IMAGE CONSCIOUS Surgeons who operate in high-def see more of the surgical cavity.

High-definition video, image routing, smaller cameras with enhanced capabilities, articulating instruments and anti-fog solutions — technology that improves views into the abdomen continues to evolve by leaps and bounds. But does clearer visualization guarantee greater surgical efficiency and better patient outcomes? We asked experts about the most important image-enhancing advances available today, the differences they make and which should be in your ORs.

Sharper image, smaller options
Any discussion of the game-changing advances in laparoscopic visualization must begin with the impact that high-definition imaging has had on the field. There's no longer even a dispute: with HD cameras and video monitors, surgeons simply see more.

"There is more accurate visualization with high-definition equipment," says Gary Barth, MD, a general surgeon at Hastings Surgical Center in Hastings, Neb., "and therefore you may be able to diagnose some diseases that you may have missed before."

"The cameras are better than what we had even 10 years ago," notes Srinivasa Gorjala, MD, FACS, medical director of the bariatric program at the Southern Regional Medical Center in Riverdale, Ga. "The cameras were not very sharp. Now, high definition is great. The picture is better in intensity, color and field of magnification. You don't have to guesstimate as much."

The high quality of the latest generation of high-definition video imaging is due in part to improvements in the cable that carries the signal between the lens and the camera control unit, says Robert Baxt, MD, a hernia repair and abdominal wall reconstruction specialist at the Hospital of Central Connecticut in New Britain, Conn. "The fiber optics are better made," he notes, recalling experiences with older cables in which the breakage of the fine filaments — 1 or 2 every time the cable was roughly handled during reprocessing — resulted in a gradual degradation of image quality over time. "They've improved the glass strands and packed more of them into the cable for better visualization."

SITE LINES High-quality visualization hasn't been proven to improve efficiency or outcomes, but surgeons tout its practical benefits.

The cameras that capture these sharper images have gotten smaller, too. "We went from 10mm cameras and moderately good pixel strength to HD cameras with many more pixels" that are down to 5mm or less, says Dr. Baxt. "The 3mm cameras get into places that you couldn't get into before."

Miniaturization, says Dr. Gorjala, "adds great improvement to seeing in small areas. Under the liver, doing reflux surgery, or in the chest or pelvis, visualization is phenomenal."

One big advantage of smaller cameras, and consequently smaller incisions, is less intraoperative blood loss and less post-surgical discomfort for patients, says Dr. Barth. But there's also something of a trade-off in shrinking technology. "The bad part of laparoscopy is, you've got a small cone of vision," says Dr. Gorjala. "You can't see the whole area." For example, he says, a surgeon performing an open sigmoid colectomy would easily notice complications involving the appendix. Performing the procedure laparoscopically, however, he wouldn't.

Incomplete visualization can lead to unintended consequences, such as inadvertent injuries caused when trocars nick the bowel or electrosurgical instruments cause stray current burns. "The smaller the camera, the less range of field you have," says Dr. Baxt. "The 5mm doesn't get as much of a wide-angle view, and you lose a little of the peripheral vision." (See "The Close-Up, Wide-Angle Camera" for a possible solution to this common dilemma.)

IMAGE MANAGEMENT
Finding Room for High-Def

TECHNOLOGY BOOM There's nothing minimal about the amount of equipment needed to perform laparoscopy.

Improved laparoscopic visualization is attributable to a combination of technical innovations at work both inside and outside the sterile field. Between the HD camera and HD monitor are the streaming, routing and connections that make imaging possible, says Jeannie Montgomery, MBA, RN, director of practice operations and development project manager for United Surgical Partners in Addison, Texas.

"The smaller the incision, the more equipment you need to manage it. You have to plan for larger spaces," she says. The necessity of imaging in laparoscopic procedures demands video monitors. The preponderance of video monitors in the technologically advanced OR requires cart stands or equipment booms for monitor placement with portability. In order to accommodate cart footprints and avoid collisions between boom-arm-mounted equipment, you'll need physical space. That's how the cutting edge of laparoscopic visualization depends on something as prosaic as the dimensions of a room.

"On average, you'll need 360 to 400 square feet to accommodate the technology without compromising the sterile field," says Ms. Montgomery. The ceiling height should be 10 feet, with a stable superstructure above that to bolt the boom to, if you're going the boom route.

That's highly advisable, she says, because the infrastructure of a boom can reduce damage to data cables and electrical cords by housing them inside its infrastructure between the control units, routers and monitors they connect; eliminate the trip hazards of exposed wires cluttered and stretched across the floor around the surgical table; facilitate the ability to add cables and outlets for new technology as needed; and even ease the ergonomic environment by making the video monitors that surgeons otherwise have to crane their necks to see maneuverable into their line of sight.

If you're considering adding booms, however, be sure to thoroughly talk through, and walk through, the project and space with your video integration vendor. This is essential to preventing conflicts in the space and forestalling the buyer's remorse that would certainly follow retrofitting your facility with a near-permanent improvement that hasn't actually improved workflow efficiency.

"For a time, a lot of video sources were different," says Ms. Montgomery. "You were left wondering, what plugs into where? Many video integration vendors are savvier now, trying to simplify systems with all-in-one connectors, a universal plug-in port. That's been a tremendous advance, regardless of which signal or input is used.

