The effect of ergonomic laparoscopic tool handle design on performance and efficiency

Musculoskeletal disorders and discomfort for female surgeons or surgeons with small hand size when using hand-held surgical instruments: a systematic review

BACKGROUND

Work-related musculoskeletal disorders (WMSDs), also referred to as work-related musculoskeletal injuries (MSKIs), cause surgeons pain and discomfort. Implementing ergonomics in the operating room has helped reduce such symptoms. However, there are still many issues that surgeons face when dealing with medical instruments, especially among female surgeons or surgeons with smaller hands.

METHODS

The Cochrane methodology for performing a systematic review was utilized to search five databases for pertinent literature based on the study question "Do female surgeons or surgeons with smaller hand size, who use surgical instruments have an increased risk of musculoskeletal disorders and discomfort compared to male or larger handed surgeons?". The literature search strategy was designed around the three conceptual domains of surgeons/surgery, smaller hand size, and instrumentation. We searched PubMed, Embase.com, CINAHL Plus with Full Text (EBSCOhost), Scopus, and Web of Science Core Collection. This exploration identified 2165 research publications, and after specific inclusion and exclusion criteria, 19 studies were included in the systematic review. Risk of bias analysis was conducted to assess the quality of the included studies. After conducting a heterogeneity test, a meta-analysis was not performed due to high heterogeneity.

RESULTS

Using certain surgical instruments presents challenges in the form of MSKIs for female and smaller-handed surgeons. Studies showed that 77% of females and 73% of surgeons who wear < 6.5 glove size report musculoskeletal issues ranging from difficulty of use to pain. Difficulties using surgical instruments and reported injuries have a greater impact on surgical trainees which might deter interest in surgical fields for future proceduralists. Recommendations for improved ergonomic tool design are suggested by some of the included studies to help tackle the MSKIs that surgeons face when performing operations.

CONCLUSIONS

The number of female surgeons has increased substantially in the last decade. Hence, there exists an urgent need to address the major challenges they encounter by focusing on this specific aspect of workplace safety and health to mitigate injury. Doing so will yield a productive environment while simultaneously protecting the health and safety of both surgeons and patients.

SYSTEMATIC REVIEW REGISTRATION

The study protocol was registered on PROSPERO (ID: CRD42022283378).

Unpacking the Broad Landscape of Intraoperative Stressors for Clinical Personnel: A Mixed-Methods Systematic Review

Purpose

The main goals of this mixed-methods systematic review are to identify what types of intraoperative stressors for operating room personnel have been reported in collected studies and examine the characteristics of each intraoperative stressor.

Methods

With a systematic literature search, we retrieved empirical studies examining intraoperative stress published between 2010 and 2020. To synthesize findings, we applied two approaches. First, a textual narrative synthesis was employed to summarize key study information of the selected studies by focusing on surgical platforms and study participants. Second, a thematic synthesis was employed to identify and characterize intraoperative stressors and their subtypes.

Results

Ninety-four studies were included in the review. Regarding the surgical platforms, the selected studies mainly focused on minimally invasive surgery and few studies examined issues around robotic surgery. Most studies examined intra-operative stress from surgeons' perspectives but rarely considered other clinical personnel such as nurses and anesthetists. Among seven identified stressors, technical factors were the most frequently examined followed by individual, operating room environmental, interpersonal, temporal, patient, and organizational factors.

Conclusion

By presenting stressors as multifaceted elements affecting collaboration and interaction between multidisciplinary team members in the operating room, we discuss the potential interactions between stressors which should be further investigated to build a safe and efficient environment for operating room personnel.

Ergonomic Design and Assessment of an Improved Handle for a Laparoscopic Dissector Based on 3D Anthropometry

Laparoscopic surgery (LS) has been shown to provide great benefits to patients compared with open surgery. However, surgeons experience discomfort, low-efficiency, and even musculoskeletal disorders (MSDs) because of the poor ergonomic design of laparoscopic instruments. A methodology for the ergonomic design of laparoscopic dissector handles considering three-dimensional (3D) hand anthropometry and dynamic hand positions was addressed in this research. Two types of hand positions for grasping and stretching were scanned from 21 volunteers using a high-resolution 3D scanner. The 3D anthropometric data were extracted from these 3D hand pose models and used to design an improved handle (IH) that provides additional support for the thumb, a better fit to the purlicue, and a more flexible grasp for the index finger. Thirty subjects were invited to evaluate the IH in terms of muscular effort, goniometric study of motion, and efficiency and effectiveness during four trials of a laparoscopic training task. Questionnaires provided subjective parameters for ergonomic assessment. Positive results included less muscle load in the trapezius as well as significant but small angular differences in the upper limb. No significant reduction in the trial time and no increased percentage of the achievement were observed between the IH and the commercial handle (CH). Improved intuitiveness, comfort, precision, stability, and overall satisfaction were reported. IH provides significant ergonomic advantages in laparoscopic training tasks, demonstrating that the proposed methodology based on 3D anthropometry is a powerful tool for the handle design of laparoscopic dissectors and other surgical instruments.

