Ergonomic problems encountered by the medical team related to products used for minimally invasive surgery

A narrative review of ergonomic problems, principles, and potential solutions in surgical operations

BACKGROUND

Ergonomic development and awareness are critical to the long-term health and well-being of surgeons. Work-related musculoskeletal disorders affect an overwhelming majority of surgeons, and various operative modalities (open, laparoscopic, and robotic surgery) differentially affect the musculoskeletal system. Previous reviews have addressed various aspects of surgical ergonomic history or methods of ergonomic assessment, but the purpose of this study is to synthesize ergonomic analysis by surgical modality while discussing future directions of the field based on current perioperative interventions.

METHODS

pubmed was queried for "ergonomics," "work-related musculoskeletal disorders," and "surgery," which returned 124 results. From the 122 English-language papers, a further search was conducted via the articles' sources for relevant literature.

RESULTS

Ninety-nine sources were ultimately included. Work-related musculoskeletal disorders culminate in detrimental effects ranging from chronic pain and paresthesias to reduced operative time and consideration for early retirement. Underreporting symptoms and a lack of awareness of proper ergonomic principles substantially hinder the widespread utilization of ergonomic techniques in the operating room, reducing the quality of life and career longevity. Therapeutic interventions exist at some institutions but require further research and development for necessary widespread implementation.

CONCLUSION

Awareness of proper ergonomic principles and the detrimental effects of musculoskeletal disorders is the first step in protecting against this universal problem. Implementing ergonomic practices in the operating room is at a crossroads, and incorporating these principles into everyday life must be a priority for all surgeons.

Ergonomic Considerations in Urologic Surgery

PURPOSE OF REVIEW

This paper aims to discuss the various work-related musculoskeletal disorders (WRMDs) among urologists and provide an overview of the latest recommendations to improve awareness of ergonomic principles that can be applied in the operating room, with special consideration of challenges faced during pregnancy.

RECENT FINDINGS

Urologists suffer from a large burden of WRMDs. The main drivers of pain associated with the various surgical approaches include repetitive movements, static and awkward body positions, and the use of burdensome equipment. Pregnant surgeons are at an even greater risk of WRMDs and face high rates of pregnancy complications. Laparoscopy, endoscopy, robot-assisted surgeries, and open surgeries present unique ergonomic challenges for the practicing urologist. Proper posture and equipment use, optimal operating room setup, intraoperative stretching breaks, and an emphasis on teaching ergonomic principles can reduce the risk of WRMDs. Surgeons are also at increased risk of WRMDs during pregnancy but may continue to operate while taking measures to limit physical exertion and fatigue. Improving awareness of and incorporating ergonomic principles early in a urologist's career may reduce the risk of injury and improve operative performance and longevity.

Investigation of the Efficiency and Quality of Lightweight Gowns with Multi-Layered Nanoparticles Compositions of Bismuth, Tungsten, Barium, and Copper

Background

Radiation protection plays a key role in medicine, due to the considerable usage of radiation in diagnosis and treatment. The protection against radiation exposure with inappropriate equipment is concerning.

Objective

The current study aimed to investigate the efficiency and quality of the radiation protection gowns with multi-layered nanoparticles compositions of Bismuth, Tungsten, Barium, and Copper, and light non-lead commercial gowns in angiography departments for approval of the manufacturers' declarations and improve the quality of gowns.

Material and Methods

In this case study, physicians, physician assistants, radiology technologists, and nurses were asked to wear two commercial and proposed gowns in the angiography departments. Dosimetry of personnel was conducted using a Thermoluminescent Dosimeter (TLD) (GR-200), and the radiation dose received by personnel was compared in both cases. The participants were asked to fill out a questionnaire about the quality and comfort of two radiation protection gowns.

Results

However, both gowns provide the necessary radiation protection; the multi-layer proposed gown has better radiation protection than the commercial sample (2 to 14 percent reduction in effective dose). The proposed gown has higher flexibility and efficiency than the commercial sample due to the use of nanoparticles and multi-layers (2.3 percent increase in personnel satisfaction according to the questionnaires).

Conclusion

However, the multi-layer gown containing nanoparticles of Bismuth, Tungsten, Barium, and Copper has no significant difference from the non-lead commercial sample in terms of radiation protection, it has higher flexibility and comfort with more satisfaction for the personnel.

A Global Survey of Ergonomics Practice Patterns and Rates of Musculoskeletal Pain Among Urologists Performing Retrograde Intrarenal Surgery

PURPOSE

Retrograde intrarenal surgery (RIRS) requires awkward body posture for long durations. Few urologists receive ergonomics training despite the availability of ergonomics best practices utilized by other surgical specialties. We characterize ergonomics practice patterns and rates of musculoskeletal (MSK) pain among urologists performing RIRS.

METHODS

A web-based survey was distributed via the Endourological Society, the EAU, and social media. Surgeon anthropometrics and ergonomic factors were compared to ergonomics best practices. Pain was assessed with the Nordic Musculoskeletal Questionnaire (NMQ).

