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March 19, 2007

3-D Surgery: A New Dimension in the OR
By Thomas G. Dolan
For The Record
Vol. 19 No. 6 P. 32

New technology gives surgeons better visualization during complex operations.

When hearing the term 3-D, people may think of those funny glasses which give flat screens another dimension. The plastic eyewear, which was popular during the ‘50s, never made much of a dent in feature films but remained a short-lived novelty. Bespectacled patrons sat on the edge of their seats as the action burst from the screen.

More recently, 3-D has made a name for itself in military applications. Topographical 2-D depictions of enemy terrain from aerial photography, given a third dimension, make troops, weapons, and facilities stand out.

In the healthcare industry, 3-D has taken its powers inside the human body to allow surgeons to perform difficult surgeries with far more confidence.

3-D Technology
The 3Di Digital Vision System from San Diego-based Viking Systems offers physicians a trio of unique options, according to CEO Donald E. Tucker.

The technology’s 3-D vision provides natural depth perception and a clear view of the patient’s anatomy. Two tiny cameras are inserted through minute incisions into the patient just as the surgical tools are inserted below the skin. The image is projected through these two cameras in visual stereo into the physician’s headset. “We see the world in three dimensions,” Tucker says. “So a physician forced to look at a patient’s magnified anatomy through two dimensions is naturally limited.”

A second innovation is the head-mounted display, a more ergonomically friendly solution that allows physicians to look directly at the operating area, saving them from craning their necks to look back and forth from the patient to the screen, which can be a strain, especially during a long operation. Up to three headsets can be attached to each system, allowing the surgeon’s assistant and scrub nurse to also have a 3-D view of the action. Tucker adds that the system allows the physician to easily bring into focus not only the immediate working area but also adjoining areas to see how the procedure is affecting them.

Along with those features, additional information can be brought into the surgeon’s view in a voice-controlled, picture-in-picture format. In other words, while viewing the anatomy, the physician can prompt a second picture, such as an ultrasound, x-ray, or CT scan, to appear simultaneously. This can facilitate decision making during surgery. In addition, Tucker envisions surgeons eventually adding other informatics, such as a patient’s medical records, for screen-in-screen viewing.

To date, the system has been used mainly in geriatrics, urology, and gynecology, as well as colorectal surgery, bariatrics, and complex general surgery. Tucker says the company is currently directing its marketing to three new areas: spinal, head and neck, and cardiac—all difficult surgeries.

Gerald Andriole, Jr, MD, professor of surgery and chief of the division of urologic surgery at Washington University School of Medicine in St. Louis, reports that as urologists and other surgeons have been increasingly switching to minimally invasive surgical techniques, such as laparoscopy, and the complexity of the procedures has been growing, the limitations of 2-D became apparent.

“If you’re doing a simple radical vasectomy, that’s one thing,” he says. “But if you’re interested in doing more complicated procedures, such as a prostatectomy or reconstruction of the urinary tract, 2-D poses a lot of limitations. With 2-D, the surgeon cannot accurately perceive depths. If you’re doing a prostatectomy, one of the major things going on is that just a few millimeters away are neurovascular bundles that need to be preserved if the erectile function is to be preserved. With 2-D, you are sometimes not able to see these nerves.

“But once I began to use the Viking 3-D system, I can categorically state that my ability to perceive the complex relationship from the edge of the prostate to this bundle of nerves has seen a substantial improvement,” he adds. “This translates into not only a better outcome for the patient but also a speedier surgery.”

Andriole says that approximately one year ago, his institution brought numerous surgeons for a three-day course to learn more about complex laparoscopies. “We put them through 2% training, then 3-D training with the Viking system,” he says. “On average, surgeons were able to learn 20% faster with 3-D over 2-D. Those with the least experience, who were still residents in training or had just entered their practice, learned up to 50% quicker.”

Julio Pow-Sang, MD, division chief of genitourinary oncology at H. Lee Moffitt Cancer Center in Tampa, Fla., started using the Viking system in late 2005 and performs approximately seven laparoscopic prostatectomies per week. “3-D makes a huge difference because you can be more precise and see the difference between different tissues,” he says.

