeting. ( b ) Axial prostate imaging showing two
needles in place. ( c ) The acrylic grid is registered to the scanner coordi-
nate system to provide a framework for needle placement. This setup is
used for prostate biopsy and prostate low-dose brachytherapy.
( d ) Sagittal image of the cervix and tandem and ring applicator
(Nucletron BV, Veenendaal, Netherlands), which facilitates cannula
placement (Courtesy of Nucletron BV). ( e ) A photograph of the ring
applicator. The patient is taken out of the AMIGO Suite to a lead vault
for insertion of radioactive sources into the cannulas

D.F. Kacher et al.
369
c d
Fig. 24.16 (continued)
Fig. 24.17 Map of sites using high-eld MRI. ( Red ) 58 sites perform-
ing neurosurgery. ( Blue ) 24 sites performing interventions (epilepsy
treatment, laser ablation, convective drug delivery). There are nine cen-
ters that do both. This map neglects centers using low-eld system and
is most likely not exhaustive

24 The Advanced Multimodality Image-Guided Operating (AMIGO) Suite
370
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