Surgical ergonomics: Assessment of surgeon posture and impact of training device during otolaryngology procedures

Objective

To identify factors associated with cervical‐thoracic spine posture in otolaryngology surgeries and evaluate the efficacy of a commercially available posture‐training device in enhancing surgeon ergonomics.

Methods

Over 3 months, neck and spine posture from individuals performing otolaryngology surgeries was recorded using UpRight Go 2™. Average baseline posture was first recorded and biofeedback was later introduced to attempt to correct posture. The proportion of time spent in upright/neutral cervical‐thoracic spine posture was correlated with surgeon and procedure characteristics and compared to proportion of upright posture time after biofeedback intervention.

Results

The proportion of upright operating time was significantly different between procedure subtypes and surgical approaches with best performance in rhinology procedures and worst performance in head and neck surgeries (90% vs. 62%; both p < .001). Female gender, shorter stature, and use of sitting stools were associated with greater proportion of surgery spent upright (all p < .05). Loupes use was associated with less time in upright posture (p < .001). With biofeedback intervention, 8 of 10 subjects demonstrated an average of 5% improvement in operating upright, with most improvement found when performing laryngology procedures (7%) and least improvement in head and neck procedures (2%).

Conclusions

While surgeon posture varies across otolaryngology surgeries, sitting and minimizing the use of loupes may help promote a more ergonomic operating environment and improve surgeon posture. Although the efficacy of biofeedback intervention from a commercially available posture‐training device differs among otolaryngologists, exploration of alternative interventions and incorporation of an ergonomics curriculum is warranted to address postural issues experienced by many surgeons.

Level of Evidence

3.

A Fully 3D-Printed Steerable Instrument for Minimally Invasive Surgery

In the field of medical instruments, additive manufacturing allows for a drastic reduction in the number of components while improving the functionalities of the final design. In addition, modifications for users’ needs or specific procedures become possible by enabling the production of single customized items. In this work, we present the design of a new fully 3D-printed handheld steerable instrument for laparoscopic surgery, which was mechanically actuated using cables. The pistol-grip handle is based on ergonomic principles and allows for single-hand control of both grasping and omnidirectional steering, while compliant joints and snap-fit connectors enable fast assembly and minimal part count. Additive manufacturing allows for personalization of the handle to each surgeon’s needs by adjusting specific dimensions in the CAD model, which increases the user’s comfort during surgery. Testing showed that the forces on the instrument handle required for steering and grasping were below 15 N, while the grasping force efficiency was calculated to be 10–30%. The instrument combines the advantages of additive manufacturing with regard to personalization and simplified assembly, illustrating a new approach to the design of advanced surgical instruments where the customization for a single procedure or user’s need is a central aspect.

Ergonomics of Endoscopy

Optimal endoscopic operations incorporate ergonomic principles into the endoscopy environment benefiting endoscopists, endoscopy unit personnel, and patients. A high prevalence of occupational musculoskeletal injuries is well established among endoscopists and gastroenterology nurses. Ergonomics can be integrated into all facets of the endoscopy unit including scheduling, endoscopy unit design, training programs, and investment in technology. Preprocedure, intraprocedure, and postprocedure areas should aim to deliver patient safety, privacy, and comfort, while also supporting endoscopists and staff with adjustable rooms and effective work flows. Team-wide educational initiatives can improve ergonomic awareness. These strategies help mitigate risks for musculoskeletal injuries and can lead to increased productivity. The COVID-19 area brings novel challenges to endoscopy.

Ergonomic Analysis of Functional Endoscopic Sinus Surgery Using Novel Inertial Sensors

OBJECTIVES/HYPOTHESIS

Suboptimal ergonomics during endoscopic sinus surgery can lead to considerable physical discomfort and fatigue for the surgeon. The purpose of this pilot study is to objectively evaluate the ergonomic positions of trainee and attending surgeons while performing functional endoscopic sinus surgery (FESS).

STUDY DESIGN

Pilot prospective trial.

