Surgeons' physical workload in open surgery versus robot-assisted surgery and nonsurgical tasks

Identification of surgical human-robot interactions and measures during robotic-assisted surgery: A scoping review

This study aims to identify the dynamics of robotic-assisted surgery (RAS) teams and their metrics. A scoping review across seven science, engineering, and clinical databases was conducted. It was found that literature focuses on skills and interactions centralized around the surgeon and technical components of the robotic system; however, limited literature exists on skill proceduralization specific for other surgical team members performing robotic-assisted surgery procedures. A framework that identifies the individuals (i.e., surgeon, surgical team members, and robotic platform), with their respective skill requirements (technical and nontechnical), and the required interactions among the team and RAS systems was developed. Future research in RAS human-robot interaction can address the need to understand changing dynamics and skills required by the surgical team with the continuing evolution and adoption of surgical robot technology.

Strain on the surgeon: a systematic review of the methods of measuring strain in abdominal and thoracic surgery

INTRODUCTION

Surgery can be arduous to the operating surgeon - both in terms of cognitive and physical strain. Ergonomic strain has been recognised to drive absenteeism, reduce career longevity and cause injuries. This systematic review aims to 1. Outline the nature of ergonomic strain in the context of abdominal and thoracic surgery, regardless of surgical approach 2. Identify the qualitative and quantitative measures of surgical strain.

METHODS

A systematic review was conducted using Pubmed, MEDLINE and Ovid EMBASE databases (date range: 1990 to Sep 2024). Of the initial 1288 articles identified, a final 71 studies were included in this review (quantitative measures = 36, qualitative measures = 49, of which 14 studies overlapped with the papers reviewed in the quantitative measures section).

RESULTS

The quantitative measures used to measure ergonomic strain included electromyography, electrocardiography, gravimetric position sensors, skin conductance and inertial measurement units. Laparoscopic surgery caused less physical strain than open surgery, however more cognitive strain during the learning curve. Robotic surgery yielded conflicting data in terms of muscle activation when compared to laparoscopic surgery however reported less cognitive and cardiovascular strain. The qualitative measures of strain included a range of self-reported questionnaires, demonstrating important gender differences and scores that typically correlated with objective physical strain.

DISCUSSION

The studies show wide variation in measuring ergonomic strain. Avenues for further research include measuring the impact of learning curves, patient factors on ergonomic strain and the impact of gender.

Reliability and Accuracy of Standard Reference Procedures for Measurements of Trunk and Arm Postures in Ergonomics

Adequate reference procedures for obtaining the reference zero-angle position are important for precise and accurate posture measurements, but few studies have systematically investigated these. A limited number of previous studies suggest differences in accuracy between procedures, with some causing an underestimation of the true arm elevation angle when sensors are taped to the skin. The reliability of commonly used reference procedures for the measurement of the trunk posture is also not well explored, and alternative procedures may improve precision. Based on this identified gap, this study evaluated the test-retest reliability of the N-position (I-pose), i.e., the standard procedure for recording trunk postures, and compared it with two new alternative procedures. Additionally, the accuracy of the N-position for measuring arm elevation angles was compared with one alternative procedure. A total of 40 participants (22 women and 18 men) aged 26-70 years performed the reference procedures in a laboratory setting. Postures were recorded using a smart workwear system equipped with two inertial measurement units (IMUs) embedded in pockets within the workwear. For the trunk posture, the N-position showed a slight lack of test-retest reliability, while one of the alternative procedures demonstrated better test-retest reliability. For the arm posture, the N-position, which does not include lateral trunk inclination, resulted in a substantial underestimation of the arm elevation angle of approximately 15°, which is a novel finding. In contrast, the posture involving trunk inclination closely matched the targeted reference, with a difference of less than 2°. This study underscores the importance of selecting appropriate reference procedures to ensure precise and accurate posture measurements.

