Viewing Images in the OR

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Access to images during surgery benefits surgical outcomes. PACS images displayed on CRTs and flat-panel monitors, mobile fluoroscopic digital imaging systems for interventional and surgical imaging and image-guided surgery systems provide physicians with precise, detailed information to shorten procedure time and improve outcomes. At the same time, filmless operation in the OR does not occur without some challenges - PACS isn't designed for OR workflow, rooms are not always ready for computer installation and cost related issues may hinder hardware options.

Surgeons typically review images outside the operating room (OR) prior to surgery for pre-procedural planning. Specialists such as orthopedic and vascular surgeons and neurosurgeons frequently use images during a case as a "guide." And intraoperative imaging provides precise, detailed information of body structures and is many times used in urology work, hardware positioning, placing pacemakers and other internal devices. Portable x-ray units have been the option for producing these images, but portable fluoroscopy and image-guided surgery (IGS) systems are the growing alternative for intraoperative imaging.

Image viewing changes substantially with the implementation of digital technologies, particularly with the integration of PACS (picture archiving and communications systems). For example, when a healthcare organization installs PACS in radiology, they won't reap the complete benefits of the system if some departments - such as the ICU, ER and the OR - continue to print film. Since these departments all have their own unique workflow, implementing PACS is a time-intensive process that requires planning, ingenuity and persistence.

Perhaps the first question that department heads, section chiefs and surgeons ask themselves when bringing images into the OR via PACS: how will surgeons view the images? Surgical areas are already small and house a lot of equipment. Hospitals also have multiple rooms to outfit, so oftentimes hardware selection is restricted by tight budgets and the variety of specialists and their particular needs. Choices typically include commercial wall- or boom-mounted monitors and/or mobile carts. East Alabama Medical Center (EAMC) in Opelika chose the latter when it rolled out its McKesson Corp. Horizon Medical Imaging PACS in the OR.

The facility is filmless for 95 percent of all the activity in surgery using a wireless network. The only wire from the mobile cart? The electrical cord. A total of six carts are used for the 11 surgery suites and two of the carts have dual monitors, with the remaining four having one. "The one- or two-monitor configuration was a concern for some surgeons who were accustomed to hanging up to five or six sheets of film for a surgical case," says Radiology Administrator Melinda Johnson. "However, after utilizing the one- and two-monitor configuration, they have been quite satisfied with the results."

EAMC planned to implement PACS in the OR within two months of going live in the remainder of the hospital. "In the interim, we purchased a mobile cart and located it in the OR suite for the purpose of training surgery staff," explains Johnson "However, since we decided to utilize McKesson's web product in the OR, the surgeons quickly found that they were familiar with the application [because it was the same application that they were accustomed to on the floor and in their offices]."


The amount of images used in the OR varies among surgical specialties. For example, ophthalmologists and general surgeons may not look at images as much as orthopedic and vascular surgeons. As a result, the number of surgeons who will access the PACS significantly impacts hardware selection and configuration. "In the beginning, we identified surgeons who look at images prior to or during their cases," says Joyce Himes, director of radiology at Ball Memorial Hospital, a 350-bed facility in Munice, Ind.

Radiology at Ball Memorial has been using Eastman Kodak Co. Health Imaging Division's DirectView PACS system 5 since the beginning of the year. The last area to roll out PACS was the OR. Himes says they first installed Kodak's DirectView Web Distribution product so that physicians could view images in their offices and throughout the facility. Next, the hospital rolled out six mobile carts with 19-inch monitors - four carts with one monitor, two with two monitors. "We evaluated the process of viewing images in the OR suite to determine our needs," says Himes.

Certain surgeons prefer to have the images displayed during each case, explains Himes, such as neurosurgeons and ear, nose and throat (ENT) surgeons. For them, images are prefetched [from the PACS] prior to the case and loaded onto a monitor for easy viewing during the procedure. During the operation, the workstations do not need to be accessed by the surgeons for image manipulation because the circulating nurses and OR technicians have been properly trained to use the web product. Himes points out that the facility is considering the possibility of implementing wireless mouses that are encased in sterile packaging for the surgeons.

Space factored into the selection of the mobile carts as well because the OR recently started doing electronic documentation. Surgeons are able to adjust the position of the cart and have it moved closer to or further away from the OR table depending on the surgical procedure and how the patient is positioned.


Richard Dow, MD, chair of the department of surgery at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., decided from the get-go that no mobile carts were going to be used for the extension of radiology's IDX Systems Corp.'s Imagecast PACS in the OR. "The chair of the OR said that he did not want any more cables in the OR, so that meant the displays had to go on the walls," says Monte Clinton, CRA, administrative director of radiology.

Wall- or boom-mounted flat-panel displays, alternatives to mobile carts, are large and therefore must be placed at an adequate distance from where the surgeon will be standing. Consideration also has to be given to the placement of the workstation, including the keyboard and hard drive, and whether or not to use plasma screens or liquid crystal displays. DHMC selected 22 42-inch [Hitachi Ltd.] plasma screens. Placed at the same level as the view boxes, there is one monitor in each OR.