RESULTS

Overall, 519 of 526 participants completed the survey (99% completion rate). Ninety-three percent of urologists consider ergonomic factors when performing RIRS to reduce fatigue (68%), increase performance (64%), improve efficiency (59%), and reduce pain (49%). Only 16% received ergonomics training. Residents/fellows had significantly lower confidence in ergonomic technique compared to attending surgeons of any career length. Adherence to proper ergonomic positioning for modifiable factors were highly variable. On NMQ, 12-month rates of RIRS-associated pain in ≥1 body part, pain limiting activities of daily living, and pain requiring medical evaluation were 81%, 51%, and 29%, respectively. Annual case volume >150 cases (OR 0.55 [0.35-0.87]) and higher adherence to proper ergonomic techniques (OR 0.67 [0.46-0.97]) were independently associated with lower odds of pain. Limitations include a predominantly male cohort which hindered the ability to assess gender disparities in pain and ergonomic preferences.

CONCLUSION

Adherence to ergonomics best practices during RIRS is variable and may explain high rates of MSK pain among urologists. These results underscore the importance of utilizing proper ergonomic techniques and may serve as a framework for establishing ergonomics guidelines for RIRS.

Surgical ergonomics for urologists: a practical guide

Poor ergonomics in the operating room can have detrimental effects on a surgeon's physical, psychological and economic well-being. This problem is of particular importance to urologists who are trained in nearly all operative approaches (open, laparoscopic, robotic-assisted, microscopic and endoscopic surgery), each with their own ergonomic considerations. The vast majority of urologists have experienced work-related musculoskeletal pain or injury at some point in their career, which can result in leaves of absence, medical and/or surgical treatment, burnout, changes of specialty and even early retirement. Surgical ergonomics in urology has been understudied and underemphasized. In this Review, we characterize the burden of musculoskeletal injury in urologists and focus on various ergonomic considerations relevant to the urology surgeon. Although the strength of evidence remains limited in this space, we highlight several practical recommendations stratified by operative approach that can be incorporated into practice without interrupting workflow whilst minimizing injury to the surgeon. These recommendations might also serve as the foundation for ergonomics training curricula in residency and continuing medical education programmes. With improved awareness of ergonomic principles and the sequelae of injury related to urological surgery, urologists can be more mindful of their operating room environment and identify ways of reducing their own symptoms and risk of injury.

NASA-TLX Assessment of Surgeon Workload Variation Across Specialties

OBJECTIVE

With advancements in surgical equipment and procedures, human-system interactions in operating rooms affect surgeon workload and performance. Workload was measured across surgical specialties using surveys to identify potential predictors of high workload for future performance improvement.

SUMMARY BACKGROUND DATA

Surgical instrumentation and technique advancements have implications for surgeon workload and human-systems interactions. To understand and improve the interaction of components in the work system, NASA-Task Load Index can measure workload across various fields. Baseline workload measurements provide a broad overview of the field and identify areas most in need of improvement.

METHODS

Surgeons were administered a modified NASA-Task Load Index survey (0 = low, 20 = high) following each procedure. Patient and procedural factors were retrieved retrospectively.

RESULTS

Thirty-four surgeons (41% female) completed 662 surgery surveys (M = 14.85, SD = 7.94), of which 506 (76%) have associated patient and procedural data. Mental demand (M = 7.7, SD = 5.56), physical demand (M = 7.0, SD = 5.66), and effort (M = 7.8, SD = 5.77) were the highest rated workload subscales. Surgeons reported difficulty levels higher than expected for 22% of procedures, during which workload was significantly higher (P < 0.05) and procedural durations were significantly longer (P > 0.001). Surgeons reported poorer perceived performance during cases with unexpectedly high difficulty (P < 0.001).

CONCLUSIONS

When procedural difficulty is greater than expected, there are negative implications for mental and physical demand that result in poorer perceived performance. Investigations are underway to identify patient and surgical variables associated with unexpected difficulty and high workload. Future efforts will focus on re-engineering the surgical planning process and procedural environment to optimize workload and performance for improved surgical care.

Musculoskeletal Symptoms Among Surgeons at a Tertiary Care Center: a Survey Based Study

Introduction:

Musculoskeletal (MSK) manifestations represent a common work-related physical complication that affect surgeons and impacts their life and the healthcare service negatively.

Aim:

The aim of this study was to determine the prevalence of work related MSK manifestations among surgeons in a tertiary care hospital and to identify the possible associated risk factors.

Methods:

A Web-based self-administered cross-sectional survey was conducted. This study targeted all surgeons regardless of their nationalities, ages, genders, and marital statuses. The questionnaire assessed the participants’ demographic data as well as musculoskeletal manifestations.

Results:

Most respondents (80%) suffered from MSK manifestations that were related to performing surgeries. Back and neck areas represented the most affected body parts (71.1% and 59.8%, respectively). A significantly higher percentage of those with musculoskeletal manifestations practiced for 5-10 years (28.9%) (p = 0.006).

Conclusion:

MSK pain is common among Saudi surgeons in different specialties. More attention should be directed to improving the physical environments in which the surgeons are operating. Moreover, surgeons should be educated about the recommended ergonomic positions that can prevent or decrease their work related MSK manifestations.

