“Photography in the operating theatre is only a small part of a wide field, but it demands not only solidly based technical competence but also the full commitment of the photographer and good co-operation with the surgical personnel” 1
Surgical photography has emerged as a specialized field within medical photography. Clinical photographs taken in operating theatres provide surgeons with precise visual records of surgical procedures and new surgical techniques.
Surgical images are useful for a number of reasons, they can be used for teaching purposes, for publication and for documentary evidence in the patient’s case notes.
Surgical images usually consist of a series of close-up views of an incision site taken at different stages of the procedure. A medical photographer will endeavour to document each stage from the same viewpoint and at the same magnification. This will ensure that the each photograph in the sequence is taken at the same scale. A knowledge and understanding of anatomy and pathology is also needed to help the photographer locate and record the correct features in the incision site.
Surgical photographic techniques
Surgical photography can be more technical than other aspects of clinical photography and specialized lenses and lighting equipment are often required. Close-up views are frequently requested, so a macro lens is essential, this will enable the photographer to record minute features in great detail.
Specialized lighting equipment is also needed when photographing deep into the body as conventional camera flashes are unable to evenly illuminate cavities. In this situation the source of illumination must be near to the lens axis and mounted at the front of the lens. There are two main methods for lighting cavities, point source and ring flash. Point source and ring flash systems provide an even illumination which is ideal for lighting deep body cavities.
Directional theatre lights are very bright and can affect the exposure of the image, they can also create un-wanted colour casts on the final photograph. The photographer will ask for the theatre lights to be turned off each time a photograph is taken to minimise these problems.
The photographer will also ask the surgeon to staunch the blood flow from vessels and mop up any excess blood prior to a photograph being taken. If this blood is not removed it may obscure the underlying anatomy and create distracting reflections on the final image.
Metal retractors and clamps are used by the surgeon to gain access to the incision site. These instruments can also create distracting reflections, sometimes it is not possible for them to be removed for the photograph. In this situation the photographer will ask the surgeon to tilt the instruments as this can often minimise the reflections.
A medical photographer will, wherever possible avoid photographing an untidy surgical field as it can appear distracting on the final image. Unnecessary surgical instruments and used swabs should be removed from the field of view. The replacement of bloody and wet drapes is also preferred.
“Patients have a fundamental legal and ethical right to determine what happens to their own bodies. Valid consent to treatment is therefore absolutely central in all forms of healthcare, from providing personal care to undertaking major surgery. Seeking consent is also a matter of common courtesy between healthcare professionals and patients.” 2
Clinical photographs can only be taken if the patient has given their consent. The patient can only give informed consent if they are fully aware of the reason for the photographs and know what the photographs will be used for.
Photographs which are taken for the patient’s case notes cannot be used for publication or research purposes unless specific written consent is given by the patient. Photographic images may be used within the clinical setting for teaching purposes without specific consent if there is no possibility of the patient being recognised.
Specific written consent must always be sought if the photographs are to be used for publication. The patient should be informed that they can view the images that have been taken before deciding whether to give consent for the photographs to be published. The patient must receive information on the possible future uses of the photographs and be made aware that it may not be possible to withdraw their consent once the images are in the public domain. If the patient then decides they are not happy for the images to be used for publication the images must be destroyed.
The patient is usually unconscious when surgical photographs are requested. The photographer may take the photographs in the operating theatre without the patient’s consent but must seek written consent as soon as the patient is conscious. If the patient then refuses consent, the surgical images must be destroyed.
Sterile and non-sterile areas
Operating theatres contain sterile areas and special infection control protocols must be observed before entering. Theatres are subject to meticulous daily cleaning regimes, they must be kept clean at all times and have a working ventilation system to keep the theatre dust free. Decontamination and aseptic procedures must be strictly adhered to.
The theatre floor should be cleaned thoroughly on a daily basis and floors and surfaces should be damp-dusted between operations to remove any spillages of blood or body fluids. To reduce airborne contamination the movement of people in and out of the theatre should be kept to a minimum and the theatre door should be kept closed where possible to ensure the efficiency of the ventilation system.
All healthcare workers must change out of their uniforms and put on clean, un-contaminated clothes before entering an operating theatre. This clothing protects the patient and healthcare workers from potential infection from pathological micro-organisms.
There are two main types of theatre clothing (sterile and non-sterile). Sterile gowns should be worn by the surgeons and the scrub nurses as they have direct contact with the sterile field, i.e. the draped patient and the instrument table. The sterile long sleeved gowns are designed to resist wetting, tearing and bacterial penetration. Surgeons and scrub nurses must also observe strict hand washing procedures and wear sterile gloves.
Healthcare workers (including medical photographers) don’t have direct contact with the surgical field and can wear non-sterile clothing which usually consists of trousers and a short sleeved top.
Non-sterile clothing is usually made of a poly-cotton material, it is not as effective as sterile gowns and, if soiled, can allow bacteria and body fluids to penetrate the weave. If non-sterile clothing does get contaminated with body fluids it is advisable to remove it and put on a clean outfit as soon as possible. When the procedure is complete all theatre clothing should be removed and placed in a specified dirty linen bin.
It is usual practice for the sterile drapes and gowns to be green and the non-sterile clothing to be a different colour. This makes the sterile field easier to identify, and therefore easier to avoid.
