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Advancement of thyroid surgery video recording: A comparison between two full HD head mounted video cameras
International Journal of Surgery 41 (2017) S65eS69
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International Journal of Surgery journal homepage: www.journal-surgery.net
Original research
Advancement of thyroid surgery video recording: A comparison between two full HD head mounted video cameras Andrea Ortensi a, 1, Andrea Panunzi a, 1, Silvia Trombetta a, Alberto Cattaneo b, Salvatore Sorrenti c, *, Valerio D'Orazi a a
Department of General Microsurgery and Hand Surgery (Reference Center for Thyroid Surgery by the Italian Association of Endocrine Surgery Units - U.E.C. CLUB), “Fabia Mater” Hospital, Via Olevano Romano 25, 00171, Rome, Italy EL.CA. by Cattaneo Alberto, Piazza Como 14, 22070, Bregnano, CO, Italy c Department of Surgical Sciences, “Sapienza” University of Rome, Italy b
h i g h l i g h t s Head Head Head Head
mounted mounted mounted mounted
video video video video
recording have been used camera - new prototype camera - new prototype camera - new prototype -
in the most varied fields of surgery. attempts to record the real point of view of the magnified vision of surgeon. shows the difference between magnified vision and the naked-eye vision. is better than conventional video cameras in surgical education and training.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 13 December 2016 Accepted 16 March 2017
Background: The aim of this study was to test two different video cameras and recording systems used in thyroid surgery in our Department. This is meant to be an attempt to record the real point of view of the magnified vision of surgeon, so as to make the viewer aware of the difference with the naked eye vision. Materials and methods: In this retrospective study, we recorded and compared twenty thyroidectomies performed using loupes magnification and microsurgical technique: ten were recorded with GoPro® 4 Session action cam (commercially available) and ten with our new prototype of head mounted video camera. Results: Settings were selected before surgery for both cameras. The recording time is about from 1 to 2 h for GoPro® and from 3 to 5 h for our prototype. The average time of preparation to fit the camera on the surgeon's head and set the functionality is about 5 min for GoPro® and 7e8 min for the prototype, mostly due to HDMI wiring cable. Videos recorded with the prototype require no further editing, which is mandatory for videos recorded with GoPro® to highlight the surgical details. Conclusion: the present study showed that our prototype of video camera, compared with GoPro® 4 Session, guarantees best results in terms of surgical video recording quality, provides to the viewer the exact perspective of the microsurgeon and shows accurately his magnified view through the loupes in thyroid surgery. These recordings are surgical aids for teaching and education and might be a method of self-analysis of surgical technique. © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Thyroid surgery Loupes magnification Microsurgery Head mounted video camera Surgical education Prototype
Abbreviations: NIM, intraoperative neuromonitoring; HD, high definition; ISO, international standard organization; LUX, unit of illuminance; FPS, frames per second; EV, exposure value; MP, megapixel; DPI, dot per inch; SD, secure digital; CM, centimeter; GR, gram; $, dollar. * Corresponding author. Department of Surgical Sciences, “Sapienza” University, Viale Regina Elena 324, 00161, Rome, Italy. E-mail addresses: [email protected] (A. Ortensi), [email protected] (A. Panunzi), [email protected] (S. Trombetta), [email protected] (A. Cattaneo), [email protected] (S. Sorrenti), [email protected] (V. D'Orazi). 1 These authors contributed equally to this work.
INTRODUCTION The history of thyroid surgery in recent decades has been characterized by the introduction of significant technical and technological innovations, improving the accuracy of diagnosis and surgical operations, patient outcomes and reducing operative time and complications [1e5]. While the surgical technique is currently almost the same as that described by Lahey in 1938 [6], the technological progress of
http://dx.doi.org/10.1016/j.ijsu.2017.03.029 1743-9191/© 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
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the past 25 years has introduced innovations and tools which entered into daily surgical practice, from the sealing devices, based on radiofrequency and ultrasound, to intraoperative neuromonitoring (NIM) to routine use of loupes magnification [7e9]. It is now common belief that use of optical and digital magnification in any field of surgery (minimally invasive video-assisted surgery, laparoscopy, endoscopy, loupes-assisted surgery, robotic surgery) [9e11] improves the performance of the surgeon and the results. The rationale is that the magnification improves the visibility and perception of depth of the operative field and facilitates the identification and preservation of anatomical structures. Just as technology is working to improve the surgeon's vision, so the surgeon is trying to find the best possible system to allow other people to see exactly what he sees and does [12]. In effect, in order to paraphrase a famous quote “a picture is worth a thousand words”, so we can say that “a video is worth a thousand pictures”. It means that certainly the best way to teach people what you're doing is to show it directly, to let them see your work. Here comes the wide spread of video recording systems of surgical procedures worldwide. The resulting footage is mainly used as a teaching tool [13] for the training and assessment of surgeons, as well as a source of material for courses and conferences or even teleconferences on live surgery [14]. It also provides a method of self-analysis of the surgical technique in order to improve it, reducing intra and postoperative complications. The literature shows many examples of the application of video recording in the most varied fields of surgery, from neurosurgery and orthopedics, to hand surgery, to get even the trauma surgery [13e17]. Several studies examined some of the most widespread commercial action cameras and their use in the operating rooms, analyzing the technical features and highlighting their major strengths and weaknesses. The most popular and used camcorders at the time are GoPro (several models) [16,18,19], Contour High Definition (HD) Helmet Camera [15], Panasonic HX-A100 and Google Glass [17,20e22]. Each of these showed its pros and cons in the operating room application. The ideal camcorder should have these features: it has to be small, lightweight, comfortable and user friendly; to be able to capture the exact surgeon's view; to provide high definition images and videos; to have a long battery life; to be as cheap as possible. To date, this camera does not exist. The aim of this study was to introduce a novel prototype of head mounted video camera which we built and patented with the exact target of being used by surgeons in the operating theater. This is meant to be an attempt to record the real point of view of the magnified vision of surgeon, so as to make the viewer (as a trainee surgeon) aware of the difference with the naked eye vision. For this purpose, we decided also to test two different cameras and recording systems, our prototype and the commercial action cam GoPro® 4 Session, used in thyroid surgery performed with loupes magnification and microsurgical technique.
