OR Excellence Award Winner

Laparoscopic surgeons work off of visual cues. New image enhancement technology that brightens dark areas and intensifies color contrasts lets them view tissue and structures like never before and perform surgery with a level of precision few imagined was possible.

Take fluorescence imaging, for example. Anesthesia providers inject indocyanine green (ICG), a cyanine dye, into the patient and surgeons toggle the laparoscopic camera from white light to the near infrared light setting, which causes areas of blood flow in tissue to glow bright green. During bowel resection surgery, colorectal surgeon John H. Marks, MD, FACS, FASCRS, uses enhanced fluorescence imaging on Stryker's fluorescence technology to check the quality of tissue perfusion at the distal and proximal ends of the bowel before sewing them together. The imaging helps him confirm that the tissue is healthy and will heal properly, which lowers the risk of anastomotic failure.

"Surgeons are often comfortable making that decision on their own without that enhancement, but there are times when truly knowing the perfusion of tissue is extremely helpful," says Dr. Marks, the director of the Colorectal Center at Lankenau Medical Center and chief of the section of colorectal surgery at Main Line Health in suburban Philadelphia.

ICG fluorescence imaging helped bariatric surgeon Kelvin Higa, MD, FACS, avoid a devastating outcome during what he thought was a routine gallbladder removal. During the case, he activated the fluorescence imaging on Karl Storz's Image1 S System and quickly realized the bile duct structures were atypical. If he had moved forward without the help of the glowing green of the contrast dye, he might not have noticed the uniqueness of the patient's anatomy until it was too late.

"That could have resulted in a significant bile duct injury," says Dr. Higa, of Fresno, Calif. "That's the potentially devastating complication of lap choles that surgeons want to avoid at all costs."

Image enhancement technology is like operating with X-ray vision and night-vision goggles, according to Dr. Higa, who says the improved views let him operate more efficiently and with more confidence. "I'm able to shave several minutes off of my procedure times," he adds. "At the end of the day and week, that adds up."

Narrow band imaging

Most surgeons want prime block times and primo parking spaces, but the docs at UMass Memorial Medical Center in Worcester, Mass., are more interested in jockeying for position in front of the hospital's new ultra-high definition monitors.

Looking at 4K images splashed across big screens in the OR has an undeniable wow factor that surgeons love. "If I can watch the Patriots in ultra-high definition at home, why shouldn't I be able to operate with the technology at work?" asks Justin Maykel, MD, chief of colon and rectal surgery at UMass Memorial.

Fair enough. (Watching in 4K as my Eagles beat Dr. Maykel's Patriots in last year's Super Bowl was pretty sweet.) But ultra-high-definition video and monitors that are stretching beyond 55 inches don't definitively improve outcomes, so why should you invest in a technology just because surgeons like how it looks in their living rooms on Sunday afternoons?

Dr. Maykel acknowledges those who question how much more detail surgeons need to see beyond what standard HD provides, but says Olympus's Visera Elite 4K ultra high-definition big-screen imaging platform provides an immersive view of surgery that gives him more confidence as he's maneuvering around the abdomen's delicate structures. He also says the technology's crisp, clear views of the surgical field presented in true-to-life colors help him differentiate between tissue that should be cut and delicate anatomy that he should definitely avoid.

The Visera Elite platform lets surgeons toggle between white light and narrow band imaging, which uses filtered light to enhance the visualization of vessels and other tissues on the mucosal surface.

Ultra-high-definition video also lets him zoom way in on anatomy without losing a bit of image quality. That's especially helpful, says Dr. Maykel, when manipulating instruments through the thicker abdominal walls of obese patients. "Trying to make up the distance between your camera and anatomy in the pelvis or abdomen can be quite challenging," he explains.

Dr. Maykel also points out that zooming in on anatomy from a distance while still achieving crisp, clear views of tissue keeps the camera head away from the action where smoke and condensation on the lens can ruin the surgeon's view, no matter how high the definition is on the screen he's watching.

Ultra-high-def video is arguably most helpful to abdominal surgeons, who rely on visual cues as they move sharp instruments around delicate anatomy during complex procedures, but orthopedic surgeons can also benefit from enhanced views as they hammer away at joints.

Patrick Smith, MD, of the Columbia (Mo.) Orthopaedic Group, operates with the Arthrex Synergy 4K System and says the technology provides incredible depth perception and clarity, which lets him see the details of cartilage injury more definitively and assess how much diseased cartilage he needs to trim. He says the platform also brightens dark areas in the back of joints, which lessens the impact the fluid and debris in joints has on views within the joint space. OSM