Best practices to optimize intraoperative photography

Best practices to optimize intraoperative photography

Accepted Manuscript Best Practices to Optimize Intra-operative Photography Sébastien Gaujoux, MD, PhD, Cecilia Ceribelli, MD, PhD, Geoffrey Goudard, M...

474KB Sizes 0 Downloads 59 Views

Accepted Manuscript Best Practices to Optimize Intra-operative Photography Sébastien Gaujoux, MD, PhD, Cecilia Ceribelli, MD, PhD, Geoffrey Goudard, MD, Antoine Khayat, MD, Mahaut Leconte, MD, PhD, Pierre-Philippe Massault, MD, Julie Balagué, Bertrand Dousset, MD PII:

S0022-4804(15)01146-4

DOI:

10.1016/j.jss.2015.11.048

Reference:

YJSRE 13598

To appear in:

Journal of Surgical Research

Received Date: 27 September 2015 Revised Date:

19 November 2015

Accepted Date: 24 November 2015

Please cite this article as: Gaujoux S, Ceribelli C, Goudard G, Khayat A, Leconte M, Massault P-P, Balagué J, Dousset B, Best Practices to Optimize Intra-operative Photography, Journal of Surgical Research (2015), doi: 10.1016/j.jss.2015.11.048. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Revised October 30th

ACCEPTED MANUSCRIPT

Best Practices to Optimize Intra-operative Photography

Sébastien Gaujoux, MD, PhD1,2,3; Cecilia Ceribelli, MD, PhD 1; Geoffrey Goudard, MD1; Antoine Khayat, MD1; MD1; Mahaut Leconte, MD, PhD1 ; Pierre-Philippe Massault, MD1 ;

RI PT

Julie Balagué1; Bertrand Dousset, MD1,2,3

Sébastien Gaujoux, Julie Balagué1and Cecilia Ceribelli: study design, data collection, analysis

SC

and interpretation, final approval

data collection, final approval

M AN U

Sébastien Gaujoux, Geoffrey Goudard, Vincent Restlinger and Antoine Khayat: study design,

Sébastien Gaujoux, Mahaut Leconte, Pierre-Philippe Massault, and Bertrand Dousset study

TE D

design, critical revision, overall responsability, final approval

EP

None of the authors have conflict of interest

AC C

1 Department of Digestive and Endocrine Surgery, Cochin Hospital, APHP, Paris, France 2 Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité 3 INSERM Unit 1016, Centre National de la Recherche Scientifique Unit Mixte de Recherche 8104, Institut Cochin

1

Revised October 30th

ACCEPTED MANUSCRIPT Corresponding author: Sébastien Gaujoux, MD, PhD Department of Digestive and Endocrine Surgery, Cochin Hospital, APHP,

27, rue du Faubourg Saint Jacques, 75014, Paris, France. Professional number: +00 33 1 58 41 17 15 Fax number: +00 33 1 58 41 29 62

AC C

EP

TE D

M AN U

SC

E-mail: [email protected]

RI PT

Université Paris Descartes, Paris, France

2

Revised October 30th

ACCEPTED MANUSCRIPT Abstract

Background: Intraoperative photography is used extensively for communication, research or teaching. The objective of the present work was to define, using a standardized methodology

RI PT

and literature review, the best technical conditions for intraoperative photography.

Materials and methods: Using either a smartphone camera, a bridge camera, or a single-lens reflex (SLR) camera, photographs were taken under various standard conditions by a

SC

professional photographer. All images were independently assessed blinded to technical conditions to define the best shooting conditions and methods.

M AN U

Results: For better photographs, an SLR camera with manual settings should be used. Photographs should be centered and taken vertically and orthogonal to the surgical field with a linear scale to avoid error in perspective. The shooting distance should be about 75 cm using an 80-100mm focal lens. Flash should be avoided and scialytic low-powered light should be

TE D

used without focus. The operative field should be clean, wet surfaces should be avoided and metal instruments should be hidden to avoid reflections. For SLR camera, ISO speed should be as low as possible, autofocus area selection mode should be on single point AF, shutter

EP

speed should be above 1/100 second, and aperture should be as narrow as possible, above f/8. For smartphone, use HDR setting if available, use of flash, digital filter, effect apps and

AC C

digital zoom is not recommended. Conclusion: If a few basic technical rules are known and applied, high-quality photographs can be taken by amateur photographers and fit the standards accepted in clinical practice, academic communication and publications.

3

Revised October 30th

ACCEPTED MANUSCRIPT Key word: intraoperative photography; camera; ethics; technique; single-lens reflex;

RI PT

smartphone

AC C

EP

TE D

M AN U

SC

.

