ON DISPLAY Surgeons want to work with crisp, clear images that portray true-to-life colors.

Have you ever visited a relative who hasn't yet sprung for a high-definition flat screen? You squint at a grainy tube set for a few days before returning home to watch your favorite shows in 60-inch, full-HD glory. That's how surgeons feel when they bounce between ORs with state-of-the-art visualization platforms and standard-def monitors that are so 10 years ago. If you haven't yet upgraded the views in your ORs, now's the time. Imaging technology is exploding, providing surgical teams with the crispest and clearest images available on the market today. Here are a few recent developments.

• Three-dimensional imaging. The technology, which is still evolving, is quite helpful to surgeons, and we're getting closer to achieving video images equivalent to the depth perception, color and vividness of native vision (see "Does 3D Make a Difference?" on page 42). Current platforms require surgeons to wear proprietary glasses or headsets to see in 3D, so they might continue to push back against the technology until it's truly user-friendly, reliable and of a quality that's worth the effort and expense of adding it.
• ED backlight. Some of the latest liquid crystal display (LCD) surgical-grade flat-screen monitors feature light-emitting diode backlight upgrades. LEDs instead of fluorescent tubes illuminate pixels behind the screens, which is said to provide brighter, truer-to-life color reproduction and wide color ranges.

We incorporated ambient green light technology in our hospital's 50 ORs to realize benefits similar to LED backlighting. Working in green ambient light, instead of dimming or turning off the OR lights, enhances pixel definition, makes motion on the screen less choppy and lets surgeons and staff look at images for longer periods of time in greater comfort (see "Green Light Improves Views.")

SCREEN SHOTS Integrated ORs let you send images to multiple flat panels.

• Ultra-high resolution. Every 6 months the electronics industry takes another step toward greater image quality. Ultra-high-definition, also referred to as "4K" because it offers 4 times the resolution of full 1080p HD monitors, represents one of those steps. The displays are said to be amazingly detailed and truly lifelike. Are they needed in today's ORs? Perhaps not yet, but it's an exciting development in surgical imaging's inexorable evolution.
  LOOKING AHEAD Some surgeons prefer HD views to what they see through loupes during open surgery.
  • OR integration. A critical part of imaging advances involves integrated audio-video systems with wireless routers and other enhancements that streamline the way video is captured, filed and shared. The ability to save images is extremely valuable to both surgeons and facilities with electronic medical records, but storage and organization issues are immense. One of the challenges is finding critical images that may be buried in hours upon hours of video, or archiving hard-drive-filling video of extended cases.

  AMBIENT AID
  Green Light Improves Views

  SOFT GLOW Green ambient light maintains image quality and brightens the sterile field's perimeter.

  James Atkinson, MD, used to operate in darkened ORs during laparoscopic cases to better see images on high-definition monitors and to improve his depth perception. But then he toured a guided missile carrier docked in San Francisco.

  "The fire control center was packed with staff manning video displays," says the chief of pediatric surgery and senior medical director of transition at UCLA Health in Los Angeles. "Instead of having the lights on high or dimmed, the room was bathed in green light, which the Navy has used for years to enhance video images and lessen eyestrain for the crew."

  Now all 50 ORs at Ronald Reagan UCLA Medical Center feature the option to turn off the main OR lights and switch to green ambient light.

  But many laparoscopic surgeons still like to work with overhead lights dimmed to improve the quality of images on video monitors, leaving the rest of the surgical team to work in near darkness. The drawbacks of working in a darkened room are many: Patient and staff safety could be jeopardized if nurses have trouble reading medication labels, identifying needed supplies or failing to see floor-level obstacles such as cords or equipment.

  At the 2011 annual meeting of the American Society of Anesthesiologists, researchers from Massachusetts General Hospital in Boston touted the benefits of green ambient light in the OR. Bathing ORs in the light during minimally invasive procedures maintains image quality on video monitors and brightens the outskirts of the sterile field, they said.

  Green lighting improves overall ambient OR illumination without hampering the surgeon's view because of the human eye's sensitivity to green light, notes the study. Luminance under low-intensity green overhead lights installed in 2 of Mass General's ORs was 5% of the luminance measured under standard white lights, and effectively illuminated OR activities without producing glare or washout on monitors.

  The researchers said avoiding floor-level obstacles and reading medication packaging was much easier with the green lighting on. They noted that skin tone and blood vessel colors appeared altered under green light, so a standard flashlight was used when white light was needed to examine patients.

