Screen height as an ergonomic factor in laparoscopic surgery

Promoting gender diversity and ergonomic equity in the cardiac surgery operating room

PURPOSE OF REVIEW

The operating room (OR) infrastructure and equipment such as gloves, were historically designed at a time when most surgeons were male. Today, there are increasing numbers of females in the OR and we should ensure that there is not a disproportionate risk of ergonomic stress and risk of work-related injuries. This review provides a perspective on the representation of female cardiac surgeons globally and examines the unique ergonomic challenges they may face.

RECENT FINDINGS

Female cardiac surgeons represent approximately 17% of practitioners in our sample of cardiac surgery centers, underscoring significant underrepresentation. Female cardiac surgeons report higher incidences of work-related musculoskeletal injuries and ergonomic challenges compared to their male colleagues. This could negatively impact their physical health and performance. Studies further highlight the inadequacy of standardized surgical tools and workstations in accommodating sex-specific anthropometry, contributing to the disproportionate strain experienced by female surgeons.

SUMMARY

To mitigate gender disparities in cardiac surgery, there is a need to optimize OR infrastructure and surgical instrumentation to accommodate sex-based anatomical differences. Implementing ergonomic solutions, such as adjustable workstations and gender-specific surgical tools, could reduce musculoskeletal injuries and improve overall surgeon performance. Addressing these disparities represents a critical step toward fostering an equitable and inclusive surgical workforce, enhancing both the health and career longevity of female cardiac surgeons.

Ergonomic endoscopy - Fundamentals of ergonomics and interventions for endoscopy-related musculoskeletal disorders

Recently, musculoskeletal disorders (MSDs) among endoscopists have attracted considerable attention. MSDs are caused by prolonged static postures, forceful manual exertions, and repetitive twisting maneuvers. Basic knowledge of ergonomics is useful for improving the posture, movements, and work environment of endoscopists, as well as developing equipment to prevent MSDs. This review discusses problematic endoscopic tasks from an ergonomic perspective, issues with MSD definitions, the prevalence of MSDs, local site interpretations, risk factors including working time and environment, and ergonomic evaluations. The evidence highlights the importance of multifaceted strategies for risk avoidance using the Hierarchy of Controls. Additionally, this review summarizes global trends and introduces the Ergonomic Endoscopy 7 Tips for MSD prevention, emphasizing a systems approach through collaboration with various stakeholders. Thus, it may serve as a guide for gastroenterologists and staff engaged in endoscopic procedures for prolonged periods.

Overcoming Barriers: Sex Disparity in Surgeon Ergonomics

BACKGROUND

Musculoskeletal discomfort is widely experienced by surgeons across multiple surgical specialties. Developing technologies and new minimally invasive techniques add further complexity and ergonomic stressors. These stressors differentially affect male and female surgeons, but little is known about the role these sex disparities play in surgical ergonomic stress. We reviewed existing literature to better understand how ergonomic stress varies between male and female surgeons.

STUDY DESIGN

A literature search was performed via PubMed including but not limited to the following topics: ergonomics, surgeons, female surgeons, women surgeons, pregnancy, and operating room. A review of available quantitative data was performed.

RESULTS

Female surgeons endure more pronounced ergonomic discomfort than their male counterparts, with added ergonomic stress associated with pregnancy.

CONCLUSIONS

A 4-fold method is proposed to overcome ergonomic barriers, including (1) improved education on prevention and treatment of ergonomic injury for active surgeons and trainees, (2) increased departmental and institutional support for ergonomic solutions for surgeons, (3) partnerships with industry to study innovative ergonomic solutions, and (4) additional research on the nature of surgical ergonomic challenges and the differential effects of surgical ergonomics on female surgeons.

Ergonomics of bronchoscopy: good advice or a pain in the neck?

