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Zeiss Informed Issue 4

1. Takagi Y Kikuta K Nozaki K Sawamura K Hashimoto N Detection of a residual nidus by surgical micro scope integrated intraoperative near infrared indo cyanine green videoangiography in a child with a cerebral arteriovenous malformation J Neurosurg Pediatrics 2007 Nov 107 5 416 8 Image courtesy Fig 1 Yasushi Takagi M D Ph D Department of Neuro surgery Kyoto University Graduate School of Medicine Japan Fig 2 Journal of Neurosurgery Pediatrics published by the American Association of Neurological Surgeons Char lottesville VA USA contact Yasushi Takagi M D Ph D Department of Neurosurgery Kyoto University Graduate School of Medicine 54 Kawahara cho Shogoin Sakyo Kyoto 606 8507 Japan www med kyoto u ac jp Facts and Figures Invention of the optical telegraph 1794 First successful electric telegraph message sent by Samuel Morse 1844 First successful telephone transmission made by Alexander Graham Bell 1876 Sputnik launch as the first artificial space satellite 1957 Demonstration of a telemedecine link of over 112 miles from the University of Nebraska Norfolk State hospital 1964 Creation of ARPAnet as the word s first computer network 1969 First robot assisted surgery in placing a needle for a brain biopsy 1985 Tim Berners Lee invented the World Wide Web 1989 Carl Zeiss develops the MKM the first surgical microscope for navigation linked to a computer 1993 C
2. 4 Gary Armstrong Barrow Neurological Institute Phoenix AZ USA Fig 5 Jackie Mercandetti Phoenix AZ USA Gary Armstrong Biomed Photographer Barrow Neurological Institute St Joseph s Hospital and Medical Center 350 West Thomas Road Phoenix AZ 85013 4409 USA Gary Armstrong chw edu www thebarrow org Expanding the Horizon of Clinical Education Practical Anatomy e Surgical Education Saint Louis University School of Medicine Karen Hutsel M S N R N Developments in the medical field advance at a tremendous rate The more sophisticated a technique the more important training and education becomes Hands on workshops in particular represent an ideal opportunity to learn about newly developed technologies and applications Individual workshops often spawn ideas series or even whole training centers through close cooperation between physicians and industrial partners INFORMED 4th Issue May 2009 3 1 Expanding the Horizon of Clinical Education 3e Surgeons have the ability to learn about newly developed technologies and applications in a most auspicious learning environment Medical progress leads to innovations that open up new opportunities in all medical specialties So now more than ever surgeons must work to stay current with the newest surgical techniques and rapidly evolving medical advancements From the very start of their training medical students gain useful expe rience w
3. Can t beat that e I m often surprised how quickly dust accumulates on a camera s image sensor You can waste a lot of time with photo editing software removing those pesky dark specks or you can keep the sensor clean Consult your camera manual for cleaning instruc tions or visit your local camera repair shop e With the camera s viewfinder exposed it is possi ble for stray light from the surgical field to affect your exposure It s a good idea to block the view finder use a piece of black electrical tape Thinking photographically Putting all the above technical issues aside one big variable factor in getting terrific photographs is the surgeon behind the scope So be aware of the fol lowing Focus focus focus It simply must be spot on for a great picture Tip Adjust the microscope s eye pieces The eyes compensate for a subject slightly INFORMED 4th Issue May 2009 Flow to Take Good Pictures 3Q out of focus The subject may look sharp to the sur geon but often the focus is quite soft for the camera Turning on the Focusing Aid Laser Spots will help they tell no lies What you see is not what you get Many beautiful shots are unacceptable because the main point of interest is off center and at the edge of the photo frame The problem is that the surgeon s field of view is different than that of the camera For accurate framing a surgeon must imagine the aspect ratio of the camera s rectangular f
4. Tomorrow s medical environment and surgical equipment will undoubt edly be connected to communication networks opening new horizons for surgical applications and knowledge exchange As Tim Berners Lee once stated The fact that we re all connected the fact that we ve got this information space does change the parameters It changes the way people live and work Image courtesy Fig 1 and 2 Gary Armstrong Barrow Neurological Institute Phoenix AZ USA INFORMED 4th Issue May 2009 10 See It All Come Together An interview with Robert F Spetzler M D The BNI is an internationally renowned neurological center where neurological procedures are the specialty Since 1962 the Institute continues to unlock the mysteries of the brain and spine through pioneering research cutting edge technology and intensive medical education In the following interview its director Dr Robert F Spetzler comments on collaboration and connectivity Barrow Neurological Institute BNI at St Joseph s Hospital and Medical Center in Phoenix AZ is inter nationally recognized as a leader in neurological research and patient care Since its beginning in 1962 when Charles Barrow made a generous gift to St Joseph sHospitaltobringrealitytoDr John Green s dream of building a neuroscience institute the BNI has grown to become one of the leading neurologi cal specialty hospitals in the world Along the way it has established acclaimed subspecial
5. e In the INFRARED 800 application the infrared cameras of navigation systems may cause distur bance in the INFRARED 800 video image on the screen display Prior to the procedure perform a function test using the fluorescence target for INFRA RED 800 in order to check whether any reflections INFORMED 4th Issue May 2009 are being caused by the positioning of the infrared light sources and reposition them if necessary If any reflections occur prevent or minimize the presence of light by tilting or covering the eyepieces Ensure that if an antenna has been installed for the navigation system the permissible overall weight on the surgical microscope including accessories e g spine adapter camera adapter stereo coobser vation tube micromanipulator does not exceed the limits specified in the user manual Video signals External video sources such as an endoscope cam era can be attached to the surgical microscope via the Video In Y C video data interface on the sus pension system This connection can be completed in a plug and play manner without any further accessories as the MultiVision system automatically recognizes NTSC and PAL video signals Use the connecting cable supplied with the mi croscope to connect a video source to the surgical microscope e The shutter which removes the surgical image is only activated when appropriate such as when an external video signal is also available When selecting an input w
6. INFORMED In what way is OPMI Pentero important for you as far as connectivity and integration is concerned Spetzler For the neurosurgeon the microscope is the tool that allows us to do modern neurosurgery So the more functions that are integrated the more effective we will be INFORMED Ath Issue May 2009 My favorite is indocyanine green videoangiogra phy The ability to look at blood vessels to see the inflow and outflow and to see whether an aneu rysm is clipped appropriately has been an incredible boost recall three cases in which the aneurysm looked to be clipped perfectly through the micro scope Yet when we checked there was no flow through one of the branches Given how long it takes to do an intraoperative angiogram or the out come of not doing an angiogram at all those three patients most likely would have had a significant stroke This new information is readily available and doesn t encumber the flow of the work That makes a huge difference to us INFORMED Does the exchange of intraopera tive data and images play a big role for you regarding the exchange with other clinical experts Spetzler As a surgeon who spends a lot of time talking to other surgeons being able to record op erations and techniques is critical The digital inter face of OPMI Pentero can be integrated with the hospital system so that can actually observe the digital images in my office have the ability to add to them onl
7. Martin grade III arteriovenous malforma tion can be seen in the left frontoparietal lobe Cerebral angiogram obtained after first operation anterior posteri or view b The residual nidus fed by the anterior cerebral artery can be seen Surgical view c and e and indocyanine green angiography d and f during the second operation The residual nidus fed by the anterior cerebral artery c was removed e ICG disclosed that the residual nidus d was totally resected f Raabe et al also showed that the findings identi fied on ICG videoangiography were consistent with those on postoperative digital subtraction angio grams As for cerebral aneurysms the ICG tech nique provided information relevant to the surgical procedure in 996 of cases including vessel occlusion or stenosis and residual filling of aneurysms Among our 14 cases of cerebral aneurysms we re arranged the position of clips in 2 cases based on the image of ICG videoangiography Perforating ar INFORMED 4th Issue May 2009 41 42 teries are commonly involved during the surgical dissection and clipping of intracranial aneurysms During aneurysm surgery Oliveira et al reported that perforating arteries were found in the surgical field in 36 of 64 cases In addition to the above mentioned cases ICG videoangiography has the potential to detect shunt point in dural arteriovenous fistula and the patency of dural sinus during tumor surgery During caro
8. U S to offer Gamma Knife radiosurgery to treat brain tumors and cerebrovascular malformations in criti cal locations of the brain which represents a revolu tion in neurosurgery And we are also one of the major clinical teaching and research centers for treating cerebrovascular disorders INFORMED Networking and connectivity are popular topics today Where do you see the greatest benefits for surgery by connecting the information flow of different devices Spetzler Just take the CyberKnife technology It combines robotics and image guidance to deliver Surgically precise radiation to destroy intracranial and extracranial lesions For me personally image guidance which is inte grated into the microscope has made a huge difference because operate on so many brain stem cavernous malformations When you look at the brain stem it can look perfectly normal and you don t know exactly where the lesion is located Knowing that image guidance can help you INFORMED 4th Issue May 2009 4 1 12 Why Barrow Neurological Institute BNI has become one of the leading neurological specialty hospitals in the world determine the exact trajectory that is best for a particular cavernous malformation has made a huge difference That we can add on an endoscope and also see the image in the eyepieces all that sort of integration and connectivity has made a huge difference in how we perform neurosurgical procedures
