Why would someone want a video of surgery? For starters, surgical residents and practicing surgeons like to keep up with the latest techniques. With apologies to the producers of Grey’s Anatomy, you just can’t see much from those galleries above the operations.
Purely educational surgical videos are usually presented at a medical convention, such as the American College of Surgeons or SAGES. Following presentation before an audience of between 20 and 1000 fellow surgeons, DVDs are available for purchase or surgeons can subscribe to a streaming web-based library.
In addition to being purely educational, a video of surgery may also be used for marketing. For example a medical device company may want to promote its latest widget, in the context of a video. In addition to the operation, we may also include a surgeon testimonial, some animation showing the widget’s features and benefits, and finally some interesting text and data depicting the widget’s success and positive patient outcomes. So there, you see, surgical video can also be a marketing video.
Since the Cow is all about production, I will discuss some technical aspects of surgical video. To be honest, I don’t spend a lot of time talking about the latest technology. If you are good at your craft, the technology involved should not really matter.
All you hear about these days is “keyhole surgery”, robotic surgery, minimally invasive surgery, short hospital stays, lower patient morbidity, etc.
I will discuss these topics in a minute. However, some surgery is still done the old fashioned way. Invasive cancer, breast surgery, transplants and large hernias are just a few of the many procedures performed using small or very large skin incisions.
When I started, I had no idea I would one day be so interested in surgical video. I simply took an open position after a job duping tapes. Working with the top surgeons in the field has opened my eyes to some amazing procedures, disturbing diseases and memorable experiences. Here are some of them.
Note: if you have not eaten breakfast, now would be a good time.
Cadaver Dissection is a staple for medical students worldwide. I am not a medical student. While I was not doing the actual dissection, this was the first time I had seen a dead body, and these were, by the way, fresh ones. It was a surreal experience, and I can still see their faces.
Nose Reconstruction remains one of the most amazing operations I have seen. One woman had been living with a prosthetic nose for years, after cancer claimed her original proboscis. This was a four-part operation. In brief, a flap of tissue from the forearm, combined with cartilage from the ear, bone from the rib, skin from the forehead and back were all combined to provide a fairly good looking nose.
Intraperitoneal Chemotherapy – Huh? In patients with serious invasive cancer, where the disease is working at the microscopic level to threaten life, a 12-hour operation first surgically removes visible disease.
Then a reservoir is created in the abdomen, covered with plastic sheeting. A pump circulates heated chemotherapy solution through the abdomen for several hours, killing the cancer you cannot see. Sounds gross, but it works.
In addition to becoming somewhat knowledgeable about surgical techniques, I have picked up some rudimentary medical knowledge along the way.
And not surprisingly, I have become pretty good at sewing buttons on my shirts.
Tips for Shooting Surgery
Our specialty is documenting open surgery, the kind where they literally open you up. We've done this with everything from a very heavy Ikegami HL-95 with dockable MII deck to the latest Sony HDV cameras. Regardless of the technology involved, the same tricks of the trade apply.
• Eat breakfast – cases often start at 7:30am and go on forever. The sight of guts on an empty stomach is not for everyone.
• White balance. Sounds obvious, but operating rooms generally have banks of fluorescent lights and overhead boom mounted halogen lights – colors that don't match. A head mounted light is yet another color temp, so beware.
• Get the camera as close to the operative field (incision) as possible.
• Don’t touch anything blue. "Blue" in the OR equals "sterile.".
• Make sure all your camera parts are secure. (Insert Seinfeld “Junior Mint” episode reference here.)
• Ask the surgeon to let you know when something important is about to happen. It also helps if the surgeon describes a technique or points out key anatomical landmarks.
• Ask the surgeon to use longer hand instruments if possible.
• Remind the surgeons to clean their gloves if they get really bloody. A 40 foot projection screen can make a messy surgical field look like a disaster.
• Develop a good rapport early, so you can get away with saying “Doctor, please get your head out of my way.” Seriously, this is most important.
Once you have seen a lot of surgery, you realize there is a lot of repetition, and that most procedures are a combination of basic skills and techniques combined with expert knowledge to accomplish the surgical goals.
