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

Bariatric Surgeon Ergonomics: A Comparison of Laparoscopy and Robotics

INTRODUCTION

Bariatric surgery is routinely performed using laparoscopic and robotic approaches. Musculoskeletal injuries are prevalent among both robotic and laparoscopic bariatric surgeons. Studies evaluating ergonomic differences between laparoscopic and robotic bariatric surgery are limited. This study aims to analyze the ergonomic, physical, and mental workload differences among surgeons performing robotic and laparoscopic bariatric surgery.

MATERIALS AND METHODS

All primary laparoscopic and robotic bariatric surgeries, Roux-en-Y gastric bypass, and sleeve gastrectomy between May and August 2022 were included in this study. Objective ergonomic analysis was performed by an observer evaluating each surgeon intraoperatively according to the validated Rapid Entire Body Assessment tool, with a higher score indicating more ergonomic strain. After each operation, surgeons subjectively evaluated their physical workload using the body part discomfort scale, and their mental workload using the surgery task load index.

RESULTS

Five bariatric surgeons participated in this study. In total, 50 operative cases were observed, 37 laparoscopic and 13 robotic. The median total Rapid Entire Body Assessmentscore as a primary surgeon was significantly higher in laparoscopic (6.0) compared to robotic (3.0) cases (P < 0.01). The laparoscopic and robotic approaches had no significant differences in the surgeons' physical (body part discomfort scale) or mental workload (surgery task load index).

CONCLUSIONS

This study identified low-risk ergonomic stress in surgeons performing bariatric surgery robotically compared to medium-risk stress laparoscopically. Since ergonomic stress can exist even without the perception of physical or mental stress, this highlights the importance of external observations to optimize ergonomics for surgeons in the operating room.

Robotic-assisted versus laparoscopic bowel anastomoses: randomized crossover in vivo experimental study

BACKGROUND

Initial learning curves are potentially shorter in robotic-assisted surgery (RAS) than in conventional laparoscopic surgery (LS). There is little evidence to support this claim. Furthermore, there is limited evidence how skills from LS transfer to RAS.

METHODS

A randomized controlled, assessor blinded crossover study to compare how RAS naïve surgeons (n = 40) performed linear-stapled side-to-side bowel anastomoses in an in vivo porcine model with LS and RAS. Technique was rated using the validated anastomosis objective structured assessment of skills (A-OSATS) score and the conventional OSATS score. Skill transfer from LS to RAS was measured by comparing the RAS performance of LS novices and LS experienced surgeons. Mental and physical workload was measured with the NASA-task load index (NASA-Tlx) and the Borg-scale.

OUTCOMES

In the overall cohort, there were no differences between RAS and LS for surgical performance (A-OSATS, time, OSATS). Surgeons that were naïve in both LS and RAS had significantly higher A-OSATS scores in RAS (Mean (Standard deviation (SD)): LS: 48.0 ± 12.1; RAS: 52.0 ± 7.5); p = 0.044) mainly deriving from better bowel positioning (LS: 8.7 ± 1.4; RAS: 9.3 ± 1.0; p = 0.045) and closure of enterotomy (LS: 12.8 ± 5.5; RAS: 15.6 ± 4.7; p = 0.010). There was no statistically significant difference in how LS novices and LS experienced surgeons performed in RAS [Mean (SD): novices: 48.9 ± 9.0; experienced surgeons: 55.9 ± 11.0; p = 0.540]. Mental and physical demand was significantly higher after LS.

CONCLUSION

The initial performance was improved for RAS versus LS for linear stapled bowel anastomosis, whereas workload was higher for LS. There was limited transfer of skills from LS to RAS.

Quantitative Analysis of the Head Tilt Using Three-Dimensional Temporal Scan in Children with Torticollis

The head tilt of patients with torticollis is usually evaluated subjectively in clinical practice and measuring it in young children is very limited due to poor cooperation. No study has yet evaluated the head tilt using a three-dimensional (3D) scan and compared it with other measurement methods. Therefore, this study aimed to objectively demonstrate head tilt through clinical measurements and a 3D scan in children with torticollis. A total of 52 children (30 males, 22 females; age 4.6 ± 3.2 years) diagnosed with torticollis and 52 adults (26 men, 26 women; age 34.42 ± 10.4 years) without torticollis participated in this study. The clinical measurements were performed using a goniometer and still photography methods. Additionally, the head tilt was analyzed using a 3D scanner (3dMD scan, 3dMD Inc., Atlanta, GA, USA). There was a high correlation between the other methods and 3D angles, and the cut-off value of the 3D angles for the diagnosis of torticollis was also presented. The area under the curve of the 3D angle was 0.872, which was confirmed by a moderately accurate test and showed a strong correlation compared with other conventional tests. Therefore, we suggest that measuring the degree of torticollis three-dimensionally is significant.