9. camera side you can change three items ISO Shut ter speed and Auto Exposure Bracketing SO sets the light sensitivity of the camera s image sensor which typically runs from 100 to 1 600 In creasing the ISO increases the light sensitivity of the sensor but also increases image noise Keep the ISO as low as you can e Shutter speed sets the length of exposure De creasing the shutter speed will increase your expo sure but also increases the chance of motion blur Keep the shutter speed as high as possible e Auto Exposure Bracketing AEB decreases and then increases the normal exposure up to 2 stops in 1 3 stop increments over three successive shots Think of it as exposure insurance for the often unpredictable intraoperative situation The down side is that the surgeon will have to pause while three pictures are taken Note that this mode will INFORMED 4th Issue May 2009 change the shutter speed to alter exposure The next set of exposure options reside on OPMI Pentero e Light Intensity can be varied from 0 to 100 In my experience this setting can change significantly from surgeon to surgeon and from procedure to procedure If possible use the same light intensity setting during intraoperative photography as your pre surgery exposure setup The Flash During Capture setting gives you a consistent level of light by flashing the light of OPMI Pentero regardless of its intensity setting The downside is th
10. has remained dedicated to the development and presentation of innovative medical health and science workshops The partnerships that have been forged with leading physicians facilities and corpo rations provide an ongoing valued resource and support for the surgical community In turn the PASE program would have been impossible without the close support of these partners To the next level Because of the organization s design and commit ment to education PASE consistently attracts the world s leading surgical experts to instruct and lead workshops providing the highest standard of educa tion for each specialty area Medical students and residents are able to engage in a positive and con structive exchange with the foremost practitioners in each respective field The dedicated commitment to practical education by medical device companies such as Carl Zeiss has ensured that the surgeons of tomor row have the ability to learn the latest surgical tech niques in a most auspicious learning environment With the ongoing challenges of microsurgery hands on training with surgical microscopes and other in strumentation is a basic integral part of our program By providing innovative solutions for visualization dur ing surgery Carl Zeiss plays a major role in developing new forms of therapy improving health and quality of life When new technologies and fields of application are developed these workshops benefit both physi cians
11. starts in the OR with digital video and photography euo INFORMED 4th Issue May 2009 As a photographer at St Joseph s Hospital and Medical Center in Phoenix Arizona encounter a wide variety of subjects to photograph and video record From complex brain surgery to exotic cran iofacial procedures to live intraoperative teleconfer encing and even photo journal art get involved in a bit of everything My job takes me right to the frontline of the multimedia explosion in medicine where get to lay my hands on the latest emerging technology in visual communication My main duty is to serve Dr Robert Spetzler and his fellow neuro Surgeons at Barrow Neurological Institute BNI As a member of the Multimedia Lab team digital image capture in the BNI Operating Rooms is my area of responsibility This year out of Barrow s roughly 6 000 cases we will video record 1 600 of them and shoot over 3 000 photographs Those numbers testify to Barrow s investment in cutting edge digital technology for documentation lecture presentations teleconferencing interactive multi media journal publication research and teaching With eleven OPMI Pentero surgical microscopes and nine digital still cameras to setup and manage daily l ve done my share of intraoperative photography experimentation Fig 2 High quality intraoperative still image of an aneurysm captured with an externally mounted camera on the microscope So please cons
12. the modern OR and in medical technology in general M D Ph D chairman and division leader in the Department of Neurosurgery at the University of Naples Federico II INFORMED What are the main differences be tween the work in today s OR as compared to the OR of 10 years ago Cappabianca Today we use surgical equipment and instruments in the neurosurgical OR which were not available 10 years ago for example naviga INFORMED 4th Issue May 2009 the operation For example the MultiVision technol ogy of OPMI Pentero offers an intuitive open inter face for virtually any additional visual information To maximize the instruments capabilities and pro vide an improved OR workflow it is best to connect them and allow the information to flow between all the instruments In essence the surgical microscope becomes part of the surgeon s cockpit INFORMED Which are the most important in formation interfaces required in the OR and what potential do you see in improving the workflow here Cappabianca Among the most important infor mation required in the OR is radiological image data A major improvement is the interface to the radiological PACS which allows for direct access and displays the images in the OR Furthermore to be able to document communicate and share the Surgical procedures the OR instruments need to interface with communication tools such as PACS images from Pathology with the respective
13. 4th Issue May 2009 V7 Dand ie INFORM For Medical Professio EDITORIAL Dr Hans Joachim Miesner Dear Readers Network connectivity seems to be a common trend affecting nearly every aspect of our daily lives In fact without the creation of the Internet some 40 years ago we might not be talking about the flattening of the world right now Due to the increased connectivity and collaboration more people than ever can work together to develop products and provide services The resulting synergies have produced amazing innovations and the technological advancements of the last few years have been dramatically shaping our world and bringing it closer to us Consequently this trend has been making its way into the OR With the electronic integration of almost all clinical data and the capability to capture archive and share clinical information and images the medical field is becoming more and more networked Having access to skilled physicians not available on site and the ability to share knowledge with others beyond the facility s boundaries are benefits for everyone The enormous technological and scientific progress is leading to innovations that open up new opportunities 1n all medical specialties Surgical equipment 1s and will be more and more sophisticated in the future Nothing will operate in a vacuum anymore This fourth edition of INFORMED will shed some light on what the future may hold for the inte
14. a tradition since its doors opened in 1962 Our mission is to improve patient care and to advance neuroscience knowledge by continually enhancing our capabili ties in rehabilitation imaging and surgical tech niques Our staff participates in ongoing education in their respective fields Grand rounds in neurosur gery neurology and pediatric neuroscience are held weekly often hosting visiting professors from lead ence to provide current and future physicians with the education and experience needed to prepare them for a lifelong appreciation of medicine The BNI has the largest neurosurgical residency program in the U S and thus is preparing the next generation of neurosurgeons and neurologists INFORMED Thank you very much for this in formative interview Image courtesy Barrow Neurological Institute Phoenix AZ USA Robert F Spetzler M D Director Barrow Neurological Institute St Joseph s Hospital and Medical Center 350 W Thomas Road Phoenix AZ 85013 USA www thebarrow com INFORMED Ath Issue May 2009 13 The Future of the Surgical Microscope 1n the Integrated OR Jurgen Meixensberger M D Ph D IT networks play a key role in the modern hospital The integrated OR requires state of the art information and communication technologies as well as stan dardized interfaces The surgical microscope is an ideal platform for streamlining various types of information making it easily available
15. and Carl Zeiss alike according to the motto Give away everything you know and more will come back to you as author Paul Arden once wrote The support PASE has received from companies such as Carl Zeiss has kept us at the forefront as one of the world s leading education institutions Carl Zeiss has been an instrumental industrial part ner in helping PASE reach some of our major pro gram milestones In January 2003 Lab A officially was renamed the ZEISS Learning Center in honor of the donation of 26 new surgical microscopes The Carl Zeiss sponsorship has elevated this state of the art laboratory to the next level The ZEISS Learning Center now consists of 26 dissection work stations equipped with floor mounted surgical mi croscopes high resolution monitors suction irriga tion and other essential surgical instrumentation which work to simulate a standard operating room setting Step by step surgical procedures are dem onstrated at the master workstation and are pro Hands on training with the surgical microscope is an integral part of microsurgery courses INFORMED 4th Issue May 2009 vided through a direct video feed to each participant workstation Many influential medical organizations such as the American Academy of Orthopedic Surgeons AAOS American Association of Neurological Sur geons AANS Cervical Spine Research Society CSRS and the Congress of Neurological Surgeons CNS hold annual workshops in t
