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A Window Into The Body

Fri, 03/05/2010 - 7:04am
Amanda McGowan

Manufacturers of surgical display systems discuss how the technology has evolved to accommodate minimally invasive surgery, features to consider when purchasing displays for your operating room, and what to expect in the future for visualization in the OR.

March 5, 2010

Advances in minimally invasive surgery (MIS) have increased surgeons’ reliance on visualization in the operating room (OR). As surgical techniques have progressed, so has the technology allowing the surgical team to better see inside the patient’s body—in the form of surgical display systems. The rise of HD endoscopic systems used in MIS procedures has driven the need for HD surgical displays in the OR.

Advances in minimally invasive surgery (MIS) have increased surgeons’ reliance on visualization in the operating room (OR). As surgical techniques have progressed, so has the technology allowing the surgical team to better see inside the patient’s body—in the form of surgical display systems.

The Impact Of MIS
“Certainly, as MIS has taken over for a lot of different procedures in the OR, cameras are inside the body, and the surgeon’s only window into the body is the display,” says Brian Zimmer Senior Marketing Manager at Sony Electronics, Inc.
“It is much more than a reference display for other staff members in the OR. The monitor is essentially the surgeon's view inside the body providing valuable visual feedback during a procedure."

Based on the importance of cameras in MIS, advancements in surgical display systems have followed in the footsteps of emerging technology related to camera systems.

“MIS has had a big influence on surgical display technology,” says Jens Ruppert, Vice President and General Manager, Surgical Business Unit at NDS Surgical Imaging. “Fast responding LCD panels, as well as accurate color reproduction, are more important since MIS is now using high-definition (HD) endoscopic camera systems.”

Therefore, there are features of surgical display systems that have emerged, at least in part, due to MIS:

HD resolution. The move toward HD endoscopic systems has driven the rise of HD surgical displays in order for surgeons to fully utilize the 1920 x 1080 resolution available to them in new camera technologies.

With the rise of HD resolution, OR displays have become larger. According to Tom Kenna, Product Manager for Surgical Displays/Cameras at Sony Electronics, Inc., widescreen surgical displays are becoming a necessity in the OR, as they provide a larger field of view to allow the surgical team to see more of the procedural area. Split-screen capabilities facilitate quick decision-making while requiring only one display in the OR.

“What is still on-going is the fact that endoscopy has gone the route of HD, so HD endoscopy has stimulated the trend to go from standard-definition (SD) displays to HD displays, and also larger displays,” says Johan Stockman, Market Director for Surgical Imaging at Barco. “MIS has determined which type of form factors and which type of resolution are dominant in the OR. The camera has driven HD displays, and I think the transition will only accelerate.”

With the rise of HD resolution, OR displays have become larger. According to Tom Kenna, Product Manager for Surgical Displays/Cameras at Sony Electronics, Inc., widescreen surgical displays are becoming a necessity in the OR, as they provide a larger field of view to allow the surgical team to see more of the procedural area.

 “We have seen screens in the OR become larger than before,” Stockman adds. “While in the past, it was a 19" screen size, we have seen the change over to 24", and even 26" or 27".”

Color accuracy. With HD camera systems working to provide a surgeon and the surgical team the clearest view possible, color reproduction must enhance the benefits of the camera system being used.

“Surgeons want to be able to see the exact colors of the tissue of the surgical area,” Zimmer says. “Those colors provide a lot of information to the surgeon in terms of the health of the tissue, so they demand a display that has color accuracy. It is a measurement tool.”

A wide viewing angle and fast response. Color reproduction must  also be consistent, regardless of the viewing angle—requiring LCD technology with a larger viewing angle and faster response time.

“Dual IPS (In-Plane-Switching) LCD technology provides a wide 178-degree viewing angle, which delivers consistent color appearance to all members of the surgical team,” Ruppert says. “Without fast responding displays, ‘smearing’ can occur in moving images, which will irritate the surgeon, especially in disciplines such as arthroscopy.”

The ‘Digital OR’
While MIS alone has certainly impacted technological features of surgical display systems, there are other aspects of which surgical professionals should be aware. “MIS has been driving the need for surgical displays, but I think in general, advanced visualization in medical imaging is getting more and more important,” says Stockman. “It’s a combination of MIS, in which displays are needed, and the digitalization in medical imaging in general that has created the demand for the concept of a ‘digital OR’.”

As the OR ‘goes digital,’ it presents additional considerations in selecting a surgical display system:

Full Multi-Modality Imaging (MMI). “As more and more operating room integration occurs whereby different imaging systems are being connected, the demand for a surgical display that can display multiple images in various, flexible ways is increasing,” Zimmer says.

