SCREEN SHOT Surgeons can view surgery like never before.

Can surgical imaging really get better than high definition? 4K ultra HD, 3D and immunofluorescence promise to improve upon the true-to-life pictures that already splash across monitors in today's ORs. There's no doubt technologies that enhance the depth, detail and color of anatomy provide a "wow" factor that's sure to grab the attention of your surgeons, but is it really necessary to move on from HD so soon after it became the standard of care? We spoke to 3 national experts to find out.

SEEING IS BELIEVING HD is so good. Will upgrading to 4K really make a clinical difference?

Will the promise of 4K ultra HD really make a big difference clinically?
Mr. Razavi: 4K practically doubles the pixel information that's currently available in HD. When watching a football game in standard def, people in the stands look like dots. In HD, you can see their faces. With 4K you might be able to see the color of their eyes. In the OR, you can see anatomical details that you didn't notice before, and enjoy better rendering of tissue surfaces and arteries. Although it's not as big of an imaging leap as what occurred when standard def was upgraded to HD, you won't realize how much detail and clarity you're missing out on until you see 4K for the first time. With 4K, you can also digitally magnify a specific portion of the image and not lose clarity. You see all the imperfections in a picture when it's zoomed in, but there are far fewer imperfections in 4K. The picture is still very usable.

Dr. Renton: The curve ends up flattening. You can get a better picture with 4K, but does it change anything you're going to do in the OR? Does seeing at a cellular level help you that much during surgery? Once you reach HD, the difference between it and ultra HD looks incredible, but I don't think it changes much clinically. I'm not sure it's worth investing thousands of dollars in a system that provides more pixels.

Dave Razavi, JD
Mr. Razavi is director of media services at California Pacific Medical Center, a Sutter Health affiliate in San Francisco, Calif.

David Renton, MD
Dr. Renton is an associate professor of general surgery at Ohio State University in Columbus.

Aurora D. Pryor, MD
Dr. Pryor is vice chair of surgery, chair for clinical affairs and chief of the bariatric, foregut, and advanced gastrointestinal surgery division at the Stony Brook School of Medicine in Stony Brook, N.Y.

Dr. Pryor: HD pictures are perfect. I have no need to upgrade my current system. My biggest issues are keeping the laparoscope lens clean and the cables in good working order. A lot of those maintenance issues are so much more obvious and important with great optical systems.

ROOM WITH A VIEW The opportunity to work with the best possible imaging technology will attract forward-thinking and safety-minded surgeons.

Mr. Razavi: Video technology is accelerating and evolving incredibly quickly. Look at innovations in broadcast television to gauge how far surgical imaging has come, and where it's going in the near future. I saw HD television in the 1980s, but it was close to 20 years later before the technology was commonplace in the home. There's a long lag time between when a technology is invented and when it becomes practical to use. As soon as we saw HD television perfected for consumers, it began to be adopted in the medical world.

The same goes for 4K. We're already installing the technology in meeting rooms and ultra HD televisions have hit the consumer market, so I'm confident it will be a regular part of medical imaging. I'd expect to start building ultra HD into ORs in the next couple years, when surgeons are happy with how the new 4K laparoscopes operate and feel in their hands. When that happens, it'll be a done deal.

Is the hype for 3D imaging warranted?
Mr. Razavi: I've been reading and hearing about 3D for the past 2 years, and yet it hasn't been fully adopted in the medical world, partly because it has never been widely adopted by consumers. There are inherent problems with the technology. Do you need to wear glasses? How comfortable are they? Surgeons like the concept of 3D. It's excellent to see relative distances between anatomical landmarks and understand which anatomy is on top of which. 3D video laparoscopes are available, but the instrumentation isn't yet fully developed. The technology is still a bit gimmicky, even though surgeons like the idea of what it can do.

Dr. Renton: Now you can wear glasses similar to what you'd use in a movie theater. Although the eyewear has improved — previous generations were much larger, heavier headsets that hurt your neck after a while — 3D is still somewhat cumbersome in the OR if you're not using the robot, which keeps your head fixed in one position within the control console. That works great. But without the robot, you must keep your head perfectly still to ensure the image remains clear. Surgeons who use the robot tout the benefits afforded by 3D's depth perception, but it's never been proven to improve clinical outcomes.

