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By: Judith Lee
Published: 10/10/2007
Video is now common in the OR and endo-scopy suite, but the products are far from ho-hum. If you may buy video equipment in the near future, you'll be sorting through a dizzying array of new technology that includes digital output camera heads, DVD burners, flat-screen LCD monitors and fully integrated ORs that let the surgeon control all lights and equipment from within the sterile field. It comes with a price, of course, but surgeons and facility managers say efficiency and better surgical outcomes make the investment well worth it.
If you're not thinking about buying video equipment soon, you probably should be. Experts say upgrades are necessary every two or three years. The good news: Manufacturers are sensitive to the pressure to improve or add components, and are designing products to accommodate upgrades.
"We call this obsolescence protection," says Carl Liebert, a product and marketing manager for Karl Storz Endoscopy. "A camera you buy today from us will work with equipment you buy 10 years from now."
That's comforting, given the size of the investment. Karl Storz Endoscopy's Image 1 three-chip camera with digital output is listed at $32,000. A surgery center usually needs a camera head (which attaches to the endoscope), a camera control unit, light source, image-capture system, medical-grade monitor and a medical-image printer. This easily costs $50,000. Upgrading or replacing your system can soar over $100,000, says Fred Newey, a market manager, visualization, for Smith & Nephew. "We work with what the facility already has and work up to what they want in the future," says Mr. Newey. "If the facility buys new cameras, they can use their existing monitors and purchase high-definition monitors later."
What surgeons want
Image quality is probably surgeons' No. 1 concern and will have a discernible impact on surgical performance and patient outcomes. Several technologies affect image quality:
' Digital output cameras. These cameras are attached to rigid endoscopes and provide a digital signal clearer than the analog output on older cameras. Some camera controllers will convert analog signal into digital output, which is an improvement, but the state-of-the-art cameras produce a digital signal and send that across the cables to the monitor. A chip in the camera produces the signal; the more the better. You can still get a one-chip camera, but a three-chip camera (costing about 40 percent more) will offer higher resolution and better color contrast.
Stephen Halton, a clinical engineer technician at the Cleveland Clinic, is glad his facility upgraded to the Storz Image 1 camera. "This offers a better picture, more pixels. You can control the VCR and DVD right from the camera head, and take still pictures, too. You can lock onto any scope, use any light cable and adjust to a lot of other companies' products."
Look into autoclavable cameras. One study (Millennium U.S. Markets for Video and High Tech Hardware 2003) indicates a facility with high turnover can save as much as $40,000 with steam sterilization versus chemical systems.
' Flat-screen LCD monitors. These are a hot item, but there's some controversy about image quality. Some surgeons feel they get a better image on CRT monitors. Robert Marema, MD, a bariatric surgeon in Ft. Lauderdale, says he prefers the flat screen.
"We have extremely high-end ones," says Dr. Marema. "The image quality is excellent. Their footprint is smaller, and they don't get in the way of patient handling. We have ours parked over the patient's head. If it was a CRT monitor, it would require a significant amount of space."
Everyone agrees the flat-screen monitor is easier to place, and even suspend, in the OR. For this more compact footprint, you'll pay about double the cost of a medical-grade CRT monitor. One of the most popular ones, the Sony 18-inch flat-screen monitor, lists for $5,620. Another benefit of flat-screen monitors is they can accommodate a high-definition television (HDTV) signal better than CRT monitors can.
' HDTV. You've heard the buzz about this in consumer television, and now it's coming to medicine. JVC Corp. produced the first HDTV medical camera, which is now in its second generation. The camera offers twice the vertical resolution of standard-definition cameras.
"This model was optimized for endoscopy. The optics are compatible with endoscopes and light sources. It is smaller than the previous model to fit comfortably in the surgeon's hand," says Steve Martin, an assistant vice president, special markets, for JVC.
The JVC camera head and control unit list for $11,995 and require an adaptor that costs up to $2,000 (sold through TTI Medical, www.ttimedical.com). Several companies are expected to introduce HDTV cameras in the coming 12 months.
' Improved visualization. This comes in several forms. Surgeons who use flexible endoscopes are already familiar with the video endoscope, in which the camera is built right into the tip of the instrument. Now there are instruments with extra flexibility at the tip to facilitate visualization.
Olympus' Laparo-Flexible Videoscope's flexible tip lets the surgeon see around anat-omical structures he could not previously access. The laparoscope offers the ability to perform procedures such as colon resections and bariatric procedures, says Michael Malave, the video product manager for Oly-mpus. The scope, introduced last year, lists for about $15,000.