As close-up views of the surgical procedure are often requested, the photographer must stand next to the sterile field. The photographer must ensure they don’t touch or rub against any sterile areas, for example the instrument table, surgeons, scrub nurses or patient. If the photographer does touch a sterile area they must tell the surgeon immediately and the drapes, clothing or instruments can be replaced.
Safe working practices
The most important thing a medical photographer should do before and after photographing each patient is wash their hands. This is necessary as it prevents the hands from becoming contaminated with micro-organisms. If the hands were not washed cross-contamination could occur. This is especially important when photographing a surgical procedure in an operating theatre environment.
The use of protective clothing such as a surgical mask, theatre clogs and hair net is also essential to avoid contaminating the theatre or incision site. Outside shoes should never be worn in an operating theatre as they harbour bacteria and could contaminate the floor. The hospital should supply non-slip, anti-static theatre clogs which can be washed after use. Hair nets should also be worn to prevent loose hair and skin from falling on the incision site or sterile areas.
Medical photographers should wear masks when photographing patients in operating theatres, or when they are in close contact with patients undergoing any form of surgical procedure. This is necessary as masks trap any organisms exhaled by the photographer. A fresh mask should be worn for each procedure and masks should be replaced when they become damp, as damp masks no longer deflect organisms. At the end of the procedure the mask should be removed and placed in a yellow clinical waste bin.
The photographer’s camera bag should be left outside the theatre and the photographer should only bring in the camera equipment which is needed. It is imperative that the photographer decontaminates this camera equipment with alcohol wipes before entering the theatre. If the photographer doesn’t disinfect their equipment they could inadvertently introduce micro-organisms into the incision site.
The photographer should display their identity badge clearly so that the other theatre staff know who they are and will not ask them to perform tasks they are not trained to do, for example help transfer the patient from the bed to the operating table.
The photographer should always let the surgeon know when they are about to take a photograph and should never deploy the flash without warning. If they do they might distract the surgeon at a critical point in the procedure. The photographer should also make sure they are not in the way and should only step up to the table when a photograph is being taken. This will prevent the surgeons and scrub nurses from bumping into the photographer and contaminating their sterile clothing.
X-rays and lasers
Portable x-ray machines are often used in operating theatres as they are a useful diagnostic tool. An image is produced on photographic film by passing electromagnetic radiation through parts of the body. Dense structures such as bone absorb the x-rays and appear as lighter regions on the developed film.
Precautions should be taken to protect theatre staff from the damaging effects of occupational exposure to x-rays as radiation has the potential to cause mutations in the germ cells that may then be passed on to future generations. Pregnant theatre staff should avoid all exposure to x-rays as the radiation can also cause foetal abnormalities. Theatre staff can limit their exposure by wearing special protective clothing such as a lead apron.
Lead aprons are very effective at absorbing diagnostic x-rays to the parts of the body shielded by the apron. The aprons contain lead and often other metals such as tin, tungsten, antimony and barium. These metals are mixed with synthetic rubber or polyvinyl chloride (PVC). Sheets of the metal impregnated rubber/PVC are placed between sheets of nylon fabric which has been coated with urethane. This material is then cut into a pattern and sewn together to form the protective apron.
When an x-ray is taken the number of people present in the theatre should be limited to those performing the procedure, all other theatre staff, including medical photographers should leave the theatre. If the photographer needs to be present for any reason a lead apron must be worn.
Laser surgery is also performed in operating theatres. A laser is a device which absorbs electromagnetic energy and re-radiates it as a highly focused beam of single wavelength radiation. The wavelength of the beam determines its colour and different wavelengths have distinct effects on the body.
Carbon dioxide and infra-red lasers have a long wavelength which is easily absorbed by water in the cells. Long wavelengths are very effective at cutting through tissue. Argon lasers have a shorter wavelength which is not readily absorbed by water. Argon lasers are used in ophthalmic surgery to shine through the liquid in the eyeball and treat the retina.
Laser surgery can be hazardous for theatre staff. If the light from a laser is transmitted directly or reflected into the eye it could burn the retina causing a permanent blind spot. If the beam of light hits the head of the optic nerve it could cause partial or total blindness. Infra-red lasers can be more hazardous to theatre staff as the beam of light cannot be seen by the naked eye.
Theatre staff must wear well fitting eye protection for all laser procedures. The type of goggles required depends on the wavelength of the laser. The glass in the goggles consists of alternate layers of two different optical materials (Bragg mirrors). Each optical layer reflects a certain wavelength. This stops the harmful wavelengths from entering the eye and damaging it.
Modern laser safety goggles are labelled with the wavelengths that the goggles protect from and the strength of the goggles. This information should correspond exactly with the information on the laser. It is vital that the correct goggles are worn, if the wrong ones are selected they will offer no protection from the laser beam.
Medical photographers have a responsibility to the patient and other healthcare workers to ensure that they wear the correct protective clothing. The photographer must also have a working knowledge of sterile and non-sterile areas within the theatre. If the photographer is not aware of the correct protocols they could put themselves, the patient and surgical staff at risk. It is therefore essential that medical photographers rigorously adhere to theatre protocols when photographing surgical procedures.
- Hansell, P., (Ed.) 1979. A Guide to Medical Photography. MPT Press Limited.
- South Manchester University Hospital NHS Trust. 2006. Consent to examination or treatment policy. SMUHT.