Ergonomics and Musculoskeletal Health of the Surgeon

Surgeons face hazardous working conditions due to ergonomic deficiencies found throughout the operating room. More than 80% of surgeons have succumbed to a work-related injury or illness as a consequence of sustaining awkward or static positions throughout lengthy operations over a career. While the focus of the procedure is directed to the patient, there is little concurrent regard for proper posture or spinal stability. Even when symptoms of discomfort are experienced, they are often ignored. This results in decreased production and may ultimately threaten surgical careers. Surgeons are often unaware of recommendations or guidelines designed to improve their comfort while operating. Furthermore, there is a significant lack of any formal ergonomic education, especially for minimally invasive procedures. Several modifiable risk factors can be adjusted in the operating room to provide a safer working environment. In addition, strengthening, stability, and exercise programs directed by a trained therapist may be employed to improve the surgeon's musculoskeletal health.

Surgeons' muscle load during robotic-assisted laparoscopy performed with a regular office chair and the preferred of two ergonomic chairs: A pilot study

Surgeons work in awkward work postures and have high precision demands - well-known risk factors for musculoskeletal pain. Robotic-assisted laparoscopy is expected to be less demanding compared to conventional laparoscopy; however, studies indicate that robotic-assisted laparoscopy is also associated with poor ergonomics and musculoskeletal pain. The ergonomic condition in the robotic console is partially dependent upon the chair provided, which often is a regular office chair. Our study quantified and compared the muscular load during robotic-assisted laparoscopy using one of two custom built ergonomic chairs and a regular office chair. The results demonstrated no differences that could be considered clinically relevant. Overall, the study showed high levels of static and mean muscular activity, increased perceived physical exertion from pre-to-post surgery, and moderate to high risk for musculoskeletal injuries measured by the Rapid Upper Limb Assessment worksheet. Authors advocate for further investigation in surgeons' ergonomics and physical work demands in robotic surgery.

Ergonomic Assessment of the Mental Workload Confronted by Surgeons during Laparoscopic Surgery

Although the mental workload confronted by laparoscopic surgeons is rather high, there is presently no reliable, established method for evaluating this workload. In the present study, four evaluation indices of eye movement metrics were applied to evaluate surgeons’ mental workload. Correlations between these indices and National Aeronautics and Space Administration Task Load Index (NASA-TLX) scores were also explored. Sixteen participants were recruited to complete four laparoscopic procedures. Eye movement was recorded during the tasks, and NASA-TLX scales were also introduced for subjective evaluation. The data were analyzed using R 3.3.2. Significant differences in the mental workload of each task were observed. Statistically significant correlations between mean pupil diameter change and NASA-TLX scores were also observed. The correlation coefficients were 0.763, 0.675, 0.405, and 0.547, and the P values correspondingly were 0.001, 0.004, 0.12, and 0.028, respectively. The results clarify that the mental workload of laparoscopic surgeons is dependent on the specific demands of the operation. Appropriate objective physiological indices can be used to identify the mental workload state of the surgeon.

Ergonomic assessment of the first assistant during robot-assisted surgery

The use of the da Vinci robot in minimal invasive surgery comes with numerous advantages. Recent papers describe improvements in the ergonomic environment and benefits for the surgeon's posture in the console. Ergonomics for first assistants or scrub nurses at the OR table during robot-assisted procedures, however, have gained minor attention. The aim of this study, therefore, is to analyse the ergonomic environment specifically for first assistants during robot-assisted surgery. Three techniques were used to evaluate body posture and ergonomics during three discriminated actions. First of all, a questionnaire was conducted. Second, sagittal and dorsal photographs of all first assistants were shot. From these photographs, joint angles of the trunk, neck, shoulder, elbow, pelvic girdle and spine were calculated and rapid upper limb assessment (RULA) scores were determined. In addition, intra-observer variability was assessed to determine the robustness of the results. Lastly, the number of obstructions during the surgery was registered by an observer present at the operation theatre. The questionnaires displayed that 73% of the first assistants were in uncomfortable working positions for longer periods of time. Twenty percent of the participants even report pain or visible bruising due to hinderance of the robot arm. Furthermore, an average of 2.8 obstructions per surgical procedure was registered, mainly affecting the lower arm (60%). The photographs demonstrated that all joint angles, except for the elbow joint, are potentially harmful when assisting during robot-assisted surgery. RULA scores revealed high-risk ergonomic risk scores for all measured actions. Tissue traction was recognized as the action with the highest physical workload. During robot-assisted surgery, first assistants experience non-ergonomic trunk, neck and shoulder angles. These recordings are supported by posture analysis. Tissue traction is reported as the most intensive action by the nurses. Tacking, however, can lead to the most unfavourable RULA score. The surgeon's awareness of the position of the robot arms could reduce the number of obstructive moments for the first assistant. Lowering the number of instrument replacements is plausible to lead to better ergonomic postures for first assistant.

Real-Time Vision-Based Stiffness Mapping †

This paper presents new findings concerning a hand-held stiffness probe for the medical diagnosis of abnormalities during palpation of soft-tissue. Palpation is recognized by the medical community as an essential and low-cost method to detect and diagnose disease in soft-tissue. However, differences are often subtle and clinicians need to train for many years before they can conduct a reliable diagnosis. The probe presented here fills this gap providing a means to easily obtain stiffness values of soft tissue during a palpation procedure. Our stiffness sensor is equipped with a multi degree of freedom (DoF) Aurora magnetic tracker, allowing us to track and record the 3D position of the probe whilst examining a tissue area, and generate a 3D stiffness map in real-time. The stiffness probe was integrated in a robotic arm and tested in an artificial environment representing a good model of soft tissue organs; the results show that the sensor can accurately measure and map the stiffness of a silicon phantom embedded with areas of varying stiffness.

