The ergonomic impact of patient body mass index on surgeon posture during simulated laparoscopy

Impact of morbid obesity on surgical and oncological outcomes in patients with endometrial cancer undergoing robotic assisted laparoscopic hysterectomy and pelvic lymph node staging

INTRODUCTION

Minimally invasive surgery is the preferred surgical approach in endometrial cancer. Robotic assisted laparoscopy could provide benefits in the obese population.

OBJECTIVE

To compare surgical and oncological outcomes between patients with a BMI < 35 kg/m2 (Group 1) and those with a BMI ≥ 35 kg/m2 (Group 2) who underwent robotic assisted laparoscopic total non-conservative hysterectomy with pelvic lymph node staging for endometrial cancer.

MATERIAL AND METHODS

This retrospective monocentric study was conducted at Saint-Louis University Hospital in Paris. The two groups were compared using a univariate analysis.

RESULTS

52 patients were included, 39 patients in Group 1 and 13 patients in Group 2. Operative room occupancy time and operative time were significantly longer in Group 2 than in Group 1 (255.1 min ± 57.0 vs 210.5 min ± 38.3, p = 0.02 and 166.8 min ± 39.7 vs 139.6 min ± 35.3, p = 0.04 respectively). No significant difference was found in length of hospital stay between the 2 groups even if it appears that patients in Group 2 had slightly longer hospitalization than patients in Group 1 (2 days vs 1 day). Only one complication (laparotomy conversion for digestive injury) was observed in Group 2. No significant difference was found in recurrence between the 2 groups.

DISCUSSION

Severe morbid obesity does not affect surgical morbidity or oncological outcomes in women with endometrial cancer who underwent robotic-assisted laparoscopic hysterectomy, bilateral adnexectomy, and pelvic lymph node staging. Optimizing operating room occupancy management must be improved in this patient population.

The Burden of Revision Arthroplasty: An Ergonomic Analysis of Surgeon Posture in the Operating Room

BACKGROUND

Revision total joint arthroplasties are physically demanding cases. Recent studies have shown increased cardiovascular stress in surgeons performing revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA) compared with primary cases. To our knowledge, no study has compared surgeon ergonomics during these cases. The purpose of this study was to analyze surgeon posture during primary and revision THA and TKA.

METHODS

We prospectively evaluated 286 consecutive cases (103 primary TKAs, 95 primary THAs, 57 rTKAs, and 31 rTHAs) performed by three high-volume, fellowship-trained arthroplasty surgeons. Throughout each case, surgeons wore a posture-tracking device to evaluate time spent slouching. The threshold for slouching was set to 30 degrees of flexion from the neutral spinal axis. Demographic and surgical factors were collected. Two-tailed t-tests and multivariate analysis were used to assess differences between groups.

RESULTS

After controlling for individual differences in posture, we found an increase in percentage and duration of time spent slouching between rTHA and primary THA cases (58.9% vs. 43.2%, P < 0.001; 65.1 vs. 32.6 minutes, P < 0.001). In the multivariate analysis, patient body mass index and rTHA were found to be an individual contributor to slouching percentage in THAs (P = 0.001). We found increased duration of time spent slouching between rTKA and primary TKA (80.2 vs. 45.7 minutes, P < 0.001); however, percentage time slouching showed no difference (67.1% vs. 58.5%, P = 0.175). Active fellow involvement was an individual contributor to decreased time slouching in both TKA and THA groups (P < 0.001).

CONCLUSIONS

Surgeons performing revision total joint arthroplasty spend markedly more case time in a slouched posture compared with primary arthroplasty, particularly in patients with a higher body mass index. Awareness of the surgical and patient factors that can affect posture in TKAs and THAs can help arthroplasty surgeons gain more awareness about injury prevention and potentially help prolong their career.