"Initially we contacted our equipment supplier and they brought in five to six flat-panel monitors," describes Clinton. "We brought down the section chiefs from the OR and we put different images on each monitors. We then had the section chiefs pick which monitor they wanted in the OR."

Mounting the large monitors and getting the surgeons accustomed to viewing softcopy images was not too difficult, says Clinton. "Each of the ORs had a data jack in it, sufficient outlets and wall space," explains Clinton. "We had to make a special shelf to hold the workstation and those are placed right below the plasma screen. Surgeons do not have to leave the patient's side to look at the image(s). And they have access to any image [from the PACS] and can enlarge it as much as they want."


Surgeons today view many types of information and images about their patients, such as electronic medical records, laparoscopic images, radiology data and pathology data. There also is an increasing trend toward image-guided surgery (IGS). As a result, ORs must implement a system for viewing images that allows surgeons to be able to switch from multiple sources of images.

At Rush University Medical Center in Chicago, neurosurgeons perform procedures while simultaneously viewing images from the PACS [Siemens Medical Solutions' Sienet PACS], IGS and an endoscopy system. Each of the two neuro rooms are equipped with 21 19-inch flat panel monitors and a Siemens' MagicView 1000 workstation with four distinct video feeds. The video sources that generate images and the PACS workstation feed data into a Stryker Corp. Video Network Hub. The video switch is manually operated by an OR technician on demand and routes video signals to various display screens. For example, a surgeon may ask that an image from the PACS workstation be displayed on a screen to the left of the OR table and the images from the endoscope be displayed on the right.

Surgeons prepare ahead of time to know exactly which PACS images are going to be displayed during the operation or procedure. "The workstation queries the PACS archive to retrieve the images, which are then displayed on one to four monitors that have been mounted on the wall next to a view box [in case the patient has hardcopy priors for comparison]," explains Kiley Rogers, PACS/IT administrator at the facility. "The surgeons will use these monitors for pre-procedural planning. During the procedure, if a physician wants to actually see a specific slice or image, [it can be routed to] a monitor which is closer to the physician."

In addition, the room is equipped with a computed radiography (CR) system. If CR images are taken during a case, the technologist develops the cassette across the hall and the digital information is immediately forwarded to the OR room. The images also are archived in the central PACS server in radiology.


Intraoperative imaging allows surgeons to evaluate structures such as bones, joints and hardware during surgery. While portable x-ray units produce these images outside or inside the OR depending on the placement of the film processor, C-arm fluoroscopy is an alternative because it produces immediate and real-time images on monitors in the OR. Utilization includes prosthesis/hardware positioning, cardiac catheterization, thin-needle biopsies and localization of foreign bodies.

H. Jay Boulas, MD, an orthopedic surgeon at Hand & Upper Extremity Surgery in Dallas, frequently uses Hologic Inc.'s Fluoroscan Premier Encore mini C-arm. The compact imaging system is ideal for extremity surgery because it is easily maneuverable in and out of the operative field, says Boulas. The C-arm is used for fracture care and looking at joints. "It can also be used in some reconstructive aspects," continues Boulas. "For instance, in arthroplasty, if [the surgeon is] replacing a joint and wants to see the position of the implant."

C-arms are used in orthopedic surgery to assess the work that needs to be done and the work that has been completed. "You might be using the C-arm before you even get started to assess fracture position," explains Boulas. "You may need the C-arm to help during the process of assessing the type and pattern of fracture. At the conclusion of the case, you may need to verify that the hardware is in good position and the fracture is well-aligned."

According to Boulas, C-arm fluoroscopy increases accuracy and decreases procedure time. "With conventional x-ray, there is a little bit of guessing [involved]," says Boulas. "You don't see the picture while you are taking it. You position what you think ought to be the perfect picture and you take it. With fluoroscopy, you maneuver your object of interest into the view of the fluoroscope and you see your picture in real-time."


IGS systems take pre-operative and intra-operative images and couple them to a tracking technology that follows the movement of the surgeons during the course of an operation. The surgeon can see his or her location in real-time on a computer screen with the images of the patient used as the localizing technique. One of the leading companies in the IGS market, Medtronic Inc., offers the StealthStation through its Surgical Navigation Technologies (SNT) division. Donald Bucholz, MD, the KR Smith endowed professor of neurosurgery at St. Louis University School of Medicine, is co-developer of the technology.

"The device was initially developed for cranial surgery," explains Bucholz. "Subsequently, other surgeons became interested in the device for spine, orthopedics and ENT procedures. There also is a coupling of image guidance with minimally invasive techniques to allow surgeons to orient themselves in sometimes very complicated situations when they are peering into the patient's body with an endoscope or some other device. This can help surgeons avoid damaging tiny, critical structures in the body when using minimally invasive surgery."Surgical navigation systems are oftentimes utilized with additional imaging devices, such as recording equipment and fluoroscopic equipment, for sophisticated procedures. Deep brain stimulation for Parkinson's disease is an example of this, Bucholz says. "We place electrodes deep into a part of the brain that when stimulated can enumerate many of the symptoms associated with Parkinson's disease," he says. "The trick is getting the electrodes in the right place, so you are trying to navigate the electrode deep into the structure. We use a combination of guidance techniques to get this in the right spot."