A head-mounted video display unit keeps the surgeon's visual focus on the procedure. One such example is the iView from MediVision. The surgeon wears the iView, hanging two tiny monitors just above eye level. The surgeon just makes a small change in his gaze and looks at a visual image that is the equivalent of looking at a 20-inch monitor from 2 feet away. Stephen DeSantis, MD, a general surgeon in Mission Viejo, Calif., says he finds it very useful in laparoscopic common bile duct exploration.
"The common bile duct is difficult to see because you work around the head of the fluoroscope," says Dr. DeSantis. "You're trying to manipulate [the instrument] with impaired visualization. Then, you have to look at the monitor. With iView, you just adjust your gaze, work on the duct and see it all the time on the video screen. You can then toggle to the fluoroscreen, toggle back and forth."
Dr. DeSantis says the device would be useful for urologists, pulmonary doctors, trauma surgeons and fertility doctors - anyone performing a procedure in which they must look directly at the patient. The iView lists for $7,000 to $9,000.
' Documenting cases. Another important new technology is digital-image capture devices that let you create CDs or DVDs of the procedures.
"We expect the market to grow by 20 to 30 percent a year for five years," says Bruce Meares of Linvatec Imaging. He says the devices provide superior ima-ges and are easier to manipulate. "Facilities are buying this rather than a medical-grade VCR and printer."
An example, from Richard Wolf Medical Instruments Corporation, lets you store up to 50 patients per unit, perform automatic or manual CD/DVD burning and multi-archiving of patients to one CD (the unit works with cameras that have S-video or RGB outputs, and lists for $15,000). This equipment is a step toward making motion pictures of each procedure as part of the medical record.
"What is the next standard of care? If you're going to document, document something moving rather than still. The image capture system allows you to record a procedure, and create a two-minute video summary that is a motion picture," says Alex Vidas of Pentax research and development.
Mr. Vidas says Pentax's EndoPRO system provides the bridge between the technology of today and tomorrow: "This is a computer system that lets you take and store still pictures. You can catalog and keep pictures, along with procedure notes. This can become the foundation for a true motion picture product three-to-four years down road."
Consider whether your image-capture device will work with the equipment you have or the equipment you will purchase down the road. Some devices will only work with one manufacturer's equipment.
"Don't get handcuffed by the vendor," suggests Kurt Cannon, the director of marketing for Fujinon, Inc. "Look for open-architecture software that can be used with more than one endoscope."
As more facilities acquire digital-image capture, it will get easier to exchange information with surgeon's offices, other facilities or for education.
"Image capturing is very important for training. I can view a procedure performed in another location, and use the telestrator to mark on the screen for the other surgeon to see," says Dr. Marema. "It allows for review of procedures for teaching or evaluation purposes, and provides digital images for conferences."
If you should invest in a digital image-capture device, you will gain another documentation capability. Sony's medical-grade printers produce a photo-like still image. These are compatible with digital-image capture, and list for $2379 to $4995.
The big Kahuna
In video, the big Kahuna is the integrated OR. Often selected by new facilities that design to accommodate these systems, they carry a hefty price tag: $100,000 to $300,000. Usually, video equipment is mounted on the ceiling, with the operating system outside the OR. The surgeon can control all the video equipment and room lights from within the sterile field.
"We purposefully designed a technologically advanced facility. An integrated OR ... gives us a competitive edge. The surgeons love it; they fight to have their cases scheduled there. We believe it improves patient outcomes and gives you an advantage over other facilities in your market," says Deborah Molnar, CEO of Jewish Medical Center East in Louisville, Ken.
Her facility has Karl Storz Endoscopy's OR1. Ms. Molnar says having video equipment on booms contributes to efficiency because rooms are easier to turn over. Image capture happens automatically, so staff aren't distracted by moving video carts.
Giselle Hamad, MD, works with Stryker Endoscopy's EndoSuite at Magee Women's Hospital in Pittsburgh. She says the images are excellent on the combination of flat screen, CRT and one 42-inch plasma monitor. She regularly teleconferences about the bariatric laparoscopic procedures she performs. Dr. Hamad recommends the voice-activation system, but cautions that it doesn't always recognize her voice.
Stryker's Kevin Unger reports an increase in EndoSuite installations in surgery centers: "These rooms are ideal for the efficient model a surgery center is designed around," he says. "Beyond the improvements in efficiency and integration, Stryker's Endosuite ORs are the most technologically advanced rooms available and provide a draw to patients who want the best care, as well as surgical staff that want to work in an enjoyable environment designed around their needs."
Dr. Marema, who uses the Storz OR1 integrated system, says the cost wasn't difficult to justify at Holy Cross Hospital.
"It was more cost-effective because we could do one additional case a day per room [with an integrated system]," says Dr. Marema. "That alone pays for the investment. Enhanced image quality allows for improved patient safety and less risk/exposure to facility."
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