SCREEN SHOT Surgical video technology continues to promise more pixels and higher resolution to display impossibly detailed images.

Advances in surgical video are making procedures that once required an overnight stay possible in outpatient settings. Just ask Susan Alexander, MSN, RN, CPAN, CSSM, director of nursing at the Reading Hospital SurgiCenter in Wyomissing, Pa. A few years ago, the center added 4K technology to its ORs. Thanks to their gynecological surgeons' newfound confidence with the system's picture quality, Ms. Alexander says that the group was able to bring a complex procedure like laparoscopic supracervical hysterectomies to the surgical center.

"The amazing picture quality let surgeons visualize so much better that they felt this risk of complications or further surgeries was minimal," says Ms. Alexander.

4K is derived from a 3840 x 2160-pixel matrix, or more than 8 million pixels compared with standard HD's 2 million pixels. The more pixels you have on the screen, the better the image quality. This increased clarity is especially apparent when magnifying images on large — typically 55-inch — monitors, says Daniel D. Eun, MD, chief of robotic surgical services at Lewis Katz School of Medicine at Temple University in Philadelphia, Pa. "That's where you can really see the difference between HD and 4K," he says.

Though there's little research clinically proving that 4K makes a difference in surgical outcomes, Ms. Alexander says her surgeons are more than convinced of its benefits, especially since they have expanded their service line due to their increased ability to see intraoperatively. Some of her physicians also say the system lets them complete procedures more quickly and safely because the high level of definition lets them see every anatomical detail.

"The latest 4K systems also offer more than a pretty picture. At least one manufacturer's system has an autofocus feature, which keeps the surgeon's image sharp as he changes location or settings in the surgical field. Additionally, 4K scopes also come in 5 mm size — an improvement on the larger 10 mm options of the past — and most scopes now are fully autoclavable to make reprocessing easier.

Some, though, aren't sure that 4K is worth the high cost — at least not yet. Seeing in 4K means acquiring both 4K-compatible monitors and cameras, which can cost hundreds of thousands of dollars, and some say their HD images are all they need for now. "Surgical monitors are not necessarily used to diagnose," points out Stacy Lund, BSN, RN, CNOR, MSSL, director of surgical services at Stanford Medical Center in Fargo (N.D.).

8K UHD
Is 8K Endoscopic Imaging on the Way?

Move over 4K — it looks like 8K ultra-high definition surgical video is heading our way. 8K video has a whopping 7680 x 4320-pixel matrix, twice that of 4K's 3840 x 2160-pixel matrix and 4 times that of 2K high-definition's 1920 x 1080. For perspective, 8K UHD has a 16-fold higher resolution than the current 2K high-def.

How's it work in the OR? Using a custom-built 8K UHD endoscope, researchers say they successfully performed 2 cholecystectomies using an 8K camera, a 30-degrees angled rigid endoscope with a lens adapter, a pair of 300-W xenon light sources, an 85-inch 8K LCD monitor and an 8K video recorder. Their 2016 study (osmag.net/Q4FnBx) found that 8K could be promising for complex, minimally invasive procedures.

The researchers say that 8K endoscopic imaging "promises to open up new possibilities for intricate procedures, including anastomoses of thin nerves and blood vessels as well as more confident surgical resections of a diversity of cancer tissues."

The surgeons and other surgical staff reported the following positive evaluations of the 8K UHD endoscope:

• With sufficient illumination, they could view laparoscopic images with quite high resolution.
• 8K laparoscopic images were excellent in reproducing the appearances of solidity and reality.
• They could clearly recognize vessels on the multilayer membrane around the bile duct and the gallbladder.
• Viewing of 8K laparoscopic images caused less eyestrain.

On the other hand, they also reported the following negative evaluations:

• Without sufficient illumination, the darkness and low quality of color reproduction of the images made laparoscopic surgery impossible.
• The large size of the 8K camera head interfered with the surgical field.
• The weight of the heavy 8K camera head made it difficult to hold in position even by 2 laparoscopists.

— Kendal Gapinski

3D ROBOTS Daniel D. Eun, MD, chief of robotic surgical services at Lewis Katz School of Medicine at Temple University in Philadelphia, Pa., is looking forward to using 3D-4K surgical robots.

3D technology
Attention may be on 4K video, but 3D is still making waves in ORs around the country. 3D technology has entered into the surgical world in 2 ways: robots equipped with 3D video and independent, standalone systems where viewers wear glasses to give them enhanced views. These systems promise to give surgeons better depth perception during procedures, which can be especially helpful for tasks such as suturing or separating tissue.

Ms. Lund notes that while her surgery center has yet to add 4K, it has added 3D laparoscopic cameras to several of its ORs. The decision came after surgeons trialed the system and found it let them clearly see different layers of tissue. There are some quirks, though, with using a 3D system. Though the glasses for standalone systems have improved, some surgeons find them cumbersome, and others simply may not like the 3D images. Because of that, be sure to conduct a thorough trial with the system you're considering, says Ms. Lund, who arranged for 4 vendors to come to her facility over several months. Afterward, the surgeons filled out evaluations that measured quality, ease of use and imaging capabilities.

"We maintained our standard system as well, and the physicians choose which system to use depending on procedure and case," says Ms. Lund. "Some of our team find the 3D to be overwhelming and choose to use the standard system."

Dr. Eun says one of the reasons he prefers using a surgical robot is because of the enhanced 3D imaging the system offers. He notes that currently, robots are only offering 3D-HD images, though he expects that to expand to 3D-4K in the future. Manufacturers seem to be heading in that direction, with one company recently launching a 3D-4K microscope with a heads-up display. Until surgical robots are equipped with that technology, Dr. Eun says that he'll continue to take the robot's 3D-HD images over 2D-4K ones.

"Would you rather have one eye seeing clearly, or have the ability to see with two eyes?" he says. "I would always choose two eyes. If I had to go back to operating with one eye, it would be a huge step backward in technology and ability."

It's not just 4K and 3D
While 4K and 3D are the big players in surgical video, some manufacturers are turning to image enhancement technologies to offer docs better views. These systems use advanced algorithms to cut through obstacles like smoke, debris and fog to get a clearer image. Other systems let surgeons tune the color scheme to help them identify specific anatomic structures, depending on the specialty, as well as light up dark backgrounds that otherwise are hard to see, no matter how high the image's resolution.

One technology picking up steam is near-infrared fluorescence (NIRF) imaging, in which the surgical team injects indocyanine green (ICG) solution into the patient. These enhanced camera systems are built into some of the newer surgical robots, or they can be purchased as stand-alone systems. After injecting ICG, the surgeon can switch the camera view from standard white light to fluorescence imaging, which will then light up sensitive structures such as bile ducts and blood vessels as bright green on the screen, increasing a surgeon's visualization. A recent study found that fluorescence imaging could help prevent bile duct injuries in complicated cholecystectomies (osmag.net/X7UeTg).

Dr. Eun uses the technology extensively in his urological robotic cases. During complex repairs, he'll inject ICG solution directly into the ureter in an off-label use that's becoming more common among surgeons. He can then visualize the ureter clearly using NIRF imaging and avoid damaging it. He also uses NIRF imaging in cases where he needs to determine if tissue has good blood supply.

"When we're looking at a piece of tissue during repairs, we can easily check the blood supply," he says. "If it lights up green, then it's a confirmation that that piece of tissue is well perfused. Before, we had to judge these situations using only the naked eye." OSM