Effects of a chair for ophthalmic microsurgery on pressure distribution and pelvic tilt in surgeons

BACKGROUND: Ophthalmic surgeons experience high levels of physical strain in the neck, lower back, and buttocks. While ergonomic interventions may help to solve these problems, only a few studies have reported chair designs for ophthalmic microsurgery. OBJECTIVE: To design a chair that reduces the physical strain on surgeons and examine its effectiveness in improving posture and reducing seat pressure. METHODS: A prototype chair with a three-dimensional seat surface and a sliding adjustment mechanism for the backrest was designed to fit the surgeon’s body. A conventional chair (A) and the prototype chair (B) were compared during microsurgeries performed by five surgeons. Seat pressure was measured using a pressure-sensing device, and the pelvic tilt angle was measured using a gyroscope sensor. RESULTS: A paired t-test indicated significant differences between the chairs: average seat pressure was 70.4±12.7 mmHg for A and 40.5±3.8 mmHg for B (p = 0.008); the maximum seat pressure was 242.2±19.7 mmHg for A and 170.5±38.5 mmHg for B (p = 0.024); contact area was 906.1±114.5 cm2 for A and 1,255.9±60.1 cm2 for B (p < 0.001); and relative value of the pelvic tilt angle was –13.7°±3.7° for A and –7.1°±4.9° for B (p = 0.032). CONCLUSIONS: The prototype chair was associated with lower seat pressure and maintenance of a more neutral posture than the conventional chair, indicating that it may help to reduce physical strain in ophthalmic surgeons.

Comparison of cervical neck strain in common otolaryngology surgeries

BACKGROUND

Cervical neck strain and surgical ergonomics is an increasingly important topic being addressed in this time and age. With new technologies, visualizations, and approaches to surgeries, there are now different strains and duration of strains to the cervical neck. Recently the effect of chronic cell phone use has been described as "text neck." In a similar fashion we understand that certain otolaryngology surgeries can also impart chronic strain to the cervical neck. We aim to quantitatively describe strain for different types of surgeries by looking at posture, duration of surgery, and anatomic ergonomics of specific surgeries.

METHODS

Lateral photo documentation of posture during 6 common otolaryngology procedures, used to estimate cervical neck angle and calculate force and impulse to cervical neck.

RESULTS

Six common otolaryngology procedures show various cervical neck angles ranging from around 0° to 60° of neck flexion, with subsequent forces ranging from 16 lb to 60 lb of force. When accounting for surgical time, bigger differences arose with impulses ranging from 270,000 N∗s to 3,300,000 N∗s. Noticeably, thyroidectomy and cleft palate showed much higher impulses than the other four types of surgeries.

CONCLUSION

Both cervical neck flexion and duration of surgery play important roles in total neck theoretical strain. Variance exists between neck strains of common otolaryngology surgeries. There is a necessity for continued study and improvement in surgical ergonomics.

Minimally invasive surgery and the risk of work-related musculoskeletal disorders: Results of a survey among Israeli surgeons and review of the literature

BACKGROUND: Minimally invasive surgery (MIS) has many advantages for patients, however, it places surgeons at risk for Work-related musculoskeletal disorders (WMSD). Recently, the importance of prevention of such injuries and improvement of the ergonomics of the operating room is increasing. OBJECTIVES: To assess the prevalence of WMSD among minimally invasive surgeons in Israel, discuss the contributing factors and the overall awareness for ergonomic training. In addition, a review of the literature on the topic was conducted. METHODS: An online questionnaire was sent to the members of the Israeli Society of Endoscopic Surgery. The results were analyzed and summarized. For literature review, PubMed was used to search for English-language publications related to the issue. RESULTS: Of 83 respondents, the majority (77%) have considerable experience in MIS (more than 10 years). The prevalence of WMSD was 12% before beginning the practice of laparoscopy compared to 78% after 15–20 years of practice. Injury sites included back pain, neck and upper extremity (shoulder pain, tennis elbow and carpal tunnel syndrome) in 41%, 25% and 34% respectively. More than two thirds of responders unaware of possible ergonomic solutions and didn’t consider adopting any appropriate preventive measures. CONCLUSIONS: The incidence of WMSD among MIS surgeons is high and underestimated. There is a desperate need to prevent such morbidity among surgeons by increasing awareness and providing the means to improve their work environment. Surgeons should adhere to ergonomic recommendations for positioning of monitors, table height, posture, foot pedal placement and laparoscopic devices use.

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.