available) (Fig. 1) and ten with our new prototype (Fig. 2) of head mounted video camera (built in 2013 and patented on October 2016; Italian Patent number 102013902204193). Informed consent for picture and video recordings was submitted to all patients. Technical features of both cameras are showed in Table 1. The GoPro® was head mounted with elastic bands and oriented to the surgeon's perspective using the application of video preview function to be installed in smartphone, tablet or computer system. The prototype was head mounted with adjustable bands and oriented to the surgeon's perspective by checking the image on a HDMI-TV screen wired connected and correctly positioned by turning the tilt system of an innovative internal mirror, like a “periscope”. We use a proper and autonomous lighting provided by a double optical led (optional), assembled in an all-in-one system with the camera. 2. Results Settings were selected before surgery for both cameras. GoPro® 4 Session was set for surgical recording use with 1080p, medium field of view (the narrower selectable for this model), 30 fps (the only selectable for 1080p and medium field of view), low light was turned off, spot meter was turned on, white balance was on auto, color set on “GoPro® standard color”, International Standard Organization (ISO) limit to 400, sharpness at high and exposure value (EV) at 0. The prototype camera was set for surgical recording use with 1080p, 60 fps, and white balance was made preoperatively on a white gauze. Through a wire controller, zoom could be set manually also during surgical time, not only previously as required by the GoPro®. Using these settings, the recording time is about from 1 to 2 h for GoPro® and from 3 to 5 h for our prototype. The average time of preparation to fit the camera on the surgeon's head and set the functionality is about 5 min for GoPro® and 7e8 min for the prototype, mostly due to HDMI wiring cable. Videos recorded with the prototype require no further editing, which is mandatory for videos recorded with GoPro® to highlight the surgical details. 3. Discussion Video recording of surgical procedures has always been a subject of interest since wearable devices were introduced. Apart from
1. Materials and methods From January to July 2016, in the Department of General Microsurgery and Hand Surgery, “Fabia Mater” Hospital, Rome, Italy (reference center for thyroid surgery by the Italian Club of the Endocrine Surgery Unit) we video recorded twenty thyroidectomies performed using loupes magnification (4,5 with focal range al 17 inches) and microsurgical technique [9]. Of these, ten were recorded with GoPro® 4 Session action cam (commercially
Fig. 1. GoPro® 4 Session action cam.
A. Ortensi et al. / International Journal of Surgery 41 (2017) S65eS69
Fig. 2. New prototype of head mounted video camera.
rare and pioneering studies, only in the last 10 years several papers have been published in the literature about the use of head mounted video cameras in the operating theaters [13e26]. All commercial recording systems (defined action cams) were built and sold with other targets, very far from medicine (mainly outdoor sports); subsequently the surgical world, always in search of innovations, has adapted them to a much different role. It is obvious, therefore, that they have important limitations, mostly the lack of small anatomical details and the inability to well visualize deep cavities, which become even more remarkable in thyroid surgery.
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However, our experience in many areas of general surgery [27e29] and reconstructive microsurgery [9,30e33] prompted us to consider the benefits of microsurgical technique and the use of loupes when applied to thyroid surgery [9]. Thyroid surgery is a delicate surgery that involves working in a very narrow field, requiring the detection of even very thin structures, and for these reasons still exposes to possible severe complications. The application of a head mounted camera in thyroid surgery performed with microsurgical technique and loupes magnification has allowed us to record the magnified sight of surgeon and to optimally frame all anatomic and technical details, despite the depth of field changes during surgery. The initial assumption wasn't the simple video recording of surgical procedures, but we wanted to overcome the gap between the images captured with a commercial camera and the corresponding surgeon's view, without more post-production editing. Specifically, we wanted to provide to the viewer the exact perspective of the microsurgeon and to show accurately the magnified view through the loupes. These recordings are surgical aids for teaching, training tools for less experienced surgeons and a method of self-analysis of the surgical techniques [16,18,19,23e26,34,35]. For this reason, we developed a prototype of head mounted video camera, designed for operating room use and built specifically to guarantee optimal results in terms of surgical video recording quality. Evaluated the remarkable quality of the images obtained by prototype (Table 1), to validate these results we decided to compare it with a popular action cam, the GoPro® 4 Session. This device was the cheapest, smallest and lightest camcorder on the market and represented the best stress test for the weak points of prototype (size and weight not exiguous, price still not available). Maintaining the recording at 1080p, the prototype has the capability of up to 25 magnification, with a high-stability optical zoom (Carl Zeiss® Vario-Tessar® lens), extended until 30 and an elevated light sensitivity (0,3 lux, unit of illuminance of the International System of Units, measuring luminous flux per unit area) with minimal amounts of image aberration. This provides a high quality image, to reproduce a realistic “surgical experience”. GoPro® 4 Session was also set for surgical recording with 1080p, but otherwise use fixed focus wide angle lens and ISO limited to 1600 (moderate distortion). It's not equipped with a magnification capability but there are just two preset fields of view (wide and medium). For this model is not available the narrow field of view
Table 1 Technical features of both cameras. GoPro® 4 Session
Prototype Full HD 1.080p (60 fps) yes optical 0,3 lux minimal distortion
Zoom
Full HD 720p-1.440p (30e100 fps) yes digital 400 ISO (reduced distortion) 1600 ISO (moderate distortion) two settings (wide, medium)
Photo Supply Connectivity Storage Control of image Peculiarity Lights provided Duration in continuous recording mode (h) Dimension (cm) Weight (gr) Price ($)
5 MP medium zoom 72dpi battery WiFi Micro SD card App on electronic device Wide lens no 1-2 (depending on battery life) 444 74 200
Resolution Autofocus Image stabilizer Light sensitivity
optical, manual 25 (extended 30) Carl Zeiss® Vario-Tessar® Lens 5 MP optical zoom 300dpi power HDMI wire (WiFi module optional) SD card HDMI monitor Mirror double optical LED (optional) 4 (depending on resolution and SD card size) 10 4 5 98 not available
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option, that might actually be useful in surgery. Unlike the GoPro® 4 Session, the prototype has an optical, digital extended, magnification. The photos and videos prove to be of better quality and so do not require a post-production editing. Due to the elevated light sensitivity (0,3 lux), our prototype doesn't need of auxiliary lights, which however could be installed as an option to help the surgeon (and not the camera) to visualize shaded anatomical areas. GoPro® 4 Session footage quality was limited by reflection of operating room lights that can overexpose the video. This limit depends on the angle and intensity of the light as well as on the head position. In both devices, use of a typical headlight strap may interfere with the head mounted devices and for this reason is preferable a led light mounted on surgical loupes or alternatively an all-in-one system assembled with the camera. Battery life is one of the most relevant weaknesses of all commercial action cams (GoPro® 4 Session included) and involves an important limitation to the overall recording time [16,19]. Our prototype is not battery powered, but plugged in. For this reason, the recording time is influenced only by the storage memory size, and just later by the resolution of the image (4 h of continuous recording mode stored on 32 GB SD card). Surely a head mounted camera cannot be coaxial with the surgeon's eyes or the operating loupes. Therefore, the perspective of the camera will be directed to a specific point of the surgical field, which is defined by the intersection of the line of the sight and the surgeon's