Introduction
Advances in photographic technology and digital image capture have been accompanied by increasing interest in the use of digital cameras for quality photographic and video documentation of surgical procedures for education and research purposes.1–8 Early adaptations for camera use in the operating room involved imaging through sterile bags or double gloving to prevent contamination of the surgical field.1,2 Limitations such as glare and poor resolution led to many hospitals installing cameras built into the lights of the operating room.3–5 Sterile operating-light handles allowed for intraoperative adjustment of the camera by an aseptically prepared (ie, sterile) surgeon while also providing a hands-free method of image capture. However, noted shortcomings include the inability of the surgeon to directly control the camera functions, inability to acquire still images and quality images of structures deep within body cavities, and obstruction of the surgical field by the surgeon’s head.3,6 Furthermore, the considerable cost of these systems (> $100,000) makes their use unlikely to be widely adopted in veterinary medicine.6
More recently, affordable lightweight, high-resolution action cameras (ie, compact, durable handheld or mountable digital cameras that capture what the user sees) have been investigated for use in surgical image capture because of various desirable qualities.1,2,6–9 These cameras allow capture and remote viewing of still images and videos, with online streaming of surgical procedures that allows real-time viewing by non–aseptically prepared (ie, nonsterile) audiences. Action cameras were designed to be mounted on the user, most often via headband; however, headband use for surgical procedures often results in poor video quality owing to frequent movement of the surgeon’s head.3,5–8 Additionally, head mounts do not allow the surgeon to control the camera directly and fail to provide adequate visualization of procedures performed deep within body cavities.1,5–7,10 Recognition of these limitations has led to investigation of whether use of sterile, handheld action cameras may be possible by sterilizing their associated waterproof camera case to serve as a sterile barrier between the surgeon and the nonsterile camera.5 Recent findings suggest that the case of a certain action camera (GPa) can effectively be sterilized with hydrogen peroxide plasma.5 However, it is uncertain whether placement of the nonsterile camera into the sterile case can be performed without contamination or whether the camera case can maintain the sterile barrier with the heat and handling associated with camera use for the duration of a procedure. Given the promise of action cameras for sterilely operated image capture, safety data and guidelines are needed for this purpose.
The goals of the study reported here were to evaluate the efficacy of EtOH sterilization of the 4 types of waterproof camera cases, including 1 intended for use with SPs; determine whether the nonsterile cameras could be loaded into their respective sterile cases without contamination; and assess whether the sterile cases could then maintain a sterile barrier between the operator and the nonsterile camera with normal use for the duration of a surgical procedure. We hypothesized that the camera cases could be effectively sterilized with EtOH, that all nonsterile cameras could be loaded into their sterile cases without contamination, and that the cases would effectively maintain a sterile barrier between the sterile operator and nonsterile camera throughout standard operation regardless of whether the cameras had been disinfected or purposefully contaminated prior to loading into their cases.
Materials and Methods
Equipment
Three types of action cameras and their respective waterproof cases were evaluated: GPa, SYb, and PDc. Additionally, a generic universal waterproof SP cased was evaluated with a SP.e All cameras and cases were tested as supplied, without additional modifications (Figure 1).
Photographs of the 4 cameras evaluated in the study (GPa [A], SYb [D], PDc [G], and SPe [J]) and their respective cases (B, E, H, and K,d respectively) as well as the cameras loaded into the cases (C, F, I, and L, respectively). Notice the irregular shape of the GP camera and case relative to the uniform shapes of the other cameras and cases. The GP and SY cameras have screens (not shown) that enable the operator to see the image or video being captured. The PD camera does not have a screen. The universal SP case can hold SPs up to 6.8 inches in length.
Citation: Journal of the American Veterinary Medical Association 259, 7; 10.2460/javma.259.7.777
Photographs of the 4 cameras evaluated in the study (GPa [A], SYb [D], PDc [G], and SPe [J]) and their respective cases (B, E, H, and K,d respectively) as well as the cameras loaded into the cases (C, F, I, and L, respectively). Notice the irregular shape of the GP camera and case relative to the uniform shapes of the other cameras and cases. The GP and SY cameras have screens (not shown) that enable the operator to see the image or video being captured. The PD camera does not have a screen. The universal SP case can hold SPs up to 6.8 inches in length.