Sources of pain in laparoendoscopic gynecological surgeons: An analysis of ergonomic factors and proposal of an aid to improve comfort

Minimally invasive surgery (MIS) offers cosmetic benefits to patients; however, surgeons often experience pain during MIS. We administered an ergonomic questionnaire to 176 Korean laparoscopic gynecological surgeons to determine potential sources of pain during surgery. Logistic regression analysis was used to identify factors that had a significant impact on gynecological surgeons’ pain. Operating table height at the beginning of surgery and during the operation were significantly associated with neck and shoulder discomfort (P <0.001). The ability to control the operating table height was the single factor most significantly associated with neck (P <0.001) and shoulder discomfort (P <0.001). Discomfort of the hand/digits was significantly associated with the trocar site (P = 0.035). The type of electrocautery activation switch and foot pedal were significantly related to surgeons’ foot and leg discomfort (P <0.001). In evaluating the co-occurrence of pain in 4 different sites (neck, shoulder, back, hand/digits), the neck and shoulder were determined to have the highest co-occurrence of pain (Spearman’s ρ = 0.64, P <0.001). These results provide guidance for identifying ergonomic solutions to reduce gynecological laparoscopic surgeons’ pain. Based on our results, we propose the use of an ergonomic surgical step stool to reduce physical pain related to performing laparoscopic operations.

Use of natural user interfaces for image navigation during laparoscopic surgery: initial experience

BACKGROUND

Surgical environments require special aseptic conditions for direct interaction with the preoperative images. We aim to test the feasibility of using a set of gesture control sensors combined with voice control to interact in a sterile manner with preoperative information and an integrated operating room (OR) during laparoscopic surgery.

MATERIAL AND METHODS

Two hepatectomies and two partial nephrectomies were performed by three experienced surgeons in a porcine model. The Kinect, Leap Motion, and MYO armband in combination with voice control were used as natural user interfaces (NUIs). After surgery, surgeons completed a questionnaire about their experience.

RESULTS

Surgeons required <10 min training with each NUI. They stated that NUIs improved the access to preoperative patient information and kept them more focused on the surgical site. The Kinect system was reported as the most physically demanding NUI and the MYO armband in combination with voice commands as the most intuitive and accurate. The need to release one of the laparoscopic instruments in order to use the NUIs was identified as the main limitation.

CONCLUSIONS

The presented NUIs are feasible to directly interact in a more intuitive and sterile manner with the preoperative images and the integrated OR functionalities during laparoscopic surgery.

Ergonomics in the operating room

Background

Since the introduction of minimally invasive surgery, surgeons appear to be experiencing more occupational musculoskeletal injuries. The aim of this study is to investigate the current frequency and effects of occupational musculoskeletal injuries on work absence.

Methods

An online questionnaire was conducted among all surgeons affiliated to the Dutch Society for Endoscopic Surgery, Gastrointestinal Surgery, and Surgical Oncology. In addition, this survey was conducted among surgeons, gynaecologists, and urologists of one cluster of training hospitals in the Netherlands.

Results

There were 127 respondents. Fifty-six surgeons currently suffer from musculoskeletal complaints, and 30 have previously suffered from musculoskeletal complaints with no current complaints. Frequently reported localizations were the neck (39.5 %), the erector spinae muscle (34.9 %), and the right deltoid muscle (18.6 %). Most of the musculoskeletal complaints were present while operating (41.8 %). Currently, 37.5 % uses medication and/or therapy to reduce complaints. Of surgeons with past complaints, 26.7 % required work leave and 40.0 % made intraoperative adjustments. More surgeons with a medical history of musculoskeletal complaints have current complaints (OR 6.1, 95 % CI 1.9–19.6). There were no significant differences between surgeons of different operating techniques in localizations and frequency of complaints, or work leave.

Conclusions

Despite previous various ergonomic recommendations in the operating room, the current study demonstrated that musculoskeletal complaints and subsequent work absence are still present among surgeons, especially among surgeons with a positive medical history for musculoskeletal complaints. Even sick leave was necessary to fully recover. There were no significant differences in reported complaints between surgeons of different operating techniques. Almost half of the respondents with complaints made intraoperative ergonomic adjustments to prevent future complaints. The latter would be interesting for future research.

Methodological Infrastructure in Surgical Ergonomics: A Review of Tasks, Models, and Measurement Systems

Though in its infancy, the discipline of surgical ergonomics is increasingly valued. Still, little has been written regarding this field's tasks, models, and measurement systems. These 3 critical experimental components are crucial in objectively and accurately assessing joint and postural control as exhibited by expert laparoscopic surgeons. Such assessments will establish characteristic patterns important for surgical training. In addition, risk factors associated with both minimally invasive surgical instruments and the operating room environment can be identified and minimized. Our review focuses on evidence-based experimental ergonomic studies undertaken in the field of laparoscopic surgery. Publications were located through PubMed and other database and library searches. This article describes tasks, models, and measurement systems and considers their specific applications and the types of data obtainable with the use of each. Advantages and limitations, especially those of measurement systems, are compared and discussed. Future trends and directions believed necessary for optimal investigation and results are also addressed.

