Intraprocedural ergonomics of vascular surgeons

Biomechanical and ergonomic risks associated with cervical musculoskeletal dysfunction amongst surgeons: A systematic review

INTRODUCTION

Surgeons are at high risk of developing musculoskeletal symptoms due to a range of factors including, maladaptive positioning and surgical ergonomics. Cervical muscle strain and biomechanical load is most prevalent due to repetitive motions and prolonged static neck positioning. This issue is apparent through reports of prevalence between 10 and 74.4% among surgeons. The aim of this systematic review is to provide an objective assessment of the clinical evidence available and a descriptive analysis of the effects of kinematics and surgical ergonomics on the prevalence of surgeons' cervical musculoskeletal pain.

METHODS

This is PRISMA-compliant systematic review of clinical studies assessing the prevalence of cervical musculoskeletal dysfunction in surgeons by searching PUBMED and Ovid EMBASE databases from inception to 19th October 2023. Study quality was graded according to the National Institutes of Health study quality assessment tools.

RESULTS

A total of 9 studies were included in the final qualitative analysis. The use of loupes, open surgery and excessive neck flexion (>30°) were associated with cervical dysfunction. Comparison of study outcomes was challenging due to heterogeneity within study methods and the paucity of methodological quality.

CONCLUSION

The current literature assessing ergonomic and biomechanical factors predisposing surgeons to cervical musculoskeletal dysfunction is insufficient to provide reliable guidance for clinicians. Although the literature identifies factors contributing to work-related cervical dysfunction, few attempt to evaluate interventions for improved surgical ergonomics. An objective assessment of interventions that prompt postural correction with the aim to improve neck pain in surgeon cohorts is warranted.

Revision Total Joint Arthroplasty Places a Disproportionate Burden on Surgeons: A Comparison Using the National Aeronautics and Space Administration Task Load Index (NASA TLX)

BACKGROUND

Perceived surgeon workload of performing primary and revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) is challenging to quantify. The National Aeronautics and Space Administration Task Load Index (NASA TLX) survey was developed to quantify experiences following aviation and has been applied to healthcare fields. Our purposes were to 1) quantify the workload endured by surgeons who are performing primary and revision TKA and THA and 2) compare these values to their Center for Medicare & Medicaid Services (CMS) reimbursement.

METHODS

A prospective cohort of 5 fellowship-trained adult reconstruction surgeons completed NASA TLX surveys following primary and revision TKA/THA cases. A total of 122 surveys consisting of 70 TKA (48 primaries and 22 revisions) and 55 THA surveys (38 primaries and 17 revisions) were completed. Patient demographics and surgical variables were recorded. Final NASA TLX workloads were compared to 2021 CMS work relative value units.

RESULTS

Compared to primary TKA, revision TKA had 176% increased intraoperative workload (P < .001), 233% increased mental burden (P < .001), and 150% increased physical burden (P < .001). Compared to primary THA, revision THA had 106% increased intraoperative workload (P < .001), 96% increased mental burden (P < .001), and 91% increased physical burden (P < .001). Operative time was higher in revision versus primary TKA (118 versus 84.5 minutes, P = .05) and THA (150 versus 115 minutes, P = .001). Based upon 2021 CMS data, revision TKA and THA would need to be compensated by an additional 36% and 12.3%, respectively, to parallel intraoperative efforts.

CONCLUSIONS

Revision hip and knee arthroplasty places a major mental and physical workload upon surgeons and is disproportionately compensated by CMS.

Surgeons' dominant surgical modality: Impacts on wellbeing, burnout, and interventions for neuromusculoskeletal disorders

BACKGROUND

This study investigated the impact of surgical modalities on surgeon wellbeing with a focus on burnout, job satisfaction, and interventions used to address neuromusculoskeletal disorders (NMSDs).

METHODS

An electronic survey was sent to surgeons across an academic integrated multihospital system. The survey consisted of 47 questions investigating different aspects of surgeons' wellbeing.