hand, and is influenced by the height of the camera compared to the eyes' position. Our prototype solves this problem by aligning the sight and perspective of camera to those of the surgeon through the introduction of an internal mirror, working as a periscope. This mirror is the real, great innovation which made possible to patent our camera. Its presence enables to correctly align the camera sight with the operator's vision: this allows it to be perfectly coaxial with the surgeon's eyes, so as to provide to the observer the true first person view, a characteristic that any other video recording systems can not do. By moving a wheel placed on the top of the prototype, it's possible to aim the camera by aligning it with the same perspective of the surgeon. This is usually done before starting, but it can also be modified during surgery by an ancillary person or by foot control system, in case of misalignment due to contact between the heads of the surgeons. Our prototype is heavier in comparison to GoPro®, 98 gr and 74 gr respectively, but the difference in weight and the encumbrance are acceptable and not limiting for the surgeon. The quality of the final video obviously depends on the type of camera used, but also on the ability of the operator to be stationary during surgery so to obtain an optimal video. This means that the surgeon has to minimize head and neck movements to keep the surgical field focused and to prevent the final video is choppy, blurry or not centered. A microsurgeon, accustomed to using magnification loupes, is facilitated in this task, because he is already trained to hold the position of the head, so as to keep the surgical field at the center. Actually, technology is already ahead: the near future will be made of more advanced devices that will allow to carry out the concept of “augmented reality”, through head mounted display, to create a new interactive surgery. Google Glass® (Google Inc., Mountain View, California) represents the first and best known for this purpose. It's a wearable and wireless device, but equipped with a lower quality (720p) digital camera (lacking of zoom) and a display, operating by voice or touch control and able to interact with the surgeon showing recorded videos or step-by-step procedures. For these devices will be increasingly important to use
high quality videos, corresponding as much as possible to the real surgeon's view. 4. Conclusions Of course we know well that the existing commercial cameras are cheap, light and handy, so they are easily adaptable to surgical recording. For this reasons we decided to build our prototype to create a professional tool, specifically designed for use in the operating room, with the aim to show to the viewer the same vision of the microsurgeon through the loupes, to demonstrate the advantages achieved with the optical magnification, also, in a delicate surgery such as thyroid surgery. Surely our prototype has some significant weaknesses, such as weight: for this reason is already in progress the construction of a new prototype of our video camera, improved in every technical feature (for example better resolution, lower size and weight, WiFi connectivity), to obtain an even easier, more comfortable and practical tool. Many studies are already in progress and others will be needed to advance the existing technology, for example to make it able to track hand or eye movement and to share wireless data, in order to superimpose digital images with the real-time view of the surgeon, build 3D images or even create holograms of surgeries. Ethical approval No ethical approval was needed for this study. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author's contribution Andrea Ortensi and Alberto Cattaneo: designed the videocamera prototype. Alberto Cattaneo: built the videocamera prototype. Andrea Panunzi, Silvia Trombetta and Valerio D'Orazi: partecipated substantially in conception, design, and execution of the study and in the analysis and interpretation of data. Valerio D'Orazi, Andrea Ortensi and Andrea Panunzi: performed surgery and video recordings. Salvatore Sorrenti, Andrea Panunzi and Silvia Trombetta: performed the literature search, data acquisition and partecipated substantially in the drafting and editing of the manuscript. Salvatore Sorrenti: supported the writing of the paper. All authors read and approved the final manuscript. Conflict of interest statement None. Guarantor Andrea Ortensi is the guarantor of the study. Consent Written informed consent was obtained from the patients for surgery, video recordings and publication of this manuscript and any accompanying images. A copy of written consent is available for review by the Editorin-Chief of this Journal.
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Acknowledgements The authors are very grateful for the support by Guarnieri family, owner of “Fabia Mater” Hospital. The authors are also grateful to all anesthesiologists and nursing staff of the Hospital. In addition, the authors like to thank Omar Cattaneo for the contribution to build the videocamera, Bianca Baldassarre for technical support during video-recording and Emiliano Marchisio for legal advice. References [1] P. Caria, T. Dettori, D.V. Frau, A. Borghero, A. Cappai, A. Riola, M.L. Lai, F. Boi, , A. Nicolosi, S. Mariotti, R. Vanni, Assessing RET/PTC in thyroid nodule P. Calo fine-needle aspirates: the FISH point of view, Endocr. Relat. Cancer 20 (4) (2013) 527e536. , F. Medas, G. Pisano, F. Boi, G. Baghino, S. Mariotti, A. Nicolosi, [2] P.G. Calo Differentiated thyroid cancer: indications and extent of central neck dissectioneour experience, Int. J. Surg. Oncol. 2013 (2013) 625193, http:// dx.doi.org/10.1155/2013/625193. , G. Pisano, F. Medas, J. Marcialis, L. Gordini, E. Erdas, A. Nicolosi, Total [3] P.G. Calo thyroidectomy without prophylactic central neck dissection in clinically nodenegative papillary thyroid cancer: is it an adequate treatment? World J. Surg. Oncol. 20 (12) (2014) 152. [4] G. Conzo, N. Avenia, G. Bellastella, G. Candela, A. De Bellis, K. Esposito, D. Pasquali, A. Polistena, L. Santini, A.A. Sinisi, The role of surgery in the current management of differentiated thyroid cancer, Endocrine 47 (2014) 380e388. , A.A. Sinisi, A. De Bellis, D. Pasquali, S. Iorio, E. Tartaglia, [5] G. Conzo, P.G. Calo C. Mauriello, C. Gambardella, F. Cavallo, F. Medas, A. Polistena, L. Santini, N. Avenia, Impact of prophylactic central compartment neck dissection on locoregional recurrence of differentiated thyroid cancer in clinically nodenegative patients: a retrospective study of a large clinical series, Surgery 155 (6) (2014) 998e1005. [6] F.H. Lahey, Routine dissection and demonstration of recurrent laryngeal nerve in subtotal thyroidectomy, Surg. Gyn. Obst 66 (1938) 775. [7] Y. Matsumura, Electoro-surgical device, Kyobu Geka 62 (8 Suppl) (2009) 638e642. , G. Pisano, F. Medas, A. Tatti, M.R. Pittau, R. Demontis, P. Favoriti, [8] P.G. Calo A. Nicolosi, Intraoperative recurrent laryngeal nerve monitoring in thyroid surgery: is it really useful? Clin. Ter. 164 (3) (2013) e193ee198. [9] V. D'Orazi, A. Panunzi, E. Di Lorenzo, A.l. Ortensi, M. Cialini, S. Anichini, A. Ortensi, Use of loupes magnification and microsurgical technique in thyroid surgery: ten years experience in a single center, G. Chir. 37 (3) (2016) 101e107. [10] A. Kumar, B.B. Asaf, Robotic thoracic surgery: the state of the art, J. Minim. Access. Surg. 11 (1) (2015) 60e67. [11] P. Zhang, H.W. Zhang, X.D. Han, J.Z. Di, Q. Zheng, Meta-analysis of comparison between minimally invasive video-assisted thyroidectomy and conventional thyroidectomy, Eur. Rev. Med. Pharmacol. Sci. 19 (8) (2015) 1381e1387. [12] M.L. Levy, J.C. Chen, K. Moffitt, Z. Corber, J.G. McComb, Stereoscopic headmounted display incorporated into microsurgical procedures: technical note, Neurosurgery 43 (2) (1998) 392e395. [13] S.A. Rehim, K.C. Chung, Educational video recording and editing for the hand surgeon, J. Hand Surg. Am. 40 (5) (2015) 1048e1054. [14] A.G. Nair, S. Kamal, T.V. Dave, K. Mishra, H.S. Reddy, D. Della Rocca, R.C. Della Rocca, A. Andron, V. Jain, Surgeon point-of-view recording: using a highdefinition head-mounted video camera in the operating room, Indian J. Ophthalmol. 63 (10) (2015) 771e774. [15] S. Matsumoto, K. Sekine, M. Yamazaki, T. Funabiki, T. Orita, M. Shimizu, M. Kitano, Digital video recording in trauma surgery using commercially available equipment, Scand. J. Trauma Resusc. Emerg. Med. 21 (27) (2013), http://dx.doi.org/10.1186/1757-7241-21-27. [16] S.N. Graves, D.S. Shenaq, A.J. Langerman, D.H. Song, Video capture of plastic surgery procedures using the GoPro HERO 3þ, Plast. Reconstr. Surg. Glob. Open 6 (3(2)) (2015) e312.
