We review products independently, but we may earn affiliate commissions from buying links on this page. Terms of use. 3D TV was a television technology no one wanted, but the platform has found an unlikely second act in the operating room and attracted the attention of Sony. Imagine a TV with loads of devices hooked up to it—streaming boxes, DVDs players, DVRs—and they all use different connectors that do not hook up to one another. That's the problem OR integration systems solve. They run specialized software that allows hospital staff to connect all the pieces of a modern OR and have them work together seamlessly. The leading OR integration system is NUCLeUS, created by Belgian company eSaturnus. NUCLeUS has been successful across Europe, the Middle East, Africa, and Asia, but Sony—which acquired the company in July 2016—plans a major rollout of NUCLeUSin the US as soon as the latest version gets FDA clearance, which is expected in December. Why ORs Need NUCLeUS Operating rooms are loaded with monitors, scopes, and instruments that provide information to the surgeons, and these screens are interconnected with different types of cables. Everything has to work perfectly before any procedure can begin. Minimally invasive procedures, which use small incisions and rely on endoscopes to see inside patients, require screens, explains F. Mark Barron, principal engineer for the Medical Devices Division in Sony's Professional Solutions area. The doctor might want to see an X-ray and instrument readings during a procedure, then change up what's on the screens as the operation progresses. The typical OR has three displays, but special procedures could require five to seven. Getting all that equipment connected might fall to the rounding nurse or surgical scrub, who therefore has to be an IT pro as well. That was the problem Thomas and Bob Koninckx, the founders of eSaturnus, learned about from their father, an endoscopic surgeon. Thomas has a PhD in electrical engineering, and Bob has a PhD in mechanical engineering, so they put their heads and degrees together to create a solution. That solution is NUCLeUS, which Barron describes as the operating system of the OR. "It allows disparate pieces of equipment within the OR to communicate to each other for the purposes of routing and switching. You can bring in any type of video-based medical equipment and allow them to either be recorded, broadcast, or switched and routed to any display in the OR." It allows hospital staff to make easy connections, saving a lot of time and frustration. Because NUCLeUS is far smaller than the older equipment it replaces—it's about the size of a cigar box—it also saves a great deal of room, and space is at a premium in most ORs. After forming eSaturnus, the Koninckx brothers guided NUCLeUS through two versions and found success in operating rooms across the world. The big areas left to tap were the Americas, and that's when Sony came calling. NUCLeUS 3.0: Ready for Your Close-Up? ESaturnus is now a wholly owned subsidiary of Sony, with the Koninckx brothers still at the helm. Post-acquisition, Sony set to work on a major upgrade to NUCLeUS. Integration was a new area for Sony, and its first task was to get its hardware technology aligned with NUCLeUS' software. It also wanted to add 4K video support. At first, the idea of 4K in the operating room sounds like a stretch. ORs typically use 27-inch monitors, Barron says, and those monitors are close to the surgeons, so how much is the added resolution of 4K really going to matter? For the answer, understand that doctors performing minimally invasive surgery often work bent over binocular surgical microscopes for hours at a time. It's tough work and can be hard on the body, but they do it that way because they can't get the level of detail they need from standard monitors. 4K can change that because doctors don't need to rely on surgical microscopes for detailed views. NUCLeUS lets them stand upright. Sony's NUCLeUS upgrade—version 3.0—will introduce improvements in recording to the included content management system. Doctors will be able to record from any connected content source using a single interface. For instance, surgeons can record during a procedure, then review the recordings later at a computer. There's no limit to the number of simultaneous recordings version 3.0 can produce. NUCLeUS also supports broadcasting, although with a hospital integration system, that usually means within the building. NUCLeUS isn't a system for long-distance telemedicine—rather, it lets the OR broadcast a video feed to another room in the hospital, perhaps to med students or a surgical chief. "You always want to have med students learning directly from the doctors, but you don't necessarily want them all in the room at the same time," Barron says. "It seems like there's always a struggle between the nurses trying to keep a clean environment, and the more bodies you have in there, the more of an issue that is. So now you can have med students sitting in a lounge watching directly what's going on and having a bidirectional conversation with the doctor as if they were there. They're just physically removed from it, so that's what we call broadcasting." The other use case, which might involve a more experienced surgeon watching one who's newer perform a surgery, is called telestration, where the viewing doctor can see the procedure and offer visual guidance, perhaps by circling an area on the screen to indicate where an incision should go. That type of broadcast can be sent over the internet, but is usually done within a hospital's network where there's less chance of latency on the video stream. (Image credit: © 2019 Sony Imaging Products & Solutions Inc.) Although the NUCLeUS system can record procedures, hospitals have to be careful with how that's applied. If a surgery goes wrong and there's a recording of it, the file could be subpoenaed and used as evidence in a trial. But there's no law saying surgical procedures have to be recorded, and hospitals don't want the liability. That's why in real-world cases, the doctor simply tells the nurse to stop the recording and erase what's saved, should there be a problem. Surgeries are typically recorded only in teaching institutions, which use perfectly executed procedures as training tools. "We have one doctor who records every single procedure he's ever done. He started on VHS, he moved to CD, and now he's working with our CMS," Barron says. "We have some doctors who had never recorded anything, so they're somewhere in between. We've had doctors who say, I have enough confidence in my skills that I want to record this and I can prove that what I did was right. There's some doctors who, I guess, they don't have that confidence, and they are always worried about that liability." NUCLeUS also supports 3D video—for it, 3D is just another video component being integrated. It supports passive 3D technology, which uses inexpensive glasses to create the depth effect. 