RESULTS

Out of 245 thoracic and abdominopelvic surgeons, 79 surgeons (32.2 ​%) responded, and 65 surgeons (82 ​%) were able to be categorized as having a dominant surgical modality. Compared to robotic surgeons, laparoscopic (p ​= ​0.042) and open (p ​= ​0.012) surgeons reported more frequent feelings of burnout. The number of surgeons who used any treatment/intervention to minimize the operative discomfort/pain was lower for robotic surgeons than the other three modalities (all p ​< ​0.05).

CONCLUSIONS

NMSDs affect different aspects of surgeons' lives and occupations. Robotic surgery was associated with decreased feelings of burnout than the other modalities.

Reported pain at work is a risk factor for vascular surgery trainee burnout

BACKGROUND

Work-related pain is a known risk factor for vascular surgeon burnout. It risks early attrition from our workforce and is a recognized threat to the specialty. Our study aimed to understand whether work-related pain similarly contributed to vascular surgery trainee well-being.

METHODS

A confidential, voluntary survey was administered after the 2022 Vascular Surgery In-Service Examination to trainees in all Accreditation Council for Graduate Medical Education-accredited vascular surgery programs. Burnout was measured by a modified, abbreviated Maslach Burnout Inventory; pain after a full day of work was measured using a 10-point Likert scale and then dichotomized as "no to mild pain" (0-2) vs "moderate to severe pain" (3-9). Univariable analyses and multivariable regression assessed associations of pain with well-being indicators (eg, burnout, thoughts of attrition, and thoughts of career change). Pain management strategies were included as additional covariables in our study.

RESULTS

We included 527 trainees who completed the survey (82.2% response rate); 38% reported moderate to severe pain after a full day of work, of whom 73.6% reported using ergonomic adjustments and 67.0% used over-the-counter medications. Significantly more women reported moderate to severe pain than men (44.3% vs 34.5%; P < .01). After adjusting for gender, training level, race/ethnicity, mistreatment, and dissatisfaction with operative autonomy, moderate-to-severe pain (odds ratio, 2.52; 95% confidence interval, 1.48-4.26) and using physiotherapy as pain management (odds ratio, 3.06; 95% confidence interval, 1.02-9.14) were risk factors for burnout. Moderate to severe pain was not a risk factor for thoughts of attrition or career change after adjustment.

CONCLUSIONS

Physical pain is prevalent among vascular surgery trainees and represents a risk factor for trainee burnout. Programs should consider mitigating this occupational hazard by offering ergonomic education and adjuncts, such as posture awareness and microbreaks during surgery, early and throughout training.

Use of Soft Cervical Collar Improves Surgeon Ergonomics During Simulated Otologic Surgery

OBJECTIVE

To determine whether surgeon use of a soft cervical collar during endoscopic and microscopic otologic surgery is feasible and impacts surgeon ergonomics as measured by inertial sensors.

STUDY DESIGN

Prospective crossover trial.

SETTING

US-based otolaryngology training program.

PATIENTS

Otolaryngology residents and fellows.

INTERVENTIONS

Therapeutic-use of a soft cervical collar during simulated otologic surgery.

MAIN OUTCOME MEASURES

Time spent in high-risk angles of neck and back flexion and extension; average angle of neck flexion, extension, rotation, and lateral bending; validated assessment of neck pain; average daily phone use.

RESULTS

Fifteen subjects met criteria for inclusion. Ten of 15 (67%) were male. Seven of 15 (47%) were postgraduate year 1-2. Seven of 15 (47%) reported a history of neck pain. None reported prior spinal steroid injections or surgery. Across all subjects, use of the soft cervical collar significantly reduced time spent in high-risk angles of neck flexion/extension during both endoscopic (56% vs. 35%, p < 0.05) and microscopic (60% vs. 32%, p < 0.05) otologic surgery. There was no effect on back flexion or extension. There was no difference in time spent in high-risk neck or back angles between endoscopic and microscopic surgery. Average angles of neck or back flexion, extension, lateral bending, and rotation were not significantly different for subgroups with more operative experience, increased phone use, perception of good posture, or history of neck pain.

CONCLUSIONS

Use of a soft cervical collar during simulated otologic surgery significantly reduced time spent in high-risk neck positions. These data support feasibility of soft collar use during otologic surgery and hold promise for reduction in the high rates of neck pain reported by neurotologists.