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[17] C.K. Lee, Y. Kim, N. Lee, B. Kim, D. Kim, S. Yi, Feasibility study of utilization of action camera, GoPro Hero 4, Google Glass and panasonic HX-A100 in spine surgery, Spine (Phila Pa 1976) 17 (2016), http://dx.doi.org/10.1097/ BRS.0000000000001719. [18] B. Lee, B.R. Chen, B.B. Chen, J.Y. Lu, S.L. Giannotta, Recording stereoscopic 3D neurosurgery with a head-mounted 3D camera system, Br. J. Neurosurg. 29 (3) (2015) 371e373. [19] A.D. Vara, J. Wu, A.Y. Shin, G. Sobol, B. Wiater, Video recording with a GoPro in hand and upper extremity surgery, J. Hand Surg. Am. 41 (10) (2016) e383ee387. [20] R.G. Peden, R. Mercer, A.J. Tatham, The use of head-mounted display eyeglasses for teaching surgical skills: a prospective randomised study, Int. J. Surg. 34 (2016) 169e173. [21] H.L. Evans, D.J. O'Shea, A.E. Morris, K.A. Keys, A.S. Wright, D.C. Schaad, J.S. Ilgen, A comparison of Google Glass and traditional video vantage points for bedside procedural skill assessment, Am. J. Surg 211 (2016) 336e342. [22] A.M. Fry, R.L. Orr, A. Patterson, P. Doyle, Use of eyewear for high definition video recording in surgical training, Br. J. Oral Maxillofac. Surg. 52 (10) (2014) 983e984. [23] H. Forbes, T.K. Bucknall, A.M. Hutchinson, Piloting the feasibility of headmounted video technology to augment student feedback during simulated clinical decision-making: an observational design pilot study, Nurse Educ. Today 39 (2016) 116e121. [24] M.D. Karam, G.W. Thomas, D.M. Koehler, B.O. Westerlind, P.M. Lafferty, G.T. Ohrt, J.L. Marsh, A.E. Van Heest, D.D. Anderson, Surgical coaching from head-mounted video in the training of fluoroscopically guided articular fracture surgery, J. Bone Jt. Surg. Am. 17 (97(12)) (2015) 1031e1039. [25] O.J. Muensterer, M. Lacher, C. Zoeller, M. Bronstein, J. Kübler, Google Glass in pediatric surgery: an exploratory study, Int. J. Surg. 12 (2014) 281e289. [26] S. Yoshida, K. Kihara, H. Takeshita, Y. Fujii, Instructive head-mounted display system: pointing device using a vision-based finger tracking technique applied to surgical education, Wideochir. Inne. Tech. Maloinwazyjne 9 (3) (2014) 449e452. [27] E. Baldini, S. Sorrenti, C. Di Gioia, C. De Vito, A. Antonelli, L. Gnessi, G. Carbotta, E. D'Armiento, P. Miccoli, E. De Antoni, S. Ulisse, Cervical lymph node metastases from thyroid cancer: does thyroglobulin and calcitonin measurement in fine needle aspirates improve the diagnostic value of cytology? BMC Clin. Pathol. 19 (2013), 13:7. [28] E. Baldini, S. Sorrenti, A. Catania, E. Guaitoli, N. Prinzi, R. Mocini, F. Nardi, E. D'Armiento, M. Bianchini, P. Favoriti, F.M. Di Matteo, M. Ruggieri, E. De Antoni, S. Ulisse, Diagnostic utility of thyroglobulin measurement in the fine needle aspirates from cervical lymph nodes: a case report, G. Chir. 33 (11e12) (2012) 387e391. [29] V. Cantisani, H. Grazhdani, P. Ricci, K. Mortele, M. Di Segni, V. D'Andrea, A. Redler, G. Di Rocco, L. Giacomelli, E. Maggini, C. Chiesa, S.M. Erturk, S. Sorrenti, C. Catalano, F. D'Ambrosio, Q-elastosonography of solid thyroid nodules: assessment of diagnostic efficacy and interobserver variability in a large patient cohort, Eur. Radiol. 24 (1) (2014) 143e150. [30] V. D'Orazi, A. Panunzi, M. Paoloni, A.l. Ortensi, S. Anichini, M. Cialini, S. Nardoni, P. Urciuoli, V. Pasta, A. Ortensi, Microsurgical approach for unusual and unexpected malignant fibrous histiocytoma of the forearm: a case report, Mol. Clin. Oncol. 3 (6) (2015) 1251e1254. [31] V. D'Orazi, T. Venditto, A. Panunzi, S. Anichini, G. Manzini, A. Tallarico, A. Bernetti, M. Paoloni, Misdiagnosis of plexiform neurofibroma of the medial plantar nerve: case report, Foot Edinb. 24 (3) (2014) 143e145. [32] M. Ruggieri, A. Polizzi, A. Spalice, V. Salpietro, R. Caltabiano, V. D'Orazi, P. Pavone, C. Pirrone, G. Magro, N. Platania, S. Cavallaro, M. Muglia, F. Nicita, The natural history of spinal neurofibromatosis: a critical review of clinical and genetic features, Clin. Genet. 87 (5) (2015) 401e410. [33] A. Ortensi, F. Salsano, S. Trinchi, V. D'Orazi, S. Pisarri, Microsurgical distal sympathectomy in chronic vasospastic syndromes of the hand, Int. Surg. 90 (2) (2005) 88e92. [34] U.V. Albrecht, U. von Jan, J. Kuebler, C. Zoeller, M. Lacher, O.J. Muensterer, M. Ettinger, M. Klintschar, L. Hagemeier, Google Glass for documentation of medical findings: evaluation in forensic medicine, J. Med. Internet Res. 16 (2) (2014) e53. [35] C.A. Sarkiss, S. Philemond, J. Lee, S. Sobotka, T.D. Holloway, M.M. Moore, A.B. Costa, E.L. Gordon, J.B. Bederson, Neurosurgical skills assessment: measuring technical proficiency in neurosurgery residents through intraoperative video evaluations, World Neurosurg. 89 (2016) 1e8.
