EVERYWHERE YOU LOOK Marshall Medical Centers outfitted 9 ORs with 4K video.

When the HD video systems at Marshall Medical Centers began showing their age, the hospitals considered replacing them with new high-definition systems. After all, the technology's price had come down since their initial purchase. Instead, they chose something even better.

What's better than HD? You'll find out when you catch a glimpse of surgery in 4K, the ultra-high definition resolution that users say is taking surgical visualization to the next level. Olympus and Sony launched complete camera-to-display-screen 4K imaging systems at conference exhibit halls earlier this year, and other equipment manufacturers are likely to follow in adopting the visual standard.

These high-profile introductions couldn't have come at a better time for Marshall Medical. "We tried out 3 or 4 systems, and when our physicians saw the 4K, they just gravitated toward it," says Tim Bean, MHSA, BSN, administrative director of the Guntersville and Boaz, Ala., hospitals. "The picture was pretty stunning on it."

So do your ORs need 4K? Read on for the big picture on why you might just become an early adopter, as well as the reasons why other facilities are taking a wait-and-see approach.

Let's start with the numbers. Ultra-high definition imaging delivers 4 times the resolution of the current "full HD" video standard. What this means is, while the HD screen in your OR displays a matrix of 1,920 pixels horizontally and 1,080 vertically, ultra-HD has at least 3,840 horizontally (the approximately 4,000 pixels to which the designation "4K" refers) and 2,160 vertically.

With more than 8 million active pixels on screen, the result is an intensely detailed, immersive image, especially when it's projected on a 55-inch screen. The colors of captured images are rendered from a wider, brighter palette than HD and the sharpness of magnification astounds those who have observed the technology's complete scope-to-screen imaging chain in a procedure or an exhibit hall simulation. None of the image quality is lost or goes grainy by zooming in.

INSIDE JOB Cynthia L. Monk, MD, performs a laparoscopic cholecystectomy with 4K's assistance.

"When they rolled this out, it was a completely different level of imaging," says Mr. Bean. "You can see more detail than ever. It's almost too bright for me." While some of his ORs have been outfitted with a 55-inch screen, "the 29-inch are plenty large enough," he notes.

The step up to state-of-the-art was deemed a worthwhile expense at Marshall Medical. As the integrated components of its HD systems required more and more maintenance attention and the need to upgrade the equipment became clear, it also became apparent that 4K was within the hospitals' reach. "There was about a $200,000 difference between getting 4K and going with another HD system," says Mr. Bean. "That's not a huge difference in the big scheme of things."

In all, 9 ORs got the 4K treatment, 5 rooms in one of Marshall Medical's hospitals and 4 in the other. "We were going to do just one facility in one year and the other in the next," says Mr. Bean. "But then we looked at the advantages, and we had to acknowledge that our physicians work in both places." Case volumes had to be maintained at both Marshall Medical North and South, he jokes.

The Reading Hospital SurgiCenter at Spring Ridge in Wyomissing, Pa., made a similar leap of technological faith in its half-million dollar decision to purchase ultra-HD video tower systems for its minimally invasive specialties. "Before we took the final step, we compared the extra expense of 4K to the cost of HD," says Jeffrey B. Frank, MD, a gynecologic surgeon and one of the center's physician-owners. "One step shorter would have saved us money, but we wouldn't be at the cutting edge. I said, 'I want the better technology.'"

It's made a noticeable difference, he says. "The comparison between the new equipment I have, and the not-so-new equipment at the main hospital is night and day," says Dr. Frank. "I'm ecstatic. A year out, it's as good as we'd expected."

Do you need all those pixels?
The improved image clarity, surgical visualization and diagnostic ability that 4K's higher resolution brings to laparoscopy, endoscopy and arthroscopy is without question a physician satisfier, not only in your ORs but outside of your facility as well. "From a marketing standpoint, we're keeping up with the technology of the day," says Mr. Bean.

There's not much in the way of data or evidence-based studies to demonstrate whether and how well these optics affect a patient's surgical outcomes. As with HD, however, most physician users will be able to tell you what 4K — with the aid of on-board image enhancement software (osmag.net/T7bPnA) — is capable of.

