University of New South Wales, Sydney, Australia
Operative image capture is now widely available, and much under-rated in importance by referring practitioners and specialists. While conventional photography and digital imaging are applicable to the whole range of surgical practice, this report will focus upon image capture related to gynaecological endosurgery.
Documentation of clinical findings in medicine has advanced through the ages as technology has developed. Since the earliest obstetric writings in the Kahun gynaecological papyrus1 (c.1900 BC), the pursuit to record has been relentless. The first surgical technique (circumcision) depicted pictorially was found carved on the wall of an Egyptian Dynasty VI tomb 2 around the same time.
Medicine has permeated art in almost all ages and cultures, and gradually medical artists have evolved as specialists in their own right. The age of medical photography progressed once available. The 150th anniversary of medical photography has passed, with the earliest surviving clinical photograph being that of a woman with a goitre taken by Hill and Adamson3 c.1847. Vintage medical photographs have now become valued as art, as well as important historic and cultural documents. Photographs of nude patients, popularized in the late 19th century, have become the most valued of all4.
Photographic imaging in gynaecology began when Nordentoeft5 took photographs of the female pelvis in a cadaver in 1912. Further photo-documentation of pelvic pathology occurred in 1953 by Cohen & Guterman6 although the quality of the image was doubtful.
In 1963, Clyman7 described adaptation of the single-lens reflex camera to operative photography. He described the problems inherent with still photography and in particular, problems of light delivery to the subject. Kott8 then summarized “state of the art” technology in 1978, using a beam splitter for photography, cinematography and television. There has been little publication on the subject since that time.
The essential value of operative photography is for accurate recording of clinical findings. Documentation is useful for personal records, communication with referring practitioners and to compliment operative or legal reports. Images are particularly useful in situations where multiple treatment options exist, for example where infertility caused by tubal disease can be managed by tubal surgery or assisted reproductive technologies. More appropriate decision-making may be made upon reflection or with consultation when an accurate record is kept.
Documentation is ideal for comparison before and after surgical intervention, or for the monitoring of disease progress in certain conditions. In gynaecological practice, the documentation of normality also serves a particularly useful purpose, especially when investigating pelvic pain.
Classically clinical photography has been used for training medical students and postgraduate trainees, as well as for presentation at scientific meetings and workshops.
Finally, image capture is useful in validation of the operative procedure. When images are shown at the post-operative visit, the patient has no doubt that the planned procedure has been performed, that all areas under suspicion have been thoroughly inspected and that the appropriate findings have been recorded. This leads to the problem of image validation for which certain safeguards are available. At present, hard copy images rely upon appropriate labeling by the nursing staff, whereas electronic image capture can be programmed to allow image capture only after demographic data for a patient has been entered. We attempted to assess the value of operative photography from a patient, general practitioner and specialist perspective. We also tried to gauge a nursing perspective to operative photodocumentation.
We undertook a survey of patients, general practitioners, specialist gynaecologists, specialist anaesthetists and operating theatre nurses to assess the value of operative image capture.
We asked directed questions to assess the value each group placed upon operative image capture, and whether these professional, medical and non-medical groups thought that images may lead to problems in any way. We allowed free text commentary on any related issues.
The sample population included 40
specialists (20 gynaecologists and 20 anaesthetists), 200 general
practitioners, 40 nurses and 28 patients. From these groups we received a 50%
(60% gynaecologists & 40% anaesthetists), 61.5%, 70% and 100% response. The
responses are shown in Table 1.
We showed that patients regard operative images as valuable in assisting them to understand their disease, or alternatively the normality of their findings. Most specialists, general practitioners and nursing staff also believe that operative images assist patients in understanding their disease. Importantly, there was an almost universal denial that operative images create patient anxiety.
Our survey yielded an unexpectedly high desire to have operative images included in the medical record, by all groups surveyed. Acknowledging that captured images are often of poor quality, this deficiency did not detract from the desire to record clinical findings.
Seventy eight percent of general practitioners expressed a desire to receive operative images. It was apparent from their free correspondence that they found them useful for patient counselling. It was therefore interesting that almost half of the Nursing sisters staff surveyed thought that the general practitioner should not receive these images.
Should patients be given these images to keep in their possession? This question produced a wide range of results – from almost 90% of the patients wanting them, to nearly 70% of GP’s believing that that they should not have them. To add some weight to this question, we asked if patients would be prepared to pay for these images, and somewhat surprisingly found that 79% of patients would be prepared to pay $5.00 or more to obtain them. I’m sure we have underestimated the importance that gynaecological patients place upon operative photo-documentation.