Interventional pulmonologists require a unique set of skills including precise motor abilities and physical endurance, but surprisingly the application of ergonomic principles in the field of bronchoscopy remains limited. This is particularly intriguing when considering the significant impact that poor ergonomics can have on diagnostic aptitude, income potential and overall health. It is therefore imperative to provide comprehensive education to physicians regarding the significance of ergonomics in their work, especially considering the introduction of advanced diagnostic and therapeutic procedures. By implementing simple yet effective measures (e.g. maintaining neutral positions of the wrist, neck and shoulder; adjusting the height of tables and monitors; incorporating scheduled breaks; and engaging in regular exercises), the risk of injuries can be substantially reduced. Moreover, objective tools are readily available to assess ergonomic postures and estimate the likelihood of work-related musculoskeletal injuries. This review aims to evaluate the current literature on the impact of procedure-related musculoskeletal pain on practising pulmonologists and identify modifiable factors for future research.

Rehabilitation Program for Improved Musculoskeletal Pain in Gastrointestinal Endoscopists: Multicenter Prospective Cohort Study

Background/Aims

This study aimed to develop a rehabilitation program for musculoskeletal pain experienced by gastrointestinal endoscopists and to investigate its usefulness.

Methods

This was a multicenter cohort study. During the first 2 weeks, a questionnaire regarding daily workload and musculoskeletal symptoms was administered. Then, a rehabilitation program including equipment/posture correction and stretching was conducted during the remaining 6 weeks. Follow-up daily workload and musculoskeletal symptom surveys were distributed during the last 2 weeks. The program satisfaction survey was performed at the 6th and 8th weeks.

Results

Among 118 participants (69 men), 94% (n=111) complained of musculoskeletal pain at baseline. Various hospital activities at baseline were associated with multisite musculoskeletal pain, whereas only a few workloads were correlated with musculoskeletal pain after the rehabilitation program. Follow-up musculoskeletal pain was negatively correlated with equipment/posture program performance; arm/elbow pain was negatively correlated with elbow (R=-0.307) and wrist (R=-0.205) posture; leg/foot pain was negatively correlated with monitor position, shoulder, elbow, wrist, leg, and foot posture. Higher performance in the scope position (86.8% in the improvement vs 71.3% in the aggravation group, p=0.054) and table height (94.1% vs 79.1%, p=0.054) were associated with pain improvement. An increased number of colonoscopy procedures (6.27 in the aggravation vs 0.02 in the improvement group, p=0.017) was associated with pain aggravation. Most participants reported being average (32%) or satisfied (67%) with the program at the end of the study.

Conclusions

Our rehabilitation program is easily applicable, satisfactory, and helpful for improving the musculoskeletal pain experienced by gastrointestinal endoscopists.

Does surgeon sex and anthropometry matter for tool usability in traditional laparoscopic surgery? A systematic review and meta-analysis

INTRODUCTION

Hand size, strength, and stature all impact a surgeon's ability to perform Traditional Laparoscopic Surgery (TLS) comfortably and effectively. This is due to limitations in instrument and operating room design. This article aims to review performance, pain, and tool usability data based on biological sex and anthropometry.

METHODS

PubMed, Embase, and Cochrane databases were searched in May 2023. Retrieved articles were screened based on whether a full-text, English article was available in which original results were stratified by biological sex or physical proportions. Article quality was discussed using the Mixed Methods Appraisal Tool (MMAT). Data were summarized in three main themes: task performance, physical discomfort, and tool usability and fit. Task completion times, pain prevalence, and grip style results between male and female surgeons formed three meta-analyses.

RESULTS

A total of 1354 articles were sourced, and 54 were deemed suitable for inclusion. The collated results showed that female participants, predominantly novices, took 2.6-30.1 s longer to perform standardized laparoscopic tasks. Female surgeons reported pain at double the frequency of their male colleagues. Female surgeons and those with a smaller glove size were consistently more likely to report difficulty and require modified (potentially suboptimal) grip techniques with standard laparoscopic tools.

CONCLUSIONS

The pain and stress reported by female or small-handed surgeons when using laparoscopic tools demonstrates the need for currently available instrument handles, including robotic hand controls, to become more size-inclusive. However, this study is limited by reporting bias and inconsistencies; furthermore, most data was collected in a simulated environment. Additional research into how anthropometric tool design impacts the live operating performance of experienced female surgeons would further inform this area of investigation.