A Wearable Sensor-Based Platform for Surgeon Posture Monitoring: A Tool to Prevent Musculoskeletal Disorders

Surgeons are workers that are particularly prone to the development of musculoskeletal disorders. Recent advances in surgical interventions, such as laparoscopic procedures, have caused a worsening of the scenario, given the harmful static postures that have to be kept for long periods. In this paper, we present a sensor-based platform specifically aimed at monitoring the posture during actual surgical operations. The proposed system adopts a limited number of Inertial Measurement Units (IMUs) to obtain information about spine and neck angles across time. Such a system merges the reliability of sensor-based approaches and the validity of state-of-the-art scoring procedure, such as RULA. Specifically, three IMUs are used to estimate the flexion, lateral bending, and twisting angles of spine and neck. An ergonomic risk index is thus estimated in a time varying fashion borrowing relevant features from the RULA scoring system. The detailed functioning of the proposed systems is introduced, and the assessment results related to a real surgical procedure, consisting of a laparoscopy and mini-laparotomy sections, are shown and discussed. In the exemplary case study introduced, the surgeon kept a high score, indicating the need for an intervention on the working procedures, for a large time fraction. The system allows separately analyzing the contribution of spine and neck, also specifying the angle configuration. It is shown how the proposed approach can provide further information, as related to dynamical analysis, which could be used to enlarge the features taken into account by currently available approaches for ergonomic risk assessment. The proposed system could be adopted both for training purposes, as well as for alerting surgeons during actual surgical operations.

Intraoperative posture and workload assessment in vascular surgery

Quantifying the workload and postural demand on vascular surgeons provides valuable information on the physical and cognitive factors that predispose vascular surgeons to musculoskeletal pain and disorders. The aim of this study was to quantify the postural demand, workload, and discomfort experienced by vascular surgeons and to identify procedural factors that influence surgical workload. Both objective (wearable posture sensors) and subjective (surveys) assessment tools were used to evaluate intraoperative workload during 47 vascular surgery procedures. Results demonstrate unfavorable neck and low back postures as well as high pain scores for those body segments. Additionally, workload from subjective surveys increased significantly as a function of operative duration, and mental workload was high across all procedure types. Neck postural risk exposure and physical demand were among the variables that increased with surgical duration, procedure type, and loupes used by the surgeons. Correlations among postural angles and pain scores showed consistency between the objective assessment and the subjective surveys for neck and trunk. The authors believe that the results of this study highlight the need for developing mitigating measures such as ergonomic interventions for vascular surgery.

Comparative Assessment of Ergonomic Experience with Heads-Up Display and Conventional Surgical Microscope in the Operating Room

Purpose

Musculoskeletal pain issues are prevalent in ophthalmic surgeons and can impact surgeon well-being and productivity. Heads-up displays (HUD) can improve upon conventional microscopes by reducing ergonomic stress. This study compared ergonomic outcomes between HUD and a conventional optical microscope in the operating room, as reported by ophthalmic surgeons in the US.

Methods

An online questionnaire was distributed to a sample of surgeons who had experience operating with HUD. The questionnaire captured surgeon-specific variables, the validated Nordic Musculoskeletal Questionnaire, and custom questions to compare HUD and conventional microscope. A multivariable model was built to identify variables that were likely to predict improvement in pain-related issues.

Results

Analysis was conducted on 64 surgeons (37 posterior-segment, 25 anterior-segment, and two mixed) with a mean 14.9 years of practice and 2.3 years using HUD. Most surgeons agreed or strongly agreed that HUD reduced the severity (64%) and frequency (63%) of pain and discomfort, improved posture (73%), and improved overall comfort (77%). Of respondents who experienced headaches, or pain and discomfort during operation, 12 (44%) reported their headaches improved and 45 (82%) reported feeling less pain and discomfort since they started using HUD. The multivariable model indicated the odds of reporting an improvement in pain since introducing the HUD in the operating room were 5.12-times greater for those who used HUD in >50% of their cases (P=0.029).

Conclusion

This study indicates that heads-up display may be an important tool for wellness in the operating room as it can benefit ophthalmic surgeons across several ergonomic measures.

Head-up display assisted endoscopic lumbar discectomy-A technical note

BACKGROUND

Minimally invasive surgery is heavily dependent on indirect visualization and image guidance, often resulting in non-ergonomic postures. Minimally invasive surgeons are more likely to experience neck pain, shoulder pain, and fatigue compared to open surgeons. Spinal endoscopy is rapidly increasing in popularity among minimally invasive spine surgeons. A primary ergonomic issue is the position of the endoscope display, which is often not in line with the operative field or the surgeon's natural line of sight.

METHODS

Smart glasses providing a head-up display are used in a case of percutaneous endoscopic lumbar discectomy to bring the surgeon's line of sight into parallel with the operative field.

RESULTS

Bringing the surgeon's visual and motor axes into parallel resulted in a more comfortable and ergonomic operating position.

CONCLUSIONS

Head-up displays may provide an elegant and relatively simple solution to the issue of inadequate ergonomics in minimally invasive surgery.