Physical and psychological impact of surgery on the operating surgeon

The impact of surgery on the surgeon's well-being encompasses both physical and psychological aspects. Physically, surgeons are at risk of work-related musculoskeletal symptoms due to the nature of their work, and this risk can be impacted by theater environment, equipment design, and workload. Many symptoms will be self-limiting, but work related musculoskeletal symptoms can lead to the development of an injury, which can have far reaching effects, including the need for medical or surgical treatment, time away from work, or a change in clinical duties. Additionally, surgery can place a significant cognitive workload on the lead operator and this can be exacerbated, or alleviated, by the surgical environment, experience of the assistance, surgical modality, and case complexity. Measuring and quantifying the impact of surgery on the surgeon is a challenging undertaking. Tools such as motion capture, physiological markers, including heart rate variability and salivary cortisol, and questionnaires can provide insights into understanding the overall impact of surgery on the surgeon. A holistic approach that incorporates injury prevention strategies, communication, and support, is vital in assessing and mitigating risk factors. Injury prevention assessment tools and interventions that can be used within the busy surgical environment are needed, alongside increased ergonomic awareness. Addressing the impact of surgery on the surgeon is a multifaceted challenge, and long term positive changes can only be sustained with the support of the whole surgical team and healthcare organizations by developing and maintaining a supportive working environment.

Robotic-assisted surgery in high-risk surgical patients with endometrial cancer

Many patients diagnosed with an endometrial cancer are at high-risk for surgery due to factors such as advanced age, raised body mass index or frailty. Minimally-invasive surgery, in particular robotic-assisted, is increasingly used in the surgical management of endometrial cancer however, there are a lack of clinical trials investigating outcomes in high-risk patient populations. This article will review the current evidence and identify areas of uncertainty where future research is needed.

Robot-assisted laparoscopy does not have demonstrable advantages over conventional laparoscopy in endometriosis surgery: a systematic review and meta-analysis

BACKGROUND

Endometriosis is a chronic condition affecting 6-10% of women of reproductive age, with endometriosis-related pain and infertility being the leading symptoms. Currently, the gold standard treatment approach to surgery is conventional laparoscopy (CL); however, the increasing availability of robot-assisted surgery is projected as a competitor of CL. This study aimed to compare the perioperative outcomes of robot-assisted laparoscopy (RAL) and CL in endometriosis surgery.

OBJECTIVES

We aimed to compare the effectiveness and safety of these two procedures.

METHODS

A systematic search was conducted in three medical databases. Studies investigating different perioperative outcomes of endometriosis-related surgeries were included. Results are presented as odds ratios (OR) or mean differences (MD) with 95% confidence intervals (CI).

RESULTS

Our search yielded 2,014 records, of which 13 were eligible for data extraction. No significant differences were detected between the CL and RAL groups in terms of intraoperative complications (OR = 1.07, CI 0.43-2.63), postoperative complications (OR = 1.3, CI 0.73-2.32), number of conversions to open surgery (OR = 1.34, CI 0.76-2.37), length of hospital stays (MD = 0.12, CI 0.33-0.57), blood loss (MD = 16.73, CI 4.18-37.63) or number of rehospitalizations (OR = 0.95, CI 0.13-6.75). In terms of operative times (MD = 28.09 min, CI 11.59-44.59) and operating room times (MD = 51.39 min, CI 15.07-87.72;), the RAL technique remained inferior.

CONCLUSION

RAL does not have statistically demonstrable advantages over CL in terms of perioperative outcomes for endometriosis-related surgery.

Advances in objective assessment of ergonomics in endoscopic surgery: a review

Background

Minimally invasive surgery, in particular endoscopic surgery, has revolutionized the benefits for patients, but poses greater challenges for surgeons in terms of ergonomics. Integrating ergonomic assessments and interventions into the multi-stage endoscopic procedure contributes to the surgeon's musculoskeletal health and the patient's intraoperative safety and postoperative recovery.

Objective

The purpose of this study was to overview the objective assessment techniques, tools and assessment settings involved in endoscopic procedures over the past decade and to identify the potential factors that induce differences in high workloads in endoscopic procedures and ultimately to design a framework for ergonomic assessment in endoscopic surgery.

Methods

Literature searches were systematically conducted in the OVID, pubmed and web of science database before October 2022, and studies evaluating ergonomics during the process of endoscopic procedures or simulated procedures were both recognized.

Results

Our systematic review of 56 studies underscores ergonomic variations in endoscopic surgery. While endoscopic procedures, predominantly laparoscopy, typically incur less physical load than open surgery, extended surgical durations notably elevate ergonomic risks. Surgeon characteristics, such as experience level and gender, significantly influence these risks, with less experienced and female surgeons facing greater challenges. Key assessment tools employed include electromyography for muscle fatigue and motion analysis for postural evaluation.