16. arl Zeiss introduces MultiVision display concept 2000 First robotic surgery in the removal of a brain tumor 2008 Estimated number of satellites launched by 2008 6 000 Estimated length of undersea cables linking all parts in the world 107 000 miles Estimated number of world wide Internet users by 2008 1 4 billion INFORMED For Medical Professionals in Neuro ENT and Spine 4th Issue March 2009 Published by Carl Zeiss Surgical GmbH A Carl Zeiss Meditec Company 73447 Oberkochen Germany Commercial register Ulm HRB 501602 USt IdNr DE 814 227 537 President Thomas Simmerer Editor in Chief Dr Hans Joachim Miesner Carl Zeiss Surgical GmbH Responsible as defined by Paragraph 10 Section 3 of the German Interstate Media Service Treaty MDStV Editorial Board Ed Asturias Carl Zeiss Meditec Inc Dr Bernd Kimmerle Carl Zeiss Medical Software GmbH Christian Nasdala Carl Zeiss Surgical GmbH surgical meditec zeiss com www meditec zeiss com informed Design amp Layout Publicis KommunikationsAgentur GmbH GWA 91052 Erlangen Germany Printed by Druckwerk Sud 88339 Bad Waldsee Germany Image Courtesy If not otherwise specified the photos originate from Carl Zeiss Page 3 Gary Armstrong Barrow Neurological Institute Phoenix AZ USA Page 22 23 Photo Department NASA Headquarters INFORMED 4th Issue May 2009 2009 by Carl Zeiss Surgical GmbH 73446 Oberkochen Germany All rights reser
17. at the flash can be a distracting an noyance to some surgeons e Depth of field can be set to Small or Large and is found by navigating through CONFIG OPMI and DIAPHRAGM The Small setting widens the scope s lens aperture letting in more light and de creasing the depth of focus The Large setting nar rows the aperture diminishing the light but increas ing the depth of focus However use the Small Fig 5 Live video is revolutionizing the OR experience and establishing new possibilities in medical education and communication setting because have found that the shallow depth of field helps the surgeon to focus more critically As a place to start with these options try a shutter speed of 125 at ISO 400 while setting OPMI Pentero to Flash During Capture and Small depth of field encourage you to experiment with these settings until an optimum exposure and focus is obtained Details details It s often the overlooked things that spoil a photo graph Here are three items to keep in mind Clean lenses a clean sensor and a blocked viewfinder e It s almost too obvious to mention but often find foggy residue on the scope lens having been cleaned with only a wet towel use ZEISS Lens Cloths religiously to keep both the scope lens and camera adapter tube lens clean As the box declares they are The ultimate convenience in lens cleaning for the ultimate lens and coating technology
18. ative navigation is now an indispensable tool of many surgical proce dures In the field of neurosurgery in particular the utilization of such systems has proven to be benefi cial in many procedures Additionally the simulta neous use of an endoscope and a surgical micro scope has been instrumental in order to effectively evaluate complex anatomical situations and to clearly visualize deep lying structures not directly seen with the surgical microscope However how INFORMED Ath Issue May 2009 can a surgeon process the constant flow of diag nostic navigation and system information without having to take his eyes from the surgical field Much like a pilot using an instrument display in his cockpit the surgeon should also have all the essen tial information at his disposal on demand For this purpose the surgical microscope offers a unique platform for integrating essential patient data and pre operative imaging information optimizing instrument positioning and navigation The inte grated MultiVision data injection system allows the surgeon to visualize navigation image and video data easily and quickly in his microscope eyepiece and therefore at the mere push of a button obtain information for which he would otherwise have to search on different monitors in the OR This combi nation permits the parallel use of modern technolo gies in an extremely efficient way The following recommendations will help you obtain an optimum re
19. ecorded video live video is revolutionizing the OR experience and expanding my area of service An exciting break through in intraoperative multimedia is the INFORMED 4th Issue May 2009 BNI s MedPresence System Establishing a new frontier in medical education and communication MedPresence is a 1 1 million video conferencing system allowing students and other observers to in teract live with surgeons in the OR Seated in the MedPresence Conference Room or in a similar room thousands of miles away observers can speak with the surgeon while viewing the procedure from mul tiple perspectives Well in this new era of medical multimedia it s hard to predict what the future might bring but its a good guess we will be viewing itin HD and 3D Tomorrow s medical multimedia en vironment will undoubtedly be bigger sharper and more realistic Watching a display will be like seeing through the eyes of the surgeon One can only imag ine what s next so be advised start sharpening your multimedia skills now as visually astute audiences expect more sophisticated presentations As a Biomed Photographer bobbing like a cork on this digital sea watch in wonder as the waves of change continue crashing over the medical landscape But that s a good thing sweeping patient care medical education and life saving knowledge from local shores to the world beyond Image courtesy Fig 1 Steve Barbour M D Phoenix AZ USA Fig 2
20. ectivity question in a podcast interview for IBM The idea of the Web as interaction between people is really what the Web is That was what it was designed to be as a collaboration space where people can interact The digital age of connectivity has also begun to enter many hospitals Today the medical field is becoming more and more networked with almost all clinical images medical records and supply management information available from virtually anywhere within the clinical IT network These networks often come complete with centralized control panels within the OR and real time telecon ferencing establishing an opportunity to provide remote learning via telesurgery broadcasting Things that go boom Over the course of the last decade an information and technology revolution has taken place inside the operating room OR management systems for example simplify the workflow during surgery by providing solutions ranging from patient adminis tration via OR planning to video documentation and live transmission to monitors both inside and outside the OR An intra operative MRI can pro vide the surgeon with real time feedback Ultra sonic systems allow the tracking of tissue move ment during surgery The integration of navigation systems provides high level accuracy in image guided surgery by linking intra operative images with the spatial position of the surgical instru ments relative to patient s anatomy Finally surgical mic
21. eived an additional operation using ICG videoangiography and neuronavigation ICG vid eoangiography indicated a nidus with early venous drainage in this area After temporary clipping of the feeder the residual nidus was completely re moved ICG videoangiography also indicated total removal of the nidus Fig 2 a f Case 2 A 10 year old girl showed intracerebral hemorrhage Cerebral angiography revealed a Spetzler and Martin grade parietal arteriovenous malformation We planned to perform parietal craniotomy for removal of the AVM After the nidus was totally dissected from surrounding brain paren chyma except for the draining vein ICG videoan giography demonstrated that the nidus was not vi sualized without draining vein but only with to and fro flow of ICG Discussion The integration of the ICG videoangiography tech nique into the surgical microscope improved the simplicity and speed with which the procedure can be used There is no need to move the microscope from the surgical field or to interrupt the operation The results of ICG videoangiography were available within several minutes for all patients Moreover this imaging technique can easily be repeated as needed Consequently ICG angiography may be an easy to use tool for intraoperative quality control and documentation of surgical outcomes gt 11 The two cases of cerebral AVM demonstrate that ICG videoangiography was useful in the treatment ICG videoangiograp
22. ens showing all patient informa tion Another advancement would be to make live surgeries available via teleconference systems which will allow sharing techniques impressions and advice with colleagues and experts in remote sites while performing the operations INFORMED Thank you very much for this in formative interview Image courtesy Paolo Cappabianca M D Universit degli Studi di Napoli Federico II Napoli Italy Paolo Cappabianca M D Professor and Chairman of Neurological Surgery Dept of Neurological Sciences Universit degli Studi di Napoli Federico II Via S Pansini 5 80131 Napoli Italy www neurosurgery unina it INFORMED 4th Issue May 2009 ee NASA s 50th anniversary offers a great opportunity to celebrate the power of inspiration innovation and discovery If scientists can put a man on the moon and consequently send him much farther into outer space shouldn t it also be possible to enable astronauts to perform complex surgical procedures in zero gravity INFORMED 4th Issue May 2009 When an oxygen tank on board the Mir space sta tion caught fire in February 1997 it was quickly doused with the help of a fire extinguisher and a wet towel Despite the risk of carbon monoxide poisoning and burns the crew was unharmed However emergency incidents such as this one re sulting in bruises lacerations burns or dental prob lems can always occur on a space station Naturally t
23. for surgeons to access Fig 1 Selecting pictures frum OPMI Pentero within the OR 1 ra INFORMED 4th Issue May 2009 Worklist OP Planning System OP Plan DICOM Modality Patient information ID Name Birth Date Date Time OR room number Carl Zeiss OPMI Pentero Worklist Server Intraoperative visible light images PACS Viewer Workstation Web SAP Fig 2 Schematic data workflow and management for integrating OPMI Pentero for OR planning and documentation The need for swift and detailed digital information have led to the improvement and enhancement of modern imaging techniques Thanks to the innova tion of navigation technology procedures such as magnetic resonance imaging MRI and positron emission tomography PET are used more fre quently in surgical 3D treatment planning and execution In addition to preoperative imaging intraoperative real time technologies and surgical documentation e g used in the treatment of intracranial tumors and vessel deformities are playing an increasingly important role influencing microsurgical strategy Currently technical imple mentation is characterized by manufacturer specific databases the lack of a standardized viewer and the lack of a uniform data format However intra operative documentation of the surgical field and morphological functional real time data with differentiated indexed pre operative imaging and pla
