BROADCAST NEWS Technological advances originally intended for home and movie theatres are finding great success in the operating theatre.

When it comes to surgical imaging, life imitates art. Which is why that high-definition screen you have in your OR — though it undoubtedly looks pretty good right now — may seem positively archaic in 5, 10 or 15 years. The way your old standard-definition screen would look if you trundled it back in.

Ultra-high-definition "4K" visualization and 3D are both on their way. It's just a question of when they'll reach the OR. If history is any guide, the answer is sooner, rather than later.

How do we know? "Technology follows Moore's Law," explains Steven Palter, MD, citing the wisdom of Intel founder Gordon Moore. "The law in essence says that the speed of your computer processor doubles its power at a lower cost about every 3 years. In other words, if you get a top-of-the-line computer now, you might pay $10,000, but the current $3,000 model blows away the $10,000 one from a few years ago." The price for vastly improved visualization will soon be comparable, he says, and given the choice, people will always choose the better system.

But can visualization really be dramatically improved? Haven't we gone about as far as we can go? After all, in just over 100 years, we've gone from the first choppy, black-and-white surgical footage ever recorded (in 1904), to much smoother film, to color film (in the 30s and 40s), to video (in the 70s and 80s), to color video and eventually to the high-def video we see in virtually every OR now.

"All of those innovations have stemmed from developments in the film and entertainment world," says Dr. Palter, a gynecologist and obstetrician and the medical and scientific director at Gold Coast IVF in Woodbury, N.Y. "Medicine very quickly adopts those innovations."

But not before briefly protesting that enough is enough. It was Dr. Palter who first demonstrated the value of high-definition surgical imaging, as part of a 2001 project at Yale University. "Everyone who was using standard definition at the time said there's no reason why you should do this," he recalls. "The image we have is as good as it can be and seeing more won't help. In fact, if you look back over the last 100 years, that's what people have said every 20 years or so, every time there's a new innovation."

NEW DIMENSION Relating 2-dimensional images to 3-dimensional spaces, which can take years to master, won't be necessary when 3D takes hold in the OR.

Same refrain
The initial reaction was the same, says Dr. Palter, in 2007 when, again following the lead of the entertainment industry, he broached the idea of bringing 4K video, with resolution that's about 4 times as high as that of regular HD, into the OR. "Everyone told us 2 things: Doing 4K through surgical endoscopes is impossible, and even if you did it, you won't see anything of any value. It was the same thing they told us in 2001."

Undaunted, he set up a digital theater at a large medical conference and showed 5,000 people what music videos, sports and movies looked like in 4K. Suddenly, he says, people felt as if they were looking at something live, something that was happening right in front of them.

"The goal has always been to make visualization of the patient as close to lifelike as possible," he points out. "Every new development takes it to the next logical level. If a surgeon has bad vision, you wouldn't want him to wear a pair of broken, dirty glasses. You'd want him to have a pair that gives him perfect vision."

READER PULSE
Surgical Video Survey Results

OBSOLETE? The speed of technology is likely to make today's impressive OR video displays seem dated in a few years.

How satisfied are you with your video and storage systems?
Very satisfied 28%
Satisfied 57%
Somewhat unsatisfied 10%
Unsatisfied 6%

What's your greatest challenge with surgical video and image capture?
Routing 36%
Image quality 20%
Reliability 20%
Storage 13%
Putting it all to good use 12%

Is your video system wireless?
Yes 21%
No 79%

Is surgical video technology advancing too quickly to keep up with?
Yes 45%
No 55%

SOURCE: Outpatient Surgery Magazine Reader Survey, October 2014, n=83

The 3D advantage
The same principle applies to 3D, but with a twist. Although periodic attempts through the years to make it the next big thing in movies and home entertainment have largely fallen flat, the advantages related to surgery are much more apparent.

"In entertainment, people didn't necessarily care about it, so it didn't take off," says Dr. Palter. "But in surgery, if you're working with a flat screen, your brain has to convert it to 3D. When people pick up a laparoscope, they're usually really bad at first — they can't pick up something, or they don't know when something's inside of something else. It takes months or even years to master.

"But if you give a trainee a 3D system, he doesn't have to learn that. It's instantly realistic. It's already been shown to eliminate big parts of the learning curve."

And unlike 4K, which isn't yet available for the OR, 3D has arrived. "Right now you can have a 3D system that doesn't have to be significantly more expensive and that gives a clearly superior picture to your standard 2D system," says Dr. Palter.

What's around the corner are 3D systems that don't require glasses and that operate in such a way that everyone in the room can clearly see the images, he says.

With 4K, there are still numerous obstacles to overcome, as developers try to overcome limitations related to light sensitivity, heat buildup, size, durability and waterproofing, among others. Will they clear those hurdles? Of course, says Dr. Palter, citing the technology used in military drones, the Mars rover and the Hubble Space Telescope. "Those are infinitely higher hurdles and they've been overcome already. The technology is trickling down. The technologies exist. It's just a question of delivering it in a cost-effective way."

How quickly can the price come down? In 2007, when Dr. Palter did the first 4K demonstration, the needed camera cost $200,000. Seven years later, 4K visualization is available on cell phones.

It's the "inevitable acceleration of processing and visualization," he says. "We will inevitably have higher resolution, 3D, brighter images and it will all be wireless. We're also going to be able to record in 4K and 3D."

Seeing what can't be seen
And then what? There must be an end to this road, a place where visualization reaches its apex. Well, yes and no. The next wave of innovation will involve things that are completely invisible to the naked eye.

"The course we're on is reaching a limit where increasing resolution and having 3D is getting very close to the native ability of the eye," says Dr. Palter. "We're working now with wavelengths of light not visual to the eye, with infrared, with autofluorescence, with cad dyes — and we're using the computer to process the image, so the surgeon can see things like blood flow under skin, or like the ureter through the pelvic sidewall."

The OR of the future will be able to merge cameras with imaging studies from CAT scans or MRIs in real time, allowing surgeons to see through bones and skin, to see things they were never able to see before.

"With computer-aided surgery, the CAT scan and the MRI could let the computer know where the blood vessels are and stop your instrument before you make a mistake," says Dr. Palter.

Will people continue to fight the inevitable? "If you look at the history of technology in surgery, there are themes that echo through the generations," says Dr. Palter. "First there's resistance to change; then technology-enabled change lets you do things better, faster, cheaper and easier; then people accept it and think it's the standard we've always had and nothing will be better; and then the cycle starts over again."

But as technology has sped up, people have become more open to change. They've seen it in their computers, their cell phones, their TVs and in the movies. There's no time to become complacent.

"People need to be aware these technologies are inevitably going to replace what we have," says Dr. Palter. The challenge will be determining when added value meets decreasing costs.

"Just because you see better, that doesn't necessarily translate to better outcomes," says Dr. Palter. "It will be more realistic, more comfortable and less fatiguing for the surgeon, and it will make surgery easier. But the threshold to say it produces better outcomes for patients is a very high bar to reach."