METHODS

Six surgeons (two attendings and four trainees) performed FESS while wearing 11 inertial measurement units (IMUs) affixed to either side of each major joint. Screen placement was standardized to be 1 m directly in front of the surgeon and on the patient's left, 0-15° declined from the surgeons' eyes. Bed height was standardized such that the workspace was 0 to 10 cm below the elbows. IMU data were analyzed to calculate joint angles. Ideal joint angles (i.e., <10° for neck and trunk) were determined by the validated Rapid Entire Body Assessment tool. Subjects subsequently completed a modified National Aeronautics and Space Administration Task Load Index to assess cognitive and physical burden and pain. Student's t-test was employed to detect differences between groups.

RESULTS

Trainees adopted positions involving significantly greater neck flexion (9.90° vs. -6.48°, P = .03) and reported significantly higher frustration levels (3.04 vs. 1.33, P = .02) while operating than attendings. For both cohorts, increased operative time was significantly correlated with greater back flexion (r = 0.90, P = .02; r = 0.55, P = .04, respectively).

CONCLUSIONS

Our data suggest that trainees operate with higher risk neck postures than do attendings. These data indicate high-risk operative postures may be borne of inexperience and present an opportunity for postural interventions at an early stage of training.

LEVEL OF EVIDENCE

N/A Laryngoscope, 2021.

Postural ergonomics and work-related musculoskeletal disorders in neurosurgery: lessons from an international survey

Background

Work-related musculoskeletal disorders (WMSDs) affect a significant percentage of the neurosurgical workforce. The aim of the current questionnaire-based study was to examine the prevalence of WMSDs amongst neurosurgeons, identify risk factors, and study the views of neurosurgeons regarding ergonomics.

Methods

From June to August 2020, members of the “European Association of Neurosurgical Societies,” the “Neurosurgery Research Listserv,” and the “Latin American Federation of Neurosurgical Societies” were asked to complete an electronic questionnaire on the topics of WMSDs and ergonomics.

Results

A total of 409 neurosurgeons responded to the survey, with a 4.7 male to female ratio. Most of the surgeons worked in Europe (76.9%) in academic public hospitals. The vast majority of the participants (87.9%) had experienced WMSDs, mainly affecting the shoulder, neck, and back muscles. The most common operations performed by the participants were “Craniotomy for convexity/intrinsic tumors” (24.1%) and “Open lumbar basic spine” (24.1%). Neurosurgeons agreed that ergonomics is an underexposed area in the neurosurgical field (84.8%) and that more resources should be spend (87.3%) and training curricula changes should be made (78.3%) in order to alleviate the burden of WMSDs on neurosurgeons. Univariate analysis did not reveal any associations between the development of WMSDs and age, gender, tenure, average duration of operation, operating time per week, type of operation, and surgical approach.

Conclusions

The problem of WMSDs ought to be more closely addressed and managed by the neurosurgical community. More studies ought to be designed to investigate specific ergonomic parameters in order to formulate practice recommendations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00701-021-04722-5.

The effectiveness of ergonomics interventions in reducing upper limb work-related musculoskeletal pain and dysfunction in sonographers, surgeons and dentists: a systematic review

The aim of this systematic review was to summarise the effects of ergonomics interventions on work-related upper limb musculoskeletal pain and dysfunction, and on productivity in sonographers, surgeons and dentists. A total of 31 studies were included. All studies reported effects on upper limb pain. Nine studies reported effects on dysfunction and only two studies reported effects on productivity. Moderately strong evidence in reducing upper limb pain was found for instigation of microbreaks into long duration surgical procedures, and the use of wider, lighter handles in dental instruments. Moderate evidence was also found for use of prismatic glasses and favourable positioning in reducing upper limb pain. Weak, inconsistent or no evidence was found for all other ergonomics interventions in reducing upper limb pain and dysfunction and increasing productivity. The lack of high quality research, particularly in sonographers and in the outcome of productivity, should be addressed. Practitioner summary: This systematic review investigates the effectiveness of ergonomics interventions on upper limb pain, dysfunction and productivity in sonographers, dentists and surgeons. Instigation of microbreaks during long duration procedures and the use of wider, lighter instrument handles were most effective in reducing upper limb work-related pain. Abbreviations: ANOVA: analysis of variance; CLS: conventional laparoscopic surgery; DMAIC: define, measure, analyze, improve and control; GRADE: grading of recommendations, assessment, development and evaluations; HD: high definition; PRISMA: preferred reporting items for systematic reviews and meta-analyses; PROSPERO: The International Prospective Register of Systematic Reviews; RCT: randomised control trial; SILS: single incision laparoscopic surgery; VITOM: video telescopic operative microscope; WNSWLHD: Western New South Wales Local Health District; WMSD: work related musculoskeletal disorder.