The Use of Wearable Systems for Assessing Work-Related Risks Related to the Musculoskeletal System-A Systematic Review

Work-related musculoskeletal disorders (WRMSDs) are a leading cause of chronic conditions among working-age adults. Preventing these disorders is crucial to reducing their impact, and quantitative analysis through sensors can help identify their causes and guide ergonomic solutions. This systematic review aims to compile research from 2000 to 2023 published in English and sourced from Web of Science, Scopus, or PubMed that examines workers' movements during tasks using wearable sensor systems that are applicable in workplace settings. The goal is to identify the job sectors that have been studied and highlight tasks lacking ergonomic risk research. A total of 111 papers were selected through a screening process across three databases, assessed using the McMaster risk of bias tool. The studies span various job sectors and report on the use of different technologies for data collection and study population sizes. The review identifies existing research on WRMSD risks utilizing wearable systems in different job sectors, drawing attention to under-researched areas that warrant further study. It serves as a foundation for future research aimed at understanding the causes of WRMSDs and developing solutions supported by wearable technologies to mitigate these risks.

The role of ergonomics training and posture exercises in surgeons' musculoskeletal system disorders

Objectives

The surgeon needs to understand the risks involved in performing surgery with ergonomic errors. Although there are many barriers to ergonomic effectiveness, success begins with the surgeon's awareness, recognition of existing obstacles, and education. The main purpose of the study is to evaluate the effect of ergonomic training and posture exercises on the surgeon's pain, physical workload, psychological state, and quality of life to prevent musculoskeletal system disorders and extend career life.

Material and Methods

Surgeons who had completed at least one year in their profession, worked an average of 40 hours a week, had musculoskeletal pain in at least one area, and volunteered to participate in the study, regardless of gender and age, were included in the study. Researchers carried out the ergonomics training and exercise program individually by giving face-to-face training. Surgeons were asked to complete the physical workload questionnaire (PWQ), Beck depression index (BDI), and short form health survey (SF-36) before and one month after the study. Changes in visual analogue scale (VAS) and activities of daily living were recorded.

Results

Surgeons who received ergonomic training and exercise programs showed significant improvements in pain, physical workload, depression, and quality of life measurements.

Conclusion

To prevent fatigue and pain resulting from the accumulation of ergonomic flaws, surgeons should be trained and guided on proper posture and endurance, and encouraged to maintain a comfortable and natural posture.

Intraoperative workload of the surgeon in robot-assisted radical prostatectomy: a systematic review

In the present study, we aimed to systematically evaluate the current evidence regarding the intraoperative workload of surgeons performing robot-assisted radical prostatectomy (RARP) for prostate cancer. A systematic search was carried out in the PubMed-MEDLINE and Web of Science databases through April 2024 using the following search terms: "workload AND robot assisted radical prostatectomy", "workload AND robotic radical prostatectomy", "task load AND robotic radical prostatectomy", "task load AND robot assisted radical prostatectomy" and "NASA-TLX AND robot assisted radical prostatectomy" by combining population, intervention, comparison, and outcome (PICO) terms, following preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. We therefore selected studies that included patients with prostate cancer (P) who underwent robotic radical prostatectomy (I) and reported a workload/task load questionnaire (C) to assess the intraoperative workload/task load of the surgeon performing robot-assisted radical prostatectomy (O). A total of 11 studies were identified. The surgeon's workload during RARP was assessed using the National Aeronautics and Space Administration task load index (NASA-TLX) and/or the surgery task load index (SURG-TLX) in the studies. Total NASA-TLX scores of the studies ranged from 22.7 ± 3.2 to 62.0 ± 6.4. Mental and physical demands, flow interruptions, surgeon experience, the use of single or multiple ports, and the relationship between the surgeon and other staff in the operating theater may play a role in the intraoperative workload of the console surgeon. The studies we reviewed suggest that RARP offers an acceptable workload for the console surgeon despite its mental demands.