To Dr. Frank, the technology has had a very real impact on clinical as well as business outcomes. He cites one instance in which the center's 4K imaging cast a different light on a patient's selection for ambulatory surgery and, as a result, changed the course of her surgical treatment. "This happens infrequently," he says, "but when it happens I'm comfortable that I'm making the decision with all the information that I need."

The patient was undergoing a video pelviscopy for a simple ovarian or adnexal finding. Her clinical evaluation was benign, with tumor markers negative for cancer and a CAT scan showing no malignancy. Two previous surgeries had been routine.

A look at the small uterus, however, told a different story. Normal on one side, it was obscured by bowel adhesions or other inflammatory complications on the other, says Dr. Frank. "What we saw was significantly more involved than what we'd anticipated," he recalls, and a clear signal that a much more in-depth procedure was going to be necessary, in a hospital OR, where advanced assistance and backup will be able to anticipate the situation.

The procedure was halted and the patient was notified in recovery, thanks to ultra-high definition and its image enhancement features. "With the old equipment, it would have taken 30 minutes to make the adjustments to see all I would've had to have seen," says Dr. Frank.

"In 40 years of experience, we've come a real long way," he says, recalling that laparoscopic technology in the early 1970s required the physician to peer directly into a telescopic eyepiece. "I can't predict what the next step will be, but I'll be interested in watching the progress in our industry."

TECHNOLOGY IN BLOOM "The comparison between the (4K) equipment I have, and the not-so-new equipment at the main hospital is night and day," says Jeffrey B. Frank, MD.

Wait and see
Eye-popping images and anecdotal evidence aside, there are a few reasons why the prospect of upgrading to a whole new video system has given some facilities pause, even as they acknowledge that ultra-HD technology may be the future of surgical visualization.

The Texas Spine & Joint Hospital in Tyler, Texas, recently opted for an HD system over 4K after trialing 2 examples of each. While many physician-owned, for-profit surgical facilities make their capital equipment purchases guided in large part by cost, and while the latest, greatest entries in any product field can seem cost-prohibitive, it wasn't the dollars that drove the decision at Texas Spine & Joint.

"Surprisingly, most physicians didn't see advantages with 4K, and they were not even given the pricing, because I didn't want to skew their choices," says Cheryl (Skeet) Todd, RN, BSN, CNOR, CPAN, RNFA, the hospital's director of outpatient surgical services. "They just didn't see a huge advantage in the images, not enough to warrant the price difference," which she admits was fairly steep from her vendors, though a sealed-bid process prevents her from disclosing just how steep.

Ms. Todd points out, however, that several of the physicians who had a say in the purchase were older practitioners, for whom the slick appeal of the latest, greatest technology may have held less appeal. Plus, as an orthopedic surgery facility that predominantly hosts small joint procedures, not laparoscopic abdominal cases, it may be possible that ultra-high definition resolution is of less practical use in diagnosing the anatomy, she says.

Thomas L. Lyons, MD, MS, medical director of surgical services for Rockdale Medical Center in Conyers, Ga., also puts proof before price. "Surgery is vision. The better you can see, the better you are," he says. "We use high-def, all the cameras are high-def now. But unless you're routinely working off a 55-inch screen, the need to have ridiculously high resolution doesn't exist."

He recalls taking part in a panel discussion on laparoscopic technology about 20 years ago. Even before image resolution had become a buzzword in minimally invasive ORs, the biomedical engineers on the panel explained that on smaller screens — say, 20 inches diagonal — ?there are limits on the differences that the human eye can discern, as far as pixel density is concerned.

"I'm as addicted to technology as anybody out there," says Dr. Lyons. "In my own living room I have a 55-inch screen. But there I'm not working with it 2 to 3 feet in front of me."

It's not an argument against 4K, he says, to consider how much bang you're getting for your buck. "Whenever you believe you can see better, it's probably better. But if you're going to sell me something, first you have to prove it's effectiveness. Second, you have to sell it at a price that is reasonable."

"4K is not necessarily a need," says Mr. Bean. "But when you see it alongside the other options, there's no question — to use a stereo metaphor — that the highs are higher and the lows are lower. Even if it's not resulting in better clinical outcomes, it gives the physicians more tools. I think this is the future."

"4K is going to be like HD," adds Ms. Todd. "It's coming. It'll become the standard for a lot of people. Give it a few years." OSM