Vol. 123, January Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1980 by The Williams & Wilkins Co.
COLOR PHOTOGRAPHY IN OPEN UROLOGICAL SURGERY JOHN M. BARRY*
From the Division of Urology, Department of Surgery and Division of Media Services, University of Oregon Health Sciences Center, Portland, Oregon
The quality of intraoperative color slide photography can be improved by 1) orienting the viewer with landmark outline and constant camera position during the procedure, 2) brown gloves to avoid contrast within the operative field, 3) blue sponges to absorb blood, 4) contrasting stay sutures or tapes and 5) taking multiple pictures at different exposures. These points are illustrated with the photographic record of the repair of multiple renal artery aneurysms to provide the urologist with helpful hints in the recording of his interesting or challenging operative procedures. The basic problems in color photography during an open urological operation are disorientation of the viewer, distraction by white objects in the surgical field, distraction by red blood on white sponges, blood obscuring the surgical field and technical problems, such as resolution, depth of field, shutter speed and illumination. Herein is presented a color photographic record of the repair of multiple renal artery aneurysms, demonstrating the solutions of these problems by outlines of the pertinent anatomy on the skin, constant camera position for observer orientation, the use of brown gloves to reduce contrast within the operative field, absorbing blood from the field with blue sponges, using contrasting tapes to demonstrate the surgical lesions and the excellent resolution and depth of the field provided with a 105 mm. macro lens on a single lens reflex camera with strobe light illumination. 1
lighter color,3 such as hands in white gloves, white sponges and drapes, and bright instruments. With these lighter objects in the surgical field the effect of contrasting tapes and sutures that demonstrate the surgical landmarks can be reduced. We have made blue sponges by dying those that come from the manufacturer, then washing and resterilizing them prior to use. Instruments that are either of a dull finish or ebonized will eliminate distracting highlights. Nearly any single lens reflex camera will allow for accurate composition and excellent intraoperative color photographs. The 105 mm. macro lens or a 50 mm. macro lens with a 2X teleconverter allows the photographer to be further away from the incision than an ordinary 50 mm. lens, thereby not interfering as much with the operation.
A 49'-year-old white woman was hospitalized for repair of multiple left renal artery aneurysms because of hematuria and left upper quadrant abdominal pain (fig. 1). On March 22, 1978 the lesions were repaired after in situ cold preservation with a modified Ringer's lactate solution infused through the transected renal artery and drained through the cannulated gonadal vein after occlusion of the main renal, adrenal and distal gonadal veins (fig. 2). The symptoms resolved, the hematuria did not recur and an arteriogram 6 months after the repair demonstrated a satisfactory result (fig. 3). All intraoperative photographs were taken with a 35 mm. Nikon F camera with a Nikor 105 mm. macro lens. A camera bracket allowed the guide number 25 strobe unit to be rotated for shadow control. Kodak EPR, ASA 64 film with E6 processing was used and all photographs were taken at a shutter speed of 1/60 second and F stops of 11 to 22. DISCUSSION
The best intraoperative photographic situation is to have someone other than the surgeon take the photographs because it does not interrupt the flow of the operation as much as when the surgeon operates the camera equipment. 2 The photographer and the surgeon must realize that the least expensive item they will be using is film. It is always better to have taken too many rather than too few color photographs of that unusual or complicated case. The eye has a greater tendency to be attracted to objects of Accepted for publication August 31, 1979. Read at annual meeting of Western Section, American Urological Association, Tucson, Arizona, March 18-22, 1979. * Requests for reprints: Division of Urology, University of Oregon Health Sciences Center, Portland, Oregon 97201.
FIG. 1. Selective left renal arteriogram reveals multiple left renal artery aneurysms. 55
BARRY AND RAMSEY
FIG. 2. A, proposed intercostal incision with its possible extension to pubis to allow exposure for autotransplant has been diagramed on skin. All future photographs will be taken from this angle to allow constant orientation of audience. B, partially completed intercostal incision: 105 mm. macro lens and F22 shutter opening allow maximum depth of field and entire operative field to be in focus. Strobe flash has removed uneven lighting that usually occurs when available light is used in operating room. C, identification of diaphragm fibers and pleura after incision of intercostal muscles. Notice how brown glove underneath diaphragm does not detract from operative site. Pleural reflection is just off tip of surgeon's fmgers, which are under diaphragm. D, demonstration of multiple renal artery aneurysms. With same camera position observer orientation is constant. Blue sponges have absorbed blood and do not provide usual contrasting r ed upon white, which distracts from operative field. E, isolation of renal artery aneurysm. Contrasting tapes have been placed around main renal artery and major segmental renal arteries, and blue towel has been used to absorb blood, placing main renal artery aneurysm into relief. F, completed repair. Blue sponges have again absorbed red color of blood. Suction tip is underlying renal artery repair and pointing at aorta.
COLOR PHOTOGRAPHY IN OPEN UROLOGICAL SURGERY
Available light can be used in the operating room in place of the rapidly recycling strobe flash but this usually results in under exposure of the periphery of the field because of the nature of the focused beam of the operating room lights. Color balance also is a problem with available light because most operating rooms depend on fluorescent tubes for general room light and they emit a predominantly green part of the spectrum. Introduction of a strobe light source gives adequate over-all exposure and overpowers the other 2 light sources, eliminating the need for major color correction. 4 Although rotation of the strobe unit on a camera bracket was used in this case for shadow control, without such a bracket the strobe can be handheld at a 45-degree angle from the line of sight of the camera, and less glare will result than having the strobe nearer the camera. REFERENCES 1. Goldberg, B. H.: Thirty-five mm optics and the biological photographer. J. Functional Photography, 13: 30, 1978. 2. Elovitz, M. J.: Should a doctor be a photographer. J. Biomedical
Commun., 1: 32, 1973. 3. Jacobs, L., Jr. and Photographic Magazine: Basic Guide to Photography. Los Angeles: Petersen Publishing Co., p. 74, 1973. 4. Kodak Professional Photo Guide. Rochester: The Eastman Kodak Co., pp. 16-23, 1977.
Fm. 3. Renal arteriogram 6 months postoperatively shows satisfactory repair in patient who is now asymptomatic.