HD VIDEO Before purchasing an HD endoscopy system, determine your minimum performance requirements.

In the last few years, high-definition endoscopy has grown in popularity, and it's now considered the standard of care in endoscopy. Like its standard-definition predecessors, an HD endoscopy system typically consists of a video processor, a display monitor, a light source, a video camera and an endoscope. As the image quality is only as good as the weakest component in the system, each component must be able to support HD video. Before purchasing an HD endoscopy system, the ECRI Institute, an independent laboratory for testing medical products, suggests you get answers to the following 3 questions.

• What are your minimum performance requirements? Categories to consider include image quality, the availability of advanced imaging modes, ease of use and safety (including scope heating from the light source). Letting your surgeons trial several systems is likely to highlight many of the shortcomings in these categories. Pardon Kenney, MD, chief of surgery at Brigham and Women's Faulkner Hospital in Boston, which recently renovated its ORs to include a new 1080p endoscopic imaging system, says that when trialing a new endoscopic system, get as much buy-in from staff as possible. "We looked at a variety of companies and made them bring in test versions so the surgeons could use them," he says. "Then, we sent out a poll to surgeons and had them vote, so it was a democratic process. We also made the companies aware that they were competing, which got us the best price possible."
• What is the total cost of ownership of the system? This includes service requirements and parts replacement. Forwards and backwards compatibility of the components may help to reduce or distribute the cost of upgrading over a longer time period, says ECRI. Reprocessing requirements — autoclavability is generally helpful — and interoperability of the video system with your facility's PACS (picture archiving and communication systems), s and OR integration systems are also keys.

Try to stick to a single vendor, if possible. Dr. Kenney notes that before their renovation, Brigham's ORs had equipment from one company and hardware from another, which led to big problems when there was a failure. "When a wire would break inside the booms, the one company would blame the other and vice versa," he says. "When we went with new rooms 18 months ago, our business manager insisted that the room be done by a single vendor to make things easier."

• Where is the system in its life cycle, and what technology will be coming along next? Many manufacturers market a device for about 6 years; while they typically support the system for several years after that period, buying later in the life cycle may cause you to miss out on the newest and most advanced technologies. Consider whether you want to upgrade to 3D or 4K systems in the future, and determine how the purchase of an HD system fits into that plan.

Dr. Kenney notes that you should look for a system that has some level of modularity to it, so that if you find a game-changing technology down the road, you can easily swap it in without having to buy a whole new system. "Our rooms were about $350,000 per room," says Dr. Kenney. "You don't want to have to do that every 2 years."

Immersive 4K technology
4K, with 4 times the resolution and color reproduction of standard 1080p high-definition, provides doctors an immersive experience. Currently, only one manufacturer, Arthrex, has a full 4K endoscopic system on the market, although others are expected to follow. Barry Schaeffer, RN, CNOR, helped lead the trial of the system at the Reading Hospital — SurgiCenter at Spring Ridge in Wyomissing, Pa., that ultimately led to it being one of the first centers in the country to adopt the technology.

Mr. Schaeffer says that after asking general, GYN and orthopedic surgeons to trial the 4K system and a 1080p HD system from the same manufacturer, the answer was clear: Surgeons wanted the 4K's clear, crisp images. "The 4K was a major difference compared to the HD," he says. "Every surgeon loved it. A lot of them said it was like a 3D view."

The clear images aren't the only big benefit. Compared to other endoscopic systems that require separate pieces of equipment — a computer or "brain," a light source and a camera — the 4K system consisted of a single component that performed all those functions. "It saves space and is easier to manage," says Mr. Schaeffer.

Additionally, the center liked that the camera and scope were autoclavable, so they could purchase fewer scopes than they would if they had to send them out for "old-fashioned" reprocessing, he adds. Plus, Mr. Schaeffer notes that the 4K system can send photos directly into the patient's EMR, which eliminates the expense of photo prints.