Frequency of breaks, amount of muscular rest, and sustained muscle activity related to neck pain in a pooled dataset

BACKGROUND

Neck pain remains a persistent challenge in modern society and is frequently encountered across a wide range of occupations, particularly those involving repetitive and monotonous tasks. It might be expected that patterns of trapezius muscle activity at work, characterized by few breaks and prolonged periods of sustained muscle activity, are linked to neck pain. However, previous cross-sectional studies have generally failed to establish a definitive association. While some longitudinal studies have suggested that extended periods of heightened muscle activity could be a risk factor for neck pain, these findings often relied on limited participant numbers or specific professional groups. This study aimed to investigate the relationship between trapezius muscle activity and neck pain by pooling data from seven Scandinavian research institutes encompassing a diverse range of occupational backgrounds.

METHODS

Electromyographic (EMG) data for the upper trapezius muscle, collected during working hours, were coupled with questionnaire responses pertaining to neck pain, individual characteristics, and potential confounding variables for a total of 731 subjects. Additionally, longitudinal data from 258 subjects were available. The various EMG datasets were consolidated into a standardized format, and efforts were made to harmonize inquiries about neck pain. Regression analyses, adjusting for sex and height, were conducted to explore the associations between muscle activity variables and neck pain. An exposure index was devised to quantify the cumulative neck load experienced during working hours and to differentiate between various occupational categories.

RESULTS

The cross-sectional data displayed a distinct pattern characterized by positive associations for brief periods of sustained muscle activity (SUMA) and negative associations for prolonged SUMA-periods and neck pain. The longitudinal data exhibited a contrasting trend, although it was not as pronounced as the cross-sectional findings. When employing the exposure index, notable differences in cumulative muscle load emerged among occupational groups, and positive associations with longitudinal neck pain were identified.

DISCUSSION

The results suggest that individuals with neck pain experience higher cumulative workloads and extended periods of muscle activity over the long term. In the short term, they appear to compensate by taking frequent short breaks, resulting in a lower cumulative workload. Regardless of their occupation, it is crucial to distribute work breaks throughout the workday to ensure that the cumulative load remains manageable.

Robotically assisted deployment of flow diverter stents for the treatment of cerebral and cervical aneurysms

BACKGROUND

Despite the growing sophistication of robot-assisted surgery, it is necessary to demonstrate that robots can reliably perform complex procedures on site and then remotely. Although a flow diverter stent is one of the most effective and widely used devices, its placement is sometimes challenging.

OBJECTIVE

To evaluate the feasibility and safety of the CorPath GRX robotic platform for the embolization of cerebral and cervical aneurysms using flow diverter stents.

METHODS

We performed a single-center technical study of the first 10 flow diverter stent deployments with the CorPath GRX Robotic System (Corindus Inc, Waltham, Massachusetts, USA) for the treatment of cerebral aneurysms between April and October 2022.

RESULTS

Ten patients underwent robot-assisted embolization with flow diverter stents: there were nine intracranial aneurysms (paraclinoid n=6; posterior communicating artery aneurysm n=1; anterior communicating artery n=2) and one cervical aneurysm. Four procedures were performed with coils plus a flow diverter stent, one was performed with woven endobridge plus a flow diverter stent and four were performed with flow diverter stents alone. Of these procedures, two were performed with telescoping flow diverters.All flow diverter stents were deployed with robotic assistance, with only one partial conversion to a manual technique (caused by guidewire torquability limitations). No perioperative complications were observed.

CONCLUSION

Robot-assisted flow diverter stent deployment using the CorPath GRX platform is feasible and appears to be safe. Larger, in-depth studies of the technique's safety and benefits are now warranted.

Making a Stand

OBJECTIVE

This is a review of the advertisements for basic surgical training course on social media and a comment on the ergonomics of the training.

DESIGN

The author examined social media advertisements (Twitter and Instagram) over 4 months with a focus on stitching courses. No computer algorithm was available or could be made to ensure a comprehensive inclusion of all courses.

