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

A multi-institutional machine learning algorithm for prognosticating facial nerve injury following microsurgical resection of vestibular schwannoma

Vestibular schwannomas (VS) are the most common tumor of the skull base with available treatment options that carry a risk of iatrogenic injury to the facial nerve, which can significantly impact patients' quality of life. As facial nerve outcomes remain challenging to prognosticate, we endeavored to utilize machine learning to decipher predictive factors relevant to facial nerve outcomes following microsurgical resection of VS. A database of patient-, tumor- and surgery-specific features was constructed via retrospective chart review of 242 consecutive patients who underwent microsurgical resection of VS over a 7-year study period. This database was then used to train non-linear supervised machine learning classifiers to predict facial nerve preservation, defined as House-Brackmann (HB) I vs. facial nerve injury, defined as HB II-VI, as determined at 6-month outpatient follow-up. A random forest algorithm demonstrated 90.5% accuracy, 90% sensitivity and 90% specificity in facial nerve injury prognostication. A random variable (rv) was generated by randomly sampling a Gaussian distribution and used as a benchmark to compare the predictiveness of other features. This analysis revealed age, body mass index (BMI), case length and the tumor dimension representing tumor growth towards the brainstem as prognosticators of facial nerve injury. When validated via prospective assessment of facial nerve injury risk, this model demonstrated 84% accuracy. Here, we describe the development of a machine learning algorithm to predict the likelihood of facial nerve injury following microsurgical resection of VS. In addition to serving as a clinically applicable tool, this highlights the potential of machine learning to reveal non-linear relationships between variables which may have clinical value in prognostication of outcomes for high-risk surgical procedures.

Robotic assisted surgery reduces ergonomic risk during minimally invasive colorectal resection: the VOLCANO randomised controlled trial

PURPOSE

Minimally invasive surgery benefits patients but poor operating ergonomics causes musculoskeletal injuries in surgeons. This randomised controlled trial aims to assess whether robotic-assisted surgery with the open-console Versius® system can reduce surgeons' ergonomic risks during major colorectal resections.

METHODS

Prospectively registered at ClinicalTrials.gov (NCT05262296) in March 2022. Adult patients requiring a minimally invasive colorectal resection were potentially eligible. Photographs taken at 2-min intervals were analysed using the objective Rapid Entire Body Assessment (REBA) posture analysis scale to calculate intraoperative surgeon ergonomic risk. Secondary outcomes included team communication (Oxford NOTECHS II), surgeon cognitive strain (modified NASA-TLX scale), and clinical outcomes.

RESULTS

Sixty patients were randomised in a 2:1 ratio (40 robot, 20 laparoscopic). Mean age was 65yrs and 34 (57%) were male. Body Mass Index did not differ between the 2 groups (overall mean 29.0 ± 5) and there were equal proportions of left and right-colonic resections. REBA was significantly lower in the robotic arm (median robot REBA score 3 vs lap REBA 5 [p < 0.001]), equating to an injury risk category drop from "medium" to "low risk". There were no significant differences in team communication, operative duration, or patient outcomes. Surgeon cognitive strain was lower in robotic cases (mean robot 32.4 ± 10.3 vs lap 45.6 ± 14.3 [p < 0.001]).

CONCLUSIONS

This trial demonstrates that robotic surgery with an open-console system reduces ergonomic risk scores and cognitive strain during colorectal resections, with no apparent detriment to team communication. This may therefore be a safe & feasible solution to the increasing problem of work-related musculoskeletal injuries in surgeons.

Comparison of robotic versus laparoscopic surgery for visceral obesity in mid-low rectal cancer: a propensity-matched analysis

Obesity is becoming more and more common, and measuring visceral fat area (VFA) is a useful diagnostic technique for visceral obesity (VO). The purpose of this research is to compare the surgical results of robotic versus laparoscopic rectal surgery, with a focus on assessing the benefits of the latter method for treating both VO and mid-low rectal cancer. Patients receiving laparoscopic or robotic anterior rectal excision at Northern Jiangsu People's Hospital's general surgery department were included in the retrospective analysis. 242 people in all took part in the study; 121 cases were assigned to the robotic surgery (RS) group and another 121 cases to the laparoscopic surgery (LS) group. In comparison to LS, our results show that RS led to a shorter period for the recovery of bowel function (p = 0.03), a shorter hospital stay (p < 0.001), a smaller intraoperative blood loss (p < 0.001), and a shorter time until the commencement of oral intake (p = 0.041). However, there were no statistically significant differences between the two groups in terms of the indices of histopathologic specimens, the proportion of temporary loop ileostomy, and the incidence of early postoperative problems (p > 0.05). When patients with VO undergo surgery for rectal cancer, RS has the added benefit of accelerating patient recovery while producing results that are similar to LS in the near run.

