HEADS UP The combination of 4K and heads-up 3D projection is revolutionary, says retina surgeon Shlomit Schaal, MD, PhD, seen here performing a case while wearing 3D glasses.

Unless you've actually seen some of the most stunning recent developments in surgical video, it's impossible to know what you're missing. Forget the cliché. Some pictures are worth far more than a thousand words. They're the pictures that bring anatomy into sharper relief than you've ever seen; the ones that are making surgery faster, safer and more precise; and they're the multi-source images and videos that can be routed instantly and easily from screen to screen and room to room throughout a state-of-the-art surgical facility. The practitioners we talked to can't say enough about the breakthroughs they're now seeing on an everyday basis.

1. 4K + 3D = Wow!
Retinal surgeon Shlomit Schaal, MD, PhD, gets to experience one big difference both at home and in the OR. "In my house, we have 2 75-inch TVs," says Dr. Schaal, the chair of the Department of Ophthalmology & Visual Sciences at the University of Massachusetts Medical School. One, she says, is a state-of-the-art 4K model; the other is just an old-fashioned high-def set.

Any difference? "There's a big difference," she says. "The 4K technology is really amazing."

That's true in the operating room, too, where improved clarity promises unprecedented precision. For starters, when you magnify a 4K image (which has 4 times as many pixels as high-def), you lose little or nothing in the way of resolution. That's a great feature, she says, when you're dealing with membranes that are measured in microns, and that make a strand of hair seem thick by comparison. "The image is much brighter and much easier to understand," she says.

But the real benefit of 4K comes when you combine it with heads-up 3D projection, says Dr. Schaal. Retinal surgery has traditionally been done under a microscope, where the image is flat and has only moderately good resolution. The only way to teach was to have someone sitting next to you looking through a side view of the scope and seeing the same uninspiring view.

COMBINED REALITY New technology lets ENT surgeons project CT scans onto live images, making navigation easier and safer.

"The higher resolution you get with 4K is better," says Dr. Schaal, "but the 3D is actually more revolutionary, because everyone in the room can appreciate the 3-dimensional complexity of the retina."

Rishi Singh, MD, a staff surgeon at Cleveland Clinic's Cole Eye Institute and an associate professor of ophthalmology at Case Western University, says the first time he did a 4K + 3D case, one of his nurses turned to him and said, "Wow, I can't believe that's what you've been doing all this time."

When everyone in the room can see what's going on, everyone is that much more engaged, says Dr. Singh. "They can anticipate needs and know what to do next," he says. "It helps the flow, in general."

To see the 3D image, everyone in the room has to be equipped with passive goggles (meaning there's no battery component), but that doesn't mean the lights have to be turned up. "You can use them in normal ambient light and still get a really great picture," says Dr. Singh.

That's important from a safety standpoint, says Dr. Schaal, since the retina can be exposed to potentially damaging light. "In 4K, and especially in 3D, you can use a very limited amount of light and still see very well," she says. "I think that's the biggest advantage. You don't have to kick up the light, so the chance of light-induced retinopathy is decreased."

The heads-up display is also a relief for surgeons who no longer have to spend hours hunched over microscopes in positions that are ergonomic nightmares. "Surgeons can sit upright, relax and watch everything on a screen," says Dr. Schaal.

2. Enhanced visualization
Digital microscopy, the same technology that allows images to be projected onto that screen, helps enhance the view in other ways, too, says Dr. Singh.

The vitreous, for example, is clear and hard to see, "so you can waste significant time finding and clearing it," says Dr. Singh. With the color enhancement features of new technology, you can dramatically improve the ability to visualize it, he says.

"I can use a wireless mouse to toggle between screens and profiles to get the color channel and profile I need," he says. That also helps reduce the need for dyes, which can be associated with safety issues."

FORWARD THINKING The brand new Santagati Center in Lawrence, Mass., features a completely integrated video system.

3. Augmented reality
For years, ENT surgeons have used navigation systems to try to safely traverse the vulnerable anatomy situated near and around the sinuses. With their eyes darting back and forth between images, they've consulted sophisticated CT scan maps to get through and around those delicate structures. Now, by projecting the CT scan onto live images, augmented reality is taking navigation to the next level.

"It takes the important information that you want and puts it right there on the screen where you're operating," says Marc A. Tewfik, MDCM, MSc, FRCSC, an associate professor of otolaryngology/head and neck surgery at McGill University Health Centre, in Montreal, Canada. "You can keep operating and see all the important structures actually in the image on the screen, fully integrated into the camera view. It's really quite ingenious."

The surgeon still needs to pick out and highlight the critical structures ahead of time, but the technology is so sophisticated that it promises to open the discipline to less-experienced practitioners. "Traditionally this kind of surgery has been left to people who are very specialized," says Dr. Tewfik. "But with these improvements, there's no reason why general ENT surgeons can't do this kind of surgery without being extremely specialized."

The system even lets surgeons set alarms that will warn them when, say, an instrument gets within 2 or 3 mm of the optic nerve.

Surgery of the frontal sinus has long been considered the most advanced kind of surgery of the sinuses, since it involves a very narrow area between the eyes and very close to the brain and arteries just below the brain. But, says Dr. Tewfik, once the scan is put into the system, the surgeon can highlight those structures and trace out the pathways that illustrate exactly where instruments should go.

Another advantage: The system can record with the navigation system built in, so the augmented reality you see on the screen in real time can be viewed again later.

4. Total integration
The ability to access, route, record and store video within a user-friendly and virtually seamless architecture is one of the hallmarks of the Santagati Center, which opened this past spring in Lawrence, Mass.

The $56 million multi-specialty center has 6 standard ORs, each of which has a 50-inch wall-mounted monitor at the foot of the bed, 2 large monitors mounted on booms and 3 other strategically placed monitors.

"Everything is easily controlled by touchscreen monitors," says David Spofford, RN, the hospital's senior director of surgical services and outpatient procedures, "so with the touch of a finger, the circulating nurse can do whatever it takes to route multiple images in a way that may assist the surgeon while he's performing surgery."

The system even has a patient-greeting feature. When awake patients are brought into the OR, the monitors show landscape images, the system plays soothing music and the lights dim. Once the patient is asleep, the lights come up and all the monitors display the center's customized time-out template, another plus. "By letting us go through our time out in a more formal and standardized way, it's improved our time-out process," says Mr. Spofford.

Elsewhere in the facility, a patient tracking board in the anesthesia workroom provides live video feeds of all the ORs on a wall-mounted monitor. That lets the anesthesia provider in charge see when cases are nearing their conclusions, make plans to turn rooms over, help out as needed and get patients awake and out safely.

Want to go over something later with a patient or family member? All photos and videos are stored on a secure server and accessible remotely for surgeons, via both mobile and desktop apps.

Mr. Spofford says the whole system makes an important statement, which helps recruit skilled surgeons, who were accustomed to sending patients to state-of-the-art facilities in nearby Boston.

"I think they're impressed when they walk through and see we can compete with some of the tertiary centers," he adds. "Our theme is about keeping care local — about committing to the community that they don't have to go to Boston to get good quality care." OSM