— David Bernard

Other viewpoints
Articulating laparoscopic instruments approximate the workings of the human hand. Flexible laparoscopes with articulating camera tips, however, give the devices a neck. They address the limits on peripheral vision by letting users turn their minimally invasive views to the sides and see what's around the corner.

Laparoscopic visualization with precise articulation pair up in robotic surgery. "The greatest visualization you can get is through a robot," says Dr. Gorjala. "The binocular camera and eyepiece provide huge depth perception."

Surgical robots also offer the viewing surgeon a third benefit. "What's great about robots," says Dr. Gorjala, "is that laparoscopic surgeons are not generally working in an ergonomic posture, and over time they'll suffer chronic neck and back pain as a result. With the robot, you're sitting down away from the site, and you do things more ergonomically."

Unlike urology and gynecology, which have revolutionized prostate and hysterectomy cases through the use of surgical robots, abdominal laparoscopy hasn't widely adopted the technology. Dr. Gorjala suggests that a time-consuming docking process — it takes 10 or 15 minutes to set up and take down the robot for surgery, and it can only operate in one specific area at a time — as well as the equipment's cost without additional reimbursement limits its widespread use.

Three-dimensional imaging isn't limited to robotic surgery, though. Laparoscopic systems that incorporate cameras re-engineered with a pair of lenses and polarized sunglasses for surgical personnel to wear offer to bring depth perception to any surgery viewed through a monitor's screen.

Whether 3D will join HD on the list of must-have technologies is still an open debate. "There's a huge difference between operating in 2D and 3D," says Dr. Gorjala. While laparoscopy specialists become accustomed to mentally translating flat images into deep ones, "everyone realizes the need for 3D." (He admits, however, that the glasses-assisted 3D effect has at times made him feel dizzy and nauseated.)

Dr. Baxt concedes 3D visualization is impressive, but argues that it's most valuable to novice surgeons. "In my view, the more experienced you are, the less you'd have to use it. You learn the depth of field, the visual cues. The 3D flattens the learning curve for the new guy, but it wasn't a quantum leap for me."

Keep in mind, too, that getting the best view of laparoscopic surgery isn't only about electronic imaging technology. Sometimes it involves a comparatively low-tech assist from handheld tools. The miniaturization of instruments has brought about retractors that can fit through smaller trocars to lift soft tissue structures out of the surgeon's line of sight, as well as a sponge-tipped lens cleaner that can wipe away the fog obscuring a camera lens without having to remove it from the site. Insufflators that heat and humidify the CO2 in the pneumoperitoneum, trocars that wipe the lenses of cameras passing through them, and laparoscope sheaths designed to channel insufflator air over the camera tip can also combat lens fogging in order to maintain visualization without interrupting a case.

DOUBLE VISION
The Close-Up, Wide-Angle Camera

DOC'S DILEMMA Surgeons must decide between wide-angle views or zoomed-in shots of the action.

It's the unavoidable "either/or" of minimally invasive surgery: A laparoscopic camera can either zoom in for the close-up shot, or back out for the wide-angle overview. A wider field of view captures less detail, while a closer view loses peripheral vision.

Two University of Arizona researchers are looking to re-engineer this reality. They're building a laparoscopic camera that can deliver both views, simultaneously, from a single, stationary probe.

"The combination of being able to zoom optically and being able to capture a wide-angle view has some significant advantages," says Mike Nguyen, MD, MPH, a urologist and associate professor of surgery, who's working with optical sciences professor Hong Hua on the project. "One is the camera doesn't even have to move. It just sits in one place while it zooms and tracks. It can just be mounted, and you don't need an assistant to hold it anymore, and because it's not moving, it conflicts less with other surgical instruments."

The innovative camera has not yet undergone biological testing, and the pair is still studying practical aspects of its use, such as whether displaying its dual images side-by-side or picture-in-picture would be most effective for surgeons.

— David Bernard

Accuracy is everything
Do the technologies and techniques that have improved laparoscopic visualization over the past decade have a measurable impact? If your surgeons see better, can they operate more efficiently? Do their patients enjoy better outcomes? The short answer: maybe.

Dr. Baxt notes that no outcomes study and no national database of cases has tracked the results of the laparoscopic abdominal cases that have used HD, 3D, miniaturized cameras or other cutting-edge technologies against cases done with standard equipment. Long-term data requires long-term effort, he says, and everyone's got other jobs to do.

Adds Dr. Gorjala, "Between open and laparoscopic surgery, lap wins, hands down. But between laparoscopic and different modalities of lap, the outcomes are pretty much the same."

But that's not to say there's no advantage in the visualization advances. "We're not sure it's more efficient, but it's more accurate, and accuracy is everything," says Dr. Baxt. "We do better dissections, better identification of structures, better suturing. If we can operate better and more accurately, obviously the outcomes will be better. How much time we save is not an issue."

Plus, he notes, the smaller incisions for smaller ports and smaller instruments mean less post-op pain from abdominal sutures. And who doesn't want a smaller scar? Perhaps patient preference is the only truly quantifiable result of the improvements in laparoscopic visualization. "There are positive psychological benefits that assist patients in their recovery processes," says Dr. Barth. "The less invasive the procedure is, the more likely they are to recover more quickly."