Citation: Journal of the American Veterinary Medical Association 259, 7; 10.2460/javma.259.7.777
Photographs of the 4 cameras evaluated in the study (GPa [A], SYb [D], PDc [G], and SPe [J]) and their respective cases (B, E, H, and K,d respectively) as well as the cameras loaded into the cases (C, F, I, and L, respectively). Notice the irregular shape of the GP camera and case relative to the uniform shapes of the other cameras and cases. The GP and SY cameras have screens (not shown) that enable the operator to see the image or video being captured. The PD camera does not have a screen. The universal SP case can hold SPs up to 6.8 inches in length.
Citation: Journal of the American Veterinary Medical Association 259, 7; 10.2460/javma.259.7.777
Preparation of TSB and inoculum
Trypticase soy brothf was prepared in accordance with the manufacturer’s instructions. Wide-mouth 500-mL polymethylpentane containers with polypropylene screw closuresg were filled with 300 mL of TSB and autoclaved under a 35-minute liquid cycle and then stored in a refrigerator at 4 °C until use. Three bacterial isolates—Staphylococcus pseudintermedius,h Escherichia coli,i and Pseudomonas aeruginosaj—were used as test bacteria to inoculate separate containers of sterilized TSB and incubated at 37.8 °C for 24 hours, at which time the concentration was measured with a nephelometer11 standardized to 105 CFUs/mL to ensure all isolates had a minimum concentration > 105 CFUs/mL. The 3 inocula were then combined to produce a final inoculum.
Bacterial contamination and sterilization
Each camera case, without the associated camera, was closed and immersed in the inoculum for 1 minute, allowed to dry on a sterile towel for 5 minutes, and then immersed in separate, sterile 300-mL containers of TSB (ie, postinoculation sample) to confirm that the cases had been contaminated. Broth samples were incubated at 37.8 °C for 24 hours and then used to inoculate blood agar platesk in 4 quadrants by means of a sterile, disposable plate spreader. These postinoculation blood agar plates were incubated at 37.8 °C and read 24 hours later. Colony appearance and gram stain techniques were used to identify characteristics consistent with S pseudintermedius, E coli, and P aeruginosa.
The 4 inoculated camera cases were opened 12 hours after inoculation and were sterilely processed. Sterile processing included a 3-minute soak in a 2% chlorhexidine solutionl at a 1:43 dilution, followed by manual scrubbing with a nylon soft-bristle brush. Cases were placed in standard disposable autoclavable peel pouches in an open position, with a folded laparotomy pad placed inside the SP case to hold it open, allowing gas contact with all surfaces. They were then placed in an EtOH sterilizerm for a standard 16-hour sterilization cycle at 50 °C involving 5 to 10 g of EtOH, followed by a 5-minute purge cycle (Appendix).
Experimental procedures
An operating room with a sterile surgical table and sterile towels was used for the study. Eighteen TSB containers were used during each experimental round. Sixteen TSB containers were used for simultaneous bacterial culture of the 4 camera cases at 4 time points: after EtOH exposure, prior to camera loading; after camera loading by an assistant; and after 1 and 2 hours of use. One TSB container was left open in the operating room throughout the 2-hour period to serve as a control sample for aerosol microbial contamination, and another was left closed as a control sample to confirm the TSB batch was effectively sterilized and remained sterile. No animals were used in this study.
Rounds 1 to 3—One investigator scrubbed and gowned, as for routine surgery, whereas another remained nonsterile. The sterile investigator donned 5 pairs of sterile gloves/round so that the outermost pair could be removed in between handling of each separate camera case during loading. The GP, SY, PD, and SP cases were sterilely removed from their peel pouches, locked in the closed position, and each placed in a container of TSB broth (300 mL) for 1 minute to provide a post-EtOH TSB sample. Cases were then allowed to dry on a sterile towel on the sterile table.