4

Revised October 30th

ACCEPTED MANUSCRIPT Introduction Academic oral presentations or written publications are frequently supported by illustrations. Graphical representations such as drawings, sketches, figures or photographs

RI PT

support the text, strengthen the messages and highlight the key points. In medical and surgical literature, photography has been used extensively to illustrate case series, or, more frequently, to illustrate surgical procedures and specific technical points. Nevertheless, in a clinical

SC

setting, and mainly in operating rooms, the technical constraints of photography are particularly important. As a result, the quality of photographs taken either by smartphones,

M AN U

compact cameras, or single-lens reflex (SLR) cameras, is often poor, making them frequently unsuitable for clinical or academic purposes. The quality of photographs could be improved through the enforcement of a few basic rules. The aim of this work is to define, using a standardized methodology and through literature review, the best technical conditions for

AC C

EP

TE D

intraoperative photography using the most commonly available cameras.

5

Revised October 30th

ACCEPTED MANUSCRIPT

Material and methods Camera used Three cameras, representing most of the cameras commercially available, were used,

RI PT

i.e. a smartphone camera (iPhone 4S, Apple Inc, California, USA), a bridge camera (Lumix DMC-FZ200, Panasonic, Japan), and a professional SLR camera (EOS 5D mark II, Canon, Japan, with EF USM 85 mm f/1.8 lens, Canon, Japan). Their main technical characteristics

SC

are summarized in table 1. Lighting

M AN U

The operative field was lit with either fluorescent ceiling light from the operating room, main and satellite scialytic lights focused on the operative field with a color temperature of 3800K (marLED V16 and V10, KLS Martin, Mühlheim, Germany) and/or LED, pop-up or cobra flash (Speedlight 580 EX II, Canon, Japan).

TE D

Photography condition, presetting and study protocol

All photographs, centered on the surgical field, were taken by a professional photographer. On surgical drapes, a photography test pattern was disposed, (Color Control

EP

Patches, Kodak, USA), with various fresh, moistened animal organs and a surgical blade held in a gloved hand with a surgical gown, mimicking a real operative field (Figure 1). As in

AC C

surgical conditions, the shooting distance was about 70 to 80 cm with a focal length of about 80 mm for the bridge and SLR camera. When the camera allowed for it, we preset the focal lens (at about 80 mm), autofocus area selection mode (Singlepoint AF), ISO speed (as low as possible), shutter speed (above 1/100 second), aperture (above f/8), and activated the image stabilizer to avoid motion blur. Images were recorded in RAW and/or JPEG formats. Three to five pictures were taken for each conditions. Image analysis and definition of best shooting condition

6

Revised October 30th

ACCEPTED MANUSCRIPT No post-processing treatments with image-editing software were used. All images with available shooting information were analyzed using an RGB (red, green, and blue) histogram by 2 professional photographers assessing lighting conditions, exposure, contrast, depth-of-field, noise, and color accuracy, blinded to camera and lighting conditions.

RI PT

Sharpness, geometric distortion, and chromatic aberration, mainly dependent on the lens or the camera, were not studied. According to these criteria, pictures and images quality were subjectively rated from 0 to 5 and best shooting conditions defined. These optimal conditions

SC

were then tested intraoperatively by surgeons themselves on planned surgical procedures. Systematic review

M AN U

We conducted a systematic literature review of articles published over the last 10years in MEDLINE via PubMed using the following search strategy for the MeSH and nonMeSH heading: (picture OR photography) AND (clinical OR surgery OR intraoperative) AND (guide OR guideline). After identifying relevant title, abstracts were read and eligible

TE D

articles retrieve, selecting only the ones dealing with surgical or intraoperative photography. A manual cross-reference search of the bibliography of all publications retrieved was performed for relevant references, and the « related article » function in PubMed also used to

EP

identify studies that may have been missed in the database search. English language relevant

AC C

original clinical studies or reviews on human of any level of evidence were included.