24. gloves to allow ad equate ventilation and the clean exchange of instru ments especially as sterilizing an entire space sta tion is not an option Regarding diagnostics having large imaging sys tems on board such as a MRI is also highly unlikely Then again portable low field MRT systems that is closed or folding ring shaped systems with mag netic field strengths of approx 0 5 Tesla and an in ner diameter sufficient for imaging human arms and legs are by all means conceivable Back on planet Earth Over the years aerospace has continually pioneered efforts aimed at making medical technology small er and mobile as well as interactive Already during Yuri Gagarin s space flight in 1961 ECG data were transmitted and telemetry employed Further the need for non invasive integrated sensors and diag nostics in aerospace led to the development of pul soximeters for non invasive SoO2 measurement and pulse rate calculation and also to the develop ment of an automatic self tonometer to measure intraocular pressure without a second person pro viding assistance Considerations as to how medical knowledge ex perience and skills can be combined and made readily available through communications will play an increasingly important role in the future not only in space travel There are also many applica tions for telemetry on Earth particularly wherever fast availability of expertise is called for as demon strated by
25. grated OR as well as trendsetting ideas for visualization and connecting excellence We will look at both connectivity s achievements and some ideas for it in the future We hope you will enjoy these articles and continue to find INFORMED interesting and useful Any ideas or suggested topics for the upcoming editions will be gratefully received For this reason we invite you to send us your comments using the postcard at the back of this issue Happy reading Yours p J tus Hans Joachim Miesner Director Neuro ENT amp Spine e INFORMED 4th Issue May 2009 CONTENT Get Ready to Get Wired 6 9 Making the right connections See It All Come Together 10 13 An interview with Robert F Spetzler M D The Future of the Surgical Microscope in the Integrated OR 14 17 Jurgen Meixensberger M D Ph D The Integrated OR New Horizons in Improving the Surgical Workflow 18 21 An interview with Paolo Cappabianca M D Defying Gravity Surgery in Space 22 25 Thomas Weber Dr rer medic Dipl Ing Through the Lens of a Biomed Photographer How to Take Good Pictures 26 30 Gary L Armstrong Expanding the Horizon of Clinical Education Practical Anatomy e Surgical Education Saint Louis University School of Medicine 31 35 Karen Hutsel M S N R N Visualizing a Virtual Cockpit 36 38 OPMI Application Tip 4 Microscope integrated Intraoperative Near infrared ICG Videoangiography in t
26. he Case of Cerebral Arteriovenous Malformations 39 42 Yasushi Takagi M D Ph D Nobuo Hashimoto M D Ph D Facts and Figures 43 e INFORMED 4th Issue May 2009 Get Ready to Get Wired Miaking the right connections Which of these terms were in existence 10 years ago Facebook Gmail Blackberry and iPod There was only one and it was just known as a fruit Let s face it technology is bringing the world ever closer and changing the way we experience our everyday lives This progress has even entered our hospitals The technological advances achieved by getting connected within the OR and its environment have revolutionized surgery and opened new horizons for sharing information and knowledge INFORMED Ath Issue May 2009 The word connectivity seems to engulf the world around us providing a visual where everything is somehow inter connected But connectivity is more than just a techno social phenomenon Networks seem to affect every aspect of our daily lives These networks form a foundation of today s world where you can communicate instantly and easily with anyone across the globe The Internet for example has already changed the way people do business exchange ideas collaborate and socialize with one another Today almost one quarter of the world s population is online and uses the Internet on a daily basis Tim Berners Lee the inventor of the World Wide Web has just weighed in on this conn
27. he ZEISS Learning Center at PASE Expanding the horizon Since 1991 PASE has offered students and educa tors didactic and hands on programs in medical and scientific related fields with its Adventures In Medi cine and Science AIMS The AIMS programs intro duce students to human anatomy and stimulate their awareness of good health practices The hands on programs provide an avenue of learning and discovery that help build important science literacy skills such as critical thinking problem solv ing and teamwork In May 2002 AIMS began distance learning presentations originating from the AIMS Virtual Anatomy Classroom These unique programs pro vide hands on interactive field trips designed to en hance any science curriculum Utilizing the latest in Medical students gain useful experience with the latest surgical methods during practical courses A T high definition technology distance learning offers similar opportunities for students worldwide through video conferencing A remarkable mobile videocon ferencing unit facilitates program broadcasts in high definition from anywhere in the PASE Learning Center Current plans include the expansion of the AIMS program to provide additional educational outreach in the spirit of what legendary statesman and author Benjamin Franklin once said An invest ment in knowledge always pays the best interest Image courtesy Practical Anatomy amp Surgical Education Saint Louis Un
28. here are guidelines in place to avoid leaving anything to chance The individual respon sible for handling procedures such as these is the Crew Interface Coordinator at the mission control INFORMED 4th Issue May 2009 C Defying Gravity Surgery in Space ea center on the ground Particularly in critical medical situations this person must be able to confer with someone onsite possessing the necessary training and experience Thus there is a Crew Medical Offi cer with basic medical training on board every flight who can discuss and possibly perform diagnos tic findings and treatment planning together with the Crew Surgeon the physician in charge at the control center As such a teleconsultation can be set up at any time As with every doctor patient re lationship confidentiality is also in effect between the doctor and the astronaut Deep Space Every astronaut is subjected to thorough medical screening and status examinations And naturally there are more medical provisions on board than simply a first aid kit Nevertheless if the situation becomes too critical there is always the possibility of returning to Earth Plans and procedures for such an event do exist When flying to a far destination such Mars how ever an immediate return to Earth is no longer an option In this case careful consideration must be given to matters of prevention and care and to how the necessary expertise of a given specialty ca
29. hy is effective in the cases in which cerebral AVMs are located in the superficial surface of brain In the first case we can confirm complete dissection of the nidus without antegrade flow in the drainer As for AVM removal several novel technologies were applied Neuronavigation was one of them and useful in safe removal But it cannot assess the flow of AVMs Residual nidus of AVMs was easily re ruptured according to previous reports In that case the right femoral artery occluded during the first operation Thus we could not employ intraoperative cerebral angiography In the field of cerebrovascular surgery ICG videoangiography demonstrated the possibility of improving operative outcomes As for EC IC bypass ICG videoangiography can reduce early bypass graft failure and improve surgical results in EC IC bypass surgery Based on this a reliable intraoperative as sessment of EC IC bypass function would be bene ficial and may help decrease surgical risks Wortzik et al reported that ICG videoangiogra phy was useful for revision of 4 of 35 STA MCA by passes In addition all 4 cases exhibited good fill ing of the bypass according to repeated ICG vid eoangio graphy In our cases it could detect early bypass failure in 1 of 8 cases Fig 2 The use of ICG videoangiography in the case of cere bral arteriovenous malformations AVMs Preoperative cerebral angiogram anterior posterior view a A diffuse type Spetzler
30. ianca M D plained this new approach as a visiting professor at the Carl Zeiss Honorary Lecture initiated and host ed by the Department of Neurosurgery of the Johann Wolfgang Goethe University in Frankfurt Germany INFORMED met with Paolo Cappabianca tion systems endoscopic carts and the improve ments which came with the new generations of operation microscopes These innovations have greatly increased the capabilities of neurosurgery What makes a really fundamental difference be tween yesterday and today is the full integration of information technology in the modern OR and in medical technology in general New hardware and software solutions provide completely new ap proaches changing work in a modern OR by fa cilitating communication between every connection point and by integrating the complete workflow in the OR which makes all required information avail able when and where it is needed These new tech nologies promote opportunities to foster communi cation and learning INFORMED Which major developments and trends do you foresee Cappabianca The major developments for the modern OR will concern the integration of individual instruments and systems Up to date surgical devices and instruments need to work together to be ergo nomic as well as provide the surgeon control during ee What makes a really fundamental difference between yester day and today is the full integration of information technolo gy in