The nonsterile assistant wiped each camera with a 0.5% accelerated hydrogen peroxide toweletten for 1 minute and placed it on a sterile towel on a nonsterile table to dry. The same person then applied sterile surgical gloves to transfer each camera to its respective waterproof case held by the sterile investigator, without touching the exterior of the case. The sterile investigator then closed and sealed each waterproof case without touching the camera, and a postloading TSB sample was collected as described for the previous sample.
During each round, the sterile investigator pressed all buttons on each encased camera 20 times and the cameras were simultaneously left in continuous video mode on the sterile surgical table to simulate intermittent image capture in surgery for the duration of the study. After 1 and 2 hours of camera operation, the sterile investigator placed each enclosed camera into a sterile TSB container for 1 minute as described for the previous samples to provide 1- and 2-hour TSB samples.
After the 2-hour TSB samples were collected, all of the cameras were removed from their cases and camera surfaces were swabbedo and swab samples were used to inoculate blood agar plates. All TSB samples and 4 blood agar plates were incubated at 37.8 °C for 24 hours. The TSB broth was then plated onto blood agar plates, which were incubated at 37.8 °C for 24 hours. Growth and morphology of any colonies present on the plates after incubation were evaluated and identified by a microbiologist (RR) and recorded. These procedures were then repeated twice for a total of 3 rounds. A new open and closed control TSB container was present in the operating room for the entire 2-hour period to complete each round.
Challenge round—Four sterile laparotomy pads were soaked in the same bacterial inoculum used to contaminate the camera cases prior to sterilization. The GP, SY, PD, and SP cameras were simultaneously wrapped in individual contaminated laparotomy pads for 1 minute, and the nonsterile assistant loaded each camera into its respective case held by the sterile investigator. Cameras were not disinfected prior to loading as they were in the previous 3 rounds. The remainder of the round proceeded as described for the first 3 rounds. An open and closed control TSB container was present for the duration of the challenge round.
Results
Results of bacterial culture of TSB samples for each case and the camera swabs were summarized (Table 1). No camera case yielded bacterial growth from the initial post-EtOH TSB samples. Results for each case at each sampling point in rounds 1 to 3 confirmed the absence of bacterial growth in 43 (90%) of 48 samples, with 5 (10%) samples yielding nonpathogenic environmental contaminants (nonhemolytic Staphylococcus spp and nonpathogenic gram-negative bacteria). None of the 3 test bacteria were recovered from any of these samples. Environmental contaminants (nonhemolytic Staphylococcus spp) were recovered from open TSB containers (operating room control samples) in 2 of the 3 standard rounds but not in the challenge round. No bacterial growth was obtained from closed TSB containers in any round.
Bacterial culture results for samples collected from 4 types of waterproof camera cases and associated cameras at various sampling points during 3 standard experimental rounds and a challenge (Ch) round.
| Item and sampling point | GPa | SYb | PDc | SPd | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 2 | 3 | Ch | 1 | 2 | 3 | Ch | 1 | 2 | 3 | Ch | 1 | 2 | 3 | Ch | |
| Case after inoculation | *†‡ | *†‡ | *†‡ | *†‡ | *†‡ | *†‡ | *†‡ | *†‡ | *†‡ | *†‡ | *†‡ | *†‡ | *†‡ | *†‡ | *†‡ | *†‡ |
| Case after EtOH sterilization | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — |
| Case after loading of camera | — | — | — | *† | — | — | — | * | — | — | ║ | — | — | — | ¶ | — |
| Case after 1 h of camera use | — | — | — | *† | — | — | — | — | — | — | — | — | — | — | — | — |
| Case after 2 h of camera use | — | — | — | *† | ║ | — | — | — | ║ | — | — | — | ║ | — | — | ║ |
| Camera after use | — | — | — | *† | — | — | — | * | — | — | — | * | — | — | — | * |
= Escherichia coli.
= Staphylococcus pseudintermedius.
= Pseudomonas aeruginosa.
= Nonhemolytic Staphylococcus spp.
= Gram-negative environmental contaminant (not consistent with E coli or Pseudomonas spp).
= No bacterial growth.
In the first 3 rounds, cases were first inoculated with E coli, S pseudintermedius, and P aeruginosa. In the challenge round, each camera was wrapped in a contaminated laparotomy pad for 1 min prior to loading into its case.