Design and fluid flow simulation of modified laparoscopic forceps

Laparoscopic surgery has gained prominence in recent decades and employed in minimally invasive surgeries to avoid massive cuts resulting in a reduction in pain, the chance of infection, and duration of stay in the hospital. Maryland forceps, which belongs to the category of grasper instruments, are often used in minimally invasive surgeries to hold, pull, push, manipulate, and perform dissection operations. During laparoscopic surgeries, often blood and other body fluids ooze from the site of surgery. Typically, suction-irrigation (SI) devices are used to periodically clear these fluids to get a better view of the site of surgery. To achieve this, the removal and insertion of multiple instruments are required. This process has to be repeated numerous times, which significantly increases the time needed for surgery. Literature survey and feedback from practicing surgeons suggest that this can be avoided by improving the current design of forceps. In this article, a modified design is proposed by combining the SI feature with the existing form of Maryland forceps. The modified design is first modeled in SolidWorks and then analyzed for fluid flow using ANSYS Fluent. Parametric analysis is performed to obtain the optimal design for the proposed multi-functional instrument, which can potentially improve the overall efficiency of the laparoscopic surgical process.

Ergonomic evaluation and performance of a new handle for laparoscopic tools in surgery

This paper presents a new handle for instruments used in laparoscopic surgery. This new handle has been designed to provide the best ergonomic and usability features required in this kind of surgical interventions. The main novelty of this handle is that the opening and closing motion of the end-effector is operated with the thumb using a lever located on the top of the handle. This enables the surgeon to reach the patient's organs without adopting extremely awkward postures. In order to demonstrate its advantages, the handle has been tested and compared with another commercial handle in terms of efficiency, effectiveness, and satisfaction. To this end, volunteers have been selected for participation in the experimental evaluation, which comprised two types of surveys: objective and subjective. Electromyography and goniometric studies provide objective parameters for evaluation. Questionnaires are used for the subjective assessment. Outstanding results include the lower level of pain reported by the individuals working with the new handle, as well as the reduction in the hyperflexion of the wrist. Compared with the conventional handle, electromyography reveals that no muscle load is increased when working with the new handle. The results of the subjective survey show that volunteers expressed a significant preference for the new handle, demonstrating an improvement in the ergonomic characteristics.

Ergonomic assessment of a new hand tool design for laparoscopic surgery based on surgeons' muscular activity

Laparoscopic surgery techniques are customarily used in non-invasive procedures. That said traditional surgical instruments and devices used by surgeons suffer from certain ergonomic deficiencies that may lead to physical complaints in upper limbs and back and general discomfort that may, in turn, affect the surgeon's skills during surgery. A novel design of the laparoscopic gripper handle is presented and compared with one of the most used instruments in this field in an attempt to overcome this problem. The assessment of the ergonomic feature of the novel design was performed by using time-frequency analysis of the surface electromyography (sEMG) signal during dynamic activities. Singular Spectrum Analysis (SSA) was used to decompose the sEMG signal and extract the median frequency of each muscle to assess muscle fatigue. The results reveal that using the proposed ergonomic grip reduces the mean values of the muscle activity during each of the proposed tasks. The novel design also improves the ease of use in laparoscopic surgery as it minimises high-pressure contact areas, reduces large amplitude movements and promotes a neutral position of the hand, wrist and forearm. Furthermore, the SSA method for time-frequency analysis provides a powerful tool to analyse a prescribed activity in ergonomic terms. The proposed methodology to assess muscle activity during surgery activities may be useful in the selection of surgical instruments when programming extended procedures, as it provides an additional selection criterion based on the surgeon's biomechanics and the proposed activity.

Development of an ergonomic four-finger-push manual pipette design

The purpose of this study was to develop a new pipette design in which the pipette is operated by four fingers, taking into account the anatomy and anthropometry of the hand. The proposed new pipette designs were compared with a traditional thumb-push pipette based on muscle activity, wrist posture, subjective discomfort ratings for upper extremities, and user preference. The results of the study revealed that the four-finger, ergonomic pipette design reduced muscle exertion (25% reduction for aspiration and 35% reduction for dispensing), awkward wrist posture (33% reduction in wrist flexion, radial and ulnar deviation), and perceived discomfort in the wrist, hand and lower arm. Furthermore, most participants (9 of 10) who used a pipette in their daily work preferred the new pipette designs to a traditional thumb-push pipette design. Thus, we expect that this study will contribute to the reduction of WMSDs risk factors and pain.

