Ergonomic problems encountered by the surgical team during video endoscopic surgery

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.

Effect of Assisted Surgery on Work-Related Musculoskeletal Disorder Prevalence by Body Area among Surgeons: Systematic Review and Meta-Analysis

Surgeons are highly exposed to work-related musculoskeletal disorders (WMSDs). The objective of this review was to summarize the WMSD prevalence by body area with and without assistive devices. The underlying question was whether there is an effect of assistive device use (robot, video, or other) during surgery on WMSD prevalence by body area among surgeons, regardless of their specialty. The systematic review was conducted according to the PRISMA guidelines. The Google Scholar, Pubmed/Medline, and ScienceDirect databases were scanned to identify relevant studies. The article selection, review, critical appraisal, and data extraction were performed by two authors independently. Among the 34,854 unique identified records, 77 studies were included. They were divided into two groups: 35 focused on robotic- and video-assisted surgery (RVAS) and 48 concerning surgery without video/robotic assistance (WAS) (6 studies evaluated the prevalence for both groups). WMSD prevalence was reported for 13 body areas: the neck, back, upper back, mid-back, lower back, shoulders, elbows, wrists, fingers, thumbs, hips, knees, and ankles. The results showed that WMSD prevalence was significantly higher (unpaired t-test, p < 0.05) for RVAS in the shoulders (WAS: 28.3% vs. RVAS: 41.9%), wrists (WAS: 20.9% vs. RVAS: 31.5%), and thumbs (WAS: 9.9% vs. RVAS: 21.8%). A meta-analysis was performed for 10 body areas (with 4 areas including more than 25 studies). No sufficient data were available for the mid-back, thumbs, or hips. A high heterogeneity (Cochran's Q test and I² statistic) was observed. A random-effects model revealed that the highest worldwide prevalence was in the neck (WAS: 41% and RVAS: 45.3%), back (WAS: 37.7% and RVAS: 49.9%), lower back (WAS: 40.0% and RVAS: 37.8%), and shoulders (WAS: 27.3% and RVAS: 41.4%). Future work could focus on work environment design, particularly the positioning and adjustment of equipment, and on postural analysis to reduce the appearance of WMSDs. Recommendations are proposed for future reviews and meta-analyses.

A narrative review of ergonomic problems, principles, and potential solutions in surgical operations

BACKGROUND

Ergonomic development and awareness are critical to the long-term health and well-being of surgeons. Work-related musculoskeletal disorders affect an overwhelming majority of surgeons, and various operative modalities (open, laparoscopic, and robotic surgery) differentially affect the musculoskeletal system. Previous reviews have addressed various aspects of surgical ergonomic history or methods of ergonomic assessment, but the purpose of this study is to synthesize ergonomic analysis by surgical modality while discussing future directions of the field based on current perioperative interventions.

METHODS

pubmed was queried for "ergonomics," "work-related musculoskeletal disorders," and "surgery," which returned 124 results. From the 122 English-language papers, a further search was conducted via the articles' sources for relevant literature.

RESULTS

Ninety-nine sources were ultimately included. Work-related musculoskeletal disorders culminate in detrimental effects ranging from chronic pain and paresthesias to reduced operative time and consideration for early retirement. Underreporting symptoms and a lack of awareness of proper ergonomic principles substantially hinder the widespread utilization of ergonomic techniques in the operating room, reducing the quality of life and career longevity. Therapeutic interventions exist at some institutions but require further research and development for necessary widespread implementation.

CONCLUSION

Awareness of proper ergonomic principles and the detrimental effects of musculoskeletal disorders is the first step in protecting against this universal problem. Implementing ergonomic practices in the operating room is at a crossroads, and incorporating these principles into everyday life must be a priority for all surgeons.

In Vivo Feasibility Test of a New Flexible Ureteroscopic Robotic System, easyUretero, for Renal Stone Retrieval in a Porcine Model

PURPOSE

Using a new robotic endoscopic platform system developed for retrograde intrarenal surgery (RIRS) called easyUretero (ROEN Surgical Inc.), we evaluated the feasibility and safety of renal stone retrieval in a porcine model.