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.

Recent Advances in Endometrial Cancer Prevention, Early Diagnosis and Treatment

Endometrial cancer is the sixth commonest cancer in women worldwide, with over 417,000 diagnoses in 2020. The disease incidence has increased by 132% over the last 30 years and is set to continue to rise in response to an ageing population and increasing global rates of obesity and diabetes. A greater understanding of the mechanisms driving endometrial carcinogenesis has led to the identification of potential strategies for primary disease prevention, although prospective evaluation of their efficacy within clinical trials is still awaited. The early diagnosis of endometrial cancer is associated with improved survival, but has historically relied on invasive endometrial sampling. New, minimally invasive tests using protein and DNA biomarkers and cytology have the potential to transform diagnostic pathways and to allow for the surveillance of high-risk populations. The molecular classification of endometrial cancers has been shown to not only have a prognostic impact, but also to have therapeutic value and is increasingly used to guide adjuvant treatment decisions. Advanced and recurrent disease management has also been revolutionised by increasing the use of debulking surgery and targeted treatments, particularly immunotherapy. This review summarises the recent advances in the prevention, diagnosis and treatment of endometrial cancer and seeks to identify areas for future research.

Inpatient opioid use and pain control after robotic versus laparoscopic sleeve gastrectomy

BACKGROUND

During the past decade, the proportion of bariatric surgery performed robotically has been rising. However, the clinical benefits of the robotic approach over laparoscopy are uncertain. One area in need of further investigation is pain control after robotic versus laparoscopic bariatric surgery.

METHODS

A retrospective cohort study was conducted of bariatric surgery patients undergoing laparoscopic or robotic sleeve gastrectomy at a single institution from October 2019 to August 2022. Inpatient opioid use was measured in morphine milliequivalents. Pain scores were collected by the nursing staff.

RESULTS

A total of 368 patients were included: 286 laparoscopic and 82 robotic surgery patients. The groups shared similar demographics. For the entire cohort, the mean age was 42 years, the body mass index was 50 kg/m2, and 79% were female. Mean operative time was significantly lower for laparoscopic surgeries (87.5 ± 47.3 minutes vs 109.3 ± 30.3 minutes; P < .01). The median total inpatient morphine milligram equivalents used was similar for both groups: 52.3 (31.5-77.0) for the laparoscopic group versus 40 (24-74.5) for robotic (P = .13). Mean postoperative pain scores (scale out of 10) were not significantly different between groups: 5.2 ± 1.7 (postoperative day 0) and 4.5 ± 1.7 (day 1) for laparoscopic patients versus 5.1 ± 2.0 (day 0) and 4.4 ± 1.8 (day 1) for robotic. The proportion of patients prescribed opioids at discharge was significantly higher for the laparoscopic group (75.2% vs 62.2%; P = .02). Other clinical outcomes, including duration of stay, 30-day readmissions, and visits to the emergency department, were not significantly different.

CONCLUSION

There is no difference in inpatient opioid use or pain scores between patients undergoing laparoscopic and robotic sleeve gastrectomy.

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.

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.

A Modified Purse-String Stapling Technique for Intracorporeal Circular Stapled Esophagojejunostomy During Laparoscopic Total Gastrectomy: Comparison with Extracorporeal Reconstruction Technique