Ergonomics in Endoscopic Transsphenoidal Surgery: A Survey of the North American Skull Base Society

Objective Different surgical set-ups for endoscopic transsphenoidal surgery (ETS) have been described, but studies on their ergonomics are limited. The aim of this article is to describe present trends in the ergonomics of ETS.

Design and Participants A 33-question, web-based survey was sent to North American Skull Base Society members in 2018 and 116 responded to it (16% of all members). Most respondents were from North America (76%), in academic practice (87%), and neurosurgeons (65%); they had more than 5 years of experience in ETS (73%), had received specific training (66%), and performed at least 5 procedures/mo (55%).

Results Mean reported time for standard and complex procedures were 3.7 and 6.3 hours, respectively. The patient's body is usually positioned in a straight, supine position (84%); the head is in a neutral position (46%) or rotated to the side (38%). Most surgeons perform a binostril technique, work with a partner (95%), and operate standing (94%), holding suction (89%) and dissector (83%); sometimes the endoscope is held by the primary surgeon (22–24%). The second surgeon usually holds the endoscope (72%) and irrigation (42%). During tumor removal most surgeons stand on the same side (65–66%). Many respondents report strain at the dorsolumbar (50%) or cervical (26%) level. Almost one-third of surgeons incorporate a pause during surgery to stretch, and approximately half exercise to be fit for surgery; 16% had sought medical attention for ergonomic-related symptoms.

Conclusion Most respondents value ergonomics in ETS. The variability in surgical set-ups and the relatively high report of complaints underline the need for further studies to optimize ergonomics in ETS.

Ergonomics in IR

Ergonomic research in the field of interventional radiology remains limited. Existing literature suggests that operators are at increased risk for work-related musculoskeletal disorders related to the use of lead garments and incomplete knowledge of ergonomic principles. Data from existing surgical literature suggest that musculoskeletal disorders may contribute to physician burnout and female operators are at a higher risk of developing musculoskeletal disorders. This review article aims to summarize the existing ergonomic challenges faced by interventional radiologists, reiterate existing solutions to these challenges, and highlight the need for further ergonomic research in multiple areas, including burnout and gender.

An Ergonomic Assessment Of Four Different Donor Nephrectomy Approaches For The Surgeons And Their Assistants

Introduction

Open surgery is increasingly being replaced by laparoscopic approaches that are more demanding for the surgical team. The physical and mental workload of these approaches have not been quantified.

Materials and methods

A multicenter prospective study was performed evaluating the physical and mental stresses of 4 surgical approaches (open surgery [OS], standard laparoscopy [SL], hand-assisted laparoscopy [HAL], and robot-assisted laparoscopy [RAL]) for donor nephrectomy for the surgeon and their assistant. The Borg Scale was used to evaluate exertion in different body parts every 30 mins during surgery and the NASA-TLX score was used to evaluate overall workload.

Results

264 nephrectomies were performed over a 33-month period and 258 questionnaires evaluating these surgeries were obtained. Surgeons experienced less left shoulder and arm exertion and left forearm and hand exertion, but greater lower back exertion, as measured by the Borg scale, with RAL. Leg exertion was significantly greater with OS. Assistant surgeons experienced increased exertion in the back, right shoulder and arm, and right forearm and hand with RAL. NASA Task load index (TLX) surgeon scores showed mental demand was similar for all 4 surgical approaches. Physical demand was lower and overall performance was higher with RAL.

Discussion

Four different nephrectomy surgical approaches were evaluated in a multicenter setting. Surgeon and assistant scores of physical exertions were generally in the "easy" range but confirmed that robotic surgery is an ergonomic progress compared to other techniques, except for the axial skeleton. Further, it degrades the working conditions for the assistant.

A study of the prevalence of musculoskeletal disorders in surgeons performing minimally invasive surgery

INTRODUCTION

Minimally invasive surgery (MIS) has shown significant benefits for patients and healthcare systems. However, due to the poor ergonomic adaptation of operating rooms and surgical instruments, most surgeons suffer from pain caused by musculoskeletal disorders (MSDs).