Impact of Obesity on Surgeon Ergonomics in Robotic and Straight-Stick Laparoscopic Surgery

STUDY OBJECTIVE

Work-related musculoskeletal symptoms (WMSs) are reported to be increasing in surgeons performing minimally invasive procedures. Therefore, we investigated the use of inertial measurement units (IMUs) and electromyography (EMG) sensor recorders to record real-time information on the muscle movement/activity required to perform training exercises in simulated in normal and high body mass index (BMI) models.

DESIGN

Prospective study.

SETTING

University hospital.

PARTICIPANTS

Four consultant gynecologic oncology surgeons experienced in complex straight-stick (SS) laparoscopic and robotically assisted (RA) surgery.

INTERVENTIONS

Three exercises (hoops onto pegs and wire chase) using SS and RA surgery on 2 abdominal models: normal BMI and high BMI.

MEASUREMENTS AND MAIN RESULTS

We measured time to complete exercise and surgeon muscle movement/activity. The time to complete all exercises was significantly lower for RA surgery as compared with SS laparoscopy (p <.05 or better). The movement of the surgeons' core was significantly greater in high BMI SS laparoscopy compared with normal BMI SS laparoscopy for exercises 1 and 2 (p <.001). Muscle usage, as determined by EMG peak, was significantly higher in normal BMI SS laparoscopy and even higher in high BMI SS laparoscopy but was generally flat for all normal and high BMI RA surgery exercises (p <.05 or better).

CONCLUSION

Detailed real-time information can be collected through IMUs/EMG sensors. Our results indicate that RA surgery requires less surgeon movements and muscle activity to complete tasks compared with SS laparoscopy, particularly in a high BMI model. The implications of these results are that RA surgery in high BMI patients may therefore have less physical impact on the surgeon compared with SS laparoscopy and may result in lower WMS rates.

Surgical team workload comparison for 4-port and single-port laparoscopic cholecystectomy procedures

Advanced minimally invasive procedures may cause postural constraints and increased workload and stress for providers. This study compared workload and stress across surgical team roles for 48 laparoscopic cholecystectomies (4-port vs single-port) using a task load index (NASA-TLX), a procedural difficulty question, and salivary stress hormones. Statistical analyses were performed based on the presence intra-cluster correlation within team roles, at α=0.05. The single-port technique resulted in an 89% increase in physical workload for the surgeon and 63% increase for the assistant (both p<0.05). The surgeon had significantly higher salivary stress hormones during single-port surgeries. The degree of procedural difficulty was positively correlated between the surgeon and most roles: resident (r=0.67), assistant (r=0.81), and technician (r=0.81). There was a statistically significant positive correlation between the surgeon and assistant for all selfreported workload measures (p<0.05). The single-port technique requires further improvement to balance surgical team workload for optimal patient safety and satisfaction.

Operating hurts: a study of EAES surgeons

BACKGROUND

Work-related pain and discomfort experienced by surgeons is widely reported in the literature. A survey was, therefore, conducted to explore this issue among members of the European Association for Endoscopic Surgery (EAES).

METHODS

The survey was emailed to 2980 EAES members in 2017 enquiring about their working practice, musculoskeletal (MSK) pain and burnout.

RESULTS

A total of 569 (19%) surgeons responded, of whom 556 were practicing surgeons; 86% were consultants, 84% were male, and 94% were right-handed. Respondents operated on average 3.3 days/week with 27% of their procedures lasting longer than 3 h. The 386 endoscopists surveyed reported performing an average of 5.3 procedures/day with 83% performing endoscopy at least once per week. Over half of practicing surgeons (62%) reported their worst pain score was 3 or higher (10-point scale) in the past 7 working days, encompassing 71% of their open, 72% laparoscopic, 48% robot-assisted cases and 52% of their endoscopies. Of the 120 surgeons who had ever sought medical help for aches, pain or discomfort, 38% were currently in pain and 16% had considered leaving surgery due to their MSK pain, 26% had reported work-related pain to their employer, 26% had been on short-term disability during their career and 4% long-term disability due to MSK disorders. A significant proportion of the respondents (49%) felt their physical discomfort would influence the ability to perform or assist with surgical procedures in the future. These surgeons reported significantly lower satisfaction from their work (p = 0.024), higher burnout (p = 0.005) and significantly higher callousness toward people (p < 0.001) than those not fearing loss of career longevity.

CONCLUSION

The results show that MSK pain is prevalent amongst EAES members. Nearly half the respondents had career longevity fears from pain/discomfort which, in turn, correlated with more prevalent feelings of burnout. More emphasis should be placed on the aetiology, prevention and management of musculoskeletal pain in the surgical workforce.