Thus, as you are watching and following the action, you can anticipate is likely to happen next, and zoom in, zoom out or move your camera in anticipation. Again, this is a skill obtained through repetition.
Minimally invasive, or “laparoscopic,” surgery is where surgeons become their own cinematographers. Long before extreme sports athletes were strapping lipstick cameras to their helmets and jumping out of airplanes, surgeons have used optical scopes and video cameras to examine body cavities and perform operations.
One of the earliest uses of an optical scope was to examine the bladder, a procedure called cystoscopy. Once color video cameras small enough to use during surgery became available in the 1980’s, the first laparoscopic procedure performed was Cholecystectomy, or removal of the gallbladder.
Liver and gallbladder, center. (This is obviously a view from an "open" surgery rather than a laparoscopic one.)
Once this procedure was established as safe, many other basic and advanced procedures followed.
Early surgical video cameras were single CCD, with expectedly mediocre images. The mediocre image was combined with standard VHS recording. The arrival of 3-CCD cameras and SVHS in the mid-90’s really allowed laparoscopic surgery to thrive and made laparoscopic surgical video available to the masses. Once surgeons started recording all of their procedures, the days of DIY surgical videos began.
To this day, many laparoscopic video towers found in hospitals around the country, include a digital video recorder. Most of the systems you see in an OR are proprietary medical grade devices, sometimes featuring a hard disc and a CD or DVD burner.
In most cases the output is a CD or DVD with MPEG1, MPEG2, DIVX, Quicktime or other files. Most of the machines currently available spit out an autorun file so when you insert the disc in your computer, you get a HTML menu featuring the patient’s ID number, sometimes the surgeon’s name and thumbnails of all the video files.
This is all well and good, but what if you want to edit your video? Here’s where there can be a problem. You can certainly import various flavors of MPEG or DIVX into your editing system (sometimes) however the technical specs often leave much to be desired.
A recent visit to an OR revealed that their particular video recorder had a very small hard drive, so they used the MPEG1 setting. If using MPEG2, every 30 minutes the drive would fill up and you would have to pause the surgery and burn a DVD. Not a good situation.
Ok, so you can edit MPEG1, no problem. However MPEG1’s official spec is 352x240, VideoCD quality. Sure you can uprez this to DV, but at a loss. Even when you get MPEG2, it is often 640x480 and needs to be scaled.
Therefore, regardless of what format the OR is capable of recording, your best friend is a portable DV deck, such as the ubiquitous Sony clamshell that they even use on the space station. A home video camera with an S-Video input will do the job, but these cameras wear out quickly if you use them a lot. From 1999 to about 2003 we traveled with a desktop DVCPRO recorder.
Newer digital recording devices came to market in 2008, offering XDCAM and JPEG2000 recording. The future is looking bright!
During laparoscopy much of the imaging is out of our control, so here is a good checklist to help you advise the surgeons.
• Make sure the mounted laparoscopic camera is white balanced.
• Check the OR monitors with bars. Usually the OR CCU generates bars when first powered up.
• Keep an eye on the focus and clarity of the laparoscopic camera. Due to the temperature difference between the OR and the inside of a person, it is common for the lens to fog up, just like when you drive your car on a muggy day. Also, interns or less experienced residents are often driving the camera, and they need to be reminded to keep things in focus and to follow the action.
• It's not unusual to have establishing shots outside the patient. Many surgeons like to work with the lights down. It's easier for them to focus, and if you light it right, it can look really cool. Try to point one OR light or a low wattage video light at the ceiling, just to get enough fill to avoid having to use too much gain.
Finally, watch for smeared blood on the lens. Need I say more?
Some Other Tricks To Keep In Your Back Pocket
This headline is especially appropriate, because when you are wearing medical scrubs, you need to shove your wallet, keys, phone and some spare DV tapes in your lone back pocket. Be careful if you sit down. What am I saying, you won’t be sitting down!
Some operating rooms give you a Tyvek “bunny suit,” which labels you as an outsider, but at least you have your own pockets!