METHODS

A descriptive survey on MIS surgeons working in different surgical specialties has been carried out in Hospital Valdecilla (Spain). The aim is to determine the prevalence of MSDs using a personal interview and the standardized Nordic questionnaire. The study determines the prevalence of MSDs in different parts of the body and their relationship with epidemiological and labor variables. A questionnaire was filled out by 129 surgeons.

RESULTS

90% of surgeons reported MSDs. The higher prevalence appears in the most experienced surgeons. The most affected zones are the lower back (54%), neck (51%), upper back (44%), lower extremities (42%), right shoulder (29%) and right hand (28%).

CONCLUSIONS

The prevalence of MSDs is higher in MIS surgeons than in any other occupational group. The most vulnerable group is experienced surgeons and there is a potential risk that symptoms will be increased in the future. Muscle strength is revealed as a protective factor against MSDs.

The ergonomics of laparoscopic surgery: a quantitative study of the time and motion of laparoscopic surgeons in live surgical environments

BACKGROUND

Laparoscopic surgery presents multiple ergonomic difficulties for the surgeon, requiring awkward body postures and prolonged static muscle loading that increases risk of musculoskeletal strain and injury. This prospective study quantitatively measures the biomechanical movements of surgeons during laparoscopic procedures to determine at-risk movements from prolonged static muscle loading and repetitive motions that may lead to injury.

METHODS

A total of 150 video recordings of 18 surgeons, standing at the patient's left, were captured from three fixed camera positions during live gynecological laparoscopic surgery. Postoperative processing quantified surgeon movements at the neck, shoulders and elbows using computer software to measure extreme joint angles and time spent within defined joint angle ranges.

RESULTS

Surgeons spent a median of 98 % (range 77-100 %) of surgical time with their neck rotated at 21° (range 0°-52°). The non-dominant arm was subjected to more extreme positions for significantly longer periods of time compared to the dominant, with shoulder flexion at 45°-90° for 35 vs. 0 % (p < 0.001) and elbow flexion at >120° for 31 vs. 0 % (p < 0.001) of total surgical time. Procedures involving power morcellation required significantly greater number of instrument insertion/removals-119 (range 56-182) compared with 12 (range 2-122) when morcellation was not used (p < 0.001). Shorter surgeons maintained significantly greater degrees of neck rotation when viewing the monitor (p < 0.003) and surgeons with shorter arm lengths spent longer in extreme positions with their non-dominant shoulder at >90° (p = 0.04) and elbow at >120° (p < 0.001) compared with taller surgeons. No significant correlations were found between BMI or surgical experience and more extreme joint positions.

CONCLUSIONS

Four primary areas have been identified where surgeons are consistently demonstrating movements that increase their risk of harm: (1) extended periods of neck rotation; (2) asymmetrical loading between the dominant and non-dominant shoulders; (3) power morcellation and frequent insertions/removals of laparoscopic instruments resulting in repetitions of the most extreme shoulder positions and (4) a negative correlation between height and percentage time spent in more extreme positions.

Objective ergonomic risk assessment of wrist and spine with motion analysis technique during simulated laparoscopic cholecystectomy in experienced and novice surgeons

INTRODUCTION:

There is a rise in prevalence of work-related musculoskeletal disorders in surgeons performing laparoscopic surgeries due to lack of ergonomic considerations to the minimal access surgical environment. The objective of this study was to assess the physical ergonomics in experienced and novice surgeons during a simulated laparoscopic cholecystectomy.

METHODOLOGY:

Thirty-two surgeons participated in this study and were distributed in two groups (experienced and novices) based on the inclusion criteria. Both groups were screened for the spinal and wrist movements on the orientation sensor-based, motion analysis device while performing a simulated laparoscopic cholecystectomy. Simultaneous video recording was used to estimate the other joint positions. The RULA (Rapid Upper Limb Assessment) ergonomic risk scores were estimated with the acquired data.