"We use images to get into the vicinity of where we want to be and then we actually use the recording from the specific neurons to land ourselves right on target. You have to encounter different modalities at different times. At one point, its imaging, at another its audio recording and at still another point, it is fluoroscopic images. We are literally using the best of everything - CT scans for their accuracy and lack of distortions, MRI for their tissue detail, recordings for their exquisite localization techniques and fluoroscopy to doublecheck in the OR in real-time to make certain that there are no problem movements in the electrodes."

There is a monitor on each imaging device and they routinely have to use the largest OR room to accommodate all the different equipment. Also, the systems are not integrated or "talking" with each other. "We are suggesting that a similar protocol [to DICOM] should be adopted by the operating room so that all these diverse devices speaking the same language can be controlled in one unified way," says Bucholz.


The OR is a prime example of technology advancement that boosts outcomes, as more and more surgeons incorporate revolutionary imaging devices into their practices to improve patient care. And PACS in the OR will advance to become a seamless operation as companies continue to unveil technologies that specifically address the idiosyncrasies of OR workflow in a digital environment. For example, in May at the 2004 SCAR (Society for Computer Applications in Radiology) meeting, GE Healthcare demonstrated a surgical PACS prototype called "Rosie" that allows surgeons to interact with the application without having to use a keyboard or a mouse.

How To Do It Right
By Joseph A. Scopelliti, I.T. Section Head of Radiology Medical Informatics, Geisinger Medical Center, Danville, Pa.

Viewing of PACS images carries with it unique challenges on various fronts. In addition to the requirements associated with high-resolution image viewing, such as computed radiography, direct radiography, and clinical enterprise-wide distribution (with the infrastructure and training issues involved), PACS in the operating room carries its own set of challenges.

Clearly, implementing PACS in the operating room creates different challenges than in reading rooms, offices and even examination rooms. Some of these include:

Pulling network cables and mounting the monitors and/or shelves for the workstations requires adherence to strict Department of Health guidelines. This can, and probably will, add cost and time to the project.

In the operating room, the film lightbox is typically six to 10 feet from the wall. A standard PACS workstation placed next to the wall would more-or-less simulate the view a surgeon got hanging film. Better options include hanging monitors from ceiling-mounted C-arms, or a large-screen hanging on the wall.

OR workflow is inherently different than in other clinical areas. The primary user, the surgeon, is typically scrubbed and not in a position to use the keyboard and mouse. Therefore, either more people need to be involved in the process of selection and/or manipulation of images, such as a circulating nurse, or hands-free tools, such as foot pedals or speech recognition, need to be employed.

The operating room is a critical area, where image display is imperative. Plans must be put in place for the contingency of the PACS workstation not functioning, either because of hardware or network problems.

  • We have a second, standard PC in each operating room, which could display images if the primary PACS workstation fails.
  • The second PC is on a separate network than the PACS workstation, so, if the network fails, image access could be attained from the second workstation.
  • Film could be printed for that case and sent to the OR. (We have not removed any film viewboxes.)

Almost by definition, an operating room requires bright light; therefore, monitor display is very important. In our initial phase of PACS implementation of the operating rooms, we setup the rooms with 50-inch plasma monitors. While adequate, they did not offer quite the acuity that we had hoped. By the time we set up the second half of the 32 operating rooms on the main campus, we were able to purchase 40-inch LCD displays, which offered a much crisper view, especially from an angle. The LCDs also generated less glare, important in the brightly lit OR. Additionally, the LCDs were less susceptible to image burn-in, not an unlikely possibility in an environment that may display a single image set for hours at a time.

Given the need for a clutter-free environment in the OR, we chose to mount everything off the operating room floor. The monitors were mounted at standing eye-level; further, the CPU, mouse and keyboard also were wall-mounted with a computer holder, even allowing the keyboard/mouse plate to be folded up when not in use.

Some video settings were modified by the OR staff, which occasionally led to help-desk calls. People were in the habit of modifying certain settings on their office PCs, such as desktop backgrounds and screen-savers, so they changed the OR PACS workstations also. There were a few occasions of manually tampering with other settings, such as monitor selection, which caused problems with proper operation of the workstation. This has led us to "locking down" the workstation, so that the end-users cannot make control panel changes.

The large-screen PACS monitors were implemented, accepted and utilized quite successfully in the OR pilot project. This offers our surgeons online image access in a way that meets their needs better than hardcopy film. Clearly, if the OR challenges can be overcome, the benefits of soft-copy viewing are a real benefit to the surgeons.

In light of the unique workflow and environment, the next steps will likely involve more "hands-free" features, such as speech recognition, foot pedals, or a combination of these sorts of tools. In this manner, surgeons in the operating room will not only have large, acceptable images that can be seen from the operating table, but also the ability to manipulate those images in a hands-free environment.