In the challenge round, E coli and S pseudintermedius were consistently grown at all sampling points after the GP camera was loaded into its case, whereas E coli was recovered from the SY case at the postloading sampling point only. None of the 3 test bacteria were recovered from the PD and SP cases at any sampling point. In all rounds, the GP camera was consistently more difficult to sterilely load (Figure 2), compared with the SY, PD, and SP cameras.
Photograph showing how the irregular shape of the GP case and raised camera lens made loading difficult, frequently resulting in protrusion of the camera from the case (double-headed arrow). This required adjustment of the camera by the nonsterile assistant, increasing the risk of contamination.
Citation: Journal of the American Veterinary Medical Association 259, 7; 10.2460/javma.259.7.777
Photograph showing how the irregular shape of the GP case and raised camera lens made loading difficult, frequently resulting in protrusion of the camera from the case (double-headed arrow). This required adjustment of the camera by the nonsterile assistant, increasing the risk of contamination.
Citation: Journal of the American Veterinary Medical Association 259, 7; 10.2460/javma.259.7.777
Photograph showing how the irregular shape of the GP case and raised camera lens made loading difficult, frequently resulting in protrusion of the camera from the case (double-headed arrow). This required adjustment of the camera by the nonsterile assistant, increasing the risk of contamination.
Citation: Journal of the American Veterinary Medical Association 259, 7; 10.2460/javma.259.7.777
In rounds 1 to 3, none of the swab specimens from the 4 cameras yielded bacterial growth. In the challenge round, swab specimens from all 4 cameras yielded growth of E coli, S pseudintermedius, or both.
Discussion
The results of the present study supported the use of sterilized waterproof camera cases as a barrier between sterile personnel and nonsterile cameras, providing a direct means of high-quality image capture during surgery. All hypotheses were supported: all camera cases were effectively sterilized with EtOH, all nonsterile cameras could be loaded into their sterile cases without contamination in the first 3 experimental rounds, and the cases effectively maintained a sterile barrier between the sterile operator and nonsterile camera with use over time when cameras were disinfected prior to loading. However, when massive camera contamination was present (ie, during the challenge round), the GP case could not be safely loaded and operated without breaking the sterile field, and the SY case yielded growth of E coli after the camera had been loaded but not at other postload sampling points. For this reason, the authors recommend that all nonsterile cameras be disinfected with a 0.5% accelerated hydrogen peroxide towelette prior to loading within sterile cases.
Ethylene oxide sterilization of GP, SY, PD, and SP waterproof cases was found to be effective at eliminating a mixed culture of S pseudintermedius, E coli, and P aeruginosa. These species were chosen to represent common pathogenic microorganisms in veterinary medicine.12–14 Three bacterial species, rather than a single species, were chosen to more closely emulate a clinical scenario in which the virulence factors of multiple bacteria may synergize to create a more resistant bacterial population, thus allowing for a more rigorous test of the efficacy of EtOH sterilization.15 This efficacy, as determined in the present study, may be generalizable to other settings and adds to a previous report5 of the efficacy of hydrogen peroxide plasma sterilization for GP cases. Additionally, several camera models and cases across a range of price points, including an SP camera case, were found to be safe options for sterile acquisition of intraoperative images.