Background: Intracorporeal esophagojejunostomy (EJ) in the context of laparoscopic total gastrectomy remains a complex and technically demanding procedure. We have previously introduced a novel method of intracorporeal circular stapled EJ utilizing a conventional purse-string suture instrument. Since May 2018, we have refined this technique, and the aim of this study was to assess its safety and efficacy. Methods: Between May 2018 and June 2022, we enrolled 92 patients who underwent laparoscopic total gastrectomy with the modified intracorporeal reconstruction method. In addition, between March 2014 and June 2022, we enrolled 121 patients who underwent the procedure with the extracorporeal reconstruction method. We retrospectively collected and compared the clinical data of these 2 patient cohorts. Results: Intracorporeal reconstruction group experienced lower postoperative pain scores (2.7 ± 1.3 versus 4.5 ± 1.4, P = .032), reduced administration of analgesics (3.1 ± 2.2 versus 5.0 ± 3.5, P = .041), and shorter postoperative hospital stays (4.9 ± 2.3 versus 6.3 ± 3.5, P = .045) compared with the extracorporeal reconstruction group. In addition, anastomotic time and postoperative pain score were not increased in the overweight patients in the intracorporeal reconstruction group. Anastomotic leakage occurred in 2 (2.2%) patients in the intracorporeal reconstruction group and 4 (3.3%) patients in the extracorporeal reconstruction group. Anastomotic stricture occurred in 1 (1.1% and 0.8%) patient in each group. There was no significant difference in the overall postoperative complication rate between the 2 groups. Conclusions: The modified intracorporeal purse-string stapling technique for EJ during laparoscopic total gastrectomy is a safe and viable option, exhibiting less invasiveness and comparable outcomes to the extracorporeal reconstruction method, especially suitable for obese patients.

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.

Musculoskeletal demands in microsurgery-an explorative study comparing the ergonomics of microscope and 3D exoscope

To assess neurosurgeons' physical demands and investigate ergonomic aspects when using microsurgical visualization devices. Six neurosurgeons performed micro-surgical procedures on cadaveric specimens using the prototype of a digital 3D exoscope system (Aeos®, Aesculap, Tuttlingen, Germany) and a standard operating microscope (Pentero 900, Zeiss, Oberkochen, Germany) at two different patient positions (semisitting (SS), supine (SP)). The activities of the bilateral upper trapezius (UTM), anterior deltoid (ADM), and lumbar erector spinae (LEM) muscles were recorded using bipolar surface electromyography and neck flexion, arm abduction, and arm anteversion angles by gravimetrical posture sensors. Perceived discomfort frequency was assessed and subjects compared the two systems in terms of usability, posture, physical and mental demands, and working precision. Using the exoscope led to reduced ADM activity and increased UTM and LEM activity during SS position. The neck was extended when using the exoscope system with lower arm anteversion and abduction angles during the SS position. Subjects reported discomfort at the shoulder-neck area less frequently and lower physical demands when using the Aeos®. However, mental demands were slightly higher and two subjects reported lower working precision. The exoscope system has the potential to reduce the activity of the ADM by changing surgeons arm posture which may be accompanied by less discomfort in the shoulder-neck area. However, dependent on the applied patient position higher muscle activities could occur in the UTM and LEM.

Reproductive Surgery in Females with Obesity: Reproductive Consequences of Obesity and Applications for Surgical Care

Obesity is the most common medical problem in women of reproductive age. The surgical applications for this population, many of who are interested in current or future fertility, are critical to safe and effective evaluation and management of issues that impact the reproductive system. As rates of obesity continue to rise worldwide, it is projected that one in two individuals will have obesity by 2030 leading to increasing numbers of individuals affected by a disease process that has implications for their gynecologic surgical care, fertility-related assessment, and infertility treatment. Offering patients with obesity access to safe reproductive surgery is a cornerstone of reproductive autonomy. This review will summarize current recommendations regarding surgical concepts for the operating room, office hysteroscopy, oocyte retrieval, and embryo transfer in female patients with obesity.

Beyond the learning curve: improving outcomes in Robotic myomectomy compared to laparoscopic myomectomy