7

Revised October 30th

ACCEPTED MANUSCRIPT Results Lighting Regarding the 3 lighting sources used, ceiling fluorescent light provided an intensity

RI PT

of 164 lux, while the scialytic lights were more than 100 times as luminous with a light intensity of 21920 lux, resulting in more contrasted pictures. Flash intensity varied in accordance with the exposure condition, but was associated with important reflection,

SC

especially on wet or metallic surfaces such as retractors and surgical instruments. Exposure and focus area selection mode

M AN U

Exposure should be done in the center of the scene that is the point of interest. On smartphones, exposure and focus area selection modes are commonly non adjustable. When using a bridge camera, automatic mode could be selected to avoid incorrect settings. For more advanced use, it is possible to work in semi-automatic mode with ISO and white balance

TE D

adjustment. With an SLR camera, central single point mode can be chosen to adjust the exposure and autofocus to the center of the scene. Focal length

EP

Focal length and field of view are inversely proportional. On the smartphone, the focal length is equivalent to a 33 mm and cannot be adjusted. Consequently, the photographer must

AC C

adjust the distance between the camera and the operative field in order to get an appropriate field of view, often as close as 30 to 40 cm, which questions the need for intraoperative asepsis. Conversely, using a bridge or SLR camera allows for the adjustment of focal length, and the best results are typically obtained with a focal length from 80 to 100 mm that allows for a 70-80 cm distance from the operative field. Shutter speed Shutter speed or exposure time is the length of time the shutter is open, i.e. the time the sensor is exposed to light. The faster the shutter speed is, the less time the sensor is

8

Revised October 30th

ACCEPTED MANUSCRIPT exposed to light for, and the lower the risk is of obtaining a motion-blurred picture. On a smartphone, no shutter speed modification is possible. On bridge and SLR cameras, a shutter speed between 1/100 second and 1/200 second, using either a scialytic or fluorescent light, should be used to avoid motion blur. The shutter speed should be increased if longer focal

RI PT

lengths are used. Aperture

Aperture restricts the diameter of the lens iris and defines the depth of field, i.e. the

SC

distance between the nearest and the farthest object on the operative scene that appears sharp in the picture. The higher the f-number is, the smaller the lens iris is, and the wider the depth

M AN U

of field is. Multiple combinations of shutter speed and aperture, expressed as f-numbers, can give the same exposure. On bridge and SLR cameras, an aperture of f/8 and above was necessary to obtain good quality pictures, i.e. pictures with an optimal depth-of-field. ISO speed

TE D

ISO speed defines the sensor’s sensitivity to light. The higher the ISO speed is, the more sensitive the sensor is, but the lower the image quality is, as a result of image noise. With fluorescent light, the ISO speed needed to be increased up to 800 in order to have bright

White balance

EP

enough images. However, with scialytic light, an ISO speed of 100 was sufficient.

AC C

Color balance is the global adjustment of the colors on a picture, in order to render

them as close as they are in the reality. Color balance was improved with a manual setting using an 18% gray card with whichever light source was used. Color balance manual settings can be recorded for specific operating room, camera and lighting conditions. Overall setting Best shooting conditions were defined based on issues such as blur, light reflection, depth-of-field, noise, and color accuracy (table 2). General conditions for high quality

9

Revised October 30th

ACCEPTED MANUSCRIPT intraoperative shooting were also defined (table 3). SLR camera and manual settings provided higher quality imaging. Flash should be avoided because of troublesome light reflection, and scialytic light should be used whenever possible. Shutter speed should be above 1/100 second, aperture should be above f/8, and ISO should be as low as possible, i.e.

RI PT

between 100 and 800. Intraoperative tests by surgeons

All efforts were made to protect patient privacy and obtain patient consent according

SC

to local and international regulations. Additionally, as required by most journals, patients

either in the text or the illustration.

M AN U

should have signed specific informed consent prior to publication if they could be identified

Intraoperative tests by surgeons using either their own smartphone, or a bridge or SLR camera confirmed that high-quality photographs, in accordance with surgical journal standards, can be obtained by non-professional photographers.

TE D

Systematic review

A total of 1029 articles were revealed after electronic search. After a more detailed reading, articles without data about surgical or intraoperative photography were excluded.

EP

After cross-reference search, only 5 articles were included. Briefly, all of the retrieved articles

AC C

were review articles from anatomist, orthopedic or plastic surgeons.

10

Revised October 30th

ACCEPTED MANUSCRIPT Discussion Photography is used extensively nowadays in both our private and professional lives. In our surgical practice, photographs are now taken daily to record or teach special procedures, to illustrate oral or written communication or to be kept in a medico-legal

RI PT

perspective. In the near future, it is likely that illustrations will be included in patient health medical records. With the widespread diffusion of smartphones and their high-quality cameras [1], this tendency is likely to increase [2] in surgical departments and operating

SC

theatres. Unfortunately, most institutions do not have medical illustration departments and photographs, which are frequently unplanned, have to be taken by non-specialized staff. In

M AN U

contrast with plastic or orthopedic surgery [3, 4], little is known regarding the technical constraints associated with intraoperative photography in general surgery. We therefore believe that it is useful to provide some guidelines in order to standardize and optimize

TE D

intraoperative surgical photography.