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International Journal of Surgery journal homepage: www.journal-surgery.net
Original research
Advancement of thyroid surgery video recording: A comparison between two full HD head mounted video cameras Andrea Ortensi a, 1, Andrea Panunzi a, 1, Silvia Trombetta a, Alberto Cattaneo b, Salvatore Sorrenti c, *, Valerio D'Orazi a a
Department of General Microsurgery and Hand Surgery (Reference Center for Thyroid Surgery by the Italian Association of Endocrine Surgery Units - U.E.C. CLUB), “Fabia Mater” Hospital, Via Olevano Romano 25, 00171, Rome, Italy EL.CA. by Cattaneo Alberto, Piazza Como 14, 22070, Bregnano, CO, Italy c Department of Surgical Sciences, “Sapienza” University of Rome, Italy b
h i g h l i g h t s Head Head Head Head
mounted mounted mounted mounted
video video video video
recording have been used camera - new prototype camera - new prototype camera - new prototype -
in the most varied fields of surgery. attempts to record the real point of view of the magnified vision of surgeon. shows the difference between magnified vision and the naked-eye vision. is better than conventional video cameras in surgical education and training.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 13 December 2016 Accepted 16 March 2017
Background: The aim of this study was to test two different video cameras and recording systems used in thyroid surgery in our Department. This is meant to be an attempt to record the real point of view of the magnified vision of surgeon, so as to make the viewer aware of the difference with the naked eye vision. Materials and methods: In this retrospective study, we recorded and compared twenty thyroidectomies performed using loupes magnification and microsurgical technique: ten were recorded with GoPro® 4 Session action cam (commercially available) and ten with our new prototype of head mounted video camera. Results: Settings were selected before surgery for both cameras. The recording time is about from 1 to 2 h for GoPro® and from 3 to 5 h for our prototype. The average time of preparation to fit the camera on the surgeon's head and set the functionality is about 5 min for GoPro® and 7e8 min for the prototype, mostly due to HDMI wiring cable. Videos recorded with the prototype require no further editing, which is mandatory for videos recorded with GoPro® to highlight the surgical details. Conclusion: the present study showed that our prototype of video camera, compared with GoPro® 4 Session, guarantees best results in terms of surgical video recording quality, provides to the viewer the exact perspective of the microsurgeon and shows accurately his magnified view through the loupes in thyroid surgery. These recordings are surgical aids for teaching and education and might be a method of self-analysis of surgical technique. © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Thyroid surgery Loupes magnification Microsurgery Head mounted video camera Surgical education Prototype
Abbreviations: NIM, intraoperative neuromonitoring; HD, high definition; ISO, international standard organization; LUX, unit of illuminance; FPS, frames per second; EV, exposure value; MP, megapixel; DPI, dot per inch; SD, secure digital; CM, centimeter; GR, gram; $, dollar. * Corresponding author. Department of Surgical Sciences, “Sapienza” University, Viale Regina Elena 324, 00161, Rome, Italy. E-mail addresses: [email protected] (A. Ortensi), [email protected] (A. Panunzi), [email protected] (S. Trombetta), [email protected] (A. Cattaneo), [email protected] (S. Sorrenti), [email protected] (V. D'Orazi). 1 These authors contributed equally to this work.
INTRODUCTION The history of thyroid surgery in recent decades has been characterized by the introduction of significant technical and technological innovations, improving the accuracy of diagnosis and surgical operations, patient outcomes and reducing operative time and complications [1e5]. While the surgical technique is currently almost the same as that described by Lahey in 1938 [6], the technological progress of
http://dx.doi.org/10.1016/j.ijsu.2017.03.029 1743-9191/© 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
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the past 25 years has introduced innovations and tools which entered into daily surgical practice, from the sealing devices, based on radiofrequency and ultrasound, to intraoperative neuromonitoring (NIM) to routine use of loupes magnification [7e9]. It is now common belief that use of optical and digital magnification in any field of surgery (minimally invasive video-assisted surgery, laparoscopy, endoscopy, loupes-assisted surgery, robotic surgery) [9e11] improves the performance of the surgeon and the results. The rationale is that the magnification improves the visibility and perception of depth of the operative field and facilitates the identification and preservation of anatomical structures. Just as technology is working to improve the surgeon's vision, so the surgeon is trying to find the best possible system to allow other people to see exactly what he sees and does [12]. In effect, in order to paraphrase a famous quote “a picture is worth a thousand words”, so we can say that “a video is worth a thousand pictures”. It means that certainly the best way to teach people what you're doing is to show it directly, to let them see your work. Here comes the wide spread of video recording systems of surgical procedures worldwide. The resulting footage is mainly used as a teaching tool [13] for the training and assessment of surgeons, as well as a source of material for courses and conferences or even teleconferences on live surgery [14]. It also provides a method of self-analysis of the surgical technique in order to improve it, reducing intra and postoperative complications. The literature shows many examples of the application of video recording in the most varied fields of surgery, from neurosurgery and orthopedics, to hand surgery, to get even the trauma surgery [13e17]. Several studies examined some of the most widespread commercial action cameras and their use in the operating rooms, analyzing the technical features and highlighting their major strengths and weaknesses. The most popular and used camcorders at the time are GoPro (several models) [16,18,19], Contour High Definition (HD) Helmet Camera [15], Panasonic HX-A100 and Google Glass [17,20e22]. Each of these showed its pros and cons in the operating room application. The ideal camcorder should have these features: it has to be small, lightweight, comfortable and user friendly; to be able to capture the exact surgeon's view; to provide high definition images and videos; to have a long battery life; to be as cheap as possible. To date, this camera does not exist. The aim of this study was to introduce a novel prototype of head mounted video camera which we built and patented with the exact target of being used by surgeons in the operating theater. This is meant to be an attempt to record the real point of view of the magnified vision of surgeon, so as to make the viewer (as a trainee surgeon) aware of the difference with the naked eye vision. For this purpose, we decided also to test two different cameras and recording systems, our prototype and the commercial action cam GoPro® 4 Session, used in thyroid surgery performed with loupes magnification and microsurgical technique.