Resolution of Thumb Pain following Adoption of Mathieu Needle Holder: An Ergonomic Analysis

Background

As surveys reveal the prevalence of musculoskeletal pain among surgeons, it is important to have an appreciation and understanding of surgical ergonomics to protect against long-term injuries and mitigate the symptoms of existing conditions. Surgeons diagnosed with thumb carpometacarpal (CMC) joint osteoarthritis, a progressive and debilitating condition, can be especially vulnerable to the pain caused by the repetitive manual tasks of operating.

Methods

In this article, the authors describe a case of occupational thumb CMC arthritis in a right-hand dominant plastic surgeon and provide an ergonomic analysis of the different needle holders.

Results

Following diagnosis, the simple switch from the traditional Hegar needle holder to the Mathieu needle driver with its palm grip and rotating ratchet lock mechanism stalled the progression of the disease, allowing the surgeon to continue operating pain free.

Conclusions

This is the first report of utilization of an alternative needle holder leading to the resolution of thumb pain. In sharing this case, the authors hope to bring awareness to the importance of hand ergonomics in the operating room and offer a practical tip to surgeons with CMC arthritis.

Learning Intracorporeal Suture on Pelvitrainer Using a Robotized Versus Conventional Needle Holder

BACKGROUND

Laparoscopy is the gold standard approach in numerous surgical procedures. A new generation of robotized instruments has been developed to compensate for the ergonomic constraints of conventional instruments. The main objective was to compare the learning curves of novices for intracorporeal suturing on a laparoscopy pelvitrainer, using either a robotized needle holder or conventional needle holders. The post-training performances under ergonomically difficult conditions were also analyzed.

MATERIALS AND METHODS

Fifth-year medical students were randomized in group A using a robotized needle holder (JAIMY; Endocontrol, Grenoble, France) and group B using straight conventional needle holders. They undertook four training sessions (intracorporeal knot-tying task) followed by an evaluation session (intracorporeal knots-tying task, frontal suture, and hexagonal suture).

RESULTS

Twenty participants were included. The performances of the two groups (n = 10) were not significantly different at baseline. During the training sessions, there was a learning curve with a plateau at the third session for both the groups. At the final evaluation session, there was no significant difference between group A and group B for the intracorporeal knot-tying task (median fundamentals of laparoscopic surgery score: 468 versus 474.5 respectively; P = 0.762). There was a significant difference between group A and group B for the frontal suture (median global score: 15.75 versus 3.75 respectively; P = 0.005) but not for the hexagonal suture (median global score: 18 versus 15 respectively; P = 0.284).

CONCLUSIONS

Learning curves were equally fast using the robotized needle holder versus conventional instruments and led to equivalent performances. Under ergonomically difficult conditions, the robotized needle holder provided an advantage relative to conventional instruments.

Comparative Study of the Use of Different Sizes of an Ergonomic Instrument Handle for Laparoscopic Surgery

Previous studies have shown that the handle design of laparoscopic instruments is crucial to surgical performance and surgeon’s ergonomics. In this study, four different sizes of an ergonomic laparoscopic handle design were tested in a blind and randomized fashion with twelve surgeons. They performed three laparoscopic tasks in order to analyze the influence of handle size. Execution time, wrist posture, and finger and palm pressure were evaluated during the performance of each task. The results show a significant reduction in the time required to complete the eye-manual coordination task using the appropriate handle. The incorrectly sized handle resulted in a rise in palm pressure and a reduction in the force exerted by the thumb during the transfer task. In the hand-eye coordination task, the use of the right handle size led to an increase in middle finger pressure. In general, surgeons had an ergonomically adequate wrist flexion in all tasks and an acceptable radio-ulnar deviation during the transfer task using the ergonomic instrument handle. Surgeons found it comfortable the use of the ergonomic handle. Therefore, the use of an appropriately sized instrument handle allows surgeons to improve ergonomics and surgical performance during the laparoscopic practice.

The Current State of Surgical Ergonomics Education in U.S. Surgical Training: A Survey Study

OBJECTIVE

The aim of this study was to characterize the current state of surgical ergonomics education in the United States.

BACKGROUND

The burden of work-related musculoskeletal disorders (MSDs) in surgeons is high and no overarching strategy for redress exists. Twelve distinct specialties describe an unmet need for surgical ergonomics education (SEE). This study aimed to define the current state of SEE in U.S. surgical training programs.

METHODS

We performed a descriptive analysis of a 20-item questionnaire of ACGME-certified program directors from 14 surgical and interventional medical specialties. Formal SEE was defined as any organized education module that reviewed the occupation-specific burden of common work-related MSDs and described a framework for prevention via occupation-specific applied ergonomics. Program directors were queried regarding SEE provision, characteristics, and perceived trainee attitude toward the education.

