The Red Digital Cinema Co. camera used in a surgery filmed in 4K. ©Steven F. Palter, MD

A visionary surgeon looks to emerging technology outside of medicine to advance camera and video capabilities in the OR.

The first time a camera was hooked up to a laparoscope, it was a film camera. The archival films dating back to the 1940s and 1950s show enormous cameras hooked up in the OR to create the first film images of surgery. By the 1970s, a large video camera was suspended from the ceiling by a rope to hold its weight in the OR.

According to Steven F. Palter, MD, founder and medical director of Gold Coast IVF where he specializes in infertility and reproductive endocrinology, the historical trend of visualization technologies is to start large and rapidly miniaturize. As Dr. Palter explains, this technology has had a lasting effect on the OR since the first surgical image in the ‘40s, and is sure to change surgery as we know it not too distantly into the future.

“I was exposed to endoscopy early on,” Dr. Palter says. “It immediately struck me that this marriage of technology and surgery would change how medicine was practiced. Over the years, I was fascinated by the possibility of applying technologies from outside of the practice of medicine to try to come up with innovative ways of treating our patients and come up with solutions to their problems.”

Having been using standard definition (SD) TV monitors in the OR, in which the image quality was “mediocre at best,” Dr. Palter performed the first surgical case using a small, high-definition (HD) video camera in 2000. He presented the prize paper at the AAGL, and broadcasted the surgery in HD for the first time to a medical audience using industrial projectors.

"In 2000, most people hadn’t even heard of HD yet in their living rooms,” Dr. Palter says. “People were seeing detail and structure that had never before been seen. It was like you had been operating looking through a dirty window, and all of a sudden, you had your eye directly looking at where the disease was and not only that, but you had all the magnification of endoscopy.”

After his debut of HD, Dr. Palter began looking outside of medicine for the next cutting-edge video technology. He turned to what was being developed in broadcast TV and movie theaters, spending time researching gaming, as well as film and video in Hollywood. He focused on two areas of emerging technology: 4K “Ultra” HD and 3D video.

“Ultra” High Definition

“Since surgeons operate with their vision guiding them, I have always believed that the better we can see, the more accurate and better our results will be,” Dr. Palter says.

According to Dr. Palter, 4K refers to 4,000 lines of resolution. Just as SD is approximately 600 lines, HD exceeds 1,000 lines. “Ultra HD” 4K technology exceeds that four-fold.

In 2008, Dr. Palter flew to attend the National Association of Broadcasters meeting to explore the latest in visual technology being used in Hollywood. “I was amazed that there were 105,000 TV, video and Hollywood people there—and one doctor,” he says.

There, Dr. Palter pitched his idea to conduct a pilot project to marry the idea of 4K technology to surgery. “The idea was to come closer to the limits of resolution of the human eye,” Dr. Palter explains. “I anticipated that the better resolution surgeons could get, the more detail we could see and the better our performance would be.”

That year, he teamed up with Red Digital Cinema Company in Hollywood to film the first surgery using a 4K camera. The Red camera crew joined Dr. Palter in the OR, peering “a huge Hollywood 4K camera” into the wound, too large to be hooked up to an endoscope.

From there, Dr. Palter took the footage to a Hollywood post-production facility. Working with Fotokem, the film was produced into a digital movie. Then, in collaboration with Sony's Medical and Professional Broadcast Divisions, who produce some of the world's brightest and highest resolution 4K projectors, the film was projected on a 25-ft. wide screen as the keynote lecture at the 2008 AAGL global conference. The audience of medical professionals was amazed at the detail and resolution presented onscreen.

“Everyone thought that HD was as far as you can go and what I showed them is this is just the tip of the iceberg,” Dr. Palter says.

Using 3D cinema projectors, Dr. Palter and his Hollywood cohorts were also able to project both Hollywood 3D movies and surgical 3D movies on the largest scale, showing them a degree of realism that had never been approached with traditional endoscopy.