Two-Incision Laparoscopic Cholecystectomy: Reducing Scars in a Simple Way

BACKGROUND

About 20% of the population has cholelithiasis and this is the main abdominal cause of hospitalization in developed countries. Considering that only in the United States about 700,000 cholecystectomies are done each year, it is possible to estimate the importance of the problem for public health.

OBJECTIVE

To describe a two-incision laparoscopic cholecystectomy (TILC) technique using only conventional material, without increasing complications or operative time.

MATERIALS AND METHODS

A consecutive and prospective case series compared to another historical operated by conventional laparoscopic cholecystectomy (LC). The TILC was performed with three trocars in two incisions, two trocars in umbilical incision, and one in epigastrium.

RESULTS

A total of 72 patients were operated on by the same surgeon (36 in each group). There were no significant differences between groups for gender, mean age, body mass index, or length of hospital stay. The procedures were classified by the surgeon according to surgical difficulty and 58.3% (n = 42) were considered low grade, 9.7% (n = 7) difficult, and the other were intermediaries, with no difference between the series (P < .05). There were minor complications in 6.94% (n = 5) procedures. There were no differences between mean operative time (P = .989), which was 49 (95% confidence interval [CI] 42-56) minutes in LC and 40 (95% CI 35-44) min in TILC. There was no need for additional trocars in any case or for conversion to open surgery.

CONCLUSIONS

TILC is feasible, safe, and with good aesthetic result, using the same instruments of LC, without increasing operative time.

[Analysis of the postures adopted by operating roomtechnicians during surgery]

OBJECTIVE

During surgery, surgical technicians adopt work positions that can be harmful to their musculoskeletal system. The literature has identified that damage to the musculoskeletal system in this group depends on whether the postures are static or dynamic, the surgical specialty, the type of surgery, the location of the instrument tables and the height of the operating table. However, this study identified the postures adopted by surgical technicians of a IV level institution of Bogotá during surgery, taking into account some of their personal and work characteristics, as well as some technical conditions of the procedures assisted by them, to determine the effects of these factors on their musculoskeletal system and to suggest modifications if necessary.

METHODOLOGY

In this descriptive study, the observation units were the surgical technicians and the units of analysis were the postures adopted by them. The Ovako Working Posture Analysing System (OWAS) was used to identify and to categorize them according to their effects on the musculoskeletal system.

RESULTS

491 postures were observed, of which 42.6% were in category 2 as per the OWAS method.

CONCLUSIONS

The adoption of category 2 postures was mainly related to the surgical specialty, the use of the Mayo instrument table, the anatomic region of the patient, the type of surgery, the shift, the number of procedures assisted within the shift and the surgical assistantship.

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.

Intraoperative workload in robotic surgery assessed by wearable motion tracking sensors and questionnaires

BACKGROUND

The introduction of robotic technology has revolutionized radical prostatectomy surgery. However, the potential benefits of robotic techniques may have trade-offs in increased mental demand for the surgeon and the physical demand for the assisting surgeon. This study employed an innovative motion tracking tool along with validated workload questionnaire to assess the ergonomics and workload for both assisting and console surgeons intraoperatively.

METHODS

Fifteen RARP cases were collected in this study. Cases were performed by 10 different participants, six primarily performed console tasks and four primarily performed assisting tasks. Participants had a median 12 (min-3, max-25) years of surgical experience. Both console and assisting surgeons performed robotic prostatectomy cases while wearing inertial measurement units (IMUs) that continuously track neck, shoulder, and torso motion without interfering with the sterile environment. Postoperatively, participants completed a workload questionnaire (SURG-TLX) and a body part discomfort questionnaire.

RESULTS

Twenty-six questionnaires were completed from 13 assisting and 13 console surgeons over the 15 cases. Postoperative pain was reported highest for the right shoulder and neck. Mental demands were 41 % higher for surgeons at the console than assisting (p < 0.05), while physical demands were not significantly different. Assisting surgeons worked in demanding neck postures for 58 % of the procedure compared to 24 % for the console surgeon (p < 0.01). Surgeons at the console were primarily static and showed 2-5 times fewer movements than assisting surgeons (p < 0.01).

CONCLUSIONS

Postures were more ergonomic during console tasks than when assisting by the bedside; however, the console may constrain postures leading to static loads that have been associated with musculoskeletal symptoms for the neck, torso, and shoulders. The IMU sensors were effective at quantifying ergonomics in robotic prostatectomies, and these methods and findings have broad applications to other robotic procedures.

Surgical flow disturbances in dedicated minimally invasive surgery suites: an observational study to assess its supposed superiority over conventional suites

Background

Minimally invasive surgery (MIS) is frequently compromised by surgical flow disturbances due to technology- and equipment-related failures. Compared with MIS in a conventional cart-based OR, performing MIS in a dedicated integrated operating room (OR) is supposed to be beneficial to patient safety. The aim of this study was to compare a conventional OR with an integrated OR with regard to the incidence and effect of equipment-related surgical flow disturbances during an advanced laparoscopic gynecological procedure [laparoscopic hysterectomy (LH)].