Conclusion

This review aims to provide a comprehensive analysis and framework of objective ergonomic assessments in endoscopic surgery, and suggesting avenues for future research and intervention strategies. By improving the ergonomic conditions for surgeons, we can enhance their overall health, mitigate the risk of WMSDs, and ultimately improve patient outcomes.

Impact of Patient Body Mass Index on Post-Operative Recovery from Robotic-Assisted Hysterectomy

A longitudinal, descriptive, prospective, and prolective study of individuals with endometrial or cervical cancer/pre-cancer diagnoses and high BMI (over 35 kg/m2) undergoing RH was conducted. Of the 53 participants recruited, 3 (6%) were converted to open surgery. The 50 RH participants had median BMI 42 kg/m2 (range 35 to 60): the range 35-39.9 kg/m2 had 17 cases; the range 40-44.9 kg/m2 had 15 cases; 45-49.9 kg/m2 8 cases; and those ≥50 kg/m2 comprised 10 cases. The mean RH operating time was 128.1 min (SD 25.3) and the median length of hospital stay was 2 days (range 1-14 days). Increased BMI was associated with small, but statistically significant, increases in operating time and anaesthetic time, 65 additional seconds and 37 seconds, respectively, for each unit increase in BMI. The median self-reported time for individuals who underwent RH to return to their pre-operative activity levels was 4 weeks (range 2 to >12 weeks). There was a significant improvement in pain and physical independence scores over time (p = 0.001 and p < 0.001, respectively) and no significant difference in scores for overall QOL, pain, or physical independence scores was found between the BMI groups. Patient-reported recovery and quality of life following RH is high in individuals with high BMI (over 35 kg/m2) and does not appear to be impacted by the severity of obesity.

Growing pains: strategies for improving ergonomics in minimally invasive gynecologic surgery

PURPOSE OF REVIEW

To evaluate factors contributing to the development of work-related musculoskeletal disorders (WMSDs) and review strategies for mitigating ergonomic strain in minimally invasive gynecologic surgery.

RECENT FINDINGS

Factors associated with increased ergonomic strain and the development of WMSDs include increasing patient body mass index (BMI), smaller surgeon hand size, noninclusive design of instruments and energy devices and improper positioning of surgical equipment. Each type of minimally invasive surgery (laparoscopic, robotic, vaginal) confers its own ergonomic risk to the surgeon. Recommendations have been published regarding optimal ergonomic surgeon and equipment positioning. Intraoperative breaks and stretching are effective in reducing surgeon discomfort. Formal training in ergonomics has not yet been widely implemented, but educational interventions have been effective in reducing surgeon discomfort and can improve surgeon recognition of suboptimal ergonomics.

SUMMARY

Considering the serious downstream effects of WMSDs on surgeons, it is imperative to implement strategies for WMSD prevention. Optimal positioning of the surgeons and operative equipment should be routine. Intraoperative breaks and stretching should be incorporated during procedures and between every case. Formal education in ergonomics should be provided to surgeons and trainees. Additionally, more inclusive instrument design by industry partners should be prioritized.

Impact of minimally invasive surgery on surgeon health (ISSUE) study: protocol of a single-arm observational study conducted in the live surgery setting

INTRODUCTION

The rapid evolution of minimally invasive surgery has had a positive impact on patient outcomes; however, it is reported to be associated with work-related musculoskeletal symptoms (WMS) in surgeons. Currently there is no objective measure to monitor the physical and psychological impact of performing a live surgical procedure on the surgeon.

METHODS AND ANALYSIS

A single-arm observational study with the aim of developing a validated assessment tool to quantify the impact of surgery (open/laparoscopic/robotic-assisted) on the surgeon. Development and validation cohorts of major surgical cases of varying levels of complexity performed by consultant gynaecological and colorectal surgeons will be recruited. Recruited surgeons wear three Xsens DOT monitors (muscle activity) and an Actiheart monitor (heart rate). Salivary cortisol levels will be taken and questionnaires (WMS and State-Trait Anxiety Inventory) completed by the participants preoperatively and postoperatively. All the measures will be incorporated to produce a single score that will be called the 'S-IMPACT' score.

ETHICS AND DISSEMINATION

Ethical approval for this study has been granted by the East Midlands Leicester Central Research Ethics Committee REC ref 21/EM/0174. Results will be disseminated to the academic community through conference presentations and peer-reviewed journal publications. The S-IMPACT score developed within this study will be taken forward for use in definitive multicentre prospective randomised control trials.