“The benefit of 3D is that it directly approximates the way you use your hands in the real world,” Dr. Palter explains. “The hardest part of the learning curve for most people when they learn endoscopy is viewing everything in 2D and having to use your brain when you make 3D movements and that is incredibly awkward at first.”

Systems providing 3D capability for surgeons are presently very limited, Dr. Palter says. However, Hollywood is, again, leading the way with 3D technology containing refinements in cameras, computers and projectors, and technology in the OR is soon to follow.

"This technology is all being ported to the OR now, it’s directly being applied,” Dr. Palter says. “It’s more real. It’s a totally immersive, real environment.”

Futurevision

In addition to Hollywood, Dr. Palter has referred to other developing sectors—such as the military, space exploration and archaeology—to evolve visualization in the OR and see the invisible. He coined the term "futurevision" to refer to the idea of visualization beyond that of the human eye itself.

“I asked, ‘Could we see beyond what the human eye can see?' With high-definition, what I wanted to do was try and increase the resolution so it came close to what my eye saw,” Dr. Palter says. “But then, why not take cameras that can see different wavelengths of light and characteristics of tissue and see if we can see something that’s invisible?”

Using an autofluorescent system from Karl Storz Endoscopy-America (KSEA), Dr. Palter was able to manipulate different wavelengths of light to see beyond the capabilities of the naked eye and diagnose otherwise invisible endometriosis.

“By using technology to manipulate the light, suddenly disease was glowing fluorescent green that would have otherwise been missed,” he says. “It’s the whole idea of using wavelengths of light—autofluorescence, near band, near infrared, narrow band imaging. If you look outside medicine, from military technology to prospecting for oil, this is the technology that they use. All of those technologies that are used outside of medicine are now being applied to the OR, primarily for cancer diagnosis and therapies where disease will be visualized that can’t be seen with the naked eye.”

According to Dr. Palter, the realization of this technology as standard surgical practice is not too far off.

“I think it’s inevitable that’s where we’re going,” says Dr. Palter. “If we can put a rover on Mars and find and test a rock based on its infrared characteristics, it’s not very hard to think that we can miniaturize and manipulate the device to do that inside the body.”

The Technological Transformation Of Surgery

In the end, the advancement of camera and video technology into the OR is working to continually improve surgeons’ ability to care for their patients. Improved surgeon vision has enabled surgeons to perform procedures less invasively, providing patients with faster recoveries and less risk of complications. With endoscopy, there is now what Dr. Palter calls a "technological interface" between surgeon and patient. Now, the interface is being modified with the power of the microchip. It’s a concept Dr. Palter has dubbed the “technological transformation of surgery.”

“Would you rather have a surgeon with 20/20 vision or a surgeon with 20/100 vision?” says Dr. Palter. “If someone has blurry vision, they’re not going to perform as accurately. I believe what will happen is as the resolution increases, screens improve and the immersive reality increases, we’ll go from a surgeon operating remotely through some interface to something in the not-too-distant-future where you can have a completely immersive environment with the surgeon moving and directing activities and looking at projected images and he doesn’t realize that he’s not directly looking and touching.”

For now, Dr. Palter is working on projects to advance “futurevision” in the OR and to miniaturize 4K cameras to enable them to be attached to an endoscope. He says surgeons and hospitals should stand at the ready, because in a mere three to five years, this camera and video technology could become standard surgical practice.

“With the speed that technology is advancing, what used to take years to get a degree of increased quality, we now get that increase every year,” he says. “We get three to five years of progress each year now, and the rate of progress is only accelerating. Even though this predicts that much of what we currently do is likely to become obsolete more quickly than procedures did in the past, that is not a negative. We need to expect and be prepared to understand and embrace this rapid progress and not see it as a threat. Procedures are going to be enabled that never existed before and treatments will only become more effective and less invasive."

Check out Dr. Steven Palter’s blog, www.docinthemachine.com, for more information about surgical technology.