MATERIALS AND METHODS

Six female pigs were used for our in vivo study. First, 0.3-cm-sized phantom stones were inserted into the kidneys of each pig via the ureteral access sheath. Next, renal stone retrieval was attempted using manual RIRS in three pigs and robotic RIRS in three pigs. Three surgeons performed extraction of 10 stones in each session.

RESULTS

The mean stone retrieval time by manual RIRS was significantly shorter than that by robotic RIRS (399.9±185.4 sec vs. 1127.6±374.5 sec, p=0.001). In contrast, the questionnaire regarding usability showed high satisfaction in the surgeons' fatigue category for surgeons using robotic RIRS. The radiation exposure dose was also lower in robotic RIRS than in manual RIRS (0.14 µSv vs. 45.5 µSv). Postoperative ureteral injury assessment revealed Grade 0 in manual RIRS cases and Grades 0, 1, and 2 in robotic RIRS cases.

CONCLUSION

The easyUretero system is a new robotic RIRS system that was developed in Korea. The results of the present study suggest that using easyUretero for stone retrieval during RIRS is safe and ergonomic.

Supporting Surgical Teams: Identifying Needs and Barriers for Exoskeleton Implementation in the Operating Room

OBJECTIVE

The objective of this study was to identify potential needs and barriers related to using exoskeletons to decrease musculoskeletal (MS) symptoms for workers in the operating room (OR).

BACKGROUND

MS symptoms and injuries adversely impact worker health and performance in surgical environments. Half of the surgical team members (e.g., surgeons, nurses, trainees) report MS symptoms during and after surgery. Although the ergonomic risks in surgery are well recognized, little has been done to develop and sustain effective interventions.

METHOD

Surgical team members (n = 14) participated in focus groups, performed a 10-min simulated surgical task with a commercial upper-body exoskeleton, and then completed a usability questionnaire. Content analysis was conducted to determine relevant themes.

RESULTS

Four themes were identified: (1) characteristics of individuals, (2) perceived benefits, (3) environmental/societal factors, and (4) intervention characteristics. Participants noted that exoskeletons would benefit workers who stand in prolonged, static postures (e.g., holding instruments for visualization) and indicated that they could foresee a long-term decrease in MS symptoms with the intervention. Specifically, raising awareness of exoskeletons for early-career workers and obtaining buy-in from team members may increase future adoption of this technology. Mean participant responses from the System Usability Scale was 81.3 out of 100 (SD = 8.1), which was in the acceptable range of usability.

CONCLUSION

Adoption factors were identified to implement exoskeletons in the OR, such as the indicated need for exoskeletons and usability. Exoskeletons may be beneficial in the OR, but barriers such as maintenance and safety to adoption will need to be addressed.

APPLICATION

Findings from this work identify facilitators and barriers for sustained implementation of exoskeletons by surgical teams.

Surgeon symptoms, strain, and selections: Systematic review and meta-analysis of surgical ergonomics

Background

Many surgeons experience work-related pain and musculoskeletal symptoms; however, comprehensive reporting of surgeon ailments is lacking in the literature. We sought to evaluate surgeons' work-related symptoms, possible causes of these symptoms, and to report outcomes associated with those symptoms.

Materials and methods

Five major medical indices were queried for articles published between 1980 and 2014. Included articles evaluated musculoskeletal symptoms and ergonomic outcomes in surgeons. A meta-analysis using a fixed-effect model was used to report pooled results.