The Physical Workload of Surgeons: A Comparison of SILS and Conventional Laparoscopy

BACKGROUND

As extensively reported in the literature, laparoscopic surgery has many advantages for the patient. Surgeons, however, experience increased physical burden when laparoscopic surgery is compared with open surgery. Single-incision laparoscopic surgery (SILS) has been said to further enhance the patient's benefits of endoscopic surgery. Because in this surgical technique only 1 incision is made instead of the 3 to 5, as in conventional laparoscopic surgery (CLS), it is claimed to further reduce discomfort and pain in patients. Yet little is known about its impact on surgeons. This study aims to contribute by indicating the possible differences in physical workload between single-incision laparoscopy and CLS.

METHODS

A laparoscopic box trainer was used to simulate a surgical setting. Participants performed 2 series of 3 different tasks in the box: one in the conventional way, the other through SILS. Surface electromyography was recorded from 8 muscles bilaterally. Furthermore, questionnaires on perceived workload were completed.

RESULTS

Differences were found in the back, neck, and shoulder muscles, with significantly higher muscle activity in the musculus (M) longissimus, M trapezius pars descendens, and the M deltoideus pars clavicularis. Questionnaires did not indicate any significant differences in perceived workload.

CONCLUSION

Performing SILS versus CLS increases the objectively measured physical workload of surgeons particularly in the back, neck, and shoulder muscles.

Endoscopic add-on stiffness probe for real-time soft surface characterisation in MIS

This paper explores a novel stiffness sensor which is mounted on the tip of a laparoscopic camera. The proposed device is able to compute stiffness when interacting with soft surfaces. The sensor can be used in Minimally Invasive Surgery, for instance, to localise tumor tissue which commonly has a higher stiffness when compared to healthy tissue. The purely mechanical sensor structure utilizes the functionality of an endoscopic camera to the maximum by visually analyzing the behavior of trackers within the field of view. Two pairs of spheres (used as easily identifiable features in the camera images) are connected to two springs with known but different spring constants. Four individual indenters attached to the spheres are used to palpate the surface. During palpation, the spheres move linearly towards the objective lens (i.e. the distance between lens and spheres is changing) resulting in variations of their diameters in the camera images. Relating the measured diameters to the different spring constants, a developed mathematical model is able to determine the surface stiffness in real-time. Tests were performed using a surgical endoscope to palpate silicon phantoms presenting different stiffness. Results show that the accuracy of the sensing system developed increases with the softness of the examined tissue.

Ergon-trial: ergonomic evaluation of single-port access versus three-port access video-assisted thoracic surgery

BACKGROUND

Single-port access video-assisted thoracic surgery (VATS), a technique progressively developed from the standard three-port approach in minimally invasive surgery, offers ergonomic advantages but also new challenges for the surgeon. We compared the ergonomics of three-port versus single-port VATS.

METHODS

Posture analysis of surgeons was evaluated during 100 consecutive VATS wedge resections (50 triportal vs. 50 uniportal). Technically demanding procedures (major lung resection) were excluded. Operating table height, monitor height, distance and inclination were adjusted according to operator preference. Body posture was assessed by measuring head-trunk axial rotation and head flexion. Perceived physical strain was self-evaluated on the Borg Category Ratio (CR-10) scale. Mental workload was assessed with the National Aeronautics Space Administration-Task Load indeX (NASA-TLX), a multidimensional tool that rates workloads on six scales (mental, physical and temporal demand; effort; performance; frustration).

RESULTS

All procedures were completed without complications. Head-trunk axial rotation was significantly reduced and neck flexion significantly improved in uniportal VATS. Viewing direction significantly declined (p = 0.01), body posture as measured on the Borg CR-10 scale was perceived as more stressful and the NASA-TLX score for overall workload was higher (p = 0.04) during triportal VATS. The NASA-TLX score for frustration was higher with uniportal VATS (p = 0.02), but the score for physical demand was higher in triportal VATS (p = 0.006).

CONCLUSIONS

The surgeon can maintain a more neutral body posture during uniportal VATS by standing straight and facing the monitor with only minimal neck extension/rotation; however, frustration is greater than with triportal VATS.

Quality and safety of minimally invasive surgery: past, present, and future

Adverse events because of medical errors are a leading cause of death in the United States (US) exceeding the mortality rates of motor vehicle accidents, breast cancer, and AIDS. Improvements can and should be made to reduce the rates of preventable surgical errors because they account for nearly half of all adverse events within hospitals. Although minimally invasive surgery (MIS) has proven patient benefits such as reduced postoperative pain and hospital stay, its operative environment imposes substantial physical and cognitive strain on the surgeon increasing the risk of error. To mitigate errors and protect patients, a multidisciplinary approach is needed to improve MIS. Clinical human factors, and biomedical engineering principles and methodologies can be used to develop and assess laparoscopic surgery instrumentation, practices, and procedures. First, the foundational understanding and the imperative to transform health care into a high-quality and safe system is discussed. Next, a generalized perspective is presented on the impact of the design and redesign of surgical technologies and processes on human performance. Finally, the future of this field and the research needed to further improve the quality and safety of MIS is discussed.