Methods

Using video recording, 40 LHs performed between November 2010 and April 2012 (20 in a conventional cart-based OR and 20 in an integrated OR) were analyzed by two different observers. Outcome measures were the number, duration and effect (on a seven-point ordinal scale) of the surgical flow disturbances (e.g., malfunctioning, intraoperative repositioning, setup device).

Results

A total of 103 h and 45 min was observed. The interobserver agreement was high (kappa .85, p < .001). Procedure time was not significantly different (NS) [conventional OR vs. integrated OR, minutes ± standard deviation (SD), mean 161 ± 27 vs. 150 ± 34]. A total of 1651 surgical flow disturbances were observed (mean ± SD per procedure 40.8 ± 19.4 vs. 41.8 ± 15.9, NS). The mean number of surgical flow disturbances per procedure with regard to equipment was 6.3 ± 3.7 versus 8.5 ± 4.0, NS. No clinically relevant differences in the mean effect of these disturbances on the surgical flow between the two OR setups were observed.

Conclusions

Performing LH in an integrated OR did not reduce the number of surgical flow disturbances nor the effect of these disturbances. Furthermore, in the integrated OR, repositioning of the monitors was a frequent and time-consuming source of disturbance. In order to maintain the high standard of surgical safety, the entire surgical team has to be aware that by performing surgery in an integrated OR different potential source for disruption arise.

Impact of novel shift handle laparoscopic tool on wrist ergonomics and task performance

BACKGROUND

Laparoscopic tool handles causing wrist flexion and extension more than 15° from neutral are considered "at risk" for musculoskeletal strain. Therefore, this study measured the impact of laparoscopic tool handle angles on wrist postures and task performance.

METHODS

Eight surgeons performed standard and modified Fundamentals of Laparoscopic Surgery (FLS) tasks with laparoscopic tools. Tool A had three adjustable handle angle configurations, i.e., in-line 0° (A0), 30° (A30), and pistol-grip 70° (A70). Tool B was a fixed pistol-grip grasper. Participants performed FLS peg transfer, inverted peg transfer, and inverted circle cut with each tool and handle angle. Inverted tasks were adapted from standard FLS tasks to simulate advanced tasks observed during abdominal wall surgeries, e.g., ventral hernia. Motion tracking, video analysis, and modified NASA-TLX workload questionnaires were used to measure postures, performance (e.g., completion time and errors), and workload.

RESULTS

Task performance did not differ between tools. For FLS peg transfer, self-reported physical workload was lower for B than for A70, and mean wrist postures showed significantly higher flexion for in-line than for pistol-grip tools (B and A70). For inverted peg transfer, workload was higher for all configurations. However, less time was spent in at-risk wrist postures for in-line (47 %) than for pistol-grip (93-94 %), and most participants preferred Tool A. For inverted circle cut, workload did not vary across configurations, mean wrist posture was 10° closer to neutral for A0 than B, and median time in at-risk wrist postures was significantly less for A0 (43 %) than for B (87 %).

CONCLUSION

The best ergonomic wrist positions for FLS (floor) tasks are provided by pistol-grip tools and for tasks on the abdominal wall (ventral surface) by in-line handles. Adjustable handle angle laparoscopic tools can reduce ergonomic risks of musculoskeletal strain and allow versatility for tasks alternating between the floor and ceiling positions in a surgical trainer without impacting performance.

Direct comparison of the different conventional laparoscopic positions with the ethos surgical platform in a laparoscopic pelvic surgery simulation setting

OBJECTIVE

Laparoscopic surgery can be harmful to surgeons requiring a prolonged learning curve due to significant ergonomic drawbacks. Based on preliminary clinical experience, we present an experimental evaluation of the second-generation ETHOS™ operating chair by comparing it with two different operating positions of conventional laparoscopic pelvic surgery.

MATERIALS AND METHODS

The ETHOS operation platform consists of a seat like a saddle and five more parts that can be adjusted individually to support the surgeon's trunk and extremities. This operation platform was tested in 30 trainees who performed three standard suturing exercises in a pelvitrainer, approximating a linear and a U-shaped incision, made on the skin of a chicken leg, and completing an urethrovesical anastomosis, on a pig bladder specimen model, using interrupted sutures. The trainees performed each exercise in standing laterally to pelvitrainer (torero position) vs standing behind pelvi-trainer and sitting on ETHOS. The mean values, from all times and for each exercise and position, were documented, and the participants filled out a validated questionnaire focusing on ergonomic issues.