Results

Forty articles with 5152 surveyed surgeons were included. Sixty-eight percent of surgeons surveyed reported generalized pain. Site-specific pain included pain in the back (50%), neck (48%), and arm or shoulder (43%). Fatigue was reported by 71% of surgeons, numbness by 37%, and stiffness by 45%. Compared with surgeons performing open surgery, surgeons performing minimally invasive surgery (MIS) were significantly more likely to experience pain in the neck (OR 2.77 [95% CI 1.30–5.93]), arm or shoulder (OR 4.59 [2.19–9.61]), hands (OR 2.99 [1.33–6.71], and legs (OR 12.34 [5.43–28.06]) and experience higher odds of fatigue (8.09 [5.60–11.70]) and numbness (6.82 [1.75–26.65]). Operating exacerbated pain in 61% of surgeons, but only 29% sought treatment for their symptoms. We found no direct association between muscles strained and symptoms.

Conclusions

Most surgeons report work-related symptoms but are unlikely to seek medical attention. MIS surgeons are significantly more likely to experience musculoskeletal symptoms than surgeons performing open surgery. Symptoms experienced do not necessarily correlate with strain.

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68% of surveyed surgeons reported experiencing generalized pain from operating.

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Minimally-invasive surgeons were more likely to report pain, fatigue, and numbness.

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Only 29% of surgeons reported seeking treatment for symptoms.

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No association between objective strain on muscles and reported symptoms was found.

Ergonomics in the operating room

Background

Since the introduction of minimally invasive surgery, surgeons appear to be experiencing more occupational musculoskeletal injuries. The aim of this study is to investigate the current frequency and effects of occupational musculoskeletal injuries on work absence.

Methods

An online questionnaire was conducted among all surgeons affiliated to the Dutch Society for Endoscopic Surgery, Gastrointestinal Surgery, and Surgical Oncology. In addition, this survey was conducted among surgeons, gynaecologists, and urologists of one cluster of training hospitals in the Netherlands.

Results

There were 127 respondents. Fifty-six surgeons currently suffer from musculoskeletal complaints, and 30 have previously suffered from musculoskeletal complaints with no current complaints. Frequently reported localizations were the neck (39.5 %), the erector spinae muscle (34.9 %), and the right deltoid muscle (18.6 %). Most of the musculoskeletal complaints were present while operating (41.8 %). Currently, 37.5 % uses medication and/or therapy to reduce complaints. Of surgeons with past complaints, 26.7 % required work leave and 40.0 % made intraoperative adjustments. More surgeons with a medical history of musculoskeletal complaints have current complaints (OR 6.1, 95 % CI 1.9–19.6). There were no significant differences between surgeons of different operating techniques in localizations and frequency of complaints, or work leave.

Conclusions

Despite previous various ergonomic recommendations in the operating room, the current study demonstrated that musculoskeletal complaints and subsequent work absence are still present among surgeons, especially among surgeons with a positive medical history for musculoskeletal complaints. Even sick leave was necessary to fully recover. There were no significant differences in reported complaints between surgeons of different operating techniques. Almost half of the respondents with complaints made intraoperative ergonomic adjustments to prevent future complaints. The latter would be interesting for future research.

Ergonomics in endourology and laparoscopy: an overview of musculoskeletal problems in urology

PURPOSE

This study aims to provide an overview of type and frequency of musculoskeletal complaints among urologists. In addition, the urologists' knowledge about ergonomic conditions during minimally invasive urology was assessed, and they were asked how they would prefer to gain knowledge about this topic.

MATERIALS AND METHODS

An online and hard copy version questionnaire was administered to urologists from different countries, mainly from Europe, performing endourology and laparoscopy.

RESULTS

Of the 285 respondents, 245 (86.0%) urologists experienced musculoskeletal complaints in the past 12 months and 62.1% were considered to be work related. Most common areas for chronic complaints were neck, back, and shoulders. Almost 50% of the urologists experienced chronic musculoskeletal complaints, for which endourology (odds ratio [OR] 3.06; 95% confidence interval [CI] 1.37-6.80) and laparoscopy (OR 1.70; 95% CI 1.27-2.28) were significant risk factors. One third of the urologists considered their knowledge about ergonomics minimal, and 8% stated that they had no knowledge about these topics. Fifty percent of the respondents preferred to integrate information about ergonomic rules into hands-on training of urologic skills.

