Toward a surgical PACS

July 18, 2005

The evolution of technology reshapes the practice of medicine. Imaging replaces guesswork with facts. But not all the time. The presence of imaging technology is widely felt in diagnostics but hardly so in therapeutics.

The evolution of technology reshapes the practice of medicine. Imaging replaces guesswork with facts. But not all the time. The presence of imaging technology is widely felt in diagnostics but hardly so in therapeutics.

Imaging technology has branched into radiation therapy, certainly. It is making inroads into minimally invasive surgery. Radiographic and sonographic guidance is a staple of many procedures. But for the most part, surgery is done with precious little input from the imaging equipment we now have at hand, despite more than a decade of opportunity.

Twelve years ago, I witnessed brain surgery close up for the first time. The opening of the scalp, the sawing of the skull opened a tiny window on a living brain. Immersed in that tissue was a tumor that surgeons wanted to scoop out with a tiny, spoonlike scalpel. They wouldn't actually see the tumor, I was told, because it was well beneath the surface of the brain. And that was where it got interesting.

In the many such operations done before I witnessed this one, the doctors screwed a stereotactic frame into the skull, calibrating this frame with reference points contained in an atlas of the brain. They looked at MR or CT images to figure the location of the patient's tumor in relation to those reference points. And then, hooking their surgical instruments to the frame, they dug out the tumor.

This time was different, however. The surgeons were using a new kind of instrument. The "Viewing Wand," as it was called, created a virtual 3D model of the brain and plotted updated positions of the scalpel as the surgeon moved it to and from the tumor. The Wand was built by a company (ISG Technologies), since renamed (Cedara Software), that a few weeks ago combined with Merge eFilm, which desired the company primarily for its PACS and visualization software - not its long-lost neuronavigational skills. The Wand, you see, was way ahead of its time.

Some successors to the Viewing Wand are in use today. Some surgical teams make use of computerized preplanning aids. But, more than a decade after this groundbreaking surgery, most brain surgery still depends largely on the surgeon's motor skills and mind's eye reconstruction of brain scans during the operation.

Nowhere in medicine is there a greater dependence on art than in surgery. Yet, aside from some very high profile exceptions, the digital imaging revolution has been kept outside the door of the OR.

Some visionaries, seeking to change this, have called for the development of a surgical PACS designed specifically to help in surgical planning, intraoperative navigation, and postsurgical assessment. Considering the development of cardiology PACS and orthopedic PACS, not to mention the miniPACS built for CR/DR and ultrasound, such a development would seem to be - if you'll pardon the expression - a no-brainer. But I fear it will fare no better than the Viewing Wand did a dozen years ago, unless the surgical community champions it.

Someone needs to look hard at all the disparate technologies assembled in the typical operating suite, work with the surgeons who must struggle with this chaos, and come up with a plan for uniting these under one information umbrella, tying in the processes involved with planning, patient monitoring, intervention, and assessment. Information technology has earned a certain appeal in healthcare, based on a recognition that the precision and speed possible with computers are needed to draw medical practice into the 21st century. Bringing surgeons into the digital fold is long overdue. Development of a surgical PACS could be a critical first step in that direction.