The investigation of laparoscopic instrument movement control and learning effect

Laparoscopic surgery avoids large incisions for intra-abdominal operations as required in conventional open surgery. Whereas the patient benefits from laparoscopic techniques, the surgeon encounters new difficulties that were not present during open surgery procedures. However, limited literature has been published in the essential movement characteristics such as magnification, amplitude, and angle. For this reason, the present study aims to investigate the essential movement characteristics of instrument manipulation via Fitts' task and to develop an instrument movement time predicting model. Ten right-handed subjects made discrete Fitts' pointing tasks using a laparoscopic trainer. The experimental results showed that there were significant differences between the three factors in movement time and in throughput. However, no significant differences were observed in the improvement rate for movement time and throughput between these three factors. As expected, the movement time was rather variable and affected markedly by direction to target. The conventional Fitts' law model was extended by incorporating a directional parameter into the model. The extended model was shown to better fit the data than the conventional model. These findings pointed to a design direction for the laparoscopic surgery training program, and the predictive model can be used to establish standards in the training procedure.

Operating room of the future

Development of surgical care in the 21st century is increasingly dependent on demonstrating safety, efficacy and cost effectiveness. Over the past 2 decades, the potential role of simulation in surgery has been explored with encouraging results; this can now be linked to direct improvement in the quality of care provision. Computer-assisted surgical platforms, such as robotic surgery, offer us the versatility to embrace a host of technical and technological developments. Rapid development in nanomedicine will expand the limits of operative performance through improved navigation and surgical precision. Integration of the multiple functions of the future operating room will be essential in optimising resource management. The key to bringing about the necessary paradigm shift in the design and delivery of modern surgical care is to appreciate that we now function in an information age, where the integrity of processes is driven by apt data management.

Ergonomics principles associated with laparoscopic surgeon injury/illness

OBJECTIVE

This study sought to investigate the prevalence of laparoscopic surgeon injury/illness symptoms and evaluate associations between symptoms and operating room ergonomics.

BACKGROUND

Although laparoscopic procedures significantly benefit patients in terms of decreased recovery times and improved outcomes, they contribute to mental fatigue and musculoskeletal problems among surgeons. A variety of ergonomic interventions and applications are implemented by surgeons to reduce health problems. Currently, there is a gap in knowledge regarding a surgeon's individual assessment of the operating room, an assessment that, in turn, would prompt the implementation of these interventions.

METHOD

A new survey instrument solicited information from surgeons (N = 61) regarding surgeon demographics, perception, frequency of operating room equipment adjustment, and self-reported symptoms. Surgeons responded to questions addressing safety, ergonomics, and fatigue in the operating room, using a 5-point Likert-type scale that included the option undecided.

RESULTS

Surgeons who responded undecided were more likely to experience symptoms of injury/illness than respondents who were able to assess the features of their operating rooms. Symptoms were experienced by 100% of participants. The most prevalent symptoms were neck stiffness, back stiffness, and back pain.

CONCLUSION

This study supports hypotheses that surgeons are experiencing body part discomfort and indicators of fatigue that may be associated with performing laparoscopy. Results suggest that awareness, knowledge, and utilization of ergonomic principles could protect surgeons against symptoms that lead to occupational injury.

APPLICATION

The purpose of this brief report is to convey the importance of ergonomic principles in the operating room, specific to laparoscopic surgery and surgeon injury/illness symptoms.

Optimizing integration of electrosurgical hand controls within a laparoscopic surgical tool

Abstract In laparoscopic surgery, electrosurgical equipment is operated by means of one or more foot pedals positioned on the floor in front of the surgeon causing poor ergonomic posture and physical discomfort. The focus of this study was to ergonomically explore the integration of electrosurgical hand controls within the previously designed Intuitool™ laparoscopic surgical instrument to optimize functionality. Three different hand control designs (CDs) were implemented within the Intuitool™ and each CD contained the standard cutting and coagulation features, previously operated by foot pedals. This study used 26 right-handed participants, with no previous laparoscopic surgery experience. The participants completed simple tasks using all three CDs within a simulated abdomen. Electromyography (EMG) sensors and force sense resistors (FSRs) were utilized to measure muscle activity and button actuation force, respectively. A questionnaire was also utilized to measure comfort level of each CD. The results indicated that the close proximity of CD 1 generated greater actuation force for all tasks, was rated easier to use (P = 0.003) and was preferred more frequently by the participants (53.8%) compared to CD 2 and 3. As a result, CD 1 was determined to be an optimal ergonomic design for electrosurgical hand controls within the Intuitool™.

Survey on surgical instrument handle design: ergonomics and acceptance

Minimally invasive surgical approaches have revolutionized surgical care and considerably improved surgical outcomes. The instrumentation has changed significantly from open to laparoscopic and robotic surgery with various usability and ergonomics qualities. To establish guidelines for future designing of surgical instruments, this study assesses the effects of current surgical approaches and instruments on the surgeon. Furthermore, an analysis of surgeons' preferences with respect to instrument handles was performed to identify the main acceptance criteria. In all, 49 surgeons (24 with robotic surgery experience, 25 without) completed the survey about physical discomfort and working conditions. The respondents evaluated comfort, intuitiveness, precision, and stability of 7 instrument handles. Robotic surgery procedures generally take a longer time than conventional procedures but result in less back, shoulder, and wrist pain; 28% of surgeons complained about finger and neck pain during robotic surgery. Three handles (conventional needle holder, da Vinci wrist, and joystick-like handle) received significantly higher scores for most of the proposed criteria. The handle preference is best explained by a regression model related only to comfort and precision (R(2) = 0.91) and is significantly affected by the surgeon's background (P < .001). Although robotic surgery seems to alleviate physical discomfort during and after surgery, the results of this study show that there is room for improvement in the sitting posture and in the ergonomics of the handles. Comfort and precision have been found to be the most important aspects for the surgeon's choice of an instrument handle. Furthermore, surgeons' professional background should be considered when designing novel surgical instruments.