The use of 3-D technology in medical imaging can be traced back to 1993, when, according to Tucker, San Diego-based Vista Medical Technologies, a spin-off from what is now known as Rockwell Collins, purchased the system from the military. Vista saw the technology’s promise in the medical field and started investing heavily in it, developing it primarily for cardiac surgery.

But heart surgeons have been slower than most in developing minimally invasive techniques, so Vista started to develop it for bariatric procedures. By 2000, the company had shifted its marketing focus exclusively to providing consulting services to hospitals that offer gastric bypass surgery, an increasingly popular and lucrative procedure for helping morbidly obese people lose weight. Still, Vista was having financial troubles.

Meanwhile, Tucker was a partner and senior executive at Accenture, a global consulting company, where he specialized in product and market development, supply chain management, and strategy formulation. He knew about Vista and how it wanted to sell its vision systems. He thought it looked like a good investment. “With hospitals increasingly pushing outpatient care and minimally invasive surgery, the technology had a clearly defined and growing market,” he says. “I thought the technology should be at the value center of the hospital, which is the surgery center for most providers.”

Tucker basically bought out Vista to start Viking, which has been in business for a little more than two years. The first year of operations was devoted to putting the project back into engineering, improving its resolution, and adding new features such as the headsets and voice commands to pull up other records. The second year was spent positioning the product in the marketplace. Only in January 2006 did the company start actively building a sales and distribution presence. In May, Tucker retired from Accenture to focus solely on Viking.

Another Option
The da Vinci Surgical System, which also utilizes 3-D technology, was introduced in 1999 by Intuitive Surgical, Inc. This form of minimally invasive robotic surgery provides technology and procedural innovation across cardiac, urologic, gynecologic, pediatric, and general surgical disciplines. The system is in use at more than 300 academic and community hospitals.

Most doctors agree that urological surgery is the area where the da Vinci system is now most often used, but physicians are exploring other surgical procedures where it could be utilized.

“When it [the da Vinci system] first came out, it really didn’t take off rapidly,” explains Louis Kavoussi, MD, chairman of urology at North Shore-Long Island Jewish Health System in New York. “But then there was some interest in applying it to laparoscopic prostate surgery and, lo and behold, it actually did facilitate that surgery and markedly increased surgeons’ dexterity to the laparoscopic approach.

“That’s the main advantage,” adds Kavoussi, who has used the system for roughly five years. “It makes the laparoscopic approach easier, so potentially more surgeons will have the ability to do it.”

“It’s good for procedures that really require precision,” says Daniel Scott, MD, FACS, director of the Southwestern Center for Minimally Invasive Surgery at the University of Texas Southwestern in Dallas, who has used the system since 2002. “You achieve precision that surpasses what is humanly possible.”

Kavoussi notes that even though the da Vinci system is considered robotic, it is really a computer-aided machine.

“You can’t be lulled into a sense that it’s automatic, that you just put it on the patient and it does all the surgery for [the physician],” says Kavoussi. “The surgeon is still doing the surgery and still needs certain surgical skills and surgical knowledge to do the surgery, but at least it’s within the grasp of many more surgeons.”

The patient-side cart of the da Vinci system has arms to attach cameras and instruments that are inserted into a patient through several tiny incisions—each approximately 1 centimeter long—and subsequently perform the suturing and other tasks that comprise the procedure. As with typical laparoscopic surgery, the area where the procedure is being performed is filled with air.

Sitting several feet away from the patient on the operating table and looking into a large console is the surgeon, who uses small joysticks to make movements that are translated to the instruments and the camera inside the patient.

One difference between the Viking and Intuitive systems is cost. Tucker says the Viking price tag falls between $120,000 and $160,000, depending on the amount of informatics attachments included. Pow-Sang says the Intuitive system is effective, but his institution chose Viking in part due to financial concerns. The da Vinci Surgical System carries a price tag of approximately $1 million, plus the costs of a service contract and regular maintenance.

Also, the Viking system, Pow-Sang says, “is very ergonomic. You’re using a headset, so you don’t have to be turning your head and looking at a screen for a couple of hours. And it allows you to move around. The robot requires you to sit down and look through a microscope-type device for several hours at a time.”

— Thomas G. Dolan is a medical/business writer based in the Pacific Northwest.