When cameras were disinfected prior to use (rounds 1 to 3), results indicated that loading of the nonsterile cameras into their sterile cases can be performed safely without contamination of the sterile field, and these cases successfully maintain a sterile barrier under typical conditions of use. These conditions were simulated as 2 hours of continuous camera operation and 20 button presses to represent 10 videos or 20 photographs/h of surgery. The 5 positive bacterial culture results obtained for the camera cases during the 3 standard rounds did not necessarily reflect unsafe loading or compromise of the sterile integrity of the cases. Colony morphology and gram-staining characteristics were consistent with normal flora (nonhemolytic Staphylococcus spp) and nonpathogenic environmental contaminants (Bacillus spp and Micrococcus spp) and did not resemble those of the pathogens used in the experimental inoculum. Additionally, the lack of bacterial growth from the cameras themselves reduced the likelihood of the cultured bacteria originating from the cameras. Nonhemolytic Staphylococcus spp are part of the normal skin microflora and have been identified as the most common contaminant recovered from surgeons’ hands (58%) and gloves (46%), patients’ skin (23%), suction tips (40%), and inanimate objects (82.8%) within the human operating room, even in the absence of surgical personnel or patients.12–14,16–19 The likelihood of bacterial contamination during clean surgical procedures despite strict adherence to widely accepted antiseptic protocols is high in both veterinary and human operating rooms (81% and 46%, respectively); however, this contamination has not been associated with development of surgical site infections.12,20 Such infections occur at a substantially lower rate (3.6% to 5.8%) relative to the prevalence of operating room contamination, with different bacteria consistently isolated from infected surgical sites.12–14,16–18,20 In addition to being a common contaminant in operating rooms, nonhemolytic Staphylococcus spp are also the most commonly isolated contaminant in microbiology laboratories (36% to 44%).17,18 Therefore, the authors consider the bacteria isolated in rounds 1 to 3 of the present study to be nonpathogenic contaminants, the presence of which may have been attributable to contamination of the TSB while the containers were open for camera immersion in the operating room (as supported by similar bacterial growth in the open control TSB containers), contamination while the TSB was being plated in the microbiology laboratory, or an undetected breach in sterility of the sterile investigator.
Although the results of rounds 1 to 3 yielded an acceptable protocol for safe camera use, it may be argued that the sterile integrity of the cases could not be evaluated in these rounds because none of the camera swabs yielded bacterial growth after the cases were removed. The presence of low numbers of bacteria on the camera could not be excluded owing to the lower sensitivity of swab specimens versus enrichment broth for detection of bacterial colonization.5 Ideally, the cameras would have been immersed into enrichment broth, just as their cases had been; however, potential damage to some cameras prohibited this step. Moreover, the authors did not anticipate that wiping the camera exteriors with 0.5% accelerated hydrogen peroxide towelettes would be as effective as it was for eliminating the environmental bacterial load present on the cameras. To provide a more rigorous test of the sterile integrity of the cases, a challenge round was performed, whereby cameras were massively contaminated with the bacterial mixture prior to loading rather than disinfected. Under these conditions, not all cases performed equally. The PD and SP cases yielded no evidence of failure; however, the SY case yielded a single positive result for E coli at the postloading sampling point, and the GP case demonstrated growth of the inoculated bacteria at all sampling points after loading. The authors believe that the SY unit contamination pattern likely indicated glove contamination by the sterile investigator during camera loading rather than failure of the case to maintain a sterile barrier, considering that all culture results following the positive result were negative and the sterile investigator removed the outermost pair of gloves after loading of each camera. Had the positive culture result been attributable to a failure of the case to maintain sterility, results for all subsequent sampling points would have been positive as well. Contrarily, the uniformly positive culture results for the GP case and camera in the challenge round likely indicated that the GP case could not be safely used in this scenario. The positive culture results at 1 and 2 hours of camera operation could have been secondary to contamination of the case during camera loading or secondary to a breakdown in the sterile integrity of the case. The authors suspect that contamination of the case was more likely, given that the GP camera was the most challenging to load smoothly and required several adjustments of its position to allow closing and locking of the case because of its tight fit. Ultimately, in a clinical setting, the cameras would not be soaked in broth containing pathogenic bacteria at concentrations > 104 CFUs/mL prior to use. Rather, their care and use would more closely resemble how they were handled in rounds 1 to 3, with the most common bacteria present on the cameras reflecting normal microflora (nonhemolytic Staphylococcus spp) or nonpathogenic environmental contaminants such as Bacillus spp and Micrococcus spp.12–14,16 Therefore, given our findings for the protocol used in the initial 3 rounds, we believe that the use of any of the 4 evaluated camera-case units would be unlikely to lead to substantial contamination and subsequently cause a surgical site infection, particularly if antimicrobials are administered perioperatively.12