RESULTS

Questionnaires were received from 130 of 441 (29.5%) program directors. Two (1.5%) provided formal SEE and 33 (25.4%) provided informal SEE, which consisted of unstructured intraoperative directives and isolated lectures. Two programs previously provided SEE but discontinued the effort due to lack of an evidence-based framework and instructors. Trainees appeared to think that learning surgical ergonomics skills was a worthwhile time investment in 100% and 76.7% of current formal and informal SEE, respectively.

CONCLUSION

SEE is rarely provided in any capacity (25.4%), let alone in a consistent or evaluable fashion (1.5%). Impediments to sustainable SEE include lack of an evidence-based framework for education and instructors. An evidence-based, reproducible, and accreditation council-compliant SEE module would be a valuable resource for the surgical and interventional medical communities.

A novel anatomical woodworking chisel handle

A novel anatomically shaped ("anatomical") woodworking chisel handle was developed for wood scraping operation. 18 students participated in an evaluation study to compare the new handle against seven readymade handles of ¾-inch bench chisels in the context of a standard wood scraping task. A comfort questionnaire for hand tools (CQH) and a hand-based pain map were used for evaluating and comparing the handles. 'Functionality' and 'sweating' were found to be the most and least important comfort concerns, respectively. Maximum pain was reported at distal digit 1, and least pain at proximal digit 4. The anatomical handle was rated best for most of the comfort descriptors, least painful for most hand regions and took the least time for a standardized task.

Evaluating a Solely Mechanical Articulating Laparoscopic Device: A Prospective Randomized Crossover Study

BACKGROUND

The FlexDex^® (FD) is a solely mechanical articulating device that combines the functionality of robotic surgery with the relative low cost and simplicity of laparoscopy. We sought to evaluate the performance of first-time FD users while performing a simple suture task at locations of varying degrees of difficulty.

STUDY DESIGN

A prospective, randomized crossover study was performed comparing the FD to standard laparoscopy (SL). Two specific groups were evaluated; Group 1 consisted of complete novices, and Group 2 consisted of surgical trainees. Participants performed a simple suture with both FD and SL locations of varying degrees of difficulty (Easy, Moderate, and Hard). The following outcomes were evaluated: Instrument Function and Ergonomics (Comfort/Ergonomics survey), Task Difficulty (National Aeronautics and Space Administration Task Load Index [NASA-TLX]), Task Performance Quality (Objective Structured Assessment of Technical Skills [OSATS]), and Time (seconds).

RESULTS

Twenty-two participants were enrolled with 12 participants in Group 1 and 10 participants in Group 2. Group 1-FD participants experienced overall less shoulder strain (1.2 ± 0.40 versus 1.9 ± 0.90, P = .01), and Group 2-FD participants experienced less shoulder (2.5 ± 0.66 versus 4.0 ± 0.50, P = .01), back (1.1 ± 0.32 versus 1.9 ± 0.74, P = .01), and forearm strain (1.9 ± 0.88 versus 2.5 ± 1.1, P = .04). Group 1 participants using the FD experienced higher mental demand (73 ± 17 versus 48 ± 27, P < .01) and perceived effort (70 ± 20 versus 54 ± 23, P < .001). Both Group 1 and Group 2 FD participants performed tasks at the Hard location more effectively. Both Group 1 (70 versus 87, P = .21) and Group 2 (53 versus 60, P = .55) performed tasks at the Hard location in similar times, while Group 1 (80 versus 177, P = .03) and Group 2 (33 versus 70, P = .001) performed tasks at the Easy location in shorter times using SL.

CONCLUSIONS

This study demonstrates the first assessment of the FD, a mechanically articulating laparoscopic tool. First-time FD users demonstrated improved ergonomics and effectiveness suturing at difficult locations. Future studies will focus on comparison to robotic surgery and translation into clinical applications.

Electromyographic evaluation of different handle shapes of masons' trowels

The effects of five different handle shapes of masons' trowels on muscle activity of the arm and forearm muscles (through electromyographic measurements of the biceps brachii [BB], flexor digitorum superficialis [FDS], pronator teres [PT] and extensor carpi ulnaris [ECU]) were evaluated in a simulated masonry task. The results showed a significant effect of handle shape on the muscle activity of the BB, PT and ECU. The muscle activity of the extensor (ECU) and flexor (FDS) were generally larger than those of the supinator (BB) and pronator (PT). Some improvements were found in terms of muscular exertions with prototype designs C, D and E, which had either handles with variable diameter (designs C and E) or a slightly bent handle (design D). These findings have practical implications for the design of single-handle hand tools but may need further validation for specific contexts of use.