A minority of all groups (except patients who were not surveyed on this issue) thought that operative image capture would lead to medico-legal problems for the surgeon. A number of respondents expressed the belief that operative images would be supportive rather than detrimental in a medico-legal instance.
Systems available for image capture are compared in Table 2. 35-mm film remains the gold standard for high-resolution image capture, but is extremely difficult to use within a sterile field without expensive beam splitters, and is relatively difficult to process to the point of hard copy image.
Videotape recording and digital video printer output have been used most commonly in recent times and each medium has inherent deficiencies. Videotape suffers from difficulty in storage and retrieval of information, and requires duplicate video recorders for copy of captured images. Further, a video recorder and monitor is required in every location where the images may be viewed.
Video printed images are easy to produce and to store, but they are difficult to copy once the memory of the printer has been erased. Subsequent copy of images can only be achieved by computerised scanning and colour printing, which requires considerable additional hardware. The cost of video printed images is often not appreciated. A cost of $1.71 per image is based upon the cost of thermal paper and ink cartridges used for production. Multiple images may be recorded on one sheet to cut costs, but these images are then fixed at a relatively small size.
Computerised image capture is convenient from many aspects. The capture process, storage, retrieval and the production of as many copies as required at any time is simple. The cost of image production, at $0.12 per image of equivalent size to video print image is based upon the cost of paper and ink for printing.
The obvious disadvantage of computerised image capture is the cost of hardware and software required to support the system. In addition to a laptop computer, an image capture card and software are required. This, however, must be balanced against the cost of image production. If one considered a list of six patients, with four images per patient and four copies to provide for medical records, personal records, the referring doctor and the patient – then 96 images are required at a cost of $164.16 for video printed images and a cost of $11.52 for the electronic images. It would not take long for the electronic hardware and software costs to be offset by image production costs.
For this reason we now use electronic image capture as our primary storage method. Figure 1 shows some sample digital images printed in high-resolution mode on an inkjet printer. The versatility of the medium is valued, as images can be downloaded directly onto a hospital-based server. With appropriate security measures, they may then be visualised on a remote monitor in any department. Digital images can be transmitted over telephone networks by email for review by others, can be incorporated into educational presentations or can be synchronised by modem with remote computer systems after hours.
Photographic documentation at operative procedures is highly desirable. It is useful as part of routine documentation, and is regarded as valuable by both referring doctors and their patients. Patients in particular find photographs useful in the understanding of their disease. They place significant value upon these images.
There are many systems available for photo-documentation of operative findings, and the pros and cons of various systems have been discussed. While the resolution of 35mm film remains unchallenged, digital imaging can capture the clinical information required in a far more cost effective manner.
1. Estes J W. To become pregnant. In: Carmichael AG, Ratzan RM, editors. Medicine in Literature and Art. Könemann Verlagsgesellschaft mbH: Köln, 1991; 31-33.;
2. Estes J W. Surgical problems and solutions: The Medical Skills of Ancient Egypt. Science History Publications. 1989.
3. McFall K. A notable anniversary in the history of medical illustration. Journal of Audiovisual Media in Medicine 1997; 20(1): 5-10.
4. Burns SB. The nude in medical photography: a historical perspective, with modern legal ramifications. Journal of Biological Photography 1996; 64(1): 15-26.
5. Nordentoeft S. Uber Endoskopie Geschlossener Cavitaten mittels eines Trokar-Endoskops. Verh Dtsch Ges Chir 1912; 41(78): 412.
6. Cohen MR, Guterman HS. A pelvic photoscope. Obstet Gynecol 1953; 1: 544.
7. Clyman MJ. A new panduldoscope – diagnostic, photographic, operative aspects. Obstet Gynecol 1963; 21: 343.
8. Kott DF. Photography, cinematography and television in endoscopy. In: Phillips JM, editor. Endoscopy in Gynaecology. American Association of Gynaecological Laparoscopists: San Francisco, 1977.
