Guide to photography in the operating room – Part II (Editing)

The editing phase is almost as important as taking the photos themselves. A camera is only a tool and as such, cannot replicate the images that we see with our own eyes. If the photos turn out too dark, too bright, too blue or too red – as they tend to – this can often be corrected. In Part I, I made a few recommendations to make the editing phase easier. That includes shooting in RAW format and using a white balance card.

Software – Adobe Creative Cloud offers a photography package with Photoshop and Lightroom for a discounted price ($9.99 USD/month). Photoshop is handy for touching up my drawings but I use Lightroom exclusively for photographs. If you are looking for free software, here’s a useful link.

Tutorial –  Colin Smith has a fantastic 15-minute Lightroom tutorial that will teach you everything you need to get started.

My workflow (in 5 easy steps):

  1. From my SD card, I import the photos into Lightroom for editing.
  2. In Develop mode, I select one image to white balance (either the one with the white balance card or one with a clean white gauze in the image). Click on the dropper and apply it on to the white area. I took this image with our point-and-shoot camera at the local botanical garden:Lightroom Screenshot WB
  3. Select all images > Sync > Synchronize.
  4. There is probably a faster way to do this but with each image, I click on the Auto button in the Tone menu to correct exposure and contrast. I used to do this by manually adjusting the exposure and eyeballing the histogram (ensuring the grey curve falls in the middle) but this takes the guesswork out of it. Lightroom Screenshot Auto
  5. In Library mode, export all edited images to a secure drive and delete the images from the SD card + Lightroom.

Hope this was helpful!



Guide to photography in the operating room – Part I

With the advent of digital photography and falling costs of DSLR cameras, high quality photography has become more accessible to the masses. Intraoperative photography can be useful for documentation, capturing a rare finding and for patient or trainee education. It has become so ubiquitous that it is integrated into the consent process when surgeons discuss surgery with patients. Obtaining explicit photography consent should be the norm.

Photography is more common in medical specialties where visual documentation is essential, e.g. dermatology, plastic surgery, pathology, etc. We used to page the medical photographer to the OR whenever there was a rare finding or new technique. This was back in the era of film and he would give the surgeon physical prints. For better or worse, we have moved from professionals to surgeons taking photos.

I had the pleasure of following around two dedicated medical photographers for a day. They answered questions, demonstrated their workflow (from photographing to editing), let me use the equipment and gave feedback. I left with a better understanding of photography and changes that I could employ without buying anything new. There were a few equipment recommendations that I could invest in later, if I wanted to.

The OR presents unique challenges (e.g. artificial lighting, time constraints, distance from the subject, etc.) that can be overcome with a few simple tips. Here’s the gear I use:

  1. Camera – I recently purchased an entry-level Nikon D3200 DSLR with my credit card points (retails at $450 USD, including lens kit) that I keep at work for this purpose. It has a sharp image sensor and all of the functions that you would want in a DSLR. That being said, the gap in photo quality between point-and-shoot cameras and DSLR cameras is narrowing. If you want a light, compact and relatively inexpensive camera, point-and-shoot is the way to go. If you want more control over camera settings and are looking for an investment piece, DSLR is great for that. I was told that you can invest in some nicer lenses and change out the body every few years.
  2. Lens – The lens kit that came with my camera is meant to be cheap and versatile (AF-S DX NIKKOR 18-55mm VR II Lens Kit). For close-up photos, a macro lens is far better but it would be an investment. Given that it is super light and can zoom in decently, I am going to stay with my current lens for now.
  3. Hand strap – Great for hand-held photography. I removed the neck strap because it was cumbersome, awkwardly too long and short. Also, I would not want to fall into the sterile field.
  4. SD card – I upgraded from my 1GB to a faster, larger 64GB SD card. A larger card ensures you don’t run out of memory. In most instances, you won’t have the luxury of stopping to transfer photos off the card.
  5. White balance card – Most ORs don’t have windows. Sunlight has colors from across the light spectrum and gives some of the nicest photos. The issue with artificial light is that it has a narrower spectrum. Often, my brain knows that the “color temperature” is off but I can’t quite figure out how. Take the guess work out of it by using a white balance card and taking a photo with the same light source beforehand. It will help a lot in the editing phase.
  6. Camera cleaning kit + caviwipes

Stuff that I might get some day but I happy to do without:

  • Macro lens – much better for capturing details up-close
  • Plastic diving bag – something that both protects the camera and I can wipe with caviwipes or even sterilize, to get a little closer to the sterile field. Right now, I keep my distance for these reasons.
  • Ring flash – handy for photographing in a deep and/or small incision or space
  • Polarizing lens – reduces glare off of shiny tissues.

Here’s my current workflow:

  1. Take a photo using the overhead OR lights + white balance card on the OR table. Before the patient comes in the room, obviously. Will help in post-production.
  2. Ensure photography consent has been obtained from the patient or substitute decision-maker.
  3.  If I am not scrubbed in the case, I like to move around and take photos from different angles. If I am, I’ll often ask someone else in the room.
  4. Shoot in RAW mode, rather than JPEG. When shooting in JPEG, the camera automatically compresses the file into a JPEG file – then that data is lost forever! If you have the data storage capacity, photos in RAW format are way easier to edit later.
  5. I found that for the given OR lights, the settings on Manual that usually work for me are as follows: ISO 100, shutter speed 1/250, f/8. Shooting on Manuel seems to give far more consistent photos, which is better if you edit your photos as a batch later. I decided on these settings after reviewing my photo settings on Auto and seeing which ones gave the best photos.
  6. I changed the focus from Auto to a Single Focus in the center of the image. Usually, that’s where I want it to focus. It can be annoying when the camera focuses on the hands or instruments, rather than the tissue at the center of the image.
  7. If you have an L-shaped ruler to place in the surgical field, it will automatically make you frame the photo properly and be square with the ruler.
  8. Occasionally, I ask people to stop for literally a second so I can take the shot. Us surgeons can be very impatient! It will pay off when you don’t end up with photos of only your colleagues’ hands.

In Part II, I’ll discuss my workflow for photo editing and post-production.


Is photorealism necessary in surgical illustration?

In the few times that I have been asked to illustrate surgical techniques for publications and presentations, photorealism has been my goal. This involves sketching in a light H graphite pencil, tracing it out with an HB and shading in the darker shadows with an 3B pencil or even willow charcoal. Then I would blend with a blending stump or Q-tip and take out highlights with a fine pencil eraser. My technique was self-taught, as I had never taken an art class up until recently. Resources included Brian Duey’s website and the book he recommends entitled, “Drawing Realistic Textures in Pencil”. Both are amazing self-taught artists that can get you started in the world of photorealism.

Whenever I would try to make a drawing as realistic as possible with the above technique, I found it very time-consuming. I don’t know how many times that I blend a tone, it would fade too much and I have to add more tone to it. Or how many times that I just have to start over. The other issue that I have is that it does not scan well. I use a multipurpose HP scanner/printer and either the scan loses the fine detail of my tones or it picks up too much and the background white paper shows us as gray. The same happens when I take a photo with my DSLR camera. With my rudimentary photoshop skills, I find it difficult to strike a good balance of a keeping a clean background with sharp details and tones within the drawing. Here is an example rough sketch (although not photorealistic here, you can see how the background looks terrible):

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