31. ider the following tips and tricks External Digital Camera For high quality intraoperative still images use a digi tal Canon SLR camera for both microscope and hand held photography For high resolution microscope photos externally mount the camera on OPMI Pentero co observer port The surgeon triggers the camera via the handgrips A non sterile observer can also trigger still picture capture from the scope s touch screen To mount a camera externally you ll need three pieces of hardware the ZEISS f 340 photo adapter the T2 adaptor ring and a camera cable Once the camera is mounted setup OPMI Pentero via its touch screen by navigating through CONFIG AUDIO VIDEO and PHO TO then set the Mode Photo Button to External Next navigate through STAND HANDGRIP LEFT and RIGHT and assign Photo to the A and or B buttons Now you re setup to trigger the camera remotely via the scope handgrips and the PHOTO button on the scope s touch screen main menu Controlling Image Exposure Working without a camera lens and f stops you will have to manipulate the exposure in other ways Fig 3 High quality microscope still image of a clipped aneurysm INFORMED 4th Issue May 2009 e7 Flow to Take Good Pictures Fig 4 Maximizing technology for effective visual communication in medicine is more important than ever Between the modes and settings of the camera and OPMI Pentero you have several options On the
32. in the digital archive system Utilizing an error analysis protocol a plausibility check is mandatory as error sources can exist in the handling of the DICOM image series and in the al location of the patient to the corresponding opera tion The images can be postoperatively accessed with the viewer anywhere in the hospital via the PACS Pre and postoperative data can be visualized in different ways and compared in separate win dows for example Figs 3 4 Opportunities The standardization and automation of intraopera tive image data documentation permit high quality documentation which can reduce the required per sonnel resources and possibly increase the clinical benefit Initial experiences have shown that the sur gical microscope is suitable for centralizing the function of image data availability and storage allowing the data to be easily integrated into the radiology and hospital data management systems The surgical microscope gives surgeons the oppor tunity to assume a central cockpit function in the digital operating room of the future The standard ized and reliable data management system running in the background has the potential to archive under one patient ID all intraoperative data such as C arm ultrasound CT MR and make it useable for further clinical treatment and to process scientific clinical questions J rgen Meixensberger M D Ph D Professor and Head Department of Neurosurgery University Hos
33. ine Therefore recording and distribut ing the information become very easy Live video in particular represents a valuable op portunity to interact with other surgeons during a ing teaching institutions around the world to allow fellows and residents to broaden their base of knowledge in the field Besides generating academic material our faculty members regularly conduct lectures at conferences about the latest surgical and medical innovations being developed at the BNI INFORMED How do BNI surgeons share their knowledge and experience with the next gen eration of physicians Spetzler We have created an academic structure that is based on our rich and diverse clinical experi 1 We are dedicated to providing patients with cutting edge treatments and conducting groundbreaking research at our facility by paralleling and connecting neurological excellence procedure or to educate students sitting in the BNI s MedPresence Conference Room The audi ence can gain knowledge and experience without being physically present in the OR It provides a rev olutionary advance in education and by interacting with other surgeons in surgical decision making INFORMED Today more than ever surgeons must be willing to commit to keep up with the newest surgical techniques and advancements How do you put this concept into practice at the BNI Spetzler Both research and teaching are highly es teemed at the BNI and something of
34. is advancing the technology driving sys tematic and standardized data flow for intraopera tive management of imaging data As part of a pilot project at the clinic and polyclinic of the University Hospital in Leipzig and the Innovation Center for Computer assisted Surgery ICCAS the OPMI Pentero surgical microscope will be networked with the PACS hardware of the hospital via the DICOM module Fig 2 This project is intended to achieve the following objectives Provide access to all patient image data in post operative outpatient aftercare Enable access to preoperative image data stored in the surgical microscope as an additional safety net if the OR network fails Forward data to referring office based physicians via DICOM CD ROM including viewer Establish and secure a consistent standardized data flow by identifying patients with a uniform hospital specific ID Patient image files can be noted on the surgical microscope before the procedure allowing the re quired image information to be selected by the sur geon from the PACS in radiology and loaded onto the surgical microscope At the same time a work list can be generated The work list can be used to identify the appropriate patient during the opera tion select specific preoperative images on the microscope monitor and record screenshots and videos The surgeon can then verify and approve the data image quality save the file post procedure and store the data
35. ith the latest surgical methods during prac tical courses These innovative surgical techniques often become a natural part of their professional lives as physicians dedicate themselves to the prin ciple of lifelong learning The diversified programs of Practical Anatomy amp Surgical Education PASE strive to promote the con cept of lifelong learning by utilizing the latest tech nology to connect residents health care profession als and surgeons to world class experts and faculty INFORMED 4th Issue May 2009 The PASE facility has a long standing reputation that is widely regarded among the finest hands on educational facilities for health care professionals anywhere Shaping the future of healthcare for over 20 years Nearly 25 years ago Paul H Young a clinical pro fessor in Anatomy and Neurosurgery at Saint Louis University School of Medicine founded a state of the art healthcare education facility to provide hands on workshops Utilizing a new type of ca daver material Dr Young organized workshops on spinal and cranial techniques The curriculum ex panded to include presentations on peripheral nerve and spine as well as brain anatomy and surgical procedures The program has since expanded to in clude a growing number of new clinical disciplines and it has become a benchmark of practical clinical education in medicine In 1988 the focus of the workshops was expanded to include hands on training in the fields
36. ithout a valid signal you will see a corre sponding message for a few seconds in the display If in the OPMI Neuro MultiVision NC4 System you chose not to view the simultaneous endoscope im age in the right eyepiece and the surgical image in the left eyepiece set the shutter so that the left eyepiece remains closed i e black when the endo scope image is injected into the right eyepiece In OPMI Pentero the endoscope image is always in jected into both eyepieces Outlook The further development of micro display technology will also improve the performance of datainjection systems In the future additional data and new net working concepts will be used for systems not only in the OR but in the entire hospital and between different hospitals in order to provide the surgeon with all the information required for the procedure in his virtual cockpit simply and quickly Microscope integrated Intra operative Near infrared ICG Videoangiography in the Case of Cerebral Arteriovenous Malformations Yasushi Takagi M D Ph D Nobuo Hashimoto M D Ph D ICG videoangiography is a safe and simple method with which to assess the microcirculation of the brain In this report we show two representa tive cases which demonstrate the efficacy of ICG videoangiography in the field of cerebrovascular surgery Fluorescence angiography was first used by oph thalmologists to measure retinal blood flow by us ing the fluore
37. iversity School of Medicine Saint Louis MO USA Karen Hutsel M S N R N Director contact Practical Anatomy amp Surgical Education Center for Anatomical Science and Education Department of Surgery Saint Louis University School of Medicine 3839 Lindell Blvd Saint Louis MO 63108 USA http pa slu edu INFORMED 4th Issue May 2009 36 Getting Real with Your Virtual Cockpit OPMI Application Tip 4 Have you ever counted the number of monitors you need for data images and videos during a complex surgical procedure The IT revolution in the OR has set higher standards but it has also often led to isolated individual solutions with extensive instrument technology requiring more and more monitors Modern surgical techniques have substantially in creased the quantity of data and information diver sity available to the surgeon With the MultiVision function Carl Zeiss has created a virtual cockpit for the surgical microscope which can be used to ac cess required patient information at any time The surgeon can see critical patient data in the eyepiece at the simple push of a button This functionality turns the traditional surgical microscope into a con trol center the hub of the OR You have reached your destination Nowadays GPS systems or digital maps are not the only devices that lead us to our destination when we are on the road Due to the advent of high per formance computers intraoper
38. lleague cannot simply be replaced by a database Thus communi cation via light waves could prove instrumental for creating a fast and reliable link one day Today it is almost certain that robots will not be used to operate on people in the future All pa tients are different have individual distinctions and each surgeon works based on clinical experiences to make sound clinical decisions Would a robot ever have the capability of making solid clinical de cisions Surely there will be highly sophisticated mechanically support systems that provide assis tance in maneuvering visualization systems par ticularly for applications requiring a high level of precision much like the use of surgical microscopes today However it is difficult to imagine an autono mously operating robotic surgeon After all proce dures such as these must be clinically validated be fore being put into practice What ethics commis sion would go along with this Creating a special OR area on board is hardly fea sible either given the fact that launch weight largely determines costs As a result any idea that involves simply blowing up a shell cover to surround the sur gical area will no doubt be given much more con sideration A proven idea already exists to simply encapsulate the surgical field itself in other words to drape the patient or respective bodily region of interest The isolated area would then be properly prepared to be accessible with