Table 1. Attitudes to Operative Images
|
|
SPECIALISTN = 20 |
GENeral PRACTITIONER N
= 123 |
NURSING STAFFN
= 28 |
PATIENTSN
= 28 |
|
1. Do operative
images help in the understanding of the patient’s disease? |
||||
|
No / Slightly |
1 (5%) |
38 (29%) |
5 (18%) |
0 (0%) |
|
Mostly / Yes |
19 (95%) |
85 (69%) |
23 (82%) |
28 (100%) |
|
2. Do operative
images create anxiety for patients? |
||||
|
No / Slightly |
19 (95%) |
114 (93%) |
27 (96%) |
28 (100%) |
|
Mostly / Yes |
1 (5%) |
9 (7%) |
1 (4%) |
0 (0%) |
|
3. Should operative
images be included in the patients Medical Record? |
||||
|
No |
0 (0%) |
19 (15%) |
2 (7%) |
1 (4%) |
|
Yes |
20 (100%) |
104 (85%) |
26 (93%) |
27 (96%) |
|
4. Should operative
images be sent to the referring General Practitioner? |
||||
|
No |
3 (15%) |
27 (22%) |
12 (43%) |
5 (18%) |
|
Yes |
17 (85%) |
96 (78%) |
16 (57%) |
23 (82%) |
|
5. Should operative
images be given to patients? |
||||
|
No |
8 (40%) |
81 (66%) |
17 (61%) |
3 (11%) |
|
Yes |
12 (60%) |
42 (34%) |
11 (39%) |
25 (89%) |
|
6. Would patients
be prepared to pay for copies of their operative images? |
||||
|
No |
(1)5 (42%) |
53 (43%) |
(2)N/S |
6 (21%) |
|
$5.00 |
(1)3 (25%) |
40(33%) |
N/S |
15 (54%) |
|
$10.00 |
(1)4 (33%) |
28 (23%) |
N/S |
3 (11%) |
|
$20.00 |
(1)0 (0%) |
2 (1%) |
N/S |
4 (14%) |
|
7. Will operative
images lead to medico-legal problems? |
||||
|
No |
6 (30%) |
46 (37%) |
10 (36%) |
(2)N/S |
|
Perhaps |
11 (55%) |
67 (54%) |
15 (54%) |
N/S |
|
Yes |
3 (15%) |
10 (8%) |
3 (11%) |
N/S |
(1) 12 gynaecologists and 8 anaesthetists responded. Only gynaecologists were asked if their patients would be prepared to pay for operative images.
(2) N/S - Not surveyed.
Table 2.
Comparison of available systems for operative image capture.
|
|
35MM
FILM |
VIDEO
TAPE |
VIDEO PRINT
|
COMPUTER
IMAGE |
|
HARDWARE |
(1) 35mm SLR Camera |
(2) Video Cassette Recorder |
(3) Video Colour Printer |
(4) Computer (5) Image Capture Card |
|
COST |
$1282 |
$500 ($2,500) |
$3820 ($10,920) |
$5140+$700 = $5840 |
|
SOFTWARE |
Nil |
Nil |
Nil |
(6)Image Capture S/W |
|
COST |
- |
- |
- |
$2500 |
|
TOTAL COST |
$1282 |
$500 |
$3820 |
$8340 |
|
RECORD MEDIUM |
35mm film |
VHS tape |
Printing paper |
Computer disc |
|
RESOLUTION |
2000 lines/inch |
240 lines (SVHS –
400) |
>500 lines/inch |
(7)240 lines |
|
OUTPUT MEDIUM |
Print/transparency |
Monitor |
Print |
Monitor/disc/plain
paper |
|
COST/IMAGE |
$0.70 |
$3.00 |
$1.71 |
(8))$0.12 |
|
EASE OF CAPTURE |
Difficult |
Moderate |
Easy |
Easy |
|
EASE of STORAGE |
Moderate |
Difficult |
Easy |
Easy |
|
EASE of RETRIEVAL |
Moderate |
Difficult |
Easy |
Easy |
|
EASE of COPY |
Difficult |
Moderate |
Difficult |
Easy |
For comparative analysis, costings are based on equipment currently used in the Gynaecological Endoscopy Unit, Liverpool Hospital, Liverpool NSW.
(1)
Olympus SC-35
single lens reflex camera with through the lens exposure metering system, plus
adapter SM-R.
(2)
Panasonic
NV-J45 4-head VideoCassette Recorder. (Also used is a Panasonic Super-VHS
recorder for higher resolution recording – cost $2500.00)
(3)
Sony Video
Color Printer SONYUP-2800P. (Also used is a Sony VideoColor Printer SONYUP –
5600MDP)
(4)
Toshiba 480CDT
Notebook Computer – Pentium 233MHz, 64Mb RAM, 3.8Gb HDD – quoted price as at
06/99
(5)
Nogatech
CaptureVision PCMCIA card – quoted price as at 06/99
(6)
MedImage
distributed by PTA Computer Consultants, Sydney
(7)
Limited to
video output resolution (SVHS – 400 lines), and then to printer resolution.
(8)
Cost based on
cost of paper and printing ink with 4 images on one A4 sheet