Expertise and Skill in Minimally Invasive Surgery

New attitudes to medical ethics and demands for efficiency have brought increased attention to surgical skills and training. It is important to characterize the expertise and skill involved in the multidimensional surgical profession. At a time of change, there is a need to discuss the nature of surgical expertise, and also the prospects for resident training, with special reference to new minimally invasive techniques (MIS).

In this paper, we selectively review knowledge on surgical expertise and the specific demands placed on a skilled MIS surgeon. In addition, the review contains a selection of studies from those areas that have been seen as important for the future of training in surgery.

Ergonomic problems encountered during video‐assisted thoracic surgery

In laparoscopic surgery, the way of thinking about operating room design is beginning to include ergonomic requirements. No study has yet been published about ergonomic concerns in Video-Assisted Thoracic Surgery (VATS). The aim of this paper is to describe ergonomic issues encountered in VATS and to propose recommendations for operating room design for thoracoscopic surgery. To obtain an inventory of the ergonomic problems fifteen thoracoscopic operations were attended at the Institut Mutualiste Montsouris (Paris, France). Ergonomics can be divided into three divisions: physical, perceptual and cognitive ergonomics. During the observations of thoracoscopic operations the physical problems were registered. The perceptual and cognitive problems were obtained from a literature study. In general two different positions of the surgeon can be distinguished, depending on the placement of the trocars and the endoscope. One position resembles the body position during laparoscopy, involving the same problems such as fatigue of the legs, a static body position, a large working area, extreme movements of the upper limbs and the wrist and stiffness of the neck. The other position is specific for VATS resulting in a rotated upper body while the surgeon has to lean over the patient to be able to handle the instruments. This awkward position causes even more serious problems. The study resulted in a list of ergonomic problems encountered during VATS. Reorganisation of the operating room set-up and monitor position, design of a dedicated operating table and specific instruments might help to overcome the current ergonomic problems.

Improved physical ergonomics of laparoscopic surgery

One of the main and basic ergonomic problems associated with laparoscopy is the surgeon's non-neutral posture during laparoscopic procedures. There are five main issues that influence the posture of the surgeon: the (hand-held) instrument design, the position of the monitor, the use of foot pedals to control diathermy, the poorly adjusted operating table height, and the static body posture. This paper gives an overview of the ergonomic guidelines that have been developed in these five areas and shows product solutions that have been developed according to these guidelines. The guidelines can be used by operating room (OR) staff to evaluate the ergonomics of their OR environment and to improve issues that do not satisfy the ergonomic guidelines. When designers use these guidelines to design new OR equipment, the new designs are an improvement in the field of human factors compared to the currently used laparoscopic products. When all these products are applied in the laparoscopic operating room, a new and ergonomic environment is created for the surgeon as well as for the assistants.

Optimal ergonomics for laparoscopic surgery in minimally invasive surgery suites: a review and guidelines

BACKGROUND

With minimally invasive surgery (MIS), a man-machine environment was brought into the operating room, which created mental and physical challenges for the operating team. The science of ergonomics analyzes these challenges and formulates guidelines for creating a work environment that is safe and comfortable for its operators while effectiveness and efficiency of the process are maintained. This review aimed to formulate the ergonomic challenges related to monitor positioning in MIS. Background and guidelines are formulated for optimal ergonomic monitor positioning within the possibilities of the modern MIS suite, using multiple monitors suspended from the ceiling.

METHODS

All evidence-based experimental ergonomic studies conducted in the fields of laparoscopic surgery and applied ergonomics for other professions working with a display were identified by PubMed searches and selected for quality and applicability. Data from ergonomic studies were evaluated in terms of effectiveness and efficiency as well as comfort and safety aspects. Recommendations for individual monitor positioning are formulated to create a personal balance between these two ergonomic aspects.

RESULTS

Misalignment in the eye-hand-target axis because of limited freedom in monitor positioning is recognized as an important ergonomic drawback during MIS. Realignment of the eye-hand-target axis improves personal values of comfort and safety as well as procedural values of effectiveness and efficiency.

CONCLUSIONS

Monitor position is an important ergonomic factor during MIS. In the horizontal plain, the monitor should be straight in front of each person and aligned with the forearm-instrument motor axis to avoid axial rotation of the spine. In the sagittal plain, the monitor should be positioned lower than eye level to avoid neck extension.

Ergonomic assessment of neck posture in the minimally invasive surgery suite during laparoscopic cholecystectomy

BACKGROUND

With the expanding implementation of minimally invasive surgery, the operating team is confronted with challenges in the field of ergonomics. Visual feedback is derived from a monitor placed outside the operating field. This crossover trial was conducted to evaluate and compare neck posture in relation to monitor position in a dedicated minimally invasive surgery (MIS) suite and a conventional operating room.

