SEEING IS BELIEVING It's fair to say that high definition has become the standard of care in today's OR.

Upgrading the imaging technology in your ORs isn't just about wowing docs with near lifelike views of surgery splashed across flat-screen monitors. Giving surgeons crisp, clear displays of the abdominal cavity might in fact help them identify delicate anatomy and surrounding tissue, and perform faster, safer and more effective surgeries. For now, high def is as good as it gets and most surgeons can't imagine doing laparoscopic procedures without it, but is 3D poised to be the next big thing?

The evolution continues
It's fair to say that HD has become the standard of care in today's OR. It's the trend toward 3D that really has people talking. That renewed interest is largely attributable to the introduction of robotic surgical systems that enable 3D. When surgeons saw what the robots could do, the market responded, and at least 3 major suppliers now offer dramatically improved 3D systems for minimally invasive procedures compared with what was available in the 1990s. For one thing, surgeons now need only specially designed glasses, instead of bulky, head-mounted displays. Visual quality has also improved.

But seeing is believing for the many surgeons who can't imagine performing laparoscopic procedures without HD scopes and monitors. So far the literature to back the notion that 3D's depth and realism help produce better outcomes is scant, but not completely absent. There have been a few compelling studies. In one (tinyurl.com/nxlppew), for example, 6 surgeons were able to significantly reduce the time needed to perform various tasks with laparoscopic devices by using 3D visualization instead of standard 2D. Still, most studies have been based on very small sample sizes and have tested the metrics of training sessions using HD and 3D technologies. What they've typically found is that the participants — ranging from residents to highly skilled surgeons — made fewer mistakes in 3D than in 2D vision and needed significantly less time in the 3D mode to finish tasks.

Ultimately, the jury is still out on 3D. There isn't enough data to be definitive about its benefits, but those early initial studies appear to bolster the belief that surgeons with better tools and modalities for visualizing within the patient are going to be able to better differentiate structures and in so doing produce better outcomes. Even then, however, it's not likely to be universally true. Moving forward, the adoption of 3D technology will still depend on surgeon preference.

FRONTLINE FEEDBACK
HD and 3D: Imaging's Difference Makers

PICTURE PERFECT Surgeons love the detail HD offers and are intrigued by 3D's potential.

There aren't many surgeons who want to think about a world without high def. "The HD we have now is light years ahead of where we were 10 years ago," says David Renton, MD, MPH, an assistant professor of surgery at Ohio State University's Center for Minimally Invasive Surgery in Columbus.

"A number of times we've taken a look at a high-def and a non-high-def picture side by side in the operating room," says Jeffrey W. Hazey, MD, associate professor of general surgery at Ohio State University Medical Center. "You really don't appreciate the difference until you're able to compare images in that setup. It's like being able to see the faces of football players inside their helmets on high-def televisions. You can use the same analogy for seeing blood vessels and other structures during surgery. It improves everybody's ability to do the operation."

Sharona Ross, MD, agrees that HD is great, but believes combining it with 3D technology truly elevates the image quality. "I think the move to 3D will eventually have more impact than the move from standard to HD," says the director of minimally invasive surgery and surgical endoscopy at Florida Hospital's Southeastern Center for Digestive Disorders and Pancreatic Center, Advanced Minimally Invasive and Robotic Surgery in Tampa.

Indeed, surgeons who've seen 3D in action tend to be impressed, but not just by the quality of the visualization. The price tag also makes a big impression.

"I'm a believer. I would love to have 3D visualization in my operating room for all my cases," says Dr. Hazey, "but I've got to be able to justify the increased cost. We're being asked to go to a value equation: quality over cost. If you increase cost, you've got to increase quality proportionately or better. That's where 3D might hit a snag. Right now there are no studies that show quality is improved enough to justify the increased cost."

The data may be lacking, but the benefits are clear, says Dr. Ross. "We could and we did do the same operations before with 2D laparoscopic technology," she explains, "but I think 3D increases the level of safety and improves outcomes. You feel more confident with every aspect of the operation. And you're also more likely to be able to finish a complex operation laparoscopically, because you're less likely to have a problem with bleeding."

— Jim Burger

Lighting the way
Some surgical imaging vendors have developed visualization methods based on the use of light filters. One good example is narrow-band imaging, a technique patented by one company. The technology uses special green and blue filters that cause hemoglobin in blood cells to look darker on the screen. That can help with early detection of structures with dense vasculature, such as tumors. There is evidence that it lets surgeons identify tumors at an earlier stage than they'd otherwise be able to.

Another company has developed a technology called "infravision," which uses infrared light for enhanced visualization and can be used to identify and localize bile ducts during cholecystectomies.

These more advanced features come with higher costs, of course, but for those who are budget-conscious and whose clinical focus isn't on the kinds of procedures that call for such upgrades, suppliers usually offer systems that are more bare bones but that still include HD. Imaging towers are pretty consistently priced. It's when you're thinking about purchasing different camera heads or different endoscopes that the systems can start to get pricey.

Poised for a comeback
One technology that hasn't caught on the way many assumed it would is wireless video. Why? Mostly because some of the earlier wireless displays operated at a very narrow bandwidth and at the same frequency range as many of the other electronic devices in healthcare facilities. They started clogging up bandwidth, which resulted in a lot of interference that naturally gave facilities pause.

But wireless may be poised for a comeback. Newer wireless video monitors operate on a much wider bandwidth, which helps prevent interference between video displays and other equipment in the OR. The latest challenge, however, stems from the fact that the systems tend to have about a 30-foot range, and often there's more than a single OR within that range, so adjacent wireless systems can interfere with each other. Suppliers are now trying to solve that problem. If they succeed, it could be a great way for ORs that are riddled with wires and cables to eliminate a lot of clutter.

ANOTHER STEP FORWARD? The data to support improved outcomes with 3D hasn't arrived yet, but the technology is increasingly popular with surgeons.

Ultra-HD?
Just when you think visualization has gone about as far as it can go, along come rumblings of a new technology called ultra-HD. The claim is that ultra-HD will have about 4 times as many pixels as plain "old-fashioned" HD and that when you look at the monitor, it's going to feel as if you're looking at something with the naked eye.

Coming soon to a healthcare facility near you? It will be interesting to see. HD has arrived as a standard of care, but 3D hasn't reached that level yet. If it does, and once it does, ultra-HD might take its place as the next big thing.