Dr. Pryor: The eyewear gives me a headache and I find the whole experience to be a little disorienting. With the state of the current technology, it's not something I'd choose to use. Sure, it'd be helpful to better differentiate anatomical structures, but I don't think 3D adds a whole lot to my outcomes, because my surgical techniques are well defined for the 2D world. Would I use 3D if it didn't give me headaches or cause disorientation? Absolutely. But right now, in my view, it adds more stress than help to procedures.

How should facilities prepare to route and store the video images captured during procedures?
Dr. Pryor: It makes sense from a HIPAA standpoint and how video is processed and used that we're going to be pushed toward using a central server that's routed and stored within the facility itself. With my current system, I can download video onto an external drive, which lets me process my own images. But I think we're going to see more central servers and go through internal pathways to store and use video.

Mr. Razavi: There are so many imaging devices used simultaneously in the OR that it's not practical to have the devices connected separately to different monitors. Advancing video technology and the amount of complex imaging tools available today necessitate integrating various video signals into a single interface and controlling them from a centralized location. With wireless routers, we can now store images remotely and send them to monitors all around the OR.

Sending video signals to numerous monitors lets all members of the surgical team follow the action as surgery progresses. Video integration gives the entire team opportunity to notice potential problems and react appropriately. When it comes to patient safety, 5 heads are better than 1.

What other developments in surgical imaging are poised to make a significant difference in the OR?
Dr. Renton: Indocyanine green (ICG) immunofluorescence is an exciting new development, even though the technology has been around for 50 years. ICG is injected into the patient and distributed in the bloodstream to different parts of the body. It concentrates in the biliary system, which indicates to the surgeon where anatomy is located. Immunofluorescence is also useful for assessing perfusion. Let's say you remove a segment of the colon. Before reattaching the remaining ends, you can use immunofluorescence to check real-time blood flow to the area and use that information to decide if it's best to reattach the ends or reset to another area with a stronger blood supply.

Dr. Pryor: ICG immunofluorescence is helpful for tough lap choles. There's been a big push to improve the safety of those procedures — SAGES has put together a task force to address the issue and emphasized the problem during educational sessions at last year's annual meeting. When you look at the data, most surgeons don't perform a cholangiogram, instead opting for a critical view dissection, which is typically safe and adequate. But using ICG visualization to see the common duct without dissecting would add another level of security to the procedure and help prevent avoidable patient harm.

We've performed cholangiograms for injury prevention in the past. Surgeons have avoided it in recent years because it adds time to procedures and has its own potential for injury. They're therefore not as well trained in the technique as they once were and aren't comfortable performing it. ICG imaging may therefore help bridge the gaps in their abilities to perform difficult lap choles. The imaging is also useful during difficult cases such as esophagogastrectomy, revisional foregut procedures or bariatric cases when you're worried about the level of blood supply to the operative site.

Dr. Renton: One neat adjunct technology constantly identifies dark areas in an HD image and automatically adjusts the pixels so anatomy in those areas is still visible. The iris on conventional cameras closes when the foreground images get too bright in order to limit the glare. The technology adjusts the entire picture so the background doesn't get washed out — it becomes the same brightness so you can continue to see it without having to constantly reposition the camera.

Are imaging innovations more hype than helpful?
How much do they really matter?
Dr. Renton: The pendulum swings both ways whenever new technology is introduced. It swings one way when everyone wants to use it for everything, and then it swings in the other direction when surgeons say it makes no clinical difference. It eventually settles somewhere in the middle, where some applications are worth it and some aren't, and there's data to indicate which ones are which.

Mr. Razavi: We're actively recruiting physicians who are interested in working with the latest and greatest. Most of our docs have come from other facilities where they were involved in adding technology, but could never get to the next level. We're willing to invest in the tools they need to optimize patient care. Surgeons and surgical administrators are truly focused on better outcomes. In most cases, they're also data-driven. They're not like consumers, who want the latest smartphone because it's cool. They want to use the latest technology that shows some ability to improve the procedures they perform. Most surgeons rely heavily on video visualization to perform procedures. Every little detail they can see will provide better views of anatomy and allow for more precise decision-making, which can only lead to better care.

Dr. Pryor: It's a safety issue. It's common sense that if you can see better, you can do a better job on fine, delicate dissections such as Heller myotomy, when you have to see individual tissue fibers.

Every surgeon wants to work with the best equipment possible, so they feel like they have the capacity to perform excellent surgery. Younger surgeons are more appreciative of new technology and are driving the demand, particularly with all the great imaging we see outside of medicine. They want that technology in their ORs as well. OSM