METHODS

Assessment of the neck was conducted for 16 surgeons, assisting surgeons, and scrub nurses performing a laparoscopic cholecystectomy in both types of operating room. Flexion and rotation of the cervical spine were measured intraoperatively using a video analysis system. A two-question visual analog scale (VAS) questionnaire was used to evaluate posture in relation to the monitor position.

RESULTS

Neck rotation was significantly reduced in the MIS suite for the surgeon (p = 0.018) and the assisting surgeon (p < 0.001). Neck flexion was significantly improved in the MIS suite for the surgeon (p < 0.001) and the scrub nurse (p = 0.018). On the questionnaire, the operating room team scored their posture significantly higher in the MIS suite and also indicated fewer musculoskeletal complaints.

CONCLUSIONS

The ergonomic quality of the neck posture is significantly improved in the MIS suite for the entire operating room team.

Ergonomic problems encountered by the surgical team during video endoscopic surgery

BACKGROUND

The aim of this study is to analyze the problems related to the ergonomic conditions faced by video endoscopic surgical teams during video endoscopic surgery by means of a questionnaire.

METHODS

A questionnaire was distributed to 100 medical personnel, from 8 different disciplines, who performed video endoscopic surgeries. Participants were asked to answer 13 questions related to physical, perceptive, and cognitive problems.

RESULTS

Eighty-two questionnaires were returned. Although there were differences among the disciplines, participants assessment of various problems ranged from 32% to 72% owing to poor ergonomic conditions.

CONCLUSIONS

As the problems encountered by the staff during video endoscopic surgery and the poor ergonomic conditions of the operating room affect the productivity of the surgical team and the safety and efficiency of the surgery, redesigning of the instruments and the operating room is required.

Best Practices in OR Suite Layout and Equipment Choices to Reduce Slips, Trips, and Falls

Slips, trips, and falls (STFs) account for about 20% of lost-time injuries for health care personnel. Although the effect that OR layout and equipment choices have on STF risk has not been specifically addressed in the literature, STFs in the perioperative suite are of particular concern because of their potential to cause adverse patient consequences. Increased renovation of ORs to include equipment for minimally invasive procedures intensifies the importance of examining best practices in OR layout and equipment choices to reduce the potential for STFs.

Safety, hazards and ergonomics in the operating room

OBJECTIVE

The objective for this study was to address the lack of information regarding the working conditions in the operating room (OR). Safety issues in the OR need to be discussed not only for the sake of patients, but also for personnel, as hazards may occur for all persons within the OR.

METHODS

To evaluate the workplace conditions in the operating room, a survey was conducted among surgeons working in German hospitals. Sixty questions were asked regarding the personal profile, the architectural situation, the devices and instruments as well as working posture and associated pain.

RESULTS

The survey showed elementary ergonomic deficiencies within all fields. Surgeons stated that these deficiencies lead to potential hazards for patients and personnel, potentially on a frequent basis. 97% of the surveyed surgeons see ergonomic improvement in the operating room as necessary.

CONCLUSION

The survey results display a high potential for improvement within all fields. Therefore, industry, surgeons and their professional organizations are asked to work on the optimization of the workplace conditions in the operating room in terms of improvement of quality and efficiency.

Safety, hazards and ergonomics in the operating room

OBJECTIVE

The objective for this study was to address the lack of information regarding the working conditions in the operating room (OR). Safety issues in the OR need to be discussed not only for the sake of patients, but also for personnel, as hazards may occur for all persons within the OR.

METHODS

To evaluate the workplace conditions in the operating room, a survey was conducted among surgeons working in German hospitals. Sixty questions were asked regarding the personal profile, the architectural situation, the devices and instruments as well as working posture and associated pain.

RESULTS

The survey showed elementary ergonomic deficiencies within all fields. Surgeons stated that these deficiencies lead to potential hazards for patients and personnel, potentially on a frequent basis. 97% of the surveyed surgeons see ergonomic improvement in the operating room as necessary.

CONCLUSION

The survey results display a high potential for improvement within all fields. Therefore, industry, surgeons and their professional organizations are asked to work on the optimization of the workplace conditions in the operating room in terms of improvement of quality and efficiency.

Defining the technical skills of teamwork in surgery

Developments in surgical technology and procedure have accelerated and altered the work carried out in the operating theatre/room, but team modelling and training have not co-evolved. Evidence suggests that team structure and role allocation are sometimes unclear and contentious, and coordination and communication are not fully effective. To improve teamwork, clinicians need models that specify team resources, structure, process and tasks. They also need measures to assess performance and methods to train teamwork strategically. An effective training strategy might be to incorporate teamwork with other technical skills training in simulation. However, the measures employed for enhancing teamwork in training and practice will need to vary in their object of analysis, level of technical specificity, and system scope.

United States operating room nurses: work environment perceptions

Concerns about pending retirement of nurses working in the operating room (OR) are undeniable. The nurses' work environment and level of perceived support is part of the equation of why a nurse may choose to retire or stay in the workforce. This study compares nurses' perceptions of the work environment between OR nurses and nurses who work in other type units; and compares the work environment perceptions of OR nurses between institutions of two sizes (<300 beds and >300 beds). Findings include: OR nurses have better perceptions of their work environment than nurses in other type units and OR nurses in smaller hospitals are more satisfied with their work environment, workload and perceptions of organisational support. Implications for OR work environments are discussed.