39. ms and centers For example we have established one of the few comprehensive hypotha lamic hematoma treatment and research centers in the world one of the few places where children can undergo surgery for these tumors We are dedicated to providing patients with cut ting edge treatments and conducting groundbreak ing research at our facility Our clinicians develop innovative procedures to tackle some of the most Robert F Spetzler M D difficult diseases and conditions around The result ing synergies have produced some of the most amazing innovations in the field Barrow surgeons and scientists helped pioneer the hypothermic circulatory arrest for the treatment of brain lesions Currently they are developing new endovascular techniques that thread tiny catheters into brain vessels to correct problems too risky for traditional neurosurgery Our scientists recently identified a gene that causes the inherited form of cerebral cavernous malformations and have devel oped a blood test to identify people with this gene They also have identified a specific neural pathway that carries the sensation of itch from peripheral nerve fibers up the spinal cord to the brain This could explain how pain is transmitted and processed by the brain Moreover the BNI is one of the few centers in the U S that offers the CyberKnife a noninvasive ra diosurgery device for removing tumors We were also one of the first neuroscience centers in the
40. n be imported to the space station or spaceship Ex porting the astronaut generally proves more diffi cult The military has pioneered the technology to en hance an immediate medical response The chal lenges for example presented by exploratory mis sions to the moon and other planets are similar to those of a doctor on a naval ship that cannot sim ply change course either Naval physicians are gen eral practitioners with additional medical training tailored for managing the unique medical situations which they may encounter On board a space station or a spaceship a doctor accompanying a long mission should be a general practitioner too possessing additional knowledge in areas such as anesthesia emergency medicine cardiology and dentistry Furthermore this individu al should have a basic education in psychology to serve as a confidant for colleagues in certain situa INFORMED 4th Issue May 2009 tions Dermatology is yet another necessary field It is essential that skin changes such as those caused by coming into contact with irritants are diagnosed Telemedicine is a potential option provided the im ages are true in color Yes it s rocket science Particularly to support surgical procedures current technology trends are leaning toward the use of stereo three dimensional images Aerospace al ready possesses a broadband communications plat form offering capabilities that far surpass audiovi sual communicati
41. ng them with patient data as well as pre and post operative diagnostic images a complete set of diagnostic and intraoperative images for every patient can be created This direct linking of images with all kinds of demographic and patient specific data greatly simplifies data management and allows efficient allocation within the network e g for review in another hospital or doctor s office Having access to all image data at any time and at any appropri ate workstation provides an excellent basis for discussing cases with colleagues or sharing infor mation for educational purposes INFORMED 4th Issue May 2009 Get Ready to Get Wired Patient information images and videos can also be accessible in the OR on a real time basis The OR team does not have to leave the room or call out for additional information during the procedure Physi cians are able to dedicate more of their time and Skills to patients and education rather than on paperwork and logistics The exchange of in depth information in real time can also help facilitate a complicated surgical decision process opening new possibilities for telemedicine Tele capabilities To communicate with the skilled physicians not present in an OR and to share knowledge in real time are exciting capabilities for live video feed communication Surgeons are able to teleconfer ence and communicate audio visually in real time with external sites and transmit operations live via the I
42. ng to take your eyes from the surgical field MultiVision configuration menu of OPMI Pentero In the configuration menu of the MultiVision func tion for OPMI Pentero there are various settings for data injection which can be performed in the dis play Save your personal settings for key assignment for the MultiVision function on the handgrip or footswitch for the brightness and contrast of the display These functions will then be available again at any time with the same user profile for the next procedure e Prior to the procedure choose the type of dis play for the MultiVision key function Navigation endoscope camera or touchscreen display With simultaneous operation of the navigation system and the endoscope the injection of the endoscope image has precedence when the MultiVision key is pressed Transparent navigation data is then deac tivated e In the configuration menu you can also define what system information either individually or to gether is to be constantly projected into the Multi Vision display current zoom value current focus position current light intensity INFORMED 4th Issue May 2009 37 Getting Real with Your Virtual Cockpit 3 amp 8 IGS data of the navigation system In the OPMI Neuro MultiVision NC4 system the contours for the navigation procedure are superim posed on the current surgical image in the form of a monochrome display In the OPMI Pentero the binocular MultiVision s
43. nning for image supported treatment is not sufficiently established due to a lack of standard ization and networking in relation to integrated data management In the OR of the future The operating room of the future will be marked by the increased use of assistant systems and minimal ly invasive procedures based on image and model patient data However achieving this advanced OR requires an integrated data management structure to allow for the capture of important relevant patient data The connection to the hospital PACS can enable the surgical microscope to play a key role and provide the surgeon a surgical cockpit integrated digital system This can permanently Support and improve surgery planning for the pa tients as well as provide reliable documentation of intraoperative image information such as addressing INFORMED 4th Issue May 2009 15 The Future of the Surgical Microscope Fig 3 Side by side view of a preoperative angiogram left and an intraoperative picture after clipping of a MCA aneurysm right within the archiving software Fig 4 Side by side view of an intraoperative picture at the end of a temporal tumor resection left and a postoperative control computer tomography right within the archiving software 1 S INFORMED Ath Issue May 2009 future clinical issues or responding to inquiries about outpatient aftercare and tumor follow up Networking the surgical microscope Carl Zeiss
44. nternet Those video conferencing systems allow students and other observers to interact live with surgeons in the OR while seated in a hospi tal s conference room thousands of miles away Teleconferencing technology will become the base line for more advanced applications like telemen toring the ability to sketch surgical notes directly onto the surgeon s monitor from miles away to supervise or comment on the procedure By con necting experts during the procedure knowledge synergies can be fostered The shape of things to come Medical progress is forging ahead and develop ments in the field are advancing at a tremendous rate The enormous technological and scientific progress is leading to innovations that will open new opportunities in all medical specialties New imaging technologies for example can improve the localization accuracy of navigation systems allowing for enhanced performance of highly precise navigation procedures and robot assisted surgery Image guided robotics are already being used with the CyberKnife technology to deliver surgically precise radiation to destroy lesions with out the need of invasive surgery CyberKnife uses image guidance to track bony landmarks or small markers that have been implanted in the tumor Fig 2 The surgical microscope provides an ideal networking solution for various types of information INFORMED 4th Issue May 2009 Fig 3 Live transmission from the OR allows to in
45. of orthopedic surgery otolaryn gology and plastic surgery Three years later in 1991 Practical Anatomy amp Surgical Education orga nization found a permanent home in the St Louis Metropolitan Medical Society building In September 1998 PASE became a division of the Center for Anatomical Science and Education at the Saint Louis University School of Medicine which roots trace back to the founding of the American Association of Anatomists in 1888 Very recently the building housing the PASE organization was re named the PASE Learning Center named after a Supporting charitable organization Partners for the Advancement of Surgical Education The collaboration between PASE and Saint Louis University s Center for Anatomical Science and Edu cation further enhanced the ability to continue pro viding unique educational programs in a broad range of surgical disciplines Every year approxi mately 1 500 physicians nurses and allied health professionals attend PASE organized workshops To date health care professionals from over eighty countries representing all continents around the globe have participated in hands on training pro grams at the PASE Learning Center The key to this success is the principle of bringing together a world renowned faculty with cutting edge technology curriculum and surgical tools Since its inception INFORMED 4th Issue May 2009 33 Expanding the Horizon of Clinical Education 34 PASE
46. on Thus virtual reality would be a possible next step to display data for doctors on board and to simulate respective procedures for them with surgeons providing assistance from the Earth To ensure the quality of treatment it is cru Cial that these simulated images resemble reality as closely as possible prompting the need for new forms of support measures to be developed Dur ing a neurosurgical procedure for example a neu rosurgeon on Earth can guide the colleague on board to assist in making decisions provided they both can see the surgical field with clarity Initial test results on new IT guided procedures and sculpted 3D images have already been document ed Apart from the necessary visualizations and simulations tactile perception must also be ad dressed Surgeon sense varying pressure levels with the scalpel and other instruments including tissue hardening which is essential in medical procedures The objective is to transmit the sensation and tac tile feedback to an assisting surgeon who is not actually holding the scalpel to enhance the virtual reality experience for physicians not present but assisting with the procedure Moreover signal de lays and signal loss must be taken into account What would happen should the communication channel be somehow interrupted There are plans to localize expert knowledge thus ensuring that it is always available for the individual on board Yet the audiovisual dialogue with a co