RESULTS

There were no significant differences among the different training modalities, in step 1 and step 2. However, in step 3, which mimics the urethrovesical anastomosis, the mean times were statistically significant significantly less by using ETHOS (p<0.0001). The mean times of training in step 3 were 41.2 minutes in the behind the camera position, 49 minutes in torero position, and 39.7 minutes by using ETHOS. The position that was maintained, during the exercises, was mainly responsible for the improvement noted in the ergonomic scores.

CONCLUSIONS

The new operating platform (ETHOS chair) can significantly improve ergonomics in laparoscopy particularly concerning difficult steps like intracorporeal suturing. This may also improve the urethrovesical anastomosis times in a clinical setting.

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.

Video-Assisted Palatopharyngeal Surgery: A Model for Improved Education and Training

Objective

The learning process for intraoral procedures is arguably more difficult than for other surgical procedures because of the assistant's severely limited visibility. Consequently, trainees may not be able to adequately see and follow all steps of the procedure, and attending surgeons may be less willing to entrust trainees with critical portions of the procedure. In this report, we propose a video-assisted approach to intraoral procedures that improves lighting, visibility, and potential for effective education and training.

Design

Technical report (idea/innovation).

Setting

Tertiary referral hospital.

Patients

Children with cleft palate and velopharyngeal insufficiency requiring surgery.

Interventions

Video-assisted palatoplasty, sphincteroplasty, and pharyngoplasty.

Main Outcome Measures

Qualitative and semiquantitative educational outcomes, including learner perception regarding “real-time” (video-assisted surgery) and “non–real-time” (video-library–based) surgical education.

Results

Trainees were strongly in favor of the video-assisted modality in “real-time” surgical training. Senior trainees identified more opportunities in which they had been safely entrusted to perform critical portions of the procedure, corresponding with satisfaction with the learning process scores, and they showed greater comfort/confidence scores related to performing the procedure under supervision and alone.

Conclusions

Adoption of the video-assisted approach can be expected to markedly improve the learning curve for surgeons in training. This is now standard practice at our institution. We are presently conducting a full educational technology assessment to better characterize the effect on knowledge acquisition and technical improvement.

Ergonomics in endourology and laparoscopy: an overview of musculoskeletal problems in urology

PURPOSE

This study aims to provide an overview of type and frequency of musculoskeletal complaints among urologists. In addition, the urologists' knowledge about ergonomic conditions during minimally invasive urology was assessed, and they were asked how they would prefer to gain knowledge about this topic.

MATERIALS AND METHODS

An online and hard copy version questionnaire was administered to urologists from different countries, mainly from Europe, performing endourology and laparoscopy.

RESULTS

Of the 285 respondents, 245 (86.0%) urologists experienced musculoskeletal complaints in the past 12 months and 62.1% were considered to be work related. Most common areas for chronic complaints were neck, back, and shoulders. Almost 50% of the urologists experienced chronic musculoskeletal complaints, for which endourology (odds ratio [OR] 3.06; 95% confidence interval [CI] 1.37-6.80) and laparoscopy (OR 1.70; 95% CI 1.27-2.28) were significant risk factors. One third of the urologists considered their knowledge about ergonomics minimal, and 8% stated that they had no knowledge about these topics. Fifty percent of the respondents preferred to integrate information about ergonomic rules into hands-on training of urologic skills.

CONCLUSION

High prevalence of experienced musculoskeletal complaints was found among urologists predominantly related to endourology and laparoscopy. Urologists indicate that they have a lack of knowledge about ergonomics in the operating room. Hence, we recommend integration of ergonomics in hands-on training programs early in the residency curriculum to gain knowledge and awareness and hopefully to offer possibilities to prevent these complaints in the future.

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.

Effective and efficient learning in the operating theater with intraoperative video-enhanced surgical procedure training

BACKGROUND

INtraoperative Video Enhanced Surgical procedure Training (INVEST) is a new training method designed to improve the transition from basic skills training in a skills lab to procedural training in the operating theater. Traditionally, the master-apprentice model (MAM) is used for procedural training in the operating theater, but this model lacks uniformity and efficiency at the beginning of the learning curve. This study was designed to investigate the effectiveness and efficiency of INVEST compared to MAM.

METHODS

Ten surgical residents with no laparoscopic experience were recruited for a laparoscopic cholecystectomy training curriculum either by the MAM or with INVEST. After a uniform course in basic laparoscopic skills, each trainee performed six cholecystectomies that were digitally recorded. For 14 steps of the procedure, an observer who was blinded for the type of training determined whether the step was performed entirely by the trainee (2 points), partially by the trainee (1 point), or by the supervisor (0 points). Time measurements revealed the total procedure time and the amount of effective procedure time during which the trainee acted as the operating surgeon. Results were compared between both groups.