Chairless Chairs for Orthopedic Surgery Purpose – A Literature Review

Musculoskeletal disorders are often found in various types of work, including surgeons. Standing working position is immobile and rigid when performing surgical operations. The equipment used is less ergonomic which is the main parameter. The surgeon profession belongs to the category of the high-risk profession and has the potential to experience musculoskeletal disorders. Surgeons who suffer musculoskeletal disorders sense disease start from mild-to-severe due to the muscles receiving static loads frequently in the long-term. The emergence of musculoskeletal disorders can be caused by working environment conditions and standing position while working, causing injury to joints, vertebral discs, nerves, cartilage, tendons, and muscles. This paper describes in extensive the potential for reducing musculoskeletal problems with the use of a chairless chair for surgeons in carrying out operations. Musculoskeletal problems in surgery and the use of chairless chairs have been further explored to close the existing research gap.

An Ergonomic Assessment of Different Postures and Children Risk during Evacuations

Crawling is recommended for avoiding high heat and toxic fumes and for obtaining more breathable air during evacuations. Few studies have evaluated the effects of crawling on physical joints and velocity, especially in children. Based on motion capture technology, this study proposes a novel method of using wearable sensors to collect exposure (e.g., mean duration, frequency) on children’s joints to objectively quantify the impacts of different locomotion methods on physical characteristics. An on-site experiment was conducted in a kindergarten with 28 children (13 boys and 15 girls) of different ages (4–6 years old) who traveled up to 22 m in three different postures: upright walking (UW), stoop walking (SW), and knee and hand crawling (KHC). The results showed that: (1) The level of joint fatigue for KHC was heavier than bipedal walking (p < 0.05), which was evidenced by higher mean duration and frequency. There was no significant difference between UW and SW (p > 0.05). (2) The physical characteristics of the children in the different postures observed in this study were different (p < 0.05). The ankle was more fatigued than other joints during bipedal walking. Unlike infants, the wrists and hips of the children became fatigued while crawling. The key actions flexion/extension are more likely to induce joint fatigue vs. other actions. (3) Crawling velocity was significantly slower than the bipedal velocities, and UW was 10.6% faster than SW (p < 0.05). The bipedal walking velocity started to decrease after the children had travelled up to 13 m, while the KHC velocity started to decrease after traveling up to 11.6 m. (4) In a severe fire, the adoption of SW is suggested, as the evacuees can both evacuate quickly and avoid overworking their joints. (5) There were no significant differences in the age (p > 0.05) and gender (p > 0.05) of the children on the joints in any of the three postures. To conclude, KHC causes more damage to body joints compared to bipedal walking, as evidenced by higher exposure (mean duration, frequency), whereas UW and SW are similar in terms of the level of joint fatigue. The above findings are expected to provide a useful reference for future applications in the children’s risk assessment and in the prevention design of buildings.

Objective assessment of surgeon kinematics during simulated laparoscopic surgery: a preliminary evaluation of the effect of high body mass index models

Purpose

Laparoscopy is used in many surgical specialties. Subjective reports have suggested that performing laparoscopic surgery in patients with a high body mass index (BMI) is leading to increased prevalence of musculoskeletal symptoms in surgeons. The aim of this study was to objectively quantify the impact on surgeon upper body kinematics and dynamic workload when performing simulated laparoscopy at different BMI levels.

Methods

Upper body kinematics and dynamic workload of novice, intermediate and expert surgeons were calculated based on measurements from inertial measurement units positioned on upper body segments. Varying thicknesses of foam were used to simulate patient BMIs of 20, 30, 40 and 50 kg/m² during laparoscopic training.

Results

Significant increases in the jerkiness, angular speed and cumulative displacement of the head, torso and upper arms were found within all experience groups when subject to the 40 and 50 kg/m² models. Novice surgeons were found to have less controlled kinematics and larger dynamic workloads compared to the more experienced surgeons.

Conclusions

Our findings indicate that performing laparoscopic surgery on a high BMI model worsens upper body motion efficiency and efficacy, and increases dynamic workload, producing conditions that are more physically demanding when compared to operating on a 20 kg/m² model. These findings also suggest that the head, torso, and upper arm segments are especially affected by high BMI models and therefore exposure to patients with high BMIs may increase the risk of musculoskeletal injury when performing laparoscopic surgery.