RESULTS

One hundred nine basic surgical skills courses were identified, and 102 out of 109 (94%) courses are conducted sitting down. Courses were run in regular rooms or lecture theatres at regular table and using ordinary chairs.

CONCLUSION

The practice and acquisition of basic surgical skills needs to address correctness of the technique and ergonomics especially with regards to posture. This influences not only muscle memory and musculoskeletal health but also the position of the needle and potential trauma to the tissues.

Ergonomics and performance of using prismatic loupes in simulated surgical tasks among surgeons - a randomized controlled, cross-over trial

Introduction

Recently developed prismatic loupes may mitigate the high physical workload and risk of neck disorders associated with traditional surgical loupes among surgeons. However, research in this area, particularly among surgeons, is sparse. This study examines the impact of prismatic loupes on surgeons' physical workload, musculoskeletal discomfort, and performance during simulated surgical tasks.

Materials and methods

Nineteen out of twenty recruited surgeons performed three tasks in a fixed-order with their own loupes and both low-tilt (LT) and high-tilt (HT) prismatic loupes, in a randomized order. The primary outcomes were the median inclination angles and velocities of the head, trunk, and upper arms, along with the median muscle activity of the cervical erector spinae (CES), upper trapezius (UT), and lumbar erector spinae (LES) for each pair of loupes. The secondary outcomes included performance (completion time and errors), perceived body-part discomfort, and subjective evaluation of the three pairs of loupes.

Results

Using prismatic loupes, either LT or HT, compared with the surgeons' own loupes yielded lower head inclinations (all p < 0.001), lower neck muscle activity (all p < 0.05), and lower neck discomfort in indirect comparisons (p < 0.01) with no significant difference in surgical errors (p = 0.628). However, HT loupes resulted in a longer task completion time in two tasks (p < 0.001). Most surgeons preferred LT loupes (N = 12) for their comfort and visual functions.

Discussion

The results indicate that prismatic loupes can reduce physical workload in the neck during simulated surgical task, with no significant difference in surgical errors. Future studies are needed to investigate the long-term effects of prismatic loupes among surgeons.

The benefits of haptic feedback in robot assisted surgery and their moderators: a meta-analysis

Robot assisted surgery (RAS) provides medical practitioners with valuable tools, decreasing strain during surgery and leading to better patient outcomes. While the loss of haptic sensation is a commonly cited disadvantage of RAS, new systems aim to address this problem by providing artificial haptic feedback. N = 56 papers that compared robotic surgery systems with and without haptic feedback were analyzed to quantify the performance benefits of restoring the haptic modality. Additionally, this study identifies factors moderating the effect of restoring haptic sensation. Overall results showed haptic feedback was effective in reducing average forces (Hedges' g = 0.83) and peak forces (Hedges' g = 0.69) applied during surgery, as well as reducing the completion time (Hedges' g = 0.83). Haptic feedback has also been found to lead to higher accuracy (Hedges' g = 1.50) and success rates (Hedges' g = 0.80) during surgical tasks. Effect sizes on several measures varied between tasks, the type of provided feedback, and the subjects' levels of surgical expertise, with higher levels of expertise generally associated with smaller effect sizes. No significant differences were found between virtual fixtures and rendering contact forces. Implications for future research are discussed.

Wearable Motion Capture Devices for the Prevention of Work-Related Musculoskeletal Disorders in Ergonomics-An Overview of Current Applications, Challenges, and Future Opportunities