Tables 3 and 4 summarize the best technical shooting conditions for intraoperative photography according to the type of camera used, and provide some recommendations for

EP

high-quality intraoperative imaging for gastrointestinal surgery. Following these guidelines will allow non-professional photographers such as clinicians or nurses to take their own

AC C

photographs of a quality adequate for either academic or medical purposes. It is important to recommend the routine use of an institutional camera to obtain quality reproducible results. Even if these technical shooting conditions can be applied to most of our procedures, they should not be taken as a general rule, as they need to be adapted to specific conditions or procedures. Other surgical specialties, namely orthopedic or plastic surgery, with specific technical constraints, have previoulsy addressed the issue of intraoperative photography. They have

11

Revised October 30th

ACCEPTED MANUSCRIPT provided additional tips such as the benefit of a swivel screen on the camera [5], or the possible use of a presterilized waterproof camera case. It is always necessary to remember that everything should be done to avoid the risks of bacterial contamination by the photograph. Additionally, intraoperative photography should lead to minimal interruption of

RI PT

the operative procedure, and consequently required a “photographer” trained to this specific environment and practice.

Taking intraoperative photography can represent a challenge to preserve the patient’s

SC

privacy and anonymity as previously underlined [6, 7]. With the increased use of digital photography, a written department policy regarding the use of patients’ photography should

M AN U

be available and patient consent obtained whenever required by both national and international ethical and legal regulations [8].

Whether or not post-processing treatments with image-editing software should be used to increase the quality of pictures is still debated. Despite the fact that photographs can easily

TE D

be improved through “photoshopping”, we still believe that, in a scientific journal, as in journalism, pictures should reflect what the operative field truly was. Science is not an art, and aesthetic issues should be sacrificed to uphold scientific ethical requirements.

EP

Nevertheless, slight post-processing modifications can be tolerated if they only upgrade the image quality without modifying the scientific and medical content.

AC C

In conclusion, as digital photography has become increasingly important in academic

communications and clinical practice, we believe that, if a few basic technical rules are known and applied, high-quality photography can be taken by non-professional photographers. In the present era, specific efforts should be made to protect patient anonymity and obtain consent in order to uphold strict adherence to ethical and legal regulations.

12

Revised October 30th

ACCEPTED MANUSCRIPT Acknowledgement

AC C

EP

TE D

M AN U

SC

RI PT

We would like to thank Gabriel Coutagne for his helpful discussion and technical assistance.

13

Revised October 30th

ACCEPTED MANUSCRIPT Bibliography

1.

Kulendran, M., et al., Surgical Smartphone Applications Across Different Platforms: Their Evolution, Uses, and Users. Surg Innov, 2014. Burns, K. and S. Belton, Clinicians and their cameras: policy, ethics and practice in

RI PT

2.

an Australian tertiary hospital. Aust Health Rev, 2013. 37(4): p. 437-41. 3.

DiBernardo, B.E., Standardized photographs in aesthetic surgery. Plast Reconstr

4.

SC

Surg, 1991. 88(2): p. 373-4.

Uzun, M., et al., Medical photography: principles for orthopedics. J Orthop Surg Res,

5.

M AN U

2014. 9: p. 23.

Wang, K., E.J. Kowalski, and K.C. Chung, The art and science of photography in hand surgery. J Hand Surg Am, 2014. 39(3): p. 580-8.

6.

Koch, C.A. and W.F. Larrabee, Jr., Patient privacy, photographs, and publication.

7.

TE D

JAMA Facial Plast Surg, 2013. 15(5): p. 335-6.

Mavroforou, A., G. Antoniou, and A.D. Giannoukas, Ethical and legal aspects on the use of images and photographs in medical teaching and publication. Int Angiol, 2010.

8.

EP

29(4): p. 376-9.

Franchitto, N., et al., Photography, patient consent and scientific publications:

9.

AC C

medicolegal aspects in France. J Forensic Leg Med, 2008. 15(4): p. 210-2.

de Meijer, P.P., et al., A guideline to medical photography: a perspective on digital photography in an orthopaedic setting. Knee Surg Sports Traumatol Arthrosc, 2012. 20(12): p. 2606-11.

10.

Raigosa, M., et al., Waterproof camera case for intraoperative photographs. Aesthetic Plast Surg, 2008. 32(2): p. 368-70.

11.

Barut, C. and H. Ertilav, Guidelines for standard photography in gross and clinical anatomy. Anat Sci Educ, 2011. 4(6): p. 348-56.