Uterine myomas are benign tumours frequently seen in women of reproductive age. Myomectomy remains a viable option for treating this condition in women who wish to preserve their uterus. We undertook this study to compare the peri-operative surgical outcomes of Robotic myomectomy (RM) with laparoscopic myomectomy (LM) in Indian patients of uterine myomas after the initial learning curve of RM was achieved. A retrospective chart review was performed for the patients who underwent RM or LM for the treatment of uterine myomas. A total of 177 patients, 116 in the RM group and 61 in the LM group, were included in the study. The mean age in the RM and LM group was 34.31 ± 5.40 years and 33.54 ± 4.96 years, respectively (p = 0.355). The mean total operative time was marginally more in RM group (127.37 ± 110.67 vs. 120.66 ± 44.27, p = 0.650) but the difference was not statistically significant. Patients in the RM group had significantly less blood loss (115.43 ± 79.43 vs. 340.98 ± 453.9 ml, p = < 0.0001), hospital stay (1.28 ± 0.49 vs. 1.92 ± 1.05 days, p = < 0.0001), requirement of blood transfusion (93.97 vs. 81.97%, p = 0.031) and requirement of intravenous (IV) analgesia (41.38 vs. 34.43%, p = 0.019) as compared to the patients in the LM group. The Robotic myomectomy significantly reduces blood loss, the duration of hospital stay, and requirement of blood transfusions and IV analgesia as compared to the laparoscopic myomectomy.

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.

Robotic surgery in gynaecology: Scientific Impact Paper No. 71 (July 2022)

The use of robotic-assisted keyhole surgery in gynaecology has expanded in recent years owing to technical advances. These include 3D viewing leading to improved depth perception, limitation of tremor, potential for greater precision and discrimination of tissues, a shorter learning curve and improved comfort for surgeons compared with conventional keyhole and open abdominal surgery. Robotic-assisted keyhole surgery, compared with conventional keyhole surgery, improves surgical performance without increasing operating time, minimises blood loss and intra- or postoperative complications, while reducing the need to revert to abdominal surgery. Moreover, surgeons using a robot experience fewer skeletomuscular problems of their own in the short and long term than those operating without a robot as an additional tool. This Scientific Impact Paper looks at the use of a robot in different fields of gynaecological surgery. A robot could be considered safe and a more effective surgical tool than conventional keyhole surgery for women who have to undergo complex gynaecology surgery or have associated medical issues such as body-mass index (BMI) at 30 kg/m² or above or lung problems. The introduction of the use of robots in keyhole surgery has resulted in a decrease in the number of traditional open surgeries and the risk of conversion to open surgery after traditional keyhole surgery; both of which should be considered when examining the cost-benefit of using a robot. Limitations of robotic-assisted surgery remain the associated higher costs. In womb cancer surgery there is good evidence that introducing robotics into the service improves outcomes for women and may reduce costs.

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

Laparoscopy is a cornerstone of modern surgical care, with clear advantages for the patients. However, it has also been associated with inducing upper body musculoskeletal disorders amongst surgeons due to their propensity to assume non-neutral postures. Further, there is a perception that patients with high body mass indexes (BMI) exacerbate these factors. Therefore, surgeon upper body postures were objectively quantified using inertial measurement units and the LUBA ergonomic framework was used to assess posture during laparoscopic training on patient models that simulated BMIs of 20, 30, 40 and 50 kg/m². In all surgeons the posture of the upper body significantly worsened during simulated laparoscopic surgery on the BMI 50 kg/m² model as compared to the baseline BMI model of 20 kg/m². These findings suggest that performing laparoscopic surgery on patients with high BMIs increases the prevalence of non-neutral posture and may further increase the risk of musculoskeletal disorders in surgeons.

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.

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.

Robotic Subtotal Cholecystectomy in a Geriatric Acute Care Surgery Patient with Super Obesity

Introduction. Unique challenges exist with conventional laparoscopic operations in patients with super obesity (BMI > 50). Limited literature is available regarding use of the robotic platform to treat patients with super obesity or acute care surgery patients. This case describes an interval robotic subtotal cholecystectomy in an elderly patient with super obesity and multiple comorbidities. Case Description. A 74-year-old male with a BMI of 59.9 developed acute cholecystitis. He was deemed excessively high risk for operative intervention due to concurrent comorbid conditions and underwent percutaneous cholecystostomy. After a few months, a cholangiogram demonstrated persistent cystic duct occlusion. The patient expressed interest in tube removal and elective interval cholecystectomy. After preoperative risk stratification and optimization, he underwent a robotic subtotal cholecystectomy with near infrared fluorescence cholangiography. The patient was discharged on postoperative day one and recovered without complications. Discussion. Obesity is a risk factor for acute cholecystitis, which is most commonly treated with conventional laparoscopy (CL). CL is technically restraining and difficult to perform in patients with super obesity. The body habitus of patients with super obesity can impair proper instrumentation and increase perioperative morbidity. In this case, robotic assisted cholecystectomy console improved surgeon ergonomics and provided support for proper instrumentation. Robotic, minimally invasive cholecystectomy approaches may reduce perioperative morbidity in patients with super obesity. Further studies are necessary to address the role of robotic surgery in acute care surgery patients with super obesity.