PROFESSIONAL PRACTICE GAP AND EDUCATIONAL NEED

Improving surgeon ergonomics for otologic surgery.

LEARNING OBJECTIVE

To identify a therapeutic intervention to mitigate neck pain in surgeons caused by assumption of high-risk cervical neck flexion and extension.

DESIRED RESULT

To demonstrate that use of a readily available soft cervical collar reduces risk of neck pain in otologic surgeons.

LEVEL OF EVIDENCE

II.

INDICATE IRB OR IACUC

Exempt.

Nontechnical Skills for Intraoperative Team Members

Nontechnical skills, defined as the set of cognitive and social skills used by individuals and teams to reduce error and improve performance in complex systems, have become increasingly recognized as a key contributor to patient safety. Efforts to characterize, quantify, and teach nontechnical skills in the context of perioperative care continue to evolve. This review article summarizes the essential behaviors for safety, described in taxonomies for nontechnical skills assessments developed for intraoperative clinical team members (eg, surgeons, anesthesiologists, scrub practitioners, perfusionists). Furthermore, the authors describe emerging methods to advance understanding of the impact of nontechnical skills on perioperative outcomes.

Ergonomic Analysis of Otologic Surgery: Comparison of Endoscope and Microscope

OBJECTIVE

The comparative postural health of surgeons performing endoscopic and microscopic otologic surgeries has been a topic of active debate, with many nascent or anecdotal reports suggesting the latter encourages suboptimal ergonomics. Using inertial body sensors to measure joint angles, this study sought to objectively evaluate and compare the ergonomics of surgeons during endoscopic and microscopic otologic surgeries.

STUDY DESIGN

Prospective pilot trial.

SETTING

Large, multicenter, academic hospital system. Performed 21 otologic operations (10 endoscopic and 11 microscopic) in November 2020 and January 2021. All attendings were fellowship trained in otology/neurotology.

SUBJECTS

Eight otolaryngologists (four attendings and four residents) performing 21 otologic surgeries (11 microscopic and 10 endoscopic).

INTERVENTION

Approach to otologic surgery: endoscope or microscope.

MAIN OUTCOME MEASURES

Surgeons' neck and back angles while wearing ergonomic sensors affixed to either side of each major joint, mental and physical burdens and pain after each surgery (via modified NASA Task Load Index).

RESULTS

Residents' necks (9.54° microscopic vs. -4.79° endoscopic, p = 0.04) and backs (16.48° microscopic vs. 3.66° endoscopic, p = 0.01) were significantly more flexed when performing microscopic surgery than when performing endoscopic surgery, although attending neck and back flexion were comparable during microscopic and endoscopic surgeries. Attendings reported significantly higher pain levels after operating microscopically than after operating endoscopically (0.13 vs. 2.76, p = 0.01).

CONCLUSIONS

Residents were found to operate with significantly higher risk back and neck postures (as defined by the validated ergonomic tool, Rapid Entire Body Assessment) when operating microscopically. Attendings reported significantly higher levels of pain after operating microscopically versus endoscopically, suggesting that the suboptimal microscopic postures adopted earlier in training may pose an indelible risk later in a surgeon's career.

Intraoperative workload in elective open vascular and endovascular surgery: A study of procedural drivers

This study investigated vascular surgeon workload and its association with specific procedural drivers over different procedure types. Thirteen attending vascular surgeons (two females) were emailed a survey over a 3-month period. Data from 253 surgical procedures (118 open, 85 endovascular, 18 hybrid, and 32 venous) revealed high physical and cognitive workload among vascular surgeons. Based on the statistically significant findings and similar non-significant trends in the data (significance level of 0.01), open and hybrid vascular procedures showed higher levels of physical and cognitive workload compared to venous cases, while endovascular procedures were relatively more moderate. Additionally, the workload subscales for five subcategories of open procedures (e.g., arteriovenous access) as well as three subcategories of endovascular procedures (e.g., aortic) were compared. The granularity of the intraoperative workload drivers across various vascular procedure types and adjunct equipment could be the key to create targeted ergonomic interventions to reduce workload during vascular surgeries.