RESULTS:

We found that surgeons in both novice and experienced groups scored a high on the RULA. Limited awareness of the influence of monitor position on the postural risk caused surgeons to adopt non-neutral range cervical postures. The thoracolumbar spine is subjected to static postural demand. Awkward wrist postures were adopted during the surgery by both groups. There was no statistically significant difference in the RULA scores between the novice and experienced, but some differences in maximum joint excursions between them as detected on the motion analysis system.

CONCLUSION:

Both experienced and novice surgeons adopted poor spinal and wrist ergonomics during simulated cholecystectomy. We concluded that the physical ergonomic risk is medium as estimated by the RULA scoring method, during this minimally invasive surgical procedure, demanding implementation of change in the ergonomic practices.

Prevalence and risk factors for musculoskeletal injuries related to endoscopy

BACKGROUND

There are limited data regarding work-related injury among endoscopists.

OBJECTIVE

To define the prevalence of endoscopy-related musculoskeletal injuries and their impact on clinical practice and to identify physician and practice characteristics associated with their development.

DESIGN

Survey.

SETTING

Electronic survey of active members of the American Society for Gastrointestinal Endoscopy with registered e-mail addresses.

PARTICIPANTS

Physicians who currently or ever performed endoscopy and responded to the survey between February 2013 and November 2013.

INTERVENTION

A 25-question, self-administered, electronic survey.

MAIN OUTCOME MEASUREMENTS

Prevalence, location, and ramifications of work-related injuries and endoscopist characteristics and workload parameters associated with endoscopy-related injury.

RESULTS

The survey was completed by 684 endoscopists. Of those, 362 (53%) experienced a musculoskeletal injury perceived definitely (n = 204) or possibly (n = 158) related to endoscopy. Factors associated with a higher rate of endoscopy-related injury included higher procedure volume (>20 cases/week; P < .001), greater number of hours per week spent performing endoscopy (>16 hours/week; P < .001), and total number of years performing endoscopy (P = .004). The most common sites of injury were neck and/or upper back (29%) and thumb (28%). Only 55% of injured endoscopists used practice modifications in response to injuries. Specific treatments included medications (57%), steroid injection (27%), physiotherapy (45%), rest (34%), splinting (23%), and surgery (13%).

LIMITATIONS

Self-reported data of endoscopy-related injury.

CONCLUSION

Among endoscopists there is a high prevalence of injuries definitely or potentially related to endoscopy. Higher procedure volume, more time doing endoscopy per week, and cumulative years performing endoscopy are associated with more work-related injuries.

Laparoendoscopic single-site surgery using conventional laparoscopic instruments and glove port technique in gynecology: a single surgeon's experience

STUDY OBJECTIVE

To report a single surgeon's experience with 120 laparoendoscopic single-site surgery (LESS) procedures using conventional laparoscopic instruments and a homemade glove port system to treat benign gynecologic diseases.

DESIGN

Retrospective chart analysis (Canadian Task Force classification III).

SETTING

Eulji University Hospital.

PATIENTS

One hundred twenty patients who underwent LESS performed by a single surgeon to treat benign gynecologic diseases between November 2010 and November 2012.

INTERVENTION

LESS using conventional instrumentation was performed using our specialized glove port technique, which consists of the combination of the homemade glove port system designed to minimalize collision of the trocar on the tip of the finger of the surgical glove, a sufficient rectus fasciotomy, the surgeon's position at the patient's head, and adequate positioning of the instruments.

MEASUREMENTS AND MAIN RESULTS

The LESS procedures performed were laparoscopically assisted vaginal hysterectomy (n = 50), ovarian cystectomy (n = 25), myomectomy (n = 14), oophorectomy (n = 11), salpingectomy (n = 9), fimbrioplasty or neosalpingstomy (n = 7), and adhesiolysis only (n = 4). Median patient age was 40 years, and median body mass index was 23. Median operative time was 100 minutes (range, 50-145 minutes) for laparoscopically assisted vaginal hysterectomy, 70 minutes (range, 30-150 minutes) for ovarian cystectomy, 107 minutes (range, 65-180 minutes) for myomectomy, 55 minutes (range, 25-130 minutes) for oophorectomy, 85 minutes (range, 35-110 minutes) for salpingectomy, 70 minutes (range, 25-140 minutes) for neosalpingostomy or fimbrioplasty, and 35 minutes (range, 30-60-minutes) for adhesiolysis only. All procedures were completed successfully without the need for additional ports or conversion to the standard laparoscopic approach. One perioperative complication occurred. The complication rate was 83% (1 of 120). Other postoperative complications were not observed at follow-up.