Comparison of perioperative outcomes between standard laparoscopic and robot-assisted approach in patients with rectosigmoid endometriosis

INTRODUCTION

Robot-assisted laparoscopic surgery (RALS) has gained widespread application in several surgical specialties. Previous studies on the feasibility and safety of RALS vs standard laparoscopy (S-LPS) for rectosigmoid endometriosis are limited and reported conflicting data. This study aims to compare S-LPS and RALS in patients with rectosigmoid endometriosis in terms of perioperative surgical and clinical data.

MATERIAL AND METHODS

This is a multicentric, observational, prospective cohort study including 44 patients affected by rectosigmoid endometriosis referred to two tertiary referral centers for endometriosis from September 2018 to September 2019. Patients were divided into two groups: 22 patients underwent S-LPS, and 22 underwent RALS. Our primary outcome was to compare operative time (from skin incision to suture) between the two groups. Secondary outcomes included: operative room time (patient entry into operative room and patient out), estimated blood loss, laparotomic conversion rate, length of hospital stay, perioperative complications, and evaluation of endometriosis-related symptoms at 12-month follow up.

RESULTS

The two groups were comparable regarding preoperative and surgical data, except for higher rates of hysterectomies and bilateral uterosacral ligament removal procedures in the RALS group. Also after adjusting for these discrepancies, operative time was similar between S-LPS and RALS. Operative room time was statistically longer in the RALS group compared with that of S-LPS. No statistically significant difference was found concerning other study outcomes. Pain and bowel symptoms improved in both groups at 12-month follow up.

CONCLUSIONS

If performed by expert teams, RALS provides similar perioperative outcomes compared with S-LPS in rectosigmoid endometriosis surgical treatment, except for longer operative room time.

Economic evaluation of different routes of surgery for the management of endometrial cancer: a retrospective cohort study

OBJECTIVES

The benefits of minimally invasive surgery (MIS) for endometrial carcinoma (EC) are well established although the financial impact of robotic-assisted hysterectomy (RH) compared with laparoscopic hysterectomy (LH) is disputed.

DESIGN

Retrospective cohort study.

SETTING

English National Health Service hospitals 2011-2017/2018.

PARTICIPANTS

35 304 women having a hysterectomy for EC identified from Hospital Episode Statistics.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the association between route of surgery on cost at intervention, 30, 90 and 365 days for women undergoing an open hysterectomy (OH) or MIS (LH/RH) for EC in England. The average marginal effect was calculated to compare RH versus OH and RH versus LH which adjusted for any differences in the characteristics of the surgical approaches. Secondary outcomes were to analyse costing data for each surgical approach by age, Charlson Comorbidity Index (CCI) and hospital MIS rate classification.

RESULTS

A total of 35 304 procedures were performed, 20 405 (57.8%) were MIS (LH: 18 604 and RH: 1801), 14 291 (40.5%) OH. Mean cost for LH was significantly less than RH, whereas RH was significantly less than OH at intervention, 30, 90 and 365 days (p<0.001). Over time, patients who underwent RH had increasing CCI scores and by the 2015/2016 year had a higher average CCI than LH. Comparing the cost of LH and RH against CCI score identified that the costs closely reflected the patients' CCI. Increasing disparity was also seen between the MIS and OH costs with rising age. When exploring the association between provider volume, MIS rate and surgical costs, there was an association with the higher the MIS rate the lower the average cost.

CONCLUSIONS

Further research is needed to investigate costs in matched patient cohorts to determine the optimum surgical modality in different populations.

Are Surgeons Working Smarter or Harder? A Systematic Review Comparing the Physical and Mental Demands of Robotic and Laparoscopic or Open Surgery

BACKGROUND

Minimally invasive surgical techniques such as robotic surgical platforms have provided favourable outcomes for patients, but the impact on surgeons is not well described. This systematic review aims to synthesize and evaluate the physical and mental impact of robotic surgery on surgeons compared to standard laparoscopic or open surgery.