StemRad MD, An Exoskeleton-Based Radiation Protection System, Reduces Ergonomic Posture Risk Based on a Prospective Observational Study

OBJECTIVE

Poor ergonomic posture during interventional procedures might lead to increased physical discomfort and work-related musculoskeletal disorders. Adjunctive equipment such as lead aprons (LAs) has been shown to increase ergonomic posture risk (EPR). The objective of this study was to evaluate the effectiveness of StemRad MD (StemRad Ltd., Tel Aviv, Israel), a weightless exoskeleton-based radiation protective ensemble, in reducing EPR on the operator using wearable inertial measurement unit (IMU) sensors.

METHODS

A prospective, observational study was conducted at an academic hospital. Inertial measurement unit sensors were affixed to the upper back of 9 interventionalists to assess ergonomic risk posture during endovascular procedures while wearing a traditional LA or the StemRad MD radiation protection system. Total fluoroscopy time, procedure type, and ergonomic risk postures were recorded and analyzed.

RESULTS

Twenty-one cases were performed with StemRad MD and 30 with LAs. Mean procedure time for the StemRad MD procedures was 48.4±23.3 minutes (range: 24-106 min), and for LA procedures, it was 34.66±25.83 minutes (range: 6-100 min) (p=.060). The operators assumed low-risk ergonomic positions in 96.1% of StemRad MD cases and in 62.9% of LA cases (p=.001), and high-risk ergonomic positions in 0% and 6.2%, respectively (p=.80). Mean EPR score for StemRad MD was 1.16, and for the LA, it was 1.49 (p=.001).

CONCLUSIONS

StemRad MD significantly reduces the EPR to the torso compared with a LA-based radiation protection system.

CLINICAL IMPACT

Poor ergonomic posture during interventional procedures might leas to work-related musculoskeletal disorders for healthcare workers. StemRad MD, a weightless, exoskeleton-based radiation protection system was shown to significantly reduce ergonomic posture risk to the torso compared to conventional lead aprons. This might lead to reduced physical discomfort for procedure-based specialists.

An Exercise Prescription To Improve Posture, Minimize Injury, and Improve Career Longevity in Surgeons

A contemporary exercise and strength regimen can improve posture, minimize injury, and improve career longevity in surgeons. By targeting core stability, neck posture, and thoracoscapular strength, surgeons and operating room teams can minimize neck and lower back pain.

How Much Stress Does a Surgeon Endure? The Effects of the Robotic Approach on the Autonomic Nervous System of a Surgeon in the Modern Era of Thoracic Surgery

(1) Objective: the purpose of this study was to evaluate and quantify the stress to which a surgeon is subjected during his/her surgical activity; we compared the individual clinical and psychological responses to stress of two surgeons during their surgical activities via robotic and open approaches. (2) Materials and methods: This was a prospective observational study in which we progressively collected data concerning the surgical performances of two different thoracic surgeons (October 2021-June 2022). We evaluated 20 lung resections performed via robot-assisted surgery and 20 lung resections performed via an open approach by each surgeon; in particular, we evaluated a panel of pre-, peri-, and postoperative data concerning the interventions, the patients, and other outcomes concerning the autonomic nervous system (ANS) and psychological responses to stress of the surgeons during their surgical activities. (3) Results: When analyzing data concerning the ANS activity of two surgeons, during robotic activity we found lower maximum, minimum, and mean heart rates; lower mean respiratory frequencies; lower body temperatures; and lower mean desaturations compared to the open approach activity for both surgeons. The psychological monitoring showed that the open approach created more physical fatigue and frustration but higher levels of satisfaction and performance evaluation. The robot-assisted surgeries showed higher levels of anxiety. (4) Conclusions: for different reasons, the robotic approach stimulated the ANS to a lesser degree, causing less stress for surgeons and ensuring greater comfort.

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.

A Comparative Analysis of Ergonomic Risk Utilizing the 4K-3D Exoscope Versus Standard Operating Microscope for Male Fertility Microsurgery

OBJECTIVE

To stratify ergonomic risk in a urologic microsurgeon using the 4K-3D exoscope versus the operating microscope (OM) with wearable technology.