Work-related musculoskeletal disorders (WMSDs) are a major contributor to disability worldwide and substantial societal costs. The use of wearable motion capture instruments has a role in preventing WMSDs by contributing to improvements in exposure and risk assessment and potentially improved effectiveness in work technique training. Given the versatile potential for wearables, this article aims to provide an overview of their application related to the prevention of WMSDs of the trunk and upper limbs and discusses challenges for the technology to support prevention measures and future opportunities, including future research needs. The relevant literature was identified from a screening of recent systematic literature reviews and overviews, and more recent studies were identified by a literature search using the Web of Science platform. Wearable technology enables continuous measurements of multiple body segments of superior accuracy and precision compared to observational tools. The technology also enables real-time visualization of exposures, automatic analyses, and real-time feedback to the user. While miniaturization and improved usability and wearability can expand the use also to more occupational settings and increase use among occupational safety and health practitioners, several fundamental challenges remain to be resolved. The future opportunities of increased usage of wearable motion capture devices for the prevention of work-related musculoskeletal disorders may require more international collaborations for creating common standards for measurements, analyses, and exposure metrics, which can be related to epidemiologically based risk categories for work-related musculoskeletal disorders.

A New Approach to Quantifying Muscular Fatigue Using Wearable EMG Sensors during Surgery: An Ergonomic Case Study

(1) Background: Surgeons are exposed to musculoskeletal loads that are comparable to those of industrial workers. These stresses are harmful for the joints and muscles and can lead to musculoskeletal disorders (MSD) and working incapacity for surgeons. In this paper, we propose a novel ergonomic and visualization approach to assess muscular fatigue during surgical procedures. (2) Methods: The activity of eight muscles from the shoulder girdle and the cervical/lumbar spines were evaluated using position and electromyographic wearable sensors while a surgeon performed an arthroscopic rotator-cuff surgery on a patient. The time and frequency-domain variables of the root-mean-square amplitude and mean power frequency, respectively, were calculated from an electromyographic signal. (3) Results: The entire surgical procedure lasted 73 min and was divided into 10 sub-phases associated with specific level of muscular activity and fatigue. Most of the muscles showed activity above 60%, while the middle trapezius muscles were almost constantly activated (>20%) throughout the surgical procedure. (4) Conclusion: Wearable sensors can be used during surgical procedure to assess fatigue. Periods of low-to-high activity and fatigue can be evaluated and visualized during surgery. Micro-breaks throughout surgical procedures are suggested to avoid fatigue and to prevent the risk of developing MSD.

Mental workload during endoscopic sinus surgery is associated with surgeons' skill levels

Introduction

Surgeons' mental workload during endoscopic sinus surgery (ESS) has not been fully evaluated. The assessment was challenging due to the great diversity of each patient's anatomy and the consequence variety of surgical difficulties. In this study, we examined the mental workload of surgeons with various surgical skill levels during ESS under the standardized condition provided by novel-designed 3D sinus models.

Materials and methods

Forty-seven participants performed a high-fidelity ESS simulation with 3D-printed sinus models. Surgeons' mental workload was assessed with the national aeronautics and space administration-task load index (NASA-TLX). Associations between the total and subscales score of NASA-TLX and surgical skill index, including the board certification status, the number of experienced ESS cases, and the objective structured assessment of technical skills (OSATS), were analyzed. In addition, 10 registrars repeated the simulation surgery, and their NASA-TLX score was compared before and after the repetitive training.

Results

The total NASA-TLX score was significantly associated with OSATS score (p = 0.0001). Primary component analysis classified the surgeons' mental burden into three different categories: (1) the skill-level-dependent factors (temporal demand, effort, and performance), (2) the skill-level-independent factors (mental and physical demand), and (3) frustration. After the repetitive training, the skill-level-dependent factors were alleviated (temporal demand; z = -2.3664, p = 0.0091, effort; z = -2.1704, p = 0.0346, and performance; z = -2.5992, p = 0.0017), the independent factors were increased (mental demand; z = -2.5992, p = 0.0023 and physical demand; z = -2.2509, p = 0.0213), and frustration did not change (p = 0.3625).

Conclusion

Some of the mental workload during ESS is associated with surgical skill level and alleviated with repetitive training. However, other aspects remain a burden or could worsen even when surgeons have gained surgical experience. Routine assessment of registrars' mental burdens would be necessary during surgical training to sustain their mental health.