47. pital Leipzig Liebigstrasse 20 04103 Leipzig Germany www uniklinikum leipzig de INFORMED 4th Issue May 2009 ZONS in 7777 Ce the 0 N Workflow An Interview with Paolo Gappabianca M D Located in the Medical Center of the University Federico II of Naples Italy the Department of Neurosurgery offers a full range of modern neurosurgical techniques including skull base transsphenoidal spinal peripheral nerve and pediatric neurosurgery Dr Paolo Cappabianca President and Chairman of the Neurosurgery Department comments on the modern day integrated operating room and his vision of the future 1 e INFORMED 4th Issue May 2009 Founded in 1973 the Neurosurgical Clinic of the University of Naples is a well established reference center renowned for scientific contributions in the field of neurosurgery especially in the neurovascu lar and spinal tumor field The clinic became inter nationally recognized as a center of excellence where specialists in neuroradiology neuropatholo gy endocrinology ophthalmology otolaryngology pediatrics neurology and anesthesiology work closely together providing many specialized servic es Recently Prof Cappabianca introduced for the first time in Europe transsphenoidal endoscopic surgery a new approach to endoscopic surgery of certain brain tumors In December 2007 he ex 19 INFORMED 4th Issue May 2009 The Integrated OR eo Paolo Cappab
48. rame inside the circular view through the microscope s oculars The bottom line keep the main point of interest dead center and frame your shot loosely Use the Focusing Aid Laser Spots as a visual reminder of where center is Hopefully with this basic knowledge the right equipment and good technique you ll soon be get ting solid results with the microscope and camera which will enhance your visual communications want to encourage you to be creative have some fun and start experimenting on your own Then once you master the technical you can forget about it because as legendary photographer Ansel Adams once said There are no rules for good photo graphs there are only good photographs Good microscope photography takes persistence but for me the real challenge starts when get paged to the ORs for handheld photos never quite know what to expect what the subject might be how much time I ll have or how many rooms I ll need to work simultaneously Like the Boy Scouts my motto has become Be Prepared To my pho tographer s eye the OR can be a perplexing tangle of light sources awkward shooting angles and extremes of contrast and reflection Throw in the pressure of one chance to get it situations time restraints privacy requirements and sterile field lim itations and that great picture can become rather elusive but then all the more satisfying when I nail that perfect shot In addition to still photography and r
49. re ports operative videos and patient records All these documents should be stored in a central database that is accessible through any secure connection INFORMED What is your vision for the OR of the future Cappabianca My vision of the OR of the future is a progressive miniaturization of various OR instru ments all controllable via computer or a remote To maximize the instruments capabilities and provide an improved OR workflow it is best to connect them and allow the information to flow between all the instruments videoconference systems dictation and telephone systems It is possible to control what is happening during the operation either from the OR itself or from the surgeon s office INFORMED To what extent are you using video recording in your work and what major benefits do you see Cappabianca We record every operation for sev eral reasons The most important ones being to ob tain material for scientific and didactic papers or videos to review the cases and learn from possible errors as well as to objectively demonstrate the re sults of the operation INFORMED What improvements do you fore see would be advantageous in facilitating access and sharing of patient related surgical data and information Cappabianca would like to have one central file for each patient containing all the possible multi media information Clinical records images from site with big scre
50. rom L Svensson M Ulfarsson E Andersson T Neuronavigation for arterio venous malformation surgery by intraoperative three di mensional ultrasound angiography Neurosurgery 2007 60 4 Suppl 2 345 50 6 Muacevic A Steiger HJ Computer assisted resection of cerebral arteriovenous malformations Neurosurgery INFORMED 4th Issue May 2009 1999 45 1164 71 7 de Oliveira JG Beck J Seifert V Teixeira MJ Raabe A Assessment of flow in perforating arteries during intracra nial aneurysm surgery using intraoperative near infrared indocyanine green videoangiography Neurosurgery 2007 61 3 Suppl 63 72 8 Raabe A Beck J Gerlach R Zimmermann M Seifert V Near infrared indocyanine green video angiography a new method for intraoperative assessment of vascular flow Neurosurgery 2003 52 132 9 9 Raabe A Nakaji P Beck J Kim LJ Hsu FP Kamerman JD Seifert V Spetzler RF Prospective evaluation of surgical microscope integrated intraoperative near infrared indo cyanine green videoangiography during aneurysm surgery J Neurosurg 2005 103 982 9 10 Russell RW Ffytche TJ Sanders MD A study of retinal vascular occlusion using fluorescein angiography Lancet 1966 2 821 5 11 Woitzik J Horn P Vajkoczy P Schmiedek P Intraopera tive control of extracranial intracranial bypass patency by near infrared indocyanine green videoangiography J Neu rosurg 2005 102 692 8 The article is based on the following case report
51. roscopes also play an integral part of the oper ating room by providing an interfacing platform with ideal conditions for merging the diverse infor mation tracked in the OR With the integration of a micro display additional information from the navigation system for example can already be projected into the eyepieces of the surgical micro scope and superimposed on the surgical scene Moreover the surgeon is able to have diagnostic images and video data from MRI CT ultrasound and even an endoscope directly injected into the microscope s eyepieces The surgical microscope also provides an ideal platform to directly integrate new dimensions in visualization like the completely integrated micro scope based fluorescence options of OPMI Pentero used for fluorescence based tumor resection Connecting all these hardware and software com ponents with each other would make it possible to manage the complete OR technology from one sin gle boom system within the sterile area or even from the surgical microscope itself Getting connected anytime anywhere The current trend is not only to electronically integrate all clinical data but also to capture archive access and share clinical images medical records lab results or supply management infor mation Paperwork and films are starting to go the way of the dinosaur Intraoperatively generated pictures can be saved and centrally archived within the clinical IT network By combini
52. scent dye fluorescein Feindel et al were the first to apply the concept of fluorescence angiography to the intraoperative visualization of cerebral vertebral arteries and cerebral microcircula tion in patients undergoing neurosurgical proce dures With the use of indocyanine green ICG as a novel fluorescent dye and its integration into a compact system that takes advantage of modern video technology fluorescence angiography has re cently re emerged as a viable option Methods and patients Carl Zeiss has integrated ICG videoangiography technology into its OPMI Pentero surgical micro scope The system was designed to obtain high resolution and high contrast near infrared NIR im ages For the presented cases the operative field was illuminated by a light source with a wavelength covering part of the ICG absorption band range 700 850 nm maximum 805 nm Indocyanime green dye was injected into a peripheral vein as a bolus the standard 25 mg dose dissolved in 10 ml of water ICG fluorescence was induced after the dye solution arrived in the vessels of the NIR light illuminated field of interest The fluorescence range 780 950 nm maximum 835 nm was recorded by a non intensified video camera An optical filter blocked both ambient and excitation light so that only ICG induced fluorescence was collected Thus arterial capillary and venous angiographic images could be observed on the video screen in real time The se
53. sult for data injection in the MultiVision display Working with the data injection system Depending on the image information desired you can select between data injection excluding the object visualized through the microscope image MultiVision allows the surgeon to easily and quickly display navigation image and video data in his microscope eyepiece injection or the transparent visualization of the im age information which is overlaid on the object display through the microscope superimposing After mode switchover the current operating mode is displayed as text information for a few seconds in the eyepieces Please remember the following tips when working with MultiVision Have the point of interest in autofocus injected into the image center in the form of crosshairs in the eyepiece This is of particular benefit in mouth switch control ensuring perfect video image defini tion If a navigation system is connected system specific crosshairs should be injected e f in OPMI Pentero you inject the complete graphic touchscreen interface into the eyepieces you can change settings and system configurations with the joystick of the right handgrip without compromising sterility Prior to the procedure set the configuration menu for the INFRARED 800 application in OPMI Pentero so that the content of the touchscreen monitor is also projected into the eyepieces This way you can be guided through the procedure without havi