METHODS

A search strategy was developed to identify peer-reviewed English articles published from inception to end of December 2019 on the following databases: MEDLINE, PubMed, PsycINFO and Embase. The articles were assessed using a modified Newcastle-Ottawa tool.

RESULTS

Of the 6563 papers identified, 30 studies were included in the qualitative synthesis of this review. Most of the included studies presented a high risk of bias. A total of 13 and 21 different physical and mental tools, respectively, were used to examine the impact on surgeons. The most common tool used to measure physical and mental demand were surface electromyography (N = 9) and the NASA Task Load Index (NASA-TLX; N = 8), respectively. Majority of studies showed mixed results for physical (N = 10) and mental impact (N = 7). This was followed by eight and six studies favouring RS over other surgical modalities for physical and mental impact, respectively.

CONCLUSION

Most studies showed mixed physical and mental outcomes between the three surgical modalities. There was a high risk of bias and methodological heterogeneity. Future studies need to correlate mental and physical stress with long-term impact on the surgeons.

Outcomes of robotic-assisted vs conventional laparoscopic surgery among patients undergoing resection for rectal cancer: an observational single hospital study of 300 cases

Robotic-assisted laparoscopic surgery attempts to facilitate rectal surgery in the narrow space of the pelvis. The aim of this study is to compare the outcomes of robotic versus laparoscopic surgery for rectal cancer. Monocentric retrospective study including 300 patients who underwent robotic (n = 178) or laparoscopic (n = 122) resection between Jan 2009 and Dec 2017 for high, mid and low rectal cancer. The robotic and laparoscopic groups were comparable with regard to pretreatment characteristics, except for sex and ASA status. There were no statistical differences between groups in the conversion rate to open surgery. Surgical morbidity and oncological quality did not differ in either group, except for the anastomosis leakage rate and the affected distal resection margin. There were no differences in overall survival rate between the laparoscopic and robotic group. Robotic surgery could provide some advantages over conventional laparoscopic surgery, such as three-dimensional views, articulated instruments, lower fatigue, lower conversion rate to open surgery, shorter hospital stays and lower urinary and sexual dysfunctions. On the other hand, robotic surgery usually implies longer operation times and higher costs. As shown in the ROLARR trial, no statistical differences in conversion rate were found between the groups in our study. When performed by experienced surgeons, robotic surgery for rectal cancer could be a safe and feasible option with no significant differences in terms of oncological outcomes in comparison to laparoscopic surgery.

Uptake and outcomes of robotic gynaecological surgery in England (2006-2018): an account of Hospital Episodes Statistics (HES)

This was a retrospective study to review the uptake and outcomes of robotic gynaecological surgery in England between 1st April 2006 and 31st March 2018, analysing Hospital Episode Statistics form National Health Service hospitals in England. Women aged 18 years and above who had elective gynaecological surgery were included and those who had undergone robotic gynaecology surgery were included. Robotic gynaecological procedures were defined as procedures that used a robotic minimal access approach for hysterectomy, adnexal surgery and urogynaecological surgery (sacrocolpopexy, sacrohysteropexy and colposuspension). Numbers of procedures were reviewed by year and mapped to the 44 NHS healthcare regions. Length of stay (nights in hospital), laparotomy (conversion during primary procedure or after return to theatre for management of complication), and 30-day emergency readmission rates were calculated by year and procedure type. Overall 527,217 elective gynaecological procedures were performed in the English NHS (1st April 2006 and 31st March 2018), of which 4384 (0.83%) were performed with robotic assistance (3864 (88%) hysterectomy, 706 (16%) adnexal surgery, 192 (4%) urogynaecological surgery). There was gradual rise in the uptake of robotic surgery but there was a marked geographical variation. Median (IQR) length of stay (LOS) was 1(1-2) night, laparotomy rate was 0.3% and 30-day emergency readmission rate was 4.7%. LOS was statistically, but not clinically, different across time. Other outcomes did not differ by year. Robotic gynaecological procedures are increasingly being used in the English NHS, predominantly for hysterectomy, although in small proportions (2.6% in the most recent study year). There was wide geographical variation in robotic uptake across England and overall, outcomes were comparable to those reported in other countries.