Have you seen the new iPhone X? It's an incredible piece of technology with facial recognition software, wireless charging and more apps than you could possibly need. It makes the first-generation iPhone look like a relic from a bygone era. You might have the same thought when you walk into your facility's OR, glance up at massive, wall-mounted monitors that display larger-than-life views of surgery and think about how the past decade has given rise to see-it-to-believe-it advances in surgical imaging. That type of explosive innovation demands thinking 5 years ahead of your current video display requirements, so your surgeons won't get stuck working with imaging technology that's as primitive as a first-gen iPhone.

Surgeons used to staring at standard high-definition screens will realize a clear clinical benefit the first time they work off of the crisp, lifelike images on ultra-high-definition 4K monitors, says Nathan W. Skelley, MD, an assistant professor of orthopedic surgery at Missouri Orthopaedic Institute of the University of Missouri in Columbia. 4K imaging, which offers 4 times the resolution and a much broader color range than standard high definition, lets surgeons zoom in on minute anatomy without losing an ounce of detail. It provides better views for orthopedic surgeons as they peer through irrigation fluid in the surgical field and improves the ability of general surgeons to see anatomy through smoke and gases in the abdominal cavity.

But the conversation about the future of surgical imaging doesn't end with 4K. In fact, it's just getting started. One U.S. manufacturer has introduced a heads-up visualization system that combines 4K resolution with a 3D view; it also has the ability to delineate between tissue boundaries and highlight blood vessels and lesions. Also, one Asian manufacturer has introduced an 8K endoscope with 16 times the resolution of conventional high-def cameras. The technology promises to let surgeons operate more confidently during intricate laparoscopic procedures. Even as the call for higher resolution builds and with 8K resolution on the horizon, has surgical imaging gotten as good as it needs to be?

"Moving beyond 4K is going to be difficult," says Dr. Skelley. "Going from 4K to 8K, I don't know if I could lobby for that right now. How much more resolution do you need? I think we're going to get diminishing returns from here on out."

The required investment may soon begin to outweigh the potential benefit. To justify the expense in 4K- or 8K-compatible displays and cameras, Dr. Skelley thinks surgeons will need to show significant value apart from a system's ability to improve a surgeon's confidence. In other words, you'll want to see tangible results. However, there's currently a dearth of clinical evidence to suggest ultra-high-def cameras can improve surgical outcomes.

Dr. Skelley repairs a lot of rotator cuffs. He says no one has truly tested the technology to see if performing the procedure is easier and more accurate with ultra-high-definition versus standard-definition imaging. "If you have clinical data showing that doing 100 rotator cuffs with 4K is safer to perform and makes a significant enough difference than doing 100 rotator cuffs with standard definition, then it makes it a lot easier to justify," he says.

Justin Barad, MD, agrees. "What is the outcome difference of high-quality versus lower quality resolution?" asks Dr. Barad, a pediatric orthopedic surgeon in King City, Calif. "If the difference is not significant, it's a 'nice to have' addition to the OR."

The Minimally Invasive Spine Institute, which has locations in Dallas and Midland, Texas, has joined the big screen surgery movement by adding 60- to 70-inch surgical displays to its ORs. Michael Rimlawi, MD, the Institute's founder, doesn't see the need to go any bigger. Plus, ORs have only so much wall space and so much square footage, meaning oversized displays might start getting in the way. That said, some of the latest big screens for surgery can be mounted on specially designed mobile carts, which let staff place the monitors where surgeons prefer during surgery and move them out of high-traffic areas when they're not needed.

Dr. Skelley likes the fact that surgical displays have come a long way in terms of size and resolution, but he still forecasts room for growth. At the moment, he uses 26-inch by 26-inch LCD screens in the OR. "When I first started doing surgery, we were using 16-inch by 16-inch, low-resolution monitors," says Dr. Skelley. "Those numbers are going to continue to tick up, but I think there's got to be some added value other than just looking across the room at a bigger screen."

Surgeon satisfiers

Then again, you must consider imaging technology's value as a recruitment and retention tool. Surgeons want to work with the latest imaging platforms, especially ones that splash stunning images across OR monitors and have the potential to help them operate more comfortably by reducing eye strain and limiting risk of repetitive strain injuries.

For example, 3D imaging can now give surgeons enhanced views of the surgical field and lets them work "heads up," which is more ergonomically friendly and a definite satisfier for ophthalmic surgeons who spend endless hours hunched behind surgical microscopes. Some platforms have built-in 3D video, though some require the surgeon to don passive 3D glasses. While many surgeons swear the technology offers greater depth perception during delicate tasks, such as suturing and dissecting tissue, others are less convinced of the technology's benefits. You might be able to debate the clinical plusses of working with 4K or 3D, but you'd be hard-pressed to argue that the technologies don't please surgeons who want to work in high-tech ORs with less physical stress.

"In a way, imaging is about surgeon comfort, which is undervalued," says Dr. Barad. "We never used to think of that before, but now we're more interested than ever in provider burnout and how to prevent it. There's a value to surgeons being more comfortable, and it's not insignificant."

Although bigger screens and increasingly better resolution have clarified the surgical field, these advances have not reached the level of an inflection point in terms of surgical outcomes, according to Dr. Barad. That, he believes, will come with new technology that gives surgeons the power to "see what they can't see."

One example: near-infrared fluorescence imaging (NIRF). The technology helps surgeons see vascularization and other delicate anatomical structures that are otherwise invisible to the naked eye. Similarly, the technology can be used to show contrast between malignant tissue and healthy surrounding tissue. Here's how it works: After injecting a solution known as indocyanine green into the patient, the surgeon can view the surgical site under fluorescence imaging, which makes blood vessels and other structures appear bright green on the surgical display. Because surgeons have a clearer view of potential problem areas, such as the bile duct during laparoscopic cholecystectomy, they can work with added confidence when making cuts. NIRF also lets surgeons see where blood flows through tissue and where blood supply is best, which is where it'd be best to connect blood vessels or bowel segments. These improved views of anatomy could result in improved surgical outcomes.

What's next?

Ultra-high-def images displayed on large monitors have the potential to add tremendous clinical value, but Dr. Skelley is already looking forward to the next phase of the imaging evolution.

"It will become more interactive — more wearable and wireless technology, 3D templating and imaging software," he says. "I think we're going to get to a point where we have voice-control visualization technology where surgeons can command systems to take a picture or brighten an image — things like that."

He also cites augmented reality head-mounted displays with generated objects — 3D images of the patient's anatomy or vital signs, for example — superimposed onto real-time images. (See "What Will the Future of Surgery Look Like?" on page 28.) Although early iterations of this technology have had underwhelming results, Dr. Skelley expects future versions to offer greater clinical value.

Virtual reality (VR) helps young surgeons perfect their technique outside the walls of the operating room. But will VR and augmented reality (AR) soon have a greater presence inside the OR? "For intraoperative purposes, VR might not be the best modality, but there's a lot of interest in VR for the rehearsal space," says Dr. Barad.

Dr. Rimlawi believes the next imaging breakthroughs will involve cameras with the ability to see through such anatomical structures as the spine. He says such technology would give surgeons a full view of the patient's anatomy and let them not only treat the problem area, but also identify other issues that might affect surgical outcomes.

Surgical visualization will evolve to offer a greater understanding of a patient's pathology, even down to a cellular or genetic level, according to Dr. Barad. He says that capability would prove useful when trying to determine the exact source of knee pain in patients with meniscus tears. "Our level of understanding is really quite primitive, and I think that's where you're going to see a significant change in surgical imaging moving forward," says Dr. Barad. "From now until then, there's a lot that still needs to happen." OSM