Upper body position analysis of different experience level surgeons during laparoscopic suturing maneuvers using optical motion capture

BACKGROUND

This study aimed to analyze the posture patterns of surgeons with two different skill levels during laparoscopic surgery using an optical motion capture system.

METHODS

Twenty participants were divided into novice and expert groups. Their upper body motions during suturing tasks were captured, including average angle and angle variability (shoulder, elbow, wrist), joint fixation, head movement, and thoracolumbar flexion angle.

RESULTS

Our analysis showed that (1) the arms of the expert surgeons were more loosely held at their sides by about 7°; (2) their elbows were more bent by about 10°; (3) they had a greater change in shoulder angle by about 1.4 times and a more fluid posture; (4) their heads were more stable, particularly in the longitudinal and vertical axes; and (5) their thoracolumbar flexion angle was smaller by about 10°.

CONCLUSIONS

The posture patterns of different technical level surgeons during laparoscopic suturing maneuvers revealed differences in limb positions. These results may provide new insights into the efficient acquisition of technical skills and reduced physical stress during laparoscopic surgery.

Research on Key Indicators in Modern Surgical Practice Assessment: Ergonomic Approach

It is undeniable that fundamental requirements in surgery refer to the adequate use of medical knowledge (eg, clinical knowledge and technical skills). However, this knowledge and skills of surgeons should be supplemented with synergetic research of capabilities of surgeons, operating rooms (ORs), and nontechnical skills. In this article, by using expert research, we presented 15 key indicators in surgical practice assessment. Communication efficiency in the OR has been ranked as the first and most important among indicators using the fuzzy analytic hierarchy process method. Within the analysis of this indicator, we have shown a new method that provided us with the results describing the extent of communication, the correlation in the communication system, surgeon workload uniformity, and isolation of individual surgeons in the OR. The goal of this research is aimed at the increase of operator efficiency in the OR. It is necessary that results of this kind of research find their practical use and become an obligatory element in the construction of new ORs as well as reconstruction of old ORs.

A hand-held robotic device for peripheral intravenous catheterization

Intravenous catheterization is frequently required for numerous medical treatments. However, this process is characterized by a high failure rate, especially when performed on difficult patients such as newborns and infants. Very young patients have small veins, and that increases the chances of accidentally puncturing the catheterization needle directly through them. In this article, we present the design, development and experimental evaluation of a novel hand-held robotic device for improving the process of peripheral intravenous catheterization by facilitating the needle insertion procedure. To our knowledge, this design is the first hand-held robotic device for assisting in the catheterization insertion task. Compared to the other available technologies, it has several unique advantages such as being compact, low-cost and able to reliably detect venipuncture. The system is equipped with an electrical impedance sensor at the tip of the catheterization needle, which provides real-time measurements used to supervise and control the catheter insertion process. This allows the robotic system to precisely position the needle within the lumen of the target vein, leading to enhanced catheterization success rate. Experiments conducted to evaluate the device demonstrated that it is also effective to deskill the task. Naïve subjects achieved an average catheterization success rate of 88% on a 1.5 mm phantom vessel with the robotic device versus 12% with the traditional unassisted system. The results of this work prove the feasibility of a hand-held assistive robotic device for intravenous catheterization and show that such device has the potential to greatly improve the success rate of these difficult operations.

The "Body Mass Index" of Flexible Ureteroscopes

OBJECTIVE

To assess the "body mass index" (BMI) (weight and length) of 12 flexible ureteroscopes (digital and fiber optic) along with the light cables and camera heads, to make the best use of our instruments.

MATERIALS AND METHODS

Twelve different brand-new flexible ureteroscopes from four different manufacturers, along with eight camera heads and three light cables were evaluated. Each ureteroscope, camera head, and light cable was weighted; the total length of each ureteroscope, shaft, handle, flexible end-tip, and cable were all measured.

RESULTS

According to our measurements (in grams [g]), the lightest ureteroscope was the LithoVue (277.5 g), while the heaviest was the URF-V2 (942.5 g). The lightest fiber optic endoscope was the Viper (309 g), while the heaviest was the Cobra (351.5 g). Taking into account the entirety of the endoscopes, the lightest ureteroscope was the Lithovue and the heaviest was the Wolf Cobra with the Wolf camera "3 CHIP HD KAMERA KOPF ENDOCAM LOGIC HD" (1474 g). The longest ureteroscope was the URF-P6 (101.6 cm) and the shortest was the LithoVue (95.5 cm); whereas the Viper and Cobra had the longest shaft (69 cm) and URF-V had the shortest shaft (67.2 cm). The URF-V2 had the longest flexible end-tip (7.6 cm), while the LithoVue had the shortest end-tip (5.7 cm) in both directions (up/down), while the URF-V had the shortest upward deflection (3.7 cm).