14

Revised October 30th

ACCEPTED MANUSCRIPT

Figure legend

RI PT

Figure 1: Photography test pattern, RGB histogram and pictures of the scene mimicking an operative field A: with smartphone camera

SC

B: with bridge camera

AC C

EP

TE D

M AN U

C: with SLR camera

15

Revised October 30th

ACCEPTED MANUSCRIPT

SC

RI PT

Tables

AC C

EP

TE D

M AN U

Table 1: Technical characteristics of the 3 cameras used iPhone 4S Lumix camera DMC-FZ200 8 12.1 Camera effective megapixel 1/3.2" 1/2.3 Camera sensor size 33 mm 80 mm (25-600) Focal length (equiv. 35 mm) Up to Up to 1/4000 Shutter speed 1/2000 f/2.4 f/2.8 Maximum aperture 80-1000 100-6400 ISO speed LED Built-in Flash Yes No HDR (High Dynamic Range) Various including Auto Autofocus, Autofocus Focus mode Macro, Manual Focus Yes Yes Digital image stabilization Various including Auto / Custom White-Balance / No Color Temperature / White balancing setting Standardized WhiteBalances No Yes Auto Exposure Bracketing Various, including, JPEG, JPEG File format RAW, TIFF

Canon EOS 5D mark II with 85 mm f/1.8 21,1 24x36 Full frame 85 mm Up to 1/8000

f/1.8 100-6400 External No Various including Autofocus, Autofocus Macro, Manual Focus Yes Various including Auto / Custom White-Balance / Color Temperature / Standardized White-Balances Yes Various, including, JPEG, RAW, TIFF

16

ACCEPTED MANUSCRIPT Revised October 30th

AC C

EP

TE D

M AN U

SC

RI PT

Table 2: Mains publication on intraoperative photography in surgery Authors Years Specialty Summary of recommendations Standards have not been established for medical photography in orthopedics as in other specialty areas. Uzun et al. [4] 2014 Orthopedic Our results suggest that photographic clinical information in orthopedic publications may be limited by inadequate presentation. For intra-operative pictures, the camera operator should understand the procedure and pertinent anatomy Wang et al. [5] 2014 Hand surgery in order to properly obtain high-quality photographs. de Meijer et al. [9] 2012 Orthopedic Suggested guidelines Presterilized waterproof camera case allows the user to take very good quality pictures with the Raigosa et al. [10] 2008 Plastic photographic angle matching the surgeon’s view, minimal interruption of the operative procedure, and minimal risk of contaminating the operative field. gross and clinical Barut et al. [11] 2011 Suggested guidelines anatomy

17

Revised October 30th

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

Table 3: Settings recommendations for high-quality academic intraoperative photography Camera Ideal setting Smartphone Bridge SLR camera ≥ 1/100 ≥ 1/100 Shutter speed Fixed (30 mm) 80-100 mm 80-100 mm Focal length 100 with scialytic 100 with scialytic ISO light or as low as light or as low as possible possible Manual with grey Manual with grey White balance chart chart ≥ f/8 ≥ f/8 Aperture scialytic scialytic fluorescent Best light Overall rating + ++ +++

18

Revised October 30th

ACCEPTED MANUSCRIPT

Table 4: Golden rules for high-quality intraoperative imaging

-

RI PT

SC

M AN U

-

TE D

-

EP

-

Always use the same camera and check battery and memory first Whenever possible use an SLR camera with manual settings Any unessential accessories should be removed Subject should be centered, vertical and orthogonal to the surgical field with a linear scale, to avoid error in perspective Cranio-caudal axis should be vertical The photographer should be used to OR environment and understand the procedure and pertinent anatomy Shooting distance should be about 75 cm using a 80-100mm focal lens Optical zoom should always be preferred to digital zoom Flash should be avoided and scialytic light used instead Set color balance manually if possible The area of interest should be placed in the center of the photograph Avoid wet or metallic surfaces: dry and clean the operative field/background and hide metal instruments An easily recognizable anatomic landmark should be included in the photograph ISO speed should be as low as possible and always under 400 Autofocus area selection mode should be on Single point AF Shutter speed should be above 1/100 second and if the shutter speed is below 1/60 s, a tripod should be used Aperture should be as narrow as possible and above f/8 to have a large depth of field Lens’ built-in image stabilizer should be activated Images should be recorded in RAW and/or JPEG format Patient’s privacy should be protected, and informed consent obtained Regularly download images containing patient ID number into a securedcomputer with a back-up on a separate media in a different location

AC C

-

19