CONCLUSION

High prevalence of experienced musculoskeletal complaints was found among urologists predominantly related to endourology and laparoscopy. Urologists indicate that they have a lack of knowledge about ergonomics in the operating room. Hence, we recommend integration of ergonomics in hands-on training programs early in the residency curriculum to gain knowledge and awareness and hopefully to offer possibilities to prevent these complaints in the future.

An interactive method for achieving ergonomically optimum conditions during laparoscopic surgery

Laparoscopy is widely used during living kidney donation, nephrectomy, bariatric surgery, and surgery for gastrointestinal tumors and colorectal cancer. However, laparoscopic surgery requires prolonged use of instruments and has low mechanical efficiency. In addition, to meet specific surgical demands while visualizing the surgical area on the screen, surgical personnel frequently violate the postures proposed by human factor engineering; this naturally results in a physical burden on the personnel. In this study, using laparoscopic nephrectomy as an example, an auxiliary hoisting device for surgery was designed, and pedals from a variety of equipment were integrated into the auxiliary plant. Both entity testing conducted in the hospital and 3D surgical simulation of the auxiliary plant showed that this device could improve compliance with human factor engineering recommendations during laparoscopic surgery and could also promote interaction and tacit understanding between surgical personnel, thereby providing ergonomically optimum conditions during laparoscopy.

Spine surgeon's kinematics during discectomy according to operating table height and the methods to visualize the surgical field

PURPOSE

The ergonomic problems for surgeons during spine surgery are an awkward body posture, repetitive movements, increased muscle activity, an overflexed spine, and a protracted time in a standing posture. The authors analyzed whole spine angles during discectomy. The objective of this study is to assess differences in surgeon whole spines angles according to operating table height and the methods used to visualize surgical field.

MATERIALS AND METHODS

A cohort of 12 experienced spine surgeons was enrolled. Twelve experienced spine surgeons performed discectomy using a spine surgery simulator. Three different methods were used to visualize the surgical field (naked eye, loupe, and out of loupe) and three different operating table heights. Whole spine angles were compared for three different views during discectomy simulation; midline, ipsilateral, and contralateral. A 16-camera optoelectronic motion analysis system was used, and 16 markers were placed from head to pelvis. Lumbar lordosis, thoracic kyphosis, cervical lordosis, and occipital angle were compared at the different operating table heights, while using the three visualization methods, with natural standing position.

RESULTS

Whole spine angles were significantly different for visualization methods. Lumbar lordosis, cervical lordosis, and occipital angle were closer to natural standing values when discectomy was performed with a loupe, but most measures differed from natural standing values when performed out of loupe. Thoracic kyphosis was also similar to the natural standing position during discectomy using a loupe, but differed from the natural standing position when performed with naked eye. Whole spine angles were also found to differ from the natural standing position according to operating table height, and became closer to natural standing position values as operating table height increased, when simulation was conducted with loupe.

CONCLUSION

This study suggests that loupe use and a table height midpoint between the umbilicus and sternum are optimal for reducing surgeon musculoskeletal fatigue.

Ergonomic factors on task performance in laparoscopic surgery training

This paper evaluates the effect of ergonomic factors on task performance and trainee posture during laparoscopic surgery training. Twenty subjects without laparoscopic experience were allotted into 2 groups. Group 1 was trained under the optimal ergonomic simulation setting according to current ergonomic guidelines (Condition A). Group 2 was trained under non-optimal ergonomic simulation setting that can often be observed during training in a skills lab (Condition B). Posture analysis showed that the subjects held a much more neutral posture under Condition A than under Condition B (p<0.001). The subjects had less joint excursion and experienced less discomfort in their neck, shoulders, and arms under Condition A. Significant difference in task performance between Conditions A and B (p<0.05) was found. This study shows that the optimal ergonomic simulation setting leads to better task performance. In addition, no significant differences of task performance, for Groups 1 and 2 using the same test setting were found. However, better performance was observed for Group 1. It can be concluded that the optimal and non-optimal training setting have different learning effects on trainees' skill learning.