RESULTS

Trainees in the INVEST group were awarded statistically significant more points (115.8 vs. 70.2; p < 0.001) and performed more steps without the interference of the supervisor (46.6 vs. 18.8; p < 0.001). Total procedure time was not lengthened by INVEST, and the part performed by trainees was significantly larger (69.9 vs. 54.1 %; p = 0.004).

CONCLUSIONS

INVEST enhances effectiveness and training efficiency for procedural training inside the operating theater without compromising operating theater time efficiency.

[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.

The learning effect of intraoperative video-enhanced surgical procedure training

BACKGROUND

The transition from basic skills training in a skills lab to procedure training in the operating theater using the traditional master-apprentice model (MAM) lacks uniformity and efficiency. When the supervising surgeon performs parts of a procedure, training opportunities are lost. To minimize this intervention by the supervisor and maximize the actual operating time for the trainee, we created a new training method called INtraoperative Video-Enhanced Surgical Training (INVEST).

METHODS

Ten surgical residents were trained in laparoscopic cholecystectomy either by the MAM or with INVEST. Each trainee performed six cholecystectomies that were objectively evaluated on an Objective Structured Assessment of Technical Skills (OSATS) global rating scale. Absolute and relative improvements during the training curriculum were compared between the groups. A questionnaire evaluated the trainee's opinion on this new training method.

RESULTS

Skill improvement on the OSATS global rating scale was significantly greater for the trainees in the INVEST curriculum compared to the MAM, with mean absolute improvement 32.6 versus 14.0 points and mean relative improvement 59.1 versus 34.6% (P=0.02).

CONCLUSION

INVEST significantly enhances technical and procedural skill development during the early learning curve for laparoscopic cholecystectomy. Trainees were positive about the content and the idea of the curriculum.

Gaze disruptions experienced by the laparoscopic operating surgeon

BACKGROUND

Disruptions to surgical workflow have been correlated with an increase in surgical errors and suboptimal outcomes in patient safety measures. Yet, our ability to quantify such threats to patient safety remains inadequate. Data are needed to gauge how the laparoscopic operating room work environment, where the visual and motor axes are no longer aligned, contributes to such disruptions. We used time motion analysis techniques to measure surgeon attention during laparoscopic cholecystectomy in order to characterize disruptive events imposed by the work environment of the OR. In this investigation we identify attention disruptions as they occur in terms of the operating surgeon's gaze. We then quantify such disruptions and also seek to establish what occasioned them.

METHODS

Ten laparoscopic cholecystectomy procedures were recorded with both intra- and extracorporeal cameras. The views were synchronized to produce a video that was subsequently analyzed by a single independent observer. Each time the surgeon's gaze was diverted from the operation's video display, the event was recorded via time-stamp. The reason for looking away (e.g., instrument exchange), when discernable, was also recorded and categorized. Disruptions were then reviewed and analyzed by an interdisciplinary team of surgeons and human factors experts.

RESULTS

Gaze disruptions were classified into one of four causal categories: instrument exchange, extracorporeal work, equipment troubleshooting, and communication. On average, 40 breaks occurred in operating surgeon attention per 15 min of operating time. The most frequent reasons for these disruptions involved instrument exchange (38%) and downward gaze for extracorporeal work (28%).

CONCLUSIONS

This study of laparoscopic cholecystectomy performance reveals a high gaze disruption rate in the current operating room work environment. Improvements aimed at reducing such disruptions-and thus potentially surgical error-should center on better instrument design and realigning the axis between surgeon's eye and visual display.

Ergonomic assessment of the posture of surgeons performing endoscopic transurethral resections in urology

Background

During transurethral endoscopic prostate and bladder operations the influence of an ergonomic redesign of the arrangement of the operation equipment - including the introduction of a video-assisted resection method ('monitor endoscopy') instead of directly viewing onto the operation area via the endoscope ('direct endoscopy') - was studied with respect to the postures of the surgeons.

Methods

Postures were analysed on the basis of video recordings of the surgeons performed in the operation theatre during live operations and subsequent visual posture estimation executed by an observer. In particular, head, trunk and arm positions were assigned to posture categories according to a newly developed posture classification schema. 10 urological operations with direct endoscopy and 9 with monitor endoscopy were included.

Results

Application of direct endoscopy coincides with distinct lateral and sagittal trunk and head inclinations, trunk torsion and strong forearm and upper arm elevations of the surgeons whereas operations with monitor endoscopy were performed with an almost upright head and trunk and hanging arms. The disadvantageous postures observed during direct endoscopy are mainly caused by the necessity to hold the endoscope continuously in close contact with the eye.

Conclusion

From an ergonomic point of view, application of the video-assisted resection method should be preferred in transurethral endoscopic operations in order to prevent awkward postures of the surgeons and to limit muscular strain and fatigue. Furthermore, the application of the monitor method enables the use of a chair equipped with back support and armrests and benefits the reduction of postural stress.

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.