Establishment of safety data for the sterile operation of cameras in the operating room is valuable from an educational perspective, given that the literature supports the use of video-based instruction of surgical skills for veterinary and medical students.21,22 Studies have shown that performance following video-based instruction is equivalent to or exceeds that following expert instruction of the same material.23,24 Moreover, students generally remember the steps of a procedure by recalling the video they watched prior to the surgery, and their ability to recall the procedure 1 month later was found to be significantly greater than the ability of students who did not watch a video.25,26 Videos also play an important role in teaching in the operating room, where limited space and viewing opportunities for nonsterile people exclude their participation in the procedure, a problem that grows with increasing class size. Although previous studies3–10,27 have explored camera use in a nonsterile manner, to the authors’ knowledge the present study was the first to confirm safe handheld use by a sterile operator, offering several advantages to other intraoperative imaging options. The most pertinent benefits to medical use and education include the ability to obtain focused, magnified, HD images and videos with minimal motion artifact, direct control by any sterile individual, and documentation of procedures performed deep within body cavities where shadowing normally impedes adequate image capture by methods that are distant from the surgical site.5,6 Moreover, image quality of action cameras is affected by their wide-angled view, resulting in image distortion if the camera cannot be appropriately positioned relative to the field of interest.27 Appropriate positioning is not possible with headband use and is often too close to allow nonsterile camera use by nonsterile personnel.4,5 Headband use also impairs intraoperative teaching because the surgeon cannot maintain a fixed position, focusing instead on the surgical field while simultaneously ensuring that the area of interest is broadcasted on the operating room monitors. The software of action cameras permits intraoperatively recorded videos to be live streamed via Bluetooth to mobile or stationary devices, improving instruction of nonsterile audiences and permitting video editing for production of instructional videos.5,7,10
Overall, findings of the present study suggested the 4 evaluated cameras may be safely used by a sterile surgeon following camera disinfection, allowing choices to be made on the basis of affordability and surgeon preference. Unlike the SY and PD cameras, the GP camera proved to be consistently difficult to load into its case without introducing contamination, particularly when the camera was already massively contaminated. A recent study27 showed that the image quality of the GP camera was poorer relative to that of a standard camera (35-mm, single-lens reflex camera) with regard to brightness, color, sharpness, and contrast in surgical image capture. This poorer quality may be attributed to the wide-angle method of image capture of action cameras as well as the absence of zoom and flash capabilities and adjustable lenses.
With increasing demand for use of compact and affordable cameras, alternative settings such as medium and narrow fields of view, double-digit megapixels for still images, and HD video resolution (1080p) are now available, potentially making action cameras more comparable to single-lens reflex cameras.8,27,28 Alternatively, SPs can be used for image capture if investment in an action camera is undesirable. Smartphones can offer excellent image quality, double-digit megapixels, optical zoom, and the ability to record HD video without the limitations of a wide-angle view, and inexpensive, waterproof cases such as the SP case are available and large enough to accommodate most SPs. In the authors’ experience, operation of the SP’s touch screen while within the case can be challenging with some models, and therefore this type of case is best used when physical buttons (eg, the lock and volume buttons) can be programmed to control image capture instead of the less-responsive touch screen. Although most SPs do not have an inherent means of streaming video, they can be used with other broadcasting applications and technologies to provide live video remotely.
The present study had several limitations. First, the efficacy of sterilization was tested with only 3 bacterial species. To the authors’ knowledge, no reports have been published concerning surgical site viral, fungal, or parasitic infections in veterinary medicine. However, such concerns in humans may exist and therefore a more rigorous testing protocol may be warranted.15 Additionally, although all of the evaluated cases were immersed in an inoculum containing at least 105 CFUs of each bacterium/mL, the absolute concentration was not measured. Thus, EtOH sterilization may be less effective in the presence of even greater bacterial loads. However, we believe that greater concentrations of pathogenic bacteria would be unlikely with normal camera use. Although results suggested that all evaluated cases can be repeatedly sterilized, they were only tested 4 times and the maximum number of uses possible before a breakdown in the integrity or seal of the case remains unknown. We recommend careful inspection of all seals and buttons on cases for signs of wear before each sterilization and clinical use. Finally, this study was experimental and did not evaluate the performance of the camera cases in clinical practice. Although immersion of cases in bacterial broth may have simulated intermittent exposure to body fluids, continuous exposure to body fluids, body heat, and resident microflora was not possible.