available) (Fig. 1) and ten with our new prototype (Fig. 2) of head mounted video camera (built in 2013 and patented on October 2016; Italian Patent number 102013902204193). Informed consent for picture and video recordings was submitted to all patients. Technical features of both cameras are showed in Table 1. The GoPro® was head mounted with elastic bands and oriented to the surgeon's perspective using the application of video preview function to be installed in smartphone, tablet or computer system. The prototype was head mounted with adjustable bands and oriented to the surgeon's perspective by checking the image on a HDMI-TV screen wired connected and correctly positioned by turning the tilt system of an innovative internal mirror, like a “periscope”. We use a proper and autonomous lighting provided by a double optical led (optional), assembled in an all-in-one system with the camera. 2. Results Settings were selected before surgery for both cameras. GoPro® 4 Session was set for surgical recording use with 1080p, medium field of view (the narrower selectable for this model), 30 fps (the only selectable for 1080p and medium field of view), low light was turned off, spot meter was turned on, white balance was on auto, color set on “GoPro® standard color”, International Standard Organization (ISO) limit to 400, sharpness at high and exposure value (EV) at 0. The prototype camera was set for surgical recording use with 1080p, 60 fps, and white balance was made preoperatively on a white gauze. Through a wire controller, zoom could be set manually also during surgical time, not only previously as required by the GoPro®. Using these settings, the recording time is about from 1 to 2 h for GoPro® and from 3 to 5 h for our prototype. The average time of preparation to fit the camera on the surgeon's head and set the functionality is about 5 min for GoPro® and 7e8 min for the prototype, mostly due to HDMI wiring cable. Videos recorded with the prototype require no further editing, which is mandatory for videos recorded with GoPro® to highlight the surgical details. 3. Discussion Video recording of surgical procedures has always been a subject of interest since wearable devices were introduced. Apart from
1. Materials and methods From January to July 2016, in the Department of General Microsurgery and Hand Surgery, “Fabia Mater” Hospital, Rome, Italy (reference center for thyroid surgery by the Italian Club of the Endocrine Surgery Unit) we video recorded twenty thyroidectomies performed using loupes magnification (4,5 with focal range al 17 inches) and microsurgical technique [9]. Of these, ten were recorded with GoPro® 4 Session action cam (commercially
Fig. 1. GoPro® 4 Session action cam.
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Fig. 2. New prototype of head mounted video camera.
rare and pioneering studies, only in the last 10 years several papers have been published in the literature about the use of head mounted video cameras in the operating theaters [13e26]. All commercial recording systems (defined action cams) were built and sold with other targets, very far from medicine (mainly outdoor sports); subsequently the surgical world, always in search of innovations, has adapted them to a much different role. It is obvious, therefore, that they have important limitations, mostly the lack of small anatomical details and the inability to well visualize deep cavities, which become even more remarkable in thyroid surgery.
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However, our experience in many areas of general surgery [27e29] and reconstructive microsurgery [9,30e33] prompted us to consider the benefits of microsurgical technique and the use of loupes when applied to thyroid surgery [9]. Thyroid surgery is a delicate surgery that involves working in a very narrow field, requiring the detection of even very thin structures, and for these reasons still exposes to possible severe complications. The application of a head mounted camera in thyroid surgery performed with microsurgical technique and loupes magnification has allowed us to record the magnified sight of surgeon and to optimally frame all anatomic and technical details, despite the depth of field changes during surgery. The initial assumption wasn't the simple video recording of surgical procedures, but we wanted to overcome the gap between the images captured with a commercial camera and the corresponding surgeon's view, without more post-production editing. Specifically, we wanted to provide to the viewer the exact perspective of the microsurgeon and to show accurately the magnified view through the loupes. These recordings are surgical aids for teaching, training tools for less experienced surgeons and a method of self-analysis of the surgical techniques [16,18,19,23e26,34,35]. For this reason, we developed a prototype of head mounted video camera, designed for operating room use and built specifically to guarantee optimal results in terms of surgical video recording quality. Evaluated the remarkable quality of the images obtained by prototype (Table 1), to validate these results we decided to compare it with a popular action cam, the GoPro® 4 Session. This device was the cheapest, smallest and lightest camcorder on the market and represented the best stress test for the weak points of prototype (size and weight not exiguous, price still not available). Maintaining the recording at 1080p, the prototype has the capability of up to 25 magnification, with a high-stability optical zoom (Carl Zeiss® Vario-Tessar® lens), extended until 30 and an elevated light sensitivity (0,3 lux, unit of illuminance of the International System of Units, measuring luminous flux per unit area) with minimal amounts of image aberration. This provides a high quality image, to reproduce a realistic “surgical experience”. GoPro® 4 Session was also set for surgical recording with 1080p, but otherwise use fixed focus wide angle lens and ISO limited to 1600 (moderate distortion). It's not equipped with a magnification capability but there are just two preset fields of view (wide and medium). For this model is not available the narrow field of view
Table 1 Technical features of both cameras. GoPro® 4 Session
Prototype Full HD 1.080p (60 fps) yes optical 0,3 lux minimal distortion
Zoom
Full HD 720p-1.440p (30e100 fps) yes digital 400 ISO (reduced distortion) 1600 ISO (moderate distortion) two settings (wide, medium)
Photo Supply Connectivity Storage Control of image Peculiarity Lights provided Duration in continuous recording mode (h) Dimension (cm) Weight (gr) Price ($)
5 MP medium zoom 72dpi battery WiFi Micro SD card App on electronic device Wide lens no 1-2 (depending on battery life) 444 74 200
Resolution Autofocus Image stabilizer Light sensitivity
optical, manual 25 (extended 30) Carl Zeiss® Vario-Tessar® Lens 5 MP optical zoom 300dpi power HDMI wire (WiFi module optional) SD card HDMI monitor Mirror double optical LED (optional) 4 (depending on resolution and SD card size) 10 4 5 98 not available
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option, that might actually be useful in surgery. Unlike the GoPro® 4 Session, the prototype has an optical, digital extended, magnification. The photos and videos prove to be of better quality and so do not require a post-production editing. Due to the elevated light sensitivity (0,3 lux), our prototype doesn't need of auxiliary lights, which however could be installed as an option to help the surgeon (and not the camera) to visualize shaded anatomical areas. GoPro® 4 Session footage quality was limited by reflection of operating room lights that can overexpose the video. This limit depends on the angle and intensity of the light as well as on the head position. In both devices, use of a typical headlight strap may interfere with the head mounted devices and for this reason is preferable a led light mounted on surgical loupes or alternatively an all-in-one system assembled with the camera. Battery life is one of the most relevant weaknesses of all commercial action cams (GoPro® 4 Session included) and involves an important limitation to the overall recording time [16,19]. Our prototype is not battery powered, but plugged in. For this reason, the recording time is influenced only by the storage memory size, and just later by the resolution of the image (4 h of continuous recording mode stored on 32 GB SD card). Surely a head mounted camera cannot be coaxial with the surgeon's eyes or the operating loupes. Therefore, the perspective of the camera will be directed to a specific point of the surgical field, which is defined by the intersection of the line of the sight and the surgeon's hand, and is