CONCLUSIONS

Newer more versatile digital endoscopes were lighter than their traditional fiber optic counterparts in their entirety, with disposable endoscope having a clear advantage over other reusable ureteroscopes. Knowing the "BMI" of our flexible ureteroscopes is an important information that every endourologist should always take into consideration.

Initial experience using a robotic-driven laparoscopic needle holder with ergonomic handle: assessment of surgeons' task performance and ergonomics

PURPOSE

The objective of this study is to assess the surgeons' performance and ergonomics during the use of a robotic-driven needle holder in laparoscopic suturing tasks.

METHODS

Six right-handed laparoscopic surgeons with different levels of experience took part in this study. Participants performed a set of three different intracorporeal suturing tasks organized in ten trials during a period of five weeks. Surgeons used both conventional (Conv) and robotic (Rob) laparoscopic needle holders. Precision using the surgical needle, quality of the intracorporeal suturing performance, execution time and leakage pressure for the urethrovesical anastomosis, as well as the ergonomics of the surgeon's hand posture, were analyzed during the first, fifth and last trials.

RESULTS

No statistically significant differences in precision and quality of suturing performance were obtained between both groups of instruments. Surgeons required more time using the robotic instrument than using the conventional needle holder to perform the urethrovesical anastomosis, but execution time was significantly reduced after training ([Formula: see text] 0.05). There were no differences in leakage pressure for the anastomoses carried out by both instruments. After training, novice surgeons significantly improved the ergonomics of the wrist ([Formula: see text] 0.05) and index finger (Conv: 36.381[Formula: see text], Rob: 30.389[Formula: see text]; p = 0.024) when using the robotic instrument compared to the conventional needle holder.

CONCLUSIONS

Results have shown that, although both instruments offer similar technical performance, the robotic-driven instrument results in better ergonomics for the surgeon's hand posture compared to the use of a conventional laparoscopic needle holder in intracorporeal suturing.

The impact of intraoperative microbreaks with exercises on surgeons: A multi-center cohort study

Recent literature has demonstrated ergonomic risk to surgeons in the operating room. One method used in other industries to mitigate these ergonomic risks is the incorporation of microbreaks. Thus, intraoperative microbreaks with exercises in a non-crossover design were studied. Fifty-six attending surgeons from 4 Medical Centers volunteered first in a day of their regular surgeries and then second day where there were microbreaks with exercises that could be performed in the sterile field, answering questions after each case, without significantly increasing the duration of their surgeries. Surgeons self-reported improvement or no change in their mental focus (88%) and physical performance (100%) for the surgical day incorporating microbreaks with exercises. Discomfort in the shoulders was significantly reduced while distractions and flow impact was minimal. Eighty-seven percent of the surgeons wanted to incorporate the microbreaks with exercises into their OR routine. Intraoperative microbreaks with exercises may be a way to mitigate work-related musculoskeletal fatigue, pain and injury.

Ergonomics of laparoscopic graspers and the importance of haptic feedback: the surgeons' perspective

Haptic feedback is drastically reduced in laparoscopic surgery compared to open surgery. Introducing enhanced haptic feedback in laparoscopic instruments might well improve surgical safety and efficiency. In the design process of a laparoscopic grasper with enhanced haptic feedback, handle design should be addressed to strive for optimal usability and comfort. Additionally, the surgeons’ perspective on the potential benefits of haptic feedback should be assessed to ascertain the clinical interest of enhanced haptic feedback. A questionnaire was designed to determine surgeons’ use and preferences for laparoscopic instruments and expectations about enhanced haptic feedback. Surgeons were also asked whether they experience physical complaints related to laparoscopic instruments. The questionnaire was distributed to a group of laparoscopic surgeons based in Europe. From the 279 contacted subjects, 98 completed the questionnaire (response rate 35 %). Of all respondents, 77 % reported physical complaints directly attributable to the use of laparoscopic instruments. No evident similarity in the main preference for graspers was found, either with or without haptic feedback. According to respondents, the added value of haptic feedback could be of particular use in feeling differences in tissue consistencies, feeling the applied pressure, locating a tumor or enlarged lymph node, feeling arterial pulse, and limiting strain in the surgeon’s hand. This study stresses that the high prevalence of physical complaints directly related to laparoscopic instruments among laparoscopic surgeons is still relevant. Furthermore, the potential benefits of enhanced haptic feedback in laparoscopic surgery are recognized by laparoscopic specialists. Therefore, haptic feedback is considered an unmet need in laparoscopy.

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.