METHODS

The surgeon was calibrated with wearable sensor inertial measurement units (IMUs) on the head and upper arms. Each inertial measurement units contained an accelerometer, magnetometer, and gyroscope to measure surgeon joint angle change during microscopic procedures for male fertility. The validated modified rapid upper limb assessment was used to determine the proportion of time spent in ranges of risk. Categories 1-4 were assigned for the head and upper extremities (4= highest ergonomic risk). Chi-squared analysis was used to analyze differences in proportions.

RESULTS

A total of 500 and 479 minutes from 4K-3D exoscope and OM guided surgeries were analyzed. The 4K-3D exoscope significantly favored upper arm category 1 positioning compared to the OM (56.2% vs 37.7%; P < .0001). The OM exposed the surgeon to higher category 3 positioning (14.6% vs 1.6%; P <.0001). More time was spent with the neck "extended" using the 4K-3D exoscope (51.8% vs 19.5%; P < .0001) with 67% of neck extension between 0-10° (category 1). Overall, more time was spent with the neck in risk group 1-2 with the OM (P < .0001).

CONCLUSION

The 4K-3D exoscope offers favorable ergonomic positioning for the upper extremities which may reduce work stress-related injury. More operative time was spent with the neck in mild extension with 4K-3D exoscope utilization. However, the OM favored longer operative times in low-risk neck ergonomic positions.

Ergonomics and Work-Related Musculoskeletal Disorders: Characteristics Among Female Interventionists

Interventional radiology is a procedural specialty that performs minimally invasive operations under image guidance. Currently, there are inadequate ergonomic protocols for work-related musculoskeletal disorder (WMSD) prevention in interventional radiology (IR), and there is a paucity of information discerning gender differences in WMSDs. This article reviews current literature that addresses WMSDs in female physicians practicing interventional and fluoroscopic procedures, including interventional radiology, interventional cardiology, electrophysiology, vascular surgery, orthopedic surgery, neurosurgery, and gastroenterology. We searched PubMed and EBSCOhost databases for ergonomic studies that reported female physician WMSDs in the specialties listed above. After a thorough evaluation for inclusion based on eligibility criteria, 11 studies were included. From this search, there was poor female representation, averaging 25.7% of respondents. Several characteristics identified across the studies were that women were generally shorter, wore smaller glove sizes, and were younger than their male colleagues. Seventy-two percent of female proceduralists reported WMSDs versus 46.6% of their male colleagues. Additionally, women may experience more upper extremity pain than lumbar pain, which men commonly reported. Potential contributing factors to WMSDs are the size and design of procedural tools and the possible predisposition of female physicians to experience upper extremity WMSDs while performing the same operations as men. As more women enter medicine and pursue careers in procedural fields like interventional radiology, it is essential to address these discrepancies and develop ergonomically sound solutions for women.

Survey of Canadian vascular surgeons and trainees finds work-related musculoskeletal pain and discomfort is common

BACKGROUND

Occupational injuries and disability are a source of surgeon morbidity. The purpose of this study was to assess the physical toll of working in operating rooms by Canadian vascular surgeons.

OBJECTIVE

To assess work-place musculoskeletal (MSK) complaints and challenges faced by Canadian vascular surgeons and trainees and its implications on surgical practice and occupational longevity.

METHODS

An online survey was distributed to resident and surgeon members of the Canadian Society of Vascular Surgery. The survey collected data on demographics, operative volume, and work-related MSK symptoms.

RESULTS

The survey was distributed to 188 surgeons and trainees. After three e-mailings, 109 surveys were returned (58% response rate). Of the responders, 87% were male, 51% were 45 years or older, and 56% had been in practice for ten or more years. Workplace MSK symptoms was reported by 83% of the responders. The most common locations were the low back (78%), neck (74%), and shoulder (30%). Most responders (83%) believed that these symptoms were related to their operative environment. Almost half (48%) sought medical care. As a result of these MSK symptoms, 25% experience chronic pain with 8% reporting time off work as a consequence. Another 11% reported an impact on their operative performance with 14% considering early retirement. A lack of operating room system changes to prevent workplace injury and disability was noted by 85% of the responders although only 3% reported their disability to their department.

CONCLUSION

Occupational MSK symptoms and disability is common amongst Canadian vascular surgeons. Further research is needed to create programs to improve surgeon morbidity.

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.