Let’s say you are shooting an open operation, and no matter how you position the camera, you can’t see what’s going on. In some cases, the surgeons can’t see what they are doing either, but they can feel what they need to. Laparoscope to the rescue. Sometimes if you ask nicely, the circulating nurse will fetch a laparoscope and video tower. One of the surgeons or assistants can get this sterile camera deep down inside the body to get the shot that your overhead camera will never see.
Some surgeons have had success shooting surgery with a laparoscopic camera head mounted to a rigid instrument clamp, without the optical scope.
That being said, never try to shoot a whole operation using a hand-held laparoscope, a head mounted camera or a camera built into an OR light. Sometimes this is exactly what you get. With some clever editing, this material can be made to work, but it is not optimal, and it looks like video shot with a handheld laparoscope or head mounted camera. The overhead light mounted camera can be okay, however the exposure tends to be hot and the zoom tends to be not used.
Fixing it in Post
The first step is of course capturing your raw footage. Back in the day, we would log each tape into an EDL then auto assemble edit the first cut onto 1”. Subsequent edits were made to the EDL itself (3.5” floppy) then another auto assemble to another reel of tape, or insert edit over the for edit. However we tended to keep every edit for reference.
Today of course we just capture the tapes in their entirety into Premiere Pro. While tapes are being gobbled up, we can work on another project on another computer. Each of our three editors has at least two computers side by side so we never get bored!
The first cut requires watching the raw footage in real time. As you view, you cut out the dead space, the repetition and anything that makes the surgeon look sloppy. That is, my job is not only to edit for content, but also to make the surgeon look awesome.
Years ago, a video on hernia repair featured one shot of a dull pair of scissors trying to cut a suture. I couldn't understand why, but edit after edit, the surgeon insisted on leaving this shot in.
Hernia surgery is wildly popular, so when it came time to show the video, the house was packed. When we came to the part I was worried about, the narrator said, “…and the suture is cut with a sharp pair of scissors.”
The crowd went crazy!
Apparently dull instruments are a common pet peeve of surgeons, and presumably of their patients.
While I do not spend a lot of time talking about technology, knowing what you have and how to use it can make or break a project.
A video on the sterile environment in the OR was nearly complete. However one of the reviewers noticed that we show a contaminated item being deposited into a red medical waste bag. In reality, a contaminated item not soiled with blood can be placed in a blue, non-contaminated bag. (Note positions of colored bags, below.)
What to do? Boris FX luckily allowed me to isolate the red bag’s color range and change it to a suitable blue. Luckily the shot is only a few seconds, but it did the trick. As it turned out, there were a few other bag shots which needed to be changed. Thankfully there were no blue bags needing to turn red, because in an OR, everything is blue!
Another video I worked on, this one about electrosurgery, discusses the use of smoke evacuation. During the use of the electrosurgery pencil, surgical smoke plume, depending upon the wattage, can be plentiful and hazardous.
During our shoot we got a few shots showing the proper use of a smoke evacuation unit. However some other nice stock footage shot elsewhere showed just the use of electrosurgery being discussed, but no smoke evacuator. However, a screen grab of the correct tool from another shot, a quick visit to Photoshop to erase the background, and voila, the shot now has a smoke evacuator. A keyframe animation in Premiere and 20% reduction in opacity and it just might work.
Again, if the shot is only a few seconds, and you don’t call attention to the effect, it can be “effect”-ive. Clever huh?
Back in the mid-90’s, Ciné-Med was a leader in Virtual Reality surgical training. Thanks in part to a grant from DARPA, the same folks who brought us the Internet, and some generous sponsors, we had a traveling exhibit.
In 1995 if you wanted a 3D graphic, you used a SGI box, such as the Crimson Reality Engine. These early RISC based processors were the bee’s knees for graphics, and weighed. One simulator in particular, and the most popular E-Ticket ride, was the Virtual Journey through the Heart. The user wore a head mounted display and held a joystick. The joystick beat in sync with the sound of the heart, and the visually beating heart seen in the HMD. If you turned your head or looked up or down, magnetic sensors called Flock of Birds told the computer which way to move the heart model. The joystick allowed you to fly into the vena cava and through the atria and ventricles.
