While the technology is still in its infancy, 3D imaging for the OR could soon move from the fringe to the mainstream thanks to technological innovations (surgeons no longer have to wear bulky headsets or nausea-inducing polarized glasses) and growing consumer demand spurred by Avatar and other successes in the entertainment industry. "Anything that happens in the consumer marketplace will create interest in other areas," says Jed Kennedy, president and CEO of Viking Systems, which manufactures 3D equipment for minimally invasive surgery. "Surgeons will question, why can I have this in my home but not in my operating room?"

Stereoscopy, or 3-dimensional imaging, has already made its way into dozens of healthcare institutions, with surgical applications in 4 main areas:

• Robotic surgery. In April 2009, Intuitive Surgical unveiled its new da Vinci Si Surgical System, which features 3D-HD visualization with the ability to magnify images up to 10 times. The da Vinci Si provides surgeons with "an immersive view of the operative field" during robot-assisted laparoscopy, according to the company.
• Minimally invasive surgery. Several companies have been working for years to bring 3D visualization to traditional, non-robotic, minimally-invasive surgery. Viking Systems is marketing its 3Di Vision System, which includes stereoscopic endoscopes, cameras and other components that let surgeons view their work in 3D via head-mounted displays. The company has partnered with Sony to create a next-generation solution, set to debut at the American College of Surgeons' annual meeting in October, that lets the surgical team view 3D images on Sony flat-panel displays while wearing lightweight 3D glasses (similar to the ones you wear at the movie theater) instead of bulky headsets. Like the Viking-Sony solution, Solid-Look's EndoSteroVision uses lightweight 3D glasses and a special monitor rather than helmet-like displays to achieve stereoscopic visualization.
• Microsurgery. Neurosurgeons and ophthalmologists already see in 3D when they look through their surgical microscopes. Santa Barbara, Calif.-based TrueVision Systems has developed a camera that converts the ocular view from the microscope to a digital, 3D-HD image that can be streamed or recorded for teaching purposes or displayed on a large 3D monitor in the OR in real time. Wearing lightweight, passive polarized 3D glasses, the surgeon can switch seamlessly from looking through the microscope to looking at the 3D screen during the procedure. Since its introduction in late 2008, TrueVision has made its way into about 50 facilities in the United States, says Robert Reali, TrueVision's vice president of marketing and operations.
• Intraoperative imaging. Major C-arm manufacturers like Siemens, Medtronic and Philips are already on the market with 3D C-arms, which take a series of fluoroscopic images in rapid succession from a variety of angles, and then combine them via a software program to create a 3D image of the anatomy intraoperatively. 3D C-arms aim to give the surgeon a more complete, high-quality image with which to work intraoperatively while reducing the need for post-operative CT scans or MRIs, thereby sparing the patient exposure to higher levels of radiation. As a more affordable alternative, Israel-based Mazor Surgical Technologies has created a software system, called C-Insight, that can convert a conventional 2D C-arm's images into 3D images at a fraction of the cost and at a lower radiation dose than 3D C-arms.

Seeing the benefits
3D's primary benefit, say manufacturers and physicians who use the equipment, is the superior depth perception it affords the surgeon. "In open surgery, the surgeon uses his natural vision. That can be regained [in minimally invasive surgery] with this technology," says Brian Zimmer, senior marketing manager at Sony Electronics. Particularly in laparoscopic cases involving small organs tucked into tight spaces, that added depth of field can help surgeons maneuver with better precision — potentially yielding better outcomes at a quicker pace.

"When you're doing complicated things, there's just no question that 3D visualization is better than 2D," says Gerald Andriole, MD, chief of urologic surgery at Washington University School of Medicine in St. Louis, Mo., who uses the Viking system for 3D laparoscopy. "When you're doing a lot of suturing or removing an organ close to vital structures, you could harm the patient if you're a millimeter too far or a millimeter too close."

Mr. Reali of TrueVision says the ability to project a 3D image onto a monitor that all members of the surgical team can see also promotes "team synergy" in the OR. "Everyone in the operating room who's got the glasses on knows where the surgeon is at in the procedure; before you couldn't be sure." That advantage also aids training and education, says ophthalmologist Mark Packer, MD, who's been using TrueVision for more than 2 years at Oregon Eye Associates in Eugene. "It shows you for the first time what you would see if you were sitting there operating yourself. It's impossible to get that from a 2D video," or even from looking through observer eyepieces on the surgical microscope, he says.

A 3D C-arm could set you back $400,000; True-Vision's 3D system for microsurgery costs about $100,000; and Viking's 3D system for minimally invasive surgery comes with a 30% to 40% price premium over your standard 2D-HD system. If you only recently upgraded from standard-definition to high-definition OR equipment, do the potential benefits of 3D outweigh the cost of yet another upgrade?

While 3D technology has its true believers, for many the jury is still out. David Renton, MD, assistant professor of surgery at Ohio State University, operates on the da Vinci Si and recognizes the benefits 3D brings to robotic surgery. "With the articulating instruments and the degree of control that you have, you can make very fine movements, you can zoom in," he says. "The added depth of perception does help with robotic surgery." But when it comes to traditional laparoscopy, Dr. Renton believes the success of 3D will depend on whether manufacturers can "make it affordable enough" and be able to show that it will create better outcomes for the patient. "Does it add safety benefits? Is it better than the way we do it now? I'm not sure it is."