  — Daniel Cook

  Video monitors can now receive and display multiple images simultaneously, which is ergonomically friendly for surgeons and a space-saving plus in smaller ORs where using 1 less monitor would free up valuable real estate.

  Perhaps you're used to spending up to an hour of frustrating time trying to link imaging carts together in order to get images properly routed to monitors. Invariably, they don't appear because cables are hooked up incorrectly.

  Having a room that's integrated like a television studio solves interconnectivity issues. You generate images simply by plugging in laparoscopic cameras and routing images to anywhere in the suite or to outside conference rooms or auditoriums.

  Perception is everything
  Visualizing the surgical field has always been a critical element of conducting successful surgery. Surgeons attempting to expose and access targeted areas during traditional open procedures make fairly invasive incisions and move tissue and organs out of the way. They're limited in their abilities to deliver light and instrumentation into the surgical space without obstructing their views.

  Minimally invasive surgery solves some of those visualization issues by letting surgeons maneuver instruments and cameras directly into the surgical cavity through small ports, but HD enhancement of the images is often needed to improve surgeons' abilities to perform effectively and safely.

  HD images broadcast to flat screens let the entire surgical team track the case's progression without having to peer over the shoulders of the surgeon and tech. That means circulators and other assistants can prep needed instruments and items for the surgery's next step. It's not a stretch to say that large HD displays positioned around the OR can keep cases moving.

  Surgeons operating from video images must do so without the critical depth perception they enjoy during open surgery; their brains must learn to interpret visual cues and spatial relationships from flat monitors so they don't injure adjacent structures, organs and tissues.

  High definition makes that learning curve less steep and improves surgeons' abilities to process visual signals that replace the normal binocular vision that creates depth perception. The color, quality and definition of HD images enhance surgeons' abilities to judge depth, spatial relationships and size of anatomy. As they get used to operating with advanced imaging, their brains will automatically assimilate the clear, sharp images to the standard of care.

  IMAGING POSSIBILITIES
  Does 3D Make a Difference?

  SEE CHANGE Three-dimensional imaging improves a surgeon's depth perception.

  Three-dimensional imaging offers laparoscopic surgeons the promise of performing surgical tasks more effectively, but a pair of studies differ on whether that's actually the case.

  During two-dimensional laparoscopy, surgeons lose depth perception and must adapt to learned visual cues observed on fixed flat panel monitors, say researchers at the Medical College of Georgia in Augusta.

  In the April-June issue of the Journal of Minimal Access Surgery, they tested the abilities of novice, intermediate and expert surgeons to complete 4 running sutures and a simple suture line followed by an intracorporeal surgeon's knot and 4 square knots while wearing headsets that provided 3D views of the tasks. The researchers recorded the surgeons' suturing and knot-tying times, and measured the distances sutures were places from pre-made marks.

  Most of the participating surgeons said 3D visualization afforded them greater depth perception. The novice surgeons claimed the technology helped them during their introduction to laparoscopic suturing and knot tying. However, the researchers conclude that the 3D headshots did not ultimately improve suturing times or accuracy.

  Similarly, researchers in the department of urology at the University of California, Irvine, compared the abilities of 10 medical students, 7 surgical residents and 7 expert surgeons to complete 6 basic laparoscopic tasks — including suturing precision and peg and ring transfers — under 2D and 3D visualization. The participants performed better across the board when working off of 3D images, according to the study, which was published in the September 2013 issue of the Journal of Endourology.

  The study's authors say 3D laparoscopic camera equipment results in a significant improvement in depth perception, spatial location and precision of surgical performance compared with conventional 2D equipment. They conclude, "With this improved quality of vision even expert laparoscopic surgeons may benefit from 3D imaging."

  — Daniel Cook

  Inevitable evolution
  So why do a number of ORs still rely on standard-definition screens? High definition didn't impact the medical field as quickly as it did the consumer market. It wasn't until around 2008 that HD became widely available in the OR. The cost of high-definition monitors and imaging tools has dropped considerably since the technology hit, but a wide-scale distribution of medical-grade devices needs to continue before the use of tools that promise improved imaging becomes even more widespread.

  When the Ronald Reagan Medical Center here at UCLA opened about 5 years ago, the ORs were filled with standard-definition and high-definition screens. In the rooms outfitted with HD, some ENT and neurosurgeons pulled the operating table close to a wall-mounted flat screen and operated off its images instead of looking through the surgical microscope. I've also seen surgeons performing open surgery do the same, preferring the image provided by an HD camera over what they saw directly through their loupes.

  As video quality advances and images become more powerful, more surgery will be done with video images than direct vision, even during open surgery.