According to Ruppert, MMI capabilities allow the surgeon to simultaneously view the live video from an HD endoscopic camera along side the high-resolution output of an ultrasound machine or fluoroscope on the same display. This enables surgeons to use an endoscopic camera and other imaging systems simultaneously.

“The additional imaging systems can be used for many purposes, including navigational guidance within the body (fluoro) or diagnostic evaluation of tissue (ultrasound),” Ruppert says. “Split-screen capabilities are important when viewing two sources at the same time and in making quick decisions while requiring only
one surgical display.”

Size and weight of the display. Based upon space constraints and/or mounting location, it is important to decide the size of display that best suits a specific OR. As Stockman states, larger screens do not always have clinical relevance.

“The display size may also be dictated by the type of procedure,” Ruppert says. “A smaller display would make sense in urology and a larger display for laparoscopy or gastrointestinal procedures.”

When choosing the size of the display, it’s important to also consider the weight, Ruppert adds, as the existing suspension system (ceiling or wall-mounted arms) or the current table stand must be able to handle the weight of the new surgical display.

Medical-grade approval. According to Zimmer, a professional, medical-grade monitor is a must for the OR, with the possible exception of those outside of the sterile field, such as an observation panel on the OR wall. For surgical displays utilized in the sterile surgical field, Stockman advises to look for necessary medical approvals, and be certain the screen can be easily and comfortably cleaned and disinfected to ensure patient safety and lower infection risk.

Optimal Connectivity. In a ‘digital OR,’ displays need to be able to connect to many different imaging devices in the OR, such as ultrasound, different SD- and HD- endoscopes, as well as overhead cameras, PACS and C-Arms, Ruppert says.

In addition, he says professionals purchasing new displays need to ensure compatibility with their current equipment. Ask:

  • Are we using standard-definition (SD) or high-definition (HD) equipment?
  • What is the video interface type of my current and future equipment (DVI, HD-SDI, RGBS, YPbPr, SOG, S-video, Composite, other)?

“Ideally, [surgical professionals] should aim to purchase a surgical display which will work with their current SD camera technologies, but is also equipped with the right interfaces required for use with newer HD cameras,” Ruppert says.

According to Chris Kubashack, National Sales Manager, Medical Products for CP Technologies, DVI is a top choice for image signal quality in flat panel displays with today’s generation of 1080p endoscopy cameras. However, it has drawbacks such as a limited transmission range, physical size and possible EMI issues with OR equipment.

Therefore, fiber optic DVI extenders have been developed to convert the DVI information to optical and then back again. Many OR integration/endoscopy companies use fiber optic DVI extenders and surgical display manufactures are beginning to build this capability directly into the displays.

The Future Of Displays
Despite the advancements that have already emerged in surgical displays, the future only promises better visualization capability for OR teams.

“What I see happening is the visualization content in the OR will increase,” Stockman says. “Various kinds of imaging data from advanced modalities will be brought together in the digital OR.”

Further, Stockman says three-dimensional (3D) HD imaging could surface over the next five years as changes in minimally-invasive technique drives 3D endoscopy. According to Zimmer, future display capabilities will be most heavily driven by camera system technology, but not entirely.

“There are some stand-alone technology improvements to the displays that can enhance the ability of the camera systems,” Zimmer says. “Organic Light Emitting Diode (OLED), for example, is a display technology that offers ultra-wide color gamut and very high contrast, among other benefits, which can enhance the picture quality of an existing camera system.”

Finally, wireless connectively could be something to look for in a surgical display in the future, although it is currently more of a “technology demonstration,” Stockman says.

“From a technology point of view, those things are possible and can be integrated,” he says. “The big question is if and when it will really become adopted on the large scale.”

Wireless connectively could prove beneficial for ORs that need to upgrade their displays, but have difficulty re-installing or adapting cabling and cannot shut down the OR to put in new cabling. A wireless display could also be helpful in a case where a surgeon needs an additional screen.
“Wireless connectivity in the OR offers many benefits, including a new wave of technology for the OR of the future," Ruppert says. "A medical-grade, wireless technology can improve efficiency, flexibility and, most importantly, make the OR safer during procedures. It also improves productivity by eliminating down-time from disconnected or damaged cables, and allows a clean and professional-looking OR.”

However, when re-installing or adapting cabling is still possible, the benefits of wireless connectivity come into question. Further, there is a concern with interference among wireless connectivity when multiple screens in different ORs are working in a short-distance environment.

While these new developments are difficult to predict now, it is clear surgical displays are necessary in the surgical suite, especially as surgeries become less invasive.

“Continuing growth of MIS will drive the demand for displays, not just in overall number, but in demand for the overall functionality and capability,” Zimmer says. “Being that it is such an important tool and surgeons’ window into the patient’s body, there’s going to be a continuing need to provide cutting-edge technology in surgical displays.” 

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