Who wouldn’t want to experience the thrill of flying through the mitral valve or rounding the bend past the tricuspid valve? How exciting!
The only problem was, nearly every time we took this thing on the road, something malfunctioned. I should add that in 1995, most people did not have cell phones. One particular experience was at the Atlanta convention center. We setup our exhibit, threw the switch, and nothing happened. I found a pay phone, talked to the programmer, wrote down some UNIX commands, went back to the exhibit, and repeated this sequence until things began to work again. Those were the days indeed. These days when you see a VR surgical trainer, it runs off a laptop!
Surgeons reach a patient's skull.
One final story kids, then it’s off to bed. Live surgery is quite popular. Many hospital websites feature live and recorded webcasts of new procedures, intended to interest the general public is asking for those procedures when they need them, at that hospital. However certain medical conventions have banned live surgery broadcasts due to liability concerns (the “oh crud” factor).
So one year we devised a live-on-tape surgery session. Four surgeons recorded their procedures ahead of time and sent us the raw footage of both the laparoscopic inside view, and the outside overhead view. It was our job to edit the four cases down to about one hour each, but to do it in a way that did not look too “edited.” Let’s call it “minimally edited.”
This was back in 2000 using a Media 100 XR with 1 real time video track. The only way to keep the edit in sync was to edit everything on one timeline, make the cuts, then when ready, make a 2nd timeline for the 2nd view. Then we made a DVCPRO master for both timelines, and repeated this for all the cases.
When it was time for the main event, we flew to Chicago, took our two portable DVCPRO machines with us, wired them up to two projectors and manually synced the tapes to play in as close to synchronization as possible.
One problem, when we got to Chicago, I reviewed the tapes with the moderator of the session. One of the four procedures was unacceptable, edited too tightly, and there was not enough outside footage to match the inside.
“Don’t you have the raw footage with you?”
“No, that’s crazy talk.” I replied. This was 5pm the night before the event. I rushed to the airport, got on a 6pm flight back to Hartford, drove back to the office, digitized the missing footage, managed to have no technical glitches, and began making my two non-simultaneous DVCPRO masters at midnight. The masters were done around 3am. My return flight at 8am allowed me 2 hours time to sleep on the floor of my edit suite (not very restful).
I got back to the airport and was told I would have to go standby. With no guarantee that I would get to Chicago at all, I drove over to the airline’s freight office and checked my tapes as cargo, then went back to the airport and actually got on the flight. Only problem there is once I got to Chicago I had to wait at the freight counter for my cargo to be checked in, which apparently is considered non-urgent.
With package in hand a cab ride took me to the convention center. McCormick place for those who don’t know is slightly smaller than the Pentagon, so it was quite a walk. I arrived at 10:30am, with 20 minutes to spare before the tapes were needed. Mission accomplished. Oh wait, I needed to shower, shave and spend the rest of the day working the booth.
A crystal-clear view of surgery in progress
I have tried in this article to discuss the craft of medical/surgical video, and shed some light on how Ciné-Med has made this into a business. It is also an adventure. Every day is different and I look forward to every project, and to helping surgeons become better surgeons.
As we interface with in-hospital media services, we have learned to adapt to each situation, to think on our feet and to keep in mind the ultimate goal: capturing the best images possible. Indeed, the techniques and tricks of the trade valuable to surgical video are quite similar to broadcast production.
There are many ways to approach a situation, none of them wrong. Sharing knowledge is the key. We can learn from surgeons and their in-house resources, and they can learn from us. I enjoy knowing that we're helping doctors become better surgeons.
Michael Cohen is a charter member of the Cow, joining on its very first day. He's a specialist in Medical/Surgical video production, multimedia-based education, and project management for Cine-Med.. One of the hosts of the Business & Marketing forum, you can also find him in forums including Art of the Edit, Audio Professional, Broadcast Design, Compression Techniques, Flash and Premiere Pro. As Mike says, “Tools and technology are good to know, but craft and know-how pay the bills.”
And be sure to check out Mike's Creative Cow blog.