Kinematic design considerations for minimally invasive surgical robots: an overview

BACKGROUND

Kinematic design is a predominant phase in the design of robotic manipulators for minimally invasive surgery (MIS). However, an extensive overview of the kinematic design issues for MIS robots is not yet available to both mechanisms and robotics communities.

METHODS

Hundreds of archival reports and articles on robotic systems for MIS are reviewed and studied. In particular, the kinematic design considerations and mechanism development described in the literature for existing robots are focused on.

RESULTS

The general kinematic design goals, design requirements, and design preferences for MIS robots are defined. An MIS-specialized mechanism, namely the remote center-of-motion (RCM) mechanism, is revisited and studied. Accordingly, based on the RCM mechanism types, a classification for MIS robots is provided. A comparison between eight different RCM types is given. Finally, several open challenges for the kinematic design of MIS robotic manipulators are discussed.

CONCLUSIONS

This work provides a detailed survey of the kinematic design of MIS robots, addresses the research opportunity in MIS robots for kinematicians, and clarifies the kinematic point of view to MIS robots as a reference for the medical community.

Socio-Technical Systems Analysis in Health Care: A Research Agenda

Given the complexity of health care and the 'people' nature of healthcare work and delivery, STSA (Sociotechnical Systems Analysis) research is needed to address the numerous quality of care problems observed across the world. This paper describes open STSA research areas, including workload management, physical, cognitive and macroergonomic issues of medical devices and health information technologies, STSA in transitions of care, STSA of patient-centered care, risk management and patient safety management, resilience, and feedback loops between event detection, reporting and analysis and system redesign.

[Ergonomics in laparoscopic surgery and its importance in surgical training]

Despite the many advantages that laparoscopic surgery has for patients, it involves a series of risks for the surgeon. These are related to the reduced freedom of movement and forced postures which lead to greater muscle fatigue than with conventional surgery. In laparoscopic surgery there are few references on the introduction of training programs in ergonomics, despite the numerous advantages demonstrated in other disciplines. The application of ergonomic criteria in the surgical field could have great benefits, both for surgeons and patients. In this work we attempt to review the existing literature and our experience to provide the surgeon with some ergonomic guidelines for body stance and positioning of equipment. We also present a training model based on ergonomics which we have introduced into the training activities carried out in our Centre.

Prospective randomized evaluation of FOOT gel pads for operating room staff COMFORT during laparoscopic renal surgery

OBJECTIVES

We evaluated the comfort level of our laparoscopy team during and after laparoscopic renal surgery, with or without the use of gel footpads.

METHODS

Between September 2008 and April 2009 we prospectively randomized 100 consecutive laparoscopic renal procedures to examine whether the use of a foot gel pad altered the surgical team's comfort level. A questionnaire was used to measure the discomfort in 18 different subjects before and during surgery, and one day postoperatively. The procedures performed with or without the foot gel pads were compared.

RESULTS

One hundred laparoscopic procedures were randomized to being performed with and without gel pads. In 50 procedures, the foot gel pad was used. The mean age of the subjects was 36 years (range 25-52). The mean surgical experience was 7 years. The characteristics of the participants in procedures with and without the gel pad were similar. In the immediate postoperative period, there were significantly more breaks taken (P = .001), number of stretches (P = .001), foot pain (P = .003), knee pain (P = .001), back discomfort (P = .001), overall discomfort (P = .001), and diminished level of energy (P = .049) in the group not using the gel pad. Of the 24-hour postoperative time point, evaluation significantly favored the gel pads regarding foot pain (P = .004), overall amount of discomfort (P = .001), and energy level of the participants (P = .044).

CONCLUSIONS

The use of foot gel pads improves surgeon comfort and ergonomics during laparoscopy. The pads have been incorporated into our routine operating room set-up and may improve surgical performance by diminishing fatigue and discomfort.