Sharona Ross, MD, director of minimally invasive surgery and surgical endoscopy at Florida Hospital's Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive and Robotic Surgery in Tampa, adds that 4K's increased pixels mean that surgeons can see up to 4 images in HD at a single time. That helps give doctors a more accurate view of the patient's anatomy. "It's better than standard HD because there are so many pixels it doesn't distort the native image," she says.

However, making the switch to 4K can be pricey for some facilities, especially for those who need to adopt brand-new components to work with the new system. "You need to consider the signal, monitors, cables, recording, etc.," she says. "Generally, it's very costly to switch to the 4K."

Jeff Blackwell, MHA, administrative director of surgical services at Brigham and Women's Faulkner Hospital, notes that when the hospital upgraded to the 1080p system, they also wanted to ensure they had the capability to move to 4K as it becomes the standard. "We worked with our vendor to find out how easily we could transition to 4K in the future," he says. "You have to push back on your vendor to find out about future adaptability of the system."

Seeing in 3D
While 4K wasn't an option for the hospital at the time of their upgrade, Dr. Kenney notes that 3D was, though many weren't sure if it offered any clear benefits over HD systems.

"The big controversy at the time was whether we'd go for the 3D technology," he says. "But, the timing wasn't great since manufacturers were just getting into it. The gynecologists seemed to have the most interest in it, but a lot of surgeons found that if you're proficient with surgery, you might not need it as much."

"The 3D technology was very new at the time, and we thought that the benefits of it just weren't quite worked out yet," adds Mr. Blackwell. "We wanted the most cutting-edge technology out there that gave us the most bang for our buck."

Dr. Ross, though, disagrees. She says 3D systems offer better visualization for surgeons over 2D systems, since they get a more accurate look at a patient's anatomy, which may enhance safety. "The 3D systems improve depth, spatial orientation and you can really see from all perspectives," she says. "You can avoid small arterial and venous injuries much easier, which means less blood loss and a reduced op time."

Dr. Ross notes that because 3D gives you a more focused look at structures, surgeons see less overall space at one time. Additionally, the size of the scopes can be a problem. She says that most 3D systems on the market only offer a 10 mm scope. "For me, since I do single incision, the 10 mm scope isn't useful because it takes up a lot of space," she says. "In those cases, I'd rather have the 2D."

INNOVATORS 4K video imaging is poised to tranform operating rooms. Arthrex is the first medical devices company to use 4K camera technology. SynergyUHD4 (right) is the world's first autoclavable 4K ultra high-definition camera and image management system. Sony Olympus Medical Solutions recently launched a 4K video imaging system in Japan similar to the display shown above from a recent surgical conference.

Fluorescence imaging
One of the latest advances in surgical imaging is fluorescence imaging, which uses near-infrared technology and a special green dye to help surgeons better see blood vessels, bile ducts and other key anatomical landmarks.

Dr. Kenney notes that while the technology seems helpful in certain cases, it hasn't quite taken off yet. He notes that the technology's draw is that it claims to help prevent injuries to the main bile duct, a potentially fatal complication in laparoscopic procedures. While laparoscopic surgeons may not be demanding it just yet, he says that more and more plastic surgeons are using it to look at the viability of breast flaps and other soft tissue during reconstruction cases, since the infrared technology helps easily determine blood flow.

Dr. Ross notes that for larger hospitals with more complicated laparoscopic cases, the technology can be extremely helpful in determining if you have a good blood supply or not, and in seeing the bile duct in tricky gallbladder cases. She says the technology takes the place of cholangiograms, a special intraoperative X-ray that can eat up time in the OR.

The latest fluorescence imaging systems offer both standard HD images and the fluorescent HD images, so surgeons can switch back and forth between the two during the case. However, Dr. Ross says that while this is a nice advantage in the OR, unless you're frequently performing cholangiograms or often face difficult gallbladder cases, the technology might not be worth the upgrade just yet.