influenced by the height of the camera compared to the eyes' position. Our prototype solves this problem by aligning the sight and perspective of camera to those of the surgeon through the introduction of an internal mirror, working as a periscope. This mirror is the real, great innovation which made possible to patent our camera. Its presence enables to correctly align the camera sight with the operator's vision: this allows it to be perfectly coaxial with the surgeon's eyes, so as to provide to the observer the true first person view, a characteristic that any other video recording systems can not do. By moving a wheel placed on the top of the prototype, it's possible to aim the camera by aligning it with the same perspective of the surgeon. This is usually done before starting, but it can also be modified during surgery by an ancillary person or by foot control system, in case of misalignment due to contact between the heads of the surgeons. Our prototype is heavier in comparison to GoPro®, 98 gr and 74 gr respectively, but the difference in weight and the encumbrance are acceptable and not limiting for the surgeon. The quality of the final video obviously depends on the type of camera used, but also on the ability of the operator to be stationary during surgery so to obtain an optimal video. This means that the surgeon has to minimize head and neck movements to keep the surgical field focused and to prevent the final video is choppy, blurry or not centered. A microsurgeon, accustomed to using magnification loupes, is facilitated in this task, because he is already trained to hold the position of the head, so as to keep the surgical field at the center. Actually, technology is already ahead: the near future will be made of more advanced devices that will allow to carry out the concept of “augmented reality”, through head mounted display, to create a new interactive surgery. Google Glass® (Google Inc., Mountain View, California) represents the first and best known for this purpose. It's a wearable and wireless device, but equipped with a lower quality (720p) digital camera (lacking of zoom) and a display, operating by voice or touch control and able to interact with the surgeon showing recorded videos or step-by-step procedures. For these devices will be increasingly important to use
high quality videos, corresponding as much as possible to the real surgeon's view. 4. Conclusions Of course we know well that the existing commercial cameras are cheap, light and handy, so they are easily adaptable to surgical recording. For this reasons we decided to build our prototype to create a professional tool, specifically designed for use in the operating room, with the aim to show to the viewer the same vision of the microsurgeon through the loupes, to demonstrate the advantages achieved with the optical magnification, also, in a delicate surgery such as thyroid surgery. Surely our prototype has some significant weaknesses, such as weight: for this reason is already in progress the construction of a new prototype of our video camera, improved in every technical feature (for example better resolution, lower size and weight, WiFi connectivity), to obtain an even easier, more comfortable and practical tool. Many studies are already in progress and others will be needed to advance the existing technology, for example to make it able to track hand or eye movement and to share wireless data, in order to superimpose digital images with the real-time view of the surgeon, build 3D images or even create holograms of surgeries. Ethical approval No ethical approval was needed for this study. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author's contribution Andrea Ortensi and Alberto Cattaneo: designed the videocamera prototype. Alberto Cattaneo: built the videocamera prototype. Andrea Panunzi, Silvia Trombetta and Valerio D'Orazi: partecipated substantially in conception, design, and execution of the study and in the analysis and interpretation of data. Valerio D'Orazi, Andrea Ortensi and Andrea Panunzi: performed surgery and video recordings. Salvatore Sorrenti, Andrea Panunzi and Silvia Trombetta: performed the literature search, data acquisition and partecipated substantially in the drafting and editing of the manuscript. Salvatore Sorrenti: supported the writing of the paper. All authors read and approved the final manuscript. Conflict of interest statement None. Guarantor Andrea Ortensi is the guarantor of the study. Consent Written informed consent was obtained from the patients for surgery, video recordings and publication of this manuscript and any accompanying images. A copy of written consent is available for review by the Editorin-Chief of this Journal.
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Acknowledgements The authors are very grateful for the support by Guarnieri family, owner of “Fabia Mater” Hospital. The authors are also grateful to all anesthesiologists and nursing staff of the Hospital. In addition, the authors like to thank Omar Cattaneo for the contribution to build the videocamera, Bianca Baldassarre for technical support during video-recording and Emiliano Marchisio for legal advice. References [1] P. Caria, T. Dettori, D.V. Frau, A. Borghero, A. Cappai, A. Riola, M.L. Lai, F. Boi, , A. Nicolosi, S. Mariotti, R. Vanni, Assessing RET/PTC in thyroid nodule P. Calo fine-needle aspirates: the FISH point of view, Endocr. Relat. Cancer 20 (4) (2013) 527e536. , F. Medas, G. Pisano, F. Boi, G. Baghino, S. Mariotti, A. Nicolosi, [2] P.G. Calo Differentiated thyroid cancer: indications and extent of central neck dissectioneour experience, Int. J. Surg. Oncol. 2013 (2013) 625193, http:// dx.doi.org/10.1155/2013/625193. , G. Pisano, F. Medas, J. Marcialis, L. Gordini, E. Erdas, A. Nicolosi, Total [3] P.G. Calo thyroidectomy without prophylactic central neck dissection in clinically nodenegative papillary thyroid cancer: is it an adequate treatment? World J. Surg. Oncol. 20 (12) (2014) 152. [4] G. Conzo, N. Avenia, G. Bellastella, G. Candela, A. De Bellis, K. Esposito, D. Pasquali, A. Polistena, L. Santini, A.A. Sinisi, The role of surgery in the current management of differentiated thyroid cancer, Endocrine 47 (2014) 380e388. , A.A. Sinisi, A. De Bellis, D. Pasquali, S. Iorio, E. Tartaglia, [5] G. Conzo, P.G. Calo C. Mauriello, C. Gambardella, F. Cavallo, F. Medas, A. Polistena, L. Santini, N. Avenia, Impact of prophylactic central compartment neck dissection on locoregional recurrence of differentiated thyroid cancer in clinically nodenegative patients: a retrospective study of a large clinical series, Surgery 155 (6) (2014) 998e1005. [6] F.H. Lahey, Routine dissection and demonstration of recurrent laryngeal nerve in subtotal thyroidectomy, Surg. Gyn. Obst 66 (1938) 775. [7] Y. Matsumura, Electoro-surgical device, Kyobu Geka 62 (8 Suppl) (2009) 638e642. , G. Pisano, F. Medas, A. Tatti, M.R. Pittau, R. Demontis, P. Favoriti, [8] P.G. Calo A. Nicolosi, Intraoperative recurrent laryngeal nerve monitoring in thyroid surgery: is it really useful? Clin. Ter. 164 (3) (2013) e193ee198. [9] V. D'Orazi, A. Panunzi, E. Di Lorenzo, A.l. Ortensi, M. Cialini, S. Anichini, A. Ortensi, Use of loupes magnification and microsurgical technique in thyroid surgery: ten years experience in a single center, G. Chir. 37 (3) (2016) 101e107. [10] A. Kumar, B.B. Asaf, Robotic thoracic surgery: the state of the art, J. Minim. Access. Surg. 11 (1) (2015) 60e67. [11] P. Zhang, H.W. Zhang, X.D. Han, J.Z. Di, Q. Zheng, Meta-analysis of comparison between minimally invasive video-assisted thyroidectomy and conventional thyroidectomy, Eur. Rev. Med. Pharmacol. Sci. 19 (8) (2015) 1381e1387. [12] M.L. Levy, J.C. Chen, K. Moffitt, Z. Corber, J.G. McComb, Stereoscopic headmounted display incorporated into microsurgical procedures: technical note, Neurosurgery 43 (2) (1998) 392e395. [13] S.A. Rehim, K.C. Chung, Educational video recording and editing for the hand surgeon, J. Hand Surg. Am. 40 (5) (2015) 1048e1054. [14] A.G. Nair, S. Kamal, T.V. Dave, K. Mishra, H.S. Reddy, D. Della Rocca, R.C. Della Rocca, A. Andron, V. Jain, Surgeon point-of-view recording: using a highdefinition head-mounted video camera in the operating room, Indian J. Ophthalmol. 63 (10) (2015) 771e774. [15] S. Matsumoto, K. Sekine, M. Yamazaki, T. Funabiki, T. Orita, M. Shimizu, M. Kitano, Digital video recording in trauma surgery using commercially available equipment, Scand. J. Trauma Resusc. Emerg. Med. 21 (27) (2013), http://dx.doi.org/10.1186/1757-7241-21-27. [16] S.N. Graves, D.S. Shenaq, A.J. Langerman, D.H. Song, Video capture of plastic surgery procedures using the GoPro HERO 3þ, Plast. Reconstr. Surg. Glob. Open 6 (3(2)) (2015) e312.