CONCLUSION

Our experience shows that LESS using conventional laparoscopic instruments and our glove port technique is a feasible and safe technique for the surgical management of various gynecologic conditions. Therefore, our homemade glove port laparoscopic system used in our specialized technique provides a simple, cost-effective approach to LESS and would probably make laparoscopic procedures using conventional instruments easier.

Ergonomic considerations in endoscopic sinus surgery: lessons learned from laparoscopic surgeons

BACKGROUND

Endoscopic sinus procedures are increasingly common, and more technically difficult procedures are being undertaken to provide patients with minimally invasive alternatives to traditional open surgical techniques. However, such endoscopic approaches have increasing physical demands on the surgeon. The aim of this review is to summarize current literature on surgical ergonomic principles as they relate to endoscopic sinus and skull base surgery and focus on future needs for our specialty.

METHODS

Literature review was performed of surgical ergonomics and, particularly, laparoscopic ergonomic principles.

RESULTS

Existing ergonomic principles for laparoscopic surgery can be applied to endoscopic sinus and skull base surgery and can be expected to offer benefits in terms of surgeon fatigue, physical discomfort, and task efficiency.

CONCLUSION

Increasing surgeon awareness will allow for many basic ergonomic principles to be applied to endoscopic sinus and skull base surgery. Although many simple changes can be immediately made, there is a clear need for further study and abundant room for innovation.

Ergonomics and bronchoscopy: a survey of the American Association of Bronchology and Interventional Pulmonology

BACKGROUND

Ergonomics is defined by the United States Department of Labor as "the science of fitting workplace conditions and job demands to the capabilities of the working population." Currently, there remains a deficiency in available data regarding the impact that musculoskeletal pain and ergonomics have within the field of pulmonary endoscopic procedures. We sought to define the impact of musculoskeletal pain and ergonomics in physicians with an interest in interventional pulmonology.

METHODS

A 25-question Internet-based survey was distributed to current members of the American Association of Bronchology and Interventional Pulmonology.

RESULTS

A total of 199 surveys were distributed to members, with an overall response rate of 81% (161/199). The majority of respondents were male (85.6%) and classified themselves as interventional pulmonologists (49%). Musculoskeletal pain was present in 50.6% of the respondents, with a minority (12.3%) of respondents reporting significant adverse events related to this pain. Risks factors for work-related musculoskeletal pain included small glove size (P=0.01), younger age (P=0.02), and years in practice (P=0.01).

CONCLUSION

The presence of musculoskeletal pain seems to be common within a cohort of pulmonologists performing procedures. Although only a minority of bronchoscopists experienced adverse events related to pain directly impacting patient care, long-term outcomes impacting both patient care and the long-term careers of physicians remain uncertain. Further research regarding the role of musculoskeletal pain and ergonomics remains paramount in the continued development of technology and equipment within the field.

Ergonomic analysis of muscle activity in the forearm and back muscles during laparoscopic surgery: influence of previous experience and performed task

PURPOSE

The first aim of this study is to analyze the muscle activity in back and forearm muscles in surgeons during laparoscopic dissection and suturing maneuvers. The second aim is to determine the influence of the surgeons' previous experience in laparoscopic surgery.

METHODS

A total of 30 laparoscopic surgeons were divided in 3 groups: novice suturing, novice dissecting, and experts suturing. Electromyography data were collected from the trapezius, forearm flexors, and forearm extensors muscles, during the proposed tasks on physical simulator.

RESULTS

Muscle activity was significantly lower in the expert group. Moreover, muscle activity in the trapezius was significantly higher during the completion of intracorporeal suturing when compared with that during dissection.