54. teract live with surgeons in the OR We are already expecting the development of GPS like systems for tracking the movement of can cerous tissue during radiation therapy using electromagnetic positioning transponders which are about the size of a grain of rice Telemedicine might even become the standard of care for small rural hospitals where specialists are just not avail able Experiments with telemedicine on the battle field are already in the works Another aspiration is that astronauts will eventually be able to receive surgical care while in space The procedures could be carried out by telementoring the astronauts aboard the spaceship Today more than ever surgeons must work to keep up with the newest surgical techniques and advancements Efficient data management technol ogy should provide effective tools to speed up the dissemination of innovative medical procedures Clinical networks can play a key role in streamlining the use of medical technology by allowing data to be collected outlining physician practices proce dures and patient outcomes which can then be used to identify the most effective procedure and related technologies In this way clinical pathways can be established as the culmination of all the col lected experience and knowledge In aviation for example exactly defined procedures for the pilots to determine normal operation and emergencies is becoming a daily work routine The future has a lot in store
55. the medical emergency service of armed forces in operations conducted with a telemedical network Natural disasters place equally special de mands on aid workers for whom not only the pro vision of emergency care for injured and disaster victims is a vital concern but also more far reaching issues such as the additional threat of epidemics On site teams gathering soil and air samples for ex ample do not always have complete access to labo ratory diagnostics and experience It will be essential for future developments in space medicine that medical companies and research centers closely coordinate their research and devel opment efforts to design both innovative and prac tical products and technologies Therefore close cooperation between universities and respective in stitutes is an important step in the right direction in the combined effort of shaping our future Dr rer medic Dipl Ing Thomas Weber Head of the Working Group Telemedicine and Telematics Biomedical Science Support Center Institute of Aerospace Medicine German Aerospace Center Linder Hohe 51147 Cologne Germany INFORMED Ath Issue May 2009 eio Through the Lens of a Biomed Photographer How to Take Good Pictures Gary L Armstrong In our increasingly sophisticated world maximizing technology for effective visual communication in medicine is more important than ever That s where the job of a Biomed Photographer comes in and it all
56. tid endoarterectomy ICG videoangiography can detect the location of plaques and show the patency We already have several methods of assessing cere bral circulation during surgical procedures In the further study it is necessary to confirm the difference of the results among intraoperative cerebral angio graphy Doppler ultrasonography and ICG video angiography In summary we were able to show the efficacy of ICG videoangiography in cerebrovascular surgery in this report ICG videoangiography has the potential to achieve the goal of routine intraoperative vascu lar imaging during cerebrovascular surgery References 1 Feindel W Yamamoto YL Hodge P The human cere bral microcirculation studied by intra arterial radio active tracers Coomassie Blue and fluorescein dyes Bibl Anat 1967 9 220 4 2 Feindel W Yamamoto YL Hodge CP Intracarotid fluo rescein angiography A new method for examination of the epicerebral circulation in man Can Med Assoc J 1967 96 17 3 Hoh BL Carter BS Ogilvy CS Incidence of residual in tracranial AVMs after surgical resection and efficacy of im mediate surgical re exploration Acta Neurochir 2003 146 1 7 4 Little JR Yamamoto YL Feindel W Meyer E Hodge CP Superficial temporal artery to middle cerebral artery anas tomosis Intraoperative evaluation by fluorescein angiog raphy and xenon 133 clearance J Neurosurg 1979 May 50 5 560 9 5 Mathiesen T Peredo Edner G Kihlst
57. tup allowed high resolution NIR images based INFORMED 4th Issue May 2009 3g Microscope Integrated Videoangiography 40 Fig 1 Intraoperative visualization methods supplement the optics of the surgical microscope and open up new dimensions in vision on ICG fluorescence to be visualized without elimi nating visible light during the investigation From January 2007 to March 2008 a total of 32 patients received ICG videoangiography during a Surgical procedure at Kyoto University Hospital Among them 8 cases of extracranial intracranial EC IC bypass 4 cases of cerebral arteriovenous malformations AVMs and 13 cases of cerebral an eurysms were included Illustrated cases Case 1 A two year old girl presented sudden onset hemiparesis due to intracerebral hemorrhage Cere bral angiogram disclosed a Spetzler and Martin grade III AVM in the left frontoparietal lobe Preop eratively the feeders from anterior cerebral arteries were embolized by endovascular surgery She re ceived a frontoparietal craniotomy and the nidus was removed Intraoperative cerebral angiography INFORMED Ath Issue May 2009 could not detect residual nidus Nine days after the operation a cerebral angiogram indicated residual nidus fed by the anterior cerebral artery with early venous drainage During these procedures the right femoral artery was occluded Thus we decided not to use intraoperative digital subtraction angiogra phy She rec
58. ty centers for stroke brain tumors epilepsy skull base tumors spinal disorders or pediatric neurology The Institute is respected worldwide for its pioneering treatments procedures and research into complex brain and spinal cord related diseases and conditions Profes sionals at Barrow generate more than 5 000 pages of academic material every year including more than 200 journal articles and dozens of book chap ters Under the guiding influence of Dr Robert F Spetzler who has been Director since 1986 the BNI has been brought into the 21st century Dr Spetzler is a world renowned neurosurgeon who specializes in cerebrovascular disease and skull base tumors He has been involved in pioneering the techniques of hypothermic circulatory arrest a surgery now used INFORMED 4th Issue May 2009 worldwide in treating complex aneurysms He has contributed more than 300 articles and 180 book chapters to the neuroscience literature and has co edited a number of neurosurgical textbooks INFORMED Please describe some of the spe cialties of the Barrow Neurological Institute What is unique about the BNI and what are the most important accomplishments over the past four decades Spetzler We are considered one of the world s foremost neurological centers because we perform SO many unique as well as common neurological procedures every year And to target difficult neuro logical conditions we have created several special ized progra
59. ved CyberKnife is a registered trademark of Accuray Incorporated OPMI and Pentero are registered trademarks of Carl Zeiss MultiVision is a trademark of Carl Zeiss If trademarks trade names technical solutions etc are not explicitly mentioned this does not mean that they are not protected The information in this maga zine only contains general descriptions or perfor mance features which do not always apply in the de scribed form in each individual application or which may change during the course of further product de velopment The desired performance features are only binding if they have been expressly agreed upon in a signed contract Permission for the reproduction of individual articles and photos only after prior permission has been giv en by the editors and with the appropriate reference to the source 43 6002 A ANd Md1 08 007 0 NI NE PAS AFFRANCHIR LUFTPOST POSTAGE PREPAID Your Name ce Eee LL LLL L Clinic Practice R PONSE PAY E WERBEANTWORT ALLEMAGNE Street City State Carl Zeiss Surgical GmbH Zip Code Carl Zeiss Stra e 22 CC UM 73447 OBERKOCHEN Country ALLEMAGNE NE PAS AFFRANCHIR LUFTPOST POSTAGE PREPAID Your Name EI Clinic Practice R PONSE PAY E WERBEANTWORT ALLEMAGNE Street City State Carl Zeiss Surgical GmbH Zip Code Carl Zeiss Stra Se 22 73447 OBERKOCHEN lt ALLEMAGNE We would
60. very much appreciate your comments on this issue of INFORMED as well as your ideas and suggestions for topics of upcoming issues You can also provide us with feedback over our Internet site at www meditec zeiss com informed If you are interested in receiving previous issues of INFORMED please submit your order on the postcard below contact us at Surgical meditec zeiss com or contact your local ZEISS representative What is your overall rating of this publication Excellent Good Average Not interesting Are you familiar with the first three issues of INFORMED _ Yes No Would you recommend this magazine to your colleagues _ Yes No Your comments and suggestions Please put me on the circulation list for future issues of INFORMED What is your overall rating of this publication Excellent Good Average Notinteresting Are you familiar with the first three issues of INFORMED Yes No Would you recommend this magazine to your colleagues Yes No Your comments and suggestions Please put me on the circulation list for future issues of INFORMED
61. ystem also permits the dis play of colored contours in the superimposing mode e With the navigation interface activated the in formation is automatically projected from the navi gation system into the MultiVision display If you now press the MultiVision button programmed for navigation the shutter is closed and only the in jected navigation image is displayed Another press of the button opens the shutter again and superim poses the navigation data and the microscope im age This option allows you to also directly control functions of the connected navigation system using the joystick of the right handgrip system depen dent Also with a connected navigation system and ac tivated navigation interface you can program the MultiVision button with a different function for the endoscope camera or touchscreen display For navigated surgery it is recommended to use the autofocus as doing so guarantees that the tar geted point on the surface corresponds to the point on the screen of the navigation system This allows you to avoid errors caused by the large depth of field or misaligned eyepieces Connect the supplied synchronization cable to the OPMI Neuro MultiVision NC4 System This con nection synchronizes the MultiVision display with the video camera of the microscope If it is not con nected flickering and even the partial disappear ance of injected data and contours may result on an externally connected monitor

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