Steven Palter, MD, has always been fascinated with the intersection of technology and medicine. Tapping into advances in entertainment imaging to improve surgical outcomes has long been a passion for the GYN surgeon and founder, medical and scientific director of Gold Coast IVF in Syosset, N.Y. His latest efforts have focused on bringing 4K technology which provides 4 times the resolution of high-definition video and promises crisper images, depth perception and color fidelity beyond anything you see with HD laparoscopes into the OR. It's a journey that sent him to Hollywood, Vegas and an OR on Long Island.
Chasing a mirage
Back in 2000, high-definition imaging was starting to generate a buzz. The standard definition monitors used in the OR appeared antiquated compared with the promise of operating in HD. At that time, Dr. Palter sought out companies making industrial cameras and devised a way to perform the first laparoscopy in HD, which demanded bringing together teams from Japan and America who were expert in imaging and software engineering.
A year later, he presented a keynote lecture at a medical conference in HD for the first time ever. He showed attendees that increasing imaging resolution lets surgeons see anatomical details never before possible. But that didn't prevent experts from telling him there were no more improvements to be made to surgical imaging, that the attempt to incorporate HD into the OR would prove impossible. What they didn't know was Dr. Palter was just getting started.
He continued to operate in HD, but always kept an eye on Hollywood, where 4K technology was starting to completely transform the way movies were seen. "My fascination and passion was to see if we could push the envelope in surgery to this next level," says Dr. Palter. "I did all of my research in 4K sensors and editing, and became convinced what it could do for entertainment would have the same exponential increase in medical visualization."
He consulted with a representative from a major player in the medical imaging industry and researched how Hollywood was applying 4K technology. Meanwhile, manufacturers of medical monitors and laparoscopes told him operating in 4K would prove impossible. "They said if I tried it, I wouldn't see anything of value," recalls Dr. Palter. "I laughed because that's the same thing they told me when I did it with HD."
In 2007, he flew to the annual conference of the National Association of Broadcasters in Las Vegas, the leading trade event for TV and movie execs. There were 120,000 people in attendance. Guess who was the only physician? Dr. Palter paid his way for the sole purpose of meeting representatives from Red Digital Cinema, a camera company on the cutting edge of developing ultra HD for the entertainment industry.
At the meeting, he was blown away by the first movie ever shown in 4K. Afterward, he waited in a line at the Red Digital booth that wrapped around the exhibit hall. When he finally stood in front of Ted Scherwitz, top dog at the company and self-proclaimed leader of the imaging rebellion, Dr. Palter said he wanted to create a team that would apply 4K to health care, to take medical visualization to the next level. Mr. Scherwitz shook Dr. Palter's hand and told him Red Digital was all in.
Stephen Toback is a regular at the NAB meetings. Within a week of seeing the technology at last year's conference, the senior manager and media architect of interactive technology services at Duke University in Durham, N.C., thought this is going to be huge for medicine.
He met with Leonard White, PhD, director of education at the Duke Institute for Brain Sciences to share his impressions of the stunning images he saw in Vegas. Dr. White told him of the seminal moment in medical students' careers, when gross anatomy lessons are replaced with detailed dissections of specific anatomy. Wouldn't it be great to capture the dissections in 4K?
"As that's done, they look at all the connecting structures of the brain one by one. It's an amazing thing to film and project onto a screen," says Mr. Toback. "Everyone in the room had as good a view as the students in the front row, and the footage could be archived for viewing by students across the world."
Before using 4K technology, Dr. White would zoom in on digital images of the brain and couldn't see any detail at all. "Using 4K has solved those problems," says Mr. Toback. "It's been pretty amazing."
Back from Vegas, Dr. Palter put together a team of imaging all-stars from the University of Southern California School of Cinema, a leading manufacturer of medical imaging equipment, and staffs from post-production movie houses in L.A. and New York to figure out how to bring the magic of Hollywood to the OR.
A couple years and thousands of e-mails later, in 2009, Dr. Palter performed the first gynecologic procedure in ultra HD. His research team had to build couplers to attach a digital camera used in Hollywood to a standard laparoscope, which required hanging the heavy and bulky camera from the ceiling by a makeshift rig. The blend of movie and surgical technology was rudimentary at best.
"We performed surgery with regular cameras, paused the procedure, switched cameras and filmed through the laparoscope with the ultra HD rig," says Dr. Palter. "We then waited on pins and needles." Back then you couldn't view 4K images on monitors or computers, so Dr. Palter and the post-production experts headed to a Manhattan studio to produce a 4K digital movie of the surgery. It worked. "We showed you could capture 4K images," says Dr. Palter, "and we proved the images are better than conventional HD."
Clinically, he proved 4K provides better color fidelity, better fine detail and potentially allows for magnifying images tenfold without losing resolution.
The practical benefit to surgeons is still unproven, according to Dr. Palter. The potential? "I can imagine the possibilities," he says. "You could blow surgical images up so they could be shown on a screen the size of an entire OR wall and not lose resolution. If you're working off a monitor, you could have the image blown up five- or tenfold to work on structural details you couldn't see with your naked eye."
Image magnification and enhancement haven't yet been done in practice, but both could transform surgery. "You're going to need new tools, perhaps robotic assistance, to perform microsurgery," says Dr. Palter. "It's going to enable the creation of instrumentation and new procedures."
Mr. Toback says 4K imaging is ideally suited for telemedicine or remote surgery. "The physician on the remote end could move the camera away from the center of focus and still view the action in full resolution to help guide the operating surgeon," he explains.
Dr. Palter says we're 3 to 5 years away from ultra HD being commonplace in the OR. The monitors exist now; it's the cameras that need to catch up. "The work I've done has been a proof of concept," he explains. "We don't know where it will ultimately end up, but the potential benefits should match the innovations in medical imaging we've seen every decade."