In conclusion, the present study showed that various waterproof camera cases could be effectively sterilized with EtOH up to 4 times, their respective nonsterile cameras could be safely loaded into their sterile cases, and the cases could provide a sterile barrier between the sterile surgeon and nonsterile camera under normal operating conditions provided that surgeons adhere to the described protocol. These results provide surgeons with affordable options for safe, direct, hands-on acquisition of quality photographic and video documentation of surgical procedures for medical records, education, and research.
Acknowledgments
Funded by the Department of Small Animal Clinical Sciences, University of Florida. GoPro Inc donated a GoPro Hero4 camera and 2 waterproof cases for use in the study. Donors had no involvement in the study design, data analysis and interpretation, or writing and publication of the manuscript.
The authors declare that there were no conflicts of interest.
Footnotes
Hero4, GoPro Inc, San Mateo, Calif.
FDRX3000/W underwater camcorder, Sony Corp, San Diego, Calif.
Cube HD action video camera, Polaroid Corp, Cambridge, Mass.
Universal waterproof cellphone pouch, JOTO Ltd, Blaine, Wash.
iPhone 7, Apple Inc, Cupertino, Calif.
Bacto TSB, BD Bioscience, Franklin Lakes, NJ.
Nalgene wide-mouth straight-sided PMP jars with white polypropylene screw closure, Thermo Fisher Scientific, Waltham, Mass.
ATCC 49444, ATTC, Manassas, Va.
ATCC 25922, ATTC, Manassas, Va.
ATCC 27853, ATTC, Manassas, Va.
5% sheep blood in tryptic soy agar, Hardy Diagnostics, Santa Maria, Calif.
Nolvasan solution, Zoetis, Parsippany, NJ.
EOGas AN333, Andersen Products Inc, Haw River, NC.
Oxivir TB Wipes, Diversey Inc, Charlotte, NC.
BD CultureSwab, Becton, Dickinson and Company, Franklin Lakes, NJ.
Abbreviations
| CFU | Colony-forming unit |
| EtOH | Ethylene oxide |
| HD | High-definition |
| SP | Smartphone |
| TSB | Trypticase soy broth |
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Appendix
Recommended protocol for sterilization of camera cases and subsequent camera loading.
Nonsterile* assistant:
1. Apply sterile or nonsterile surgical gloves.
2. Wipe the camera exterior with a 0.5% accelerated hydrogen peroxide toweletten for a minimum of 1 minute. Pay particular attention to all surface irregularities.
3. Place the camera on a sterile surgical towel, separate from the sterile surgical field, to dry (approx 2 to 5 minutes).
4. Remove and apply a new pair of sterile surgical gloves.
5. Transfer the disinfected camera from the sterile towel to the sterile camera case, held by the sterile* surgeon. Avoid touching the exterior of the case.
Sterile surgeon:
1. Apply 2 pairs of sterile surgical gloves while gowning and gloving for the surgical procedure.
2. Hold the sterile camera case open and away from the sterile surgical field, ensuring that only the case’s exterior is touched, while the assistant loads the disinfected camera.
3. Close the case without touching the loaded camera.
4. Remove the outermost pair of gloves.
5. Proceed with the surgical procedure. Operate the camera via the sterile camera case.
1. Remove the camera from its case.
2. Disinfect the camera exterior using 0.5% accelerated hydrogen peroxide towelettes. Do not sterilize the camera.
3. Sterilely process the camera case:
Soak in a 2% chlorhexidine solutionl (1:43 dilution) for 3 minutes.
Manually scrub all case surfaces with a nylon soft-bristle brush.
Place the opened case in a standard disposable autoclavable peel pouch with a sterility indicator. If using an SP case,d place a folded laparotomy pad inside the case to help hold the case open and allow gas contact with all surfaces.
Sterilize the case in EtOH for 16 hours at 50 °C using 5 to 10 g of EtOH.
Store cameras and sterilized cases until next use.†