3D is often used in minimally invasive procedures that use robotics for extreme precision. In those cases, the surgical cameras supply video that is processed to create a 3D image. In specialty surgeries, including neurosurgery and ophthalmology, as well as robotic surgeries, which often include urology cases, prostate surgery, and gynecological surgery, 3D imaging adds depth to the doctor's view and leads to better outcomes. NUCLeUS can work with 3D signals created by any camera. Adopting the NUCLeUS system not only lets hospitals simplify their OR technology but also lets them recover about 10 square feet in each OR. In preparing for the US launch, Sony needed to make a few alterations to its product, the biggest being a checklist feature. Just like how pilots run through a checklist before each flight, US OR staffs go through a list to ensure they're conducting the right procedure on the right patient at the right time. It's not done in other parts of the world, but it's standard in the US. Now, before any procedure starts, NUCLeUS's screens will show a checklist. (Image credit: © 2019 Sony Imaging Products & Solutions Inc.) Why NUCLeUS? NUCLeUS has several advantages over its competition in the integration area, notes Anthony Stewart, the director of operations at Celebration Nicholson Center (a surgical training facility) and an industry expert who's been briefed on the product and had some hands-on time with it. He calls NUCLeUS the most robust system of its kind on the market. From his vantage point, he sees a lot of companies selling OR devices that don't want to work together, and that's the problem NUCLeUS was born to fix. "NUCLeUS isn't looking to put a scope or a robot on the market. What they're looking to do is take that visual and get it in front of the surgeon and the surgical team in the highest quality and the fastest way," Stewart says. "One of the other things that we run into is downtime—to put an integration system in a OR, you're looking at a six- to eight-week process with other vendors on the market, and it's also a very large system that's in the room so you're taking up a lot of landscape. "You have fans running, moving dust around. You really don't want dust in an OR. NUCLeUS, being that it's a very small device that connects directly to the visual systems and then integrates on a CAT5 network or 10BASE-T network, that infrastructure is already there. So we're not going to see downtime of pulling fiber, pulling copper, all these infrastructure changes to make the system function." (Image credit: © 2019 Sony Imaging Products & Solutions Inc.) The NUCLeUS system is a great addition to training spaces, Stewart believes, as it lets others watch and communicate from other rooms. Having as few people as possible in the OR is critical to reducing infections, he notes. "What they got right, to me, was that they thought outside of the box. And when I say box, I mean the huge box that's in every OR that has a ton of different equipment." The uses for NUCLeUS are endless, says Allen Newman, an industry expert who has consulted with Sony about the system and worked with doctors who have evaluated it. Today's OR uses cutting-edge technology to manage vital information, such as bringing in an MRI or CT scan. NUCLeUS can manage those sources on the fly, he says, while keeping the surgeon in a good posture that avoids straining. Other staff in the OR can use the touch controls to call up information when and where it's needed. Most ORs already use Sony monitors, which makes syncing with NUCLeUS even easier, he says. Looking ahead to version 4.0, though, Newman has a wish list. While the system's touch input is helpful, he'd like to see a voice control interface added—something like Amazon's Alexa but with a medical degree. "It would be really nice for that doctor, the primary surgeon, or the pilot of the surgery, to be able to call up, move, manipulate, control virtually all the secondary information with his or her voice. That would be really exciting," Newman says. "They can put it on another monitor, they can put it in a picture-on-picture, they can put it in the split screen. They could put everything, really literally all the information, on one monitor." Sony tends to be tight-lipped about new features it's developing until something is ready, Newman says. So he doesn't know whether it's taking his suggestion. Pricing for NUCLeUS varies with each installation, but Sony tries to keep the bill under $100,000 per room. That includes pre-sales support, post-sales support, and remote monitoring. Sony handles all the systems architecting and installation. The amount of hardware for each install is small—typically three inputs, three monitors, and five outputs—but the specialized software that ties it all together is what hospitals are really paying for. So far, NUCLeUS is used in only one US hospital—Seattle Children's Hospital—which is testing it with its 2.0 software as a proof of concept. But if Sony's new version of the system is successful, look for that number to increase rapidly—or at least as rapidly as hospital budgets will allow. When that happens, adding 3D and 4K video to the operating room will be even easier than adding it to the TV room.

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