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[17] C.K. Lee, Y. Kim, N. Lee, B. Kim, D. Kim, S. Yi, Feasibility study of utilization of action camera, GoPro Hero 4, Google Glass and panasonic HX-A100 in spine surgery, Spine (Phila Pa 1976) 17 (2016), http://dx.doi.org/10.1097/ BRS.0000000000001719. [18] B. Lee, B.R. Chen, B.B. Chen, J.Y. Lu, S.L. Giannotta, Recording stereoscopic 3D neurosurgery with a head-mounted 3D camera system, Br. J. Neurosurg. 29 (3) (2015) 371e373. [19] A.D. Vara, J. Wu, A.Y. Shin, G. Sobol, B. Wiater, Video recording with a GoPro in hand and upper extremity surgery, J. Hand Surg. Am. 41 (10) (2016) e383ee387. [20] R.G. Peden, R. Mercer, A.J. Tatham, The use of head-mounted display eyeglasses for teaching surgical skills: a prospective randomised study, Int. J. Surg. 34 (2016) 169e173. [21] H.L. Evans, D.J. O'Shea, A.E. Morris, K.A. Keys, A.S. Wright, D.C. Schaad, J.S. Ilgen, A comparison of Google Glass and traditional video vantage points for bedside procedural skill assessment, Am. J. Surg 211 (2016) 336e342. [22] A.M. Fry, R.L. Orr, A. Patterson, P. Doyle, Use of eyewear for high definition video recording in surgical training, Br. J. Oral Maxillofac. Surg. 52 (10) (2014) 983e984. [23] H. Forbes, T.K. Bucknall, A.M. Hutchinson, Piloting the feasibility of headmounted video technology to augment student feedback during simulated clinical decision-making: an observational design pilot study, Nurse Educ. Today 39 (2016) 116e121. [24] M.D. Karam, G.W. Thomas, D.M. Koehler, B.O. Westerlind, P.M. Lafferty, G.T. Ohrt, J.L. Marsh, A.E. Van Heest, D.D. Anderson, Surgical coaching from head-mounted video in the training of fluoroscopically guided articular fracture surgery, J. Bone Jt. Surg. Am. 17 (97(12)) (2015) 1031e1039. [25] O.J. Muensterer, M. Lacher, C. Zoeller, M. Bronstein, J. Kübler, Google Glass in pediatric surgery: an exploratory study, Int. J. Surg. 12 (2014) 281e289. [26] S. Yoshida, K. Kihara, H. Takeshita, Y. Fujii, Instructive head-mounted display system: pointing device using a vision-based finger tracking technique applied to surgical education, Wideochir. Inne. Tech. Maloinwazyjne 9 (3) (2014) 449e452. [27] E. Baldini, S. Sorrenti, C. Di Gioia, C. De Vito, A. Antonelli, L. Gnessi, G. Carbotta, E. D'Armiento, P. Miccoli, E. De Antoni, S. Ulisse, Cervical lymph node metastases from thyroid cancer: does thyroglobulin and calcitonin measurement in fine needle aspirates improve the diagnostic value of cytology? BMC Clin. Pathol. 19 (2013), 13:7. [28] E. Baldini, S. Sorrenti, A. Catania, E. Guaitoli, N. Prinzi, R. Mocini, F. Nardi, E. D'Armiento, M. Bianchini, P. Favoriti, F.M. Di Matteo, M. Ruggieri, E. De Antoni, S. Ulisse, Diagnostic utility of thyroglobulin measurement in the fine needle aspirates from cervical lymph nodes: a case report, G. Chir. 33 (11e12) (2012) 387e391. [29] V. Cantisani, H. Grazhdani, P. Ricci, K. Mortele, M. Di Segni, V. D'Andrea, A. Redler, G. Di Rocco, L. Giacomelli, E. Maggini, C. Chiesa, S.M. Erturk, S. Sorrenti, C. Catalano, F. D'Ambrosio, Q-elastosonography of solid thyroid nodules: assessment of diagnostic efficacy and interobserver variability in a large patient cohort, Eur. Radiol. 24 (1) (2014) 143e150. [30] V. D'Orazi, A. Panunzi, M. Paoloni, A.l. Ortensi, S. Anichini, M. Cialini, S. Nardoni, P. Urciuoli, V. Pasta, A. Ortensi, Microsurgical approach for unusual and unexpected malignant fibrous histiocytoma of the forearm: a case report, Mol. Clin. Oncol. 3 (6) (2015) 1251e1254. [31] V. D'Orazi, T. Venditto, A. Panunzi, S. Anichini, G. Manzini, A. Tallarico, A. Bernetti, M. Paoloni, Misdiagnosis of plexiform neurofibroma of the medial plantar nerve: case report, Foot Edinb. 24 (3) (2014) 143e145. [32] M. Ruggieri, A. Polizzi, A. Spalice, V. Salpietro, R. Caltabiano, V. D'Orazi, P. Pavone, C. Pirrone, G. Magro, N. Platania, S. Cavallaro, M. Muglia, F. Nicita, The natural history of spinal neurofibromatosis: a critical review of clinical and genetic features, Clin. Genet. 87 (5) (2015) 401e410. [33] A. Ortensi, F. Salsano, S. Trinchi, V. D'Orazi, S. Pisarri, Microsurgical distal sympathectomy in chronic vasospastic syndromes of the hand, Int. Surg. 90 (2) (2005) 88e92. [34] U.V. Albrecht, U. von Jan, J. Kuebler, C. Zoeller, M. Lacher, O.J. Muensterer, M. Ettinger, M. Klintschar, L. Hagemeier, Google Glass for documentation of medical findings: evaluation in forensic medicine, J. Med. Internet Res. 16 (2) (2014) e53. [35] C.A. Sarkiss, S. Philemond, J. Lee, S. Sobotka, T.D. Holloway, M.M. Moore, A.B. Costa, E.L. Gordon, J.B. Bederson, Neurosurgical skills assessment: measuring technical proficiency in neurosurgery residents through intraoperative video evaluations, World Neurosurg. 89 (2016) 1e8.