CONCLUSIONS

Results obtained in this study show that the surgeons with a higher degree of laparoscopic experience exhibit a lower level of muscle activity when compared with the novice surgeons. Moreover, in accordance to our results, laparoscopic suturing involves a higher degree of muscle effort than during laparoscopic dissection.

Ergonomic factors on task performance in laparoscopic surgery training

This paper evaluates the effect of ergonomic factors on task performance and trainee posture during laparoscopic surgery training. Twenty subjects without laparoscopic experience were allotted into 2 groups. Group 1 was trained under the optimal ergonomic simulation setting according to current ergonomic guidelines (Condition A). Group 2 was trained under non-optimal ergonomic simulation setting that can often be observed during training in a skills lab (Condition B). Posture analysis showed that the subjects held a much more neutral posture under Condition A than under Condition B (p<0.001). The subjects had less joint excursion and experienced less discomfort in their neck, shoulders, and arms under Condition A. Significant difference in task performance between Conditions A and B (p<0.05) was found. This study shows that the optimal ergonomic simulation setting leads to better task performance. In addition, no significant differences of task performance, for Groups 1 and 2 using the same test setting were found. However, better performance was observed for Group 1. It can be concluded that the optimal and non-optimal training setting have different learning effects on trainees' skill learning.

[Ergonomics in laparoscopic surgery and its importance in surgical training]

Despite the many advantages that laparoscopic surgery has for patients, it involves a series of risks for the surgeon. These are related to the reduced freedom of movement and forced postures which lead to greater muscle fatigue than with conventional surgery. In laparoscopic surgery there are few references on the introduction of training programs in ergonomics, despite the numerous advantages demonstrated in other disciplines. The application of ergonomic criteria in the surgical field could have great benefits, both for surgeons and patients. In this work we attempt to review the existing literature and our experience to provide the surgeon with some ergonomic guidelines for body stance and positioning of equipment. We also present a training model based on ergonomics which we have introduced into the training activities carried out in our Centre.

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.

Optimizing laparoscopic task efficiency: the role of camera and monitor positions

BACKGROUND

Alterations of video monitor and laparoscopic camera position may create perceptual distortion of the operative field, possibly leading to decreased laparoscopic efficiency. We aimed to determine the influence of monitor/camera position on the laparoscopic performance of surgeons of varying skill levels.

METHODS

Twelve experienced and 12 novice participants performed a one-handed task with their dominant hand in a modified laparoscopic trainer. Initially, the camera was fixed directly in front of the participant (0 degrees) and the monitor location was varied between three positions, to the left of midline (120 degrees), directly across from the participant (180 degrees), and to the right of the midline (240 degrees). In the second experiment monitor position was constant straight across from the participant (180 degrees) while the camera position was adjusted between the center position (0 degrees), to the left of midline (60 degrees), and to the right of midline (300 degrees). Participants completed five trials in each monitor/camera setting. The significance of the effects of skill level and combinations of camera and monitor angle were evaluated by analysis of variance (ANOVA) for repeated measures using restricted maximum likelihood estimation.

RESULTS

Experienced surgeons completed the task significantly faster at all monitor/camera positions. The best performance in both groups was observed when the monitor and camera were located at 180 degrees and 0 degrees, respectively. Monitor positioning to the right of midline (240 degrees) resulted in significantly worse performance compared to 180 degrees for both experienced and novice surgeons. Compared to 0 degrees (center), camera position to the left or the right resulted in significantly prolonged task times for both groups. Novice subjects also demonstrated a significantly lower ability to adjust to suboptimal camera/monitor positions.

CONCLUSION

Experienced subjects demonstrated superior performance under all study conditions. Optimally, the camera should be directly in front and the monitor should be directly across from a surgeon. Alternatively, the monitor/camera could be placed opposite to the surgeon's non-dominant hand. The suboptimal camera/monitor conditions are especially difficult to overcome for inexperienced subjects. Monitor and camera positioning must be emphasized to ensure optimal laparoscopic performance.