Inside the ‘world’s first’ organ regeneration lab

The largest health research organisation in Canada had one chance to get it right — ‘it’ being building two mini-operating rooms (ORs) in a live suite of 20 sterile ORs. “We’re talking about a city of individuals that are having different surgeries in 16 to 18 ORs at any one time,” said Christopher Rizzo, Executive director of redevelopment at the University Health Network (UHN). Complicating the endeavour was the pandemic. “The first day we did our site review was the day COVID hit,” explained Keith Button, Senior architectural designer at Kearns Mancini Architects (KMAI). “We were on site when everything locked down. We had to get the director of Infection Control at UHN to help us exit the hospital.”

Not the typical start to a new project, but then again this is among the most unique projects on the planet.

Christopher Rizzo and Keith Button are specifically speaking about the design and building of the world’s first organ regeneration laboratory (ORL) at Toronto General Hospital (TGH), the number one transplant hospital in North America. The TGH transplant surgeons who developed the regeneration technologies had been honing their techniques in an existing operating room. Such ORs can be up to 700 to 1,200 ft2 in size, so it was overkill for their spatial needs, and not the best use of precious hospital resources. They brought the concept of a dedicated lab to Christopher Rizzo.

Organ regeneration using ‘perfusion’ technology

In the past, if organs were in any sort of trauma, they couldn’t be transplanted. The organ regeneration lab is using technology that was perfected at Toronto General; it’s called perfusion. Perfusion effectively keeps the organ alive for an extended period in a specialised environment like an incubator, which gives the team time to work on it and get the organ ready for transplant. “These are the projects you do once in your life,” said Christopher Rizzo. “We now have two designated mini-ORs that have created the ability to regenerate or repair organs for transplant. There’s a third area, which is called the islet room, that harvests stem cells from a pancreas, and is being used to treat diabetes, reversing the effect of the disease in some patients.”

Toronto General completes 1,200-1,400 transplants a year, with a success rate hovering around 98%. “We’re in pretty esteemed company on a global scale,” said Christopher Rizzo. “We were the first to transplant a lung and double lungs. Right now, if a recipient needs double lungs, they are getting them in one operation. Our track record is probably the best you can get for surviving major transplants.”

Challenges of breaking ground

Groundbreaking work is being done in these facilities, but breaking ground to build them was challenging. “It was like playing Tetris in a fully functioning operating ward,” said Keith Button. “We couldn’t do one thing without it affecting something else. We had to free up three rooms that were already in use — one for perfusionists, another for anaesthetists, and an equipment storage room. Just to free up these three rooms we had to renovate 12 locations in the hospital, most of them in the operating suite itself.”

Due to the tight schedule and a need for experienced team players, the design-build team of Dineen Construction and Kearns Mancini Architects was selected to deliver the project. It was completed in less than 12 months.

“COVID shut down elective surgeries,” explained Keith Button. “The ORL project freed up one of the ORs they were using for a jerry-rigged version of the regeneration lab. Time was tight. We had to do the work as fast as we could so the additional OR could be used to deal with the surgical backlog created by COVID.”

The greatest concern for surgeons was headroom. A lot of equipment on articulated arms is hung from the ceiling in a typical OR. There needed to be enough clearance so that the equipment did not clash; however, ORs normally have a 10 to 12-foot ceiling height. The rooms being renovated for the regeneration lab did not have more than eight feet of headroom. The design-build team had to work with the manufacturers of the lighting and equipment booms to have the least possible depth for equipment overhead.

“Because we are the biggest teaching facility in Canada, and probably ranked highly in North America in teaching, we have about 1,700 to 1,800 fellows that we teach,” explained Christopher Rizzo. “As we’re doing all this stuff, we’re teaching doctors from all over the world so they can take it back to their place, where they live (and) work.”

High-definition video recording

The ORL is a laboratory and a studio at the same time. What you see in the OR is a large light fixture with high-intensity lighting for work over the organ. Everything in the room is done under high-definition video recording, so it can be viewed anywhere as it is happening. A 4K high-resolution camera built into the light fixture is centred perfectly over the surgeon’s table. There are microphones and speakers all over the ceiling. While surgeons are working in the lab, they are also teaching other professionals across the globe how to perform the work.

“One of the biggest aspects was to put in a dedicated medical-grade air-handling unit to provide the air changes that were required for an ultra-sterile environment,” explained Christopher Rizzo.

“The islet room is considered on par with a pharmaceutical lab,” added Keith Button. “It requires 40 air changes an hour. The bio-hood in that room worked in reverse. They are dealing with cell cultures. Normally a hood would be protecting you, but here the hood was protecting what was in the hood from you. The room must be HEPA filtered and positively pressurised. So, the mechanical systems were enormous — a completely independent system.”

These two labs had to remove pathogens. Most organs are worked on within a glass box so they are not exposed to the room proper. They are within their own environment, but the rooms must be ultra-sterile.

Intricate layout

“This is cutting edge,” explained Christopher Rizzo. “The intricate layout means you must be quite disciplined. The ergonomics had to be tested and proven in detail. Where is the medical gas? Are services within reaching distance of surgeons in a very tight space? When the surgeon is working around the medical bench — where they work shoulder to shoulder — there must be enough freedom for the surgeons to do their job, but the equipment must be right at their side so it’s within reach. The sightlines, lighting, microphones. It’s all recorded — so viewers can see it in real-time.”

Keith Button spent weeks meeting with their partners, Dineen Construction, about the tight tolerances, putting everything within reach, plotting out the ergonomics, and trying to gain five millimetres in ceiling height to hang equipment. There was so little space above the ceiling in the islet room that they couldn’t suspend the ceiling. It had to be supported from underneath.

On top of this, how do you build within a sterile environment during a COVID lockdown?

“The trades had to go through the OR suites to access the regeneration rooms,” explained Keith Button. “They gowned up like they were surgeons. When they made it through COVID protocols they ditched their street clothes and switched into scrubs. Eventually, the contractors gave them scrubs to put over street clothes, along with masks and hairnets. They would come in to do their work, then dispose of their personal protective equipment. There was no coming and going. The trades on site had to stay for the entire day.”

Sensitivities understood

For Christopher Rizzo, KMAI distinguished themselves from other firms. “They understood the sensitivities (and that) they couldn’t breech a sterile environment, so following the rule to gown up in the area, removing gowns just like the medical staff, and being precise in the way they executed the project, was no different than the precision of the surgeons,” he explained. KMAI’s experience gleaned from being Ontario’s leading passive house architects helped because the firm understood isolating air and moving air.

“We were able to do something that is helping a lot of people,” said Keith Button. “Beyond that, we freed up an OR that is now back up to full operation. The hospital gained the extra capacity it needs with so many postponed surgeries.” These procedures are going to change what is done across the planet,” said Christopher Rizzo. “An amazing journey about something that is cutting edge, and that is going to help save many, many people.”

Acknowledgment

• This article, titled ‘Preparing for Transplant’, first appeared in the Winter 2024 issue of Canadian Healthcare Facilities, the official magazine of the Canadian Healthcare Engineering Society (CHES). HEJ thanks the author, CHES, and the magazine’s publisher, MediaEdge, for allowing its reproduction, in slightly edited form, here.