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Should Your ORs Go High-Def?
How to get the best buy on video systems.
Nathan Hall
Publish Date: October 10, 2007   |  Tags:   Surgical Video and Imaging

She's seen a lot of technology come and go in her 22 years as a nurse, but Colleen Shevokas, RNFA, was truly impressed when she first saw the monitors aglow with impossibly clear surgical video in the ORs at Pottsville Hospital and Warne Clinic in Pottsville, Pa.

A Screen With Bells and Whistles

A crystal-clear picture on a flat screen is the bare minimum of what constitutes a high-definition system these days. Manufacturers are offering extra perks to make their systems stand out from the rest of the field. Some of the latest offerings include:

  • Depth-of-field, which presents an almost three-dimensional image on the screen.
  • Peripheral vision to allow a clear focus of what is just outside the area of focus.
  • Blue and green wavelengths of light to make abnormalities such as precancerous lesions easier to spot and remove.
  • Overnight upgrades, because few facilities can afford to keep their ORs out of service while the vendor's technicians are working on the system.
  • Recording still and video images for the facility's records and the physician's reference.
  • Open architecture so it can incorporate components from other manufacturers.
  • Easy toggle between standard and HD inputs for facilities that aren't ready to throw away functional standard cameras just yet.
  • Picture-by-picture or picture-in-picture to provide surgery personnel with a dynamic presentation.
  • Fiber-optic routing systems that can carry an image from the OR to a screen in another building.
  • Gauge readings for the patient's flow rate, light intensity, gas pressure and other readings so surgeons can glean the information at a glance.

- Nathan Hall

Before the $504,000 high-definition conversion, she heard complaints that the monitors weren't clear enough or bright enough and that the colors weren't quite right. It all looked so dishwater-dingy.

"Now everything is so enhanced, so perfected," says Ms. Shevokas, the director of outpatient surgery services. "It's been a long time since technology advanced in the laparoscopic realm, and this is a big jump that has really made a difference."

In addition to improved imaging and visualization, HD imaging technology gives Ms. Shevokas' facility that certain high-tech look and feel that could woo surgeons to bring their cases to her. "Any tech that enhances the physicians' practice only makes it better for the patient," she says.

While the clinical benefits of HD imaging systems may be difficult to quantify, those who've used them speak highly of how they've increased accuracy, reduced surgeon fatigue and let surgeons better visualize disease.

"It makes the surgeons' hands move more precisely," says Marty Ryan, RN, BSN, CNOR, clinical partner in the general OR at Greater Baltimore Medical Center in Baltimore, whose four ORs went high-def in 2004. "They need to see around structures so they won't harm the patient, and without the definition they wouldn't have a good view of where they were clipping. The less invasive the surgery, the more important the image quality is."

HD technology also lets physicians do more invasive procedures in the outpatient setting, such as laparoscopic colon resections, says Ms. Ryan.

Many say the enhanced details and depth that HD offers over standard displays could substantially improve case outcomes. It's true that the better a surgeon can see what's he's doing, the better job he'll be able to do, says James W. Maher, MD, chairman of the division of general surgery and director of the Minimally Invasive Surgery Center at Virginia Commonwealth University in Richmond, Va.

He also points to the smaller size of the newer HD endoscopes as something that may improve the patient's outcome. "To get a high sort of resolution picture with the previous systems, you had to use a 10mm scope, but with many of the HD systems you can get very good resolution picture with 5.5mm scope," says Dr. Maher. This means smaller trocars and smaller wounds, less pain and less opioids.

But for all the benefits of HD, it's still not immune to new technology's little problems.

  • We heard tales of HD camera manufacturers rushing to release products that weren't ready for prime time.
  • We heard how mixing standard devices with HD ones, buying inexpensive cable connectors and setting up an HD camera with an incompatible monitor can leave you with a subpar image. Experts told us this doesn't necessarily mean you have to get every part of your system from the same manufacturer. As long as your camera and monitor are in compatible formats (720p, 1080i or 1080p), they should work well together.

HD buying tips
A few buying tips to keep in mind:

  • Don't believe your eyes. That unbelievably clear image you see in an exhibit hall won't be the one you see in your OR, say the imaging experts we talked to. "There, they have all the ideal components and the video is shot under ideal conditions," says one expert. "They've got the image synced up to the cameras, it's made to look stellar. Doing that in the OR is much more challenging."
  • Keep your specialties in mind. "When you're looking inside a belly, it's different than looking into a knee, and you need a system that can accommodate each cavity's differences," says Ms. Ryan. If, for example, you're doing gastric work, you want something that is better for still images, not something that is better for capturing motion, says an expert, adding that rooms handling multiple specialties should have systems that accommodate different scenarios. "Too often, we see hospitals accept mediocre imaging because it's better than what they had before."
  • Look at the components you're going to use. If you're going to mix and match products from various scope vendors in the same suite, you may want to look at buying generic solutions instead of specific solutions from the same vendor, says an expert. "Make sure the outputs you're getting from the devices are all compatible. Also, ask about signal management. If the image is being sent through an analog connection, you're not getting the same image you would get from digital."
  • Compare and contrast. After you've narrowed the vendors down to a few, have two of them bring in their systems and set them up so you can do a side-by-side comparison of the images. "In the commercial world, we call those shootouts," says an expert. "There will always be trade-offs, but when you see the systems side-by-side in the conditions you're going to be using them in, you can see which ones will work best for you."
  • And don't forget the site visit. Visit a neighboring facility that has the HD systems you're considering, says Ms. Ryan. "It's definitely a good idea to tour facilities that are using these and talk to the people using them, because they'll tell you more than the sales reps," she says. "Surgeons also want to hear from other doctors who say, 'I can see this great' or 'I have a problem with that,' because surgeons are apt to be forthright with each other."
  • Lease rather than buy. Is this the right time to buy? Will something come out next year that offers more features for less money? "All of these technologies have a relatively short lifespan," says Dr. Maher. "What may cost you $3,000 today may only be fit for small jobs three years for now." It might make sense to lease rather than buy so you can upgrade every three years, says Ms. Shevokas. "My recommendation is to keep up with technology out there," she says. "If we weren't doing that, we wouldn't have our platform available to us."

What's next?
"Before I started here, I thought the old imaging systems were pretty good," says Dr. Maher. "I don't know how much better the technology can get, but it seems to keep improving." Some of the improvements that experts say they look forward to seeing in the future include:

  • Still better imaging. Monitors are available with 5,000-by-5,000 resolution, but there's a problem with getting small camera chips up to that level.
  • A fully three-dimensional display as LCD and camera technologies advance.
  • The miniaturization of existing instruments, possibly creating scopes with a circumference as small as one millimeter, that can still convert the full aspect ratio.
  • An agreed-upon format standard throughout the industry so components will more easily adapt to products by other manufacturers.