Feasibility and acceptance of a robotic surgery ergonomic training program

Ergonomic strain of robotic-assisted versus laparoscopic inguinal hernia repair (ESRALI)-a crossover trial

BACKGROUND

Robotic-assisted and laparoscopic techniques are widely used for inguinal hernia repair. While robotic-assisted transabdominal preperitoneal (rTAPP) repair is believed to offer ergonomic advantages for surgeons, there is limited evidence comparing its ergonomic impact to conventional laparoscopic TAPP (cTAPP) repair. This study aims to assess the ergonomic strain on surgeons during these procedures using subjective and objective measures.

METHODS

This crossover observational study involved four experienced hernia surgeons who performed two procedures using each technique. Ergonomic strain was evaluated through self-reported perceived exertion (using the Borg scale), surface electromyography (sEMG) of select muscle groups, and posture analysis using rapid upper limb assessment (RULA) scores derived from kinematic data collected via Xsens Awinda. Statistical comparisons were conducted using the Wilcoxon rank-sum test, with adjustments for multiple comparisons.

RESULTS

Subjectively, surgeons perceived rTAPP as less physically demanding, with lower postoperative perceived exertion scores (median 1.5 vs. 3.0, p < 0.01). Objective measurements showed higher static muscle activity in the left erector spinae and median activity in the right trapezius during rTAPP (p = 0.016), but overall ergonomic strain, as indicated by RULA scores, was similar across modalities. Median RULA scores for both techniques were 3, and no significant differences were observed in work posture scores. Despite these findings, discomfort during cTAPP was more frequently reported, with surgeons citing the neck, shoulders, and lower back as affected areas.

CONCLUSION

While rTAPP was subjectively perceived as less physically demanding, objective metrics did not corroborate these perceptions, showing comparable ergonomic strain between techniques. These findings highlight a complex relationship between subjective and objective ergonomic measures and suggest a need for further research, incorporating broader assessments of cognitive and physical loads, to optimize surgeon ergonomics in minimally invasive procedures.

Effect of forearm compression sleeve on muscle fatigue during robotic surgery: a randomized controlled study

Purpose

The aim of the study was to investigate whether wearing a forearm compression sleeve during robotic surgery (RS) reduces muscle fatigue.

Methods

A randomized controlled study of consecutive RS cases was performed with three right-handed surgeons randomly allocated to wear a non-graduated compression sleeve over either his right or left forearm. Hand-grip strength was assessed at the beginning and at the 2-hour mark during the robotic console component of surgery, using a handgrip dynamometer. The maximum strength (Fmax) and mean grip strength (Fmean) were calculated after 10 measurements. Effectiveness of the forearm sleeve was tested primarily by the difference in mean grip strength, and secondarily by the difference in fatigue ratio (Fmax/Fmean) and recovery ratio at the two time points.

Results

Thirty-two robotic cases were performed during the study period. Wearing of a compression sleeve (compared with no sleeve) on the left forearm resulted in an increase (rather than a decrease) in mean hand-grip strength after 2 hours of RS (0.5 kg increase vs. 1.3 kg decrease, p = 0.03; 95% confidence interval, 0.20-∞). Wearing a compression sleeve (compared with no sleeve) on the right forearm did not result in an improvement in grip strength reduction (1.7 kg decrease vs. 1.1 kg decrease, p = 0.79).

Conclusion

There was a statistically significant reduction in muscle fatigue with wearing a forearm compression sleeve on the nondominant left forearm during RS.

Aching for Change: Musculoskeletal Pain in the Operating Theatre Amongst Surgical Trainees

OBJECTIVES

Work-related injuries are common among surgeons with up to 70 % being found to report difficulties. Given the extension expected to career longevity for current trainees, injury prevention is more important than ever. However, ergonomics education for surgical trainees in the UK is deficient. We aimed to gauge whether current trainees in Kent, Surrey and Sussex (KSS) experience pain whilst operating and what strategies, if any, they utilise.

DESIGN, SETTING AND PARTICIPANTS

A questionnaire was distributed to trainees in the KSS School of Surgery collecting data on pain related to operating and pain management strategies. Participants discussed their experiences of operating-related pain in a focus group.

RESULTS

75 trainees across the KSS region responded. Mean age was 32 years (range 26-42) and median training level was ST4. General surgery (n = 22), orthopaedics (n = 19) and urology (n = 13) were the most prevalent specialties. All trainees reported musculoskeletal pain attributed to operating, with 36 % (n = 27) experiencing pain "frequently" or "always". 69 % (n = 52) found this pain "sometimes", "frequently" or "always" distracted them whilst operating. The most common sites for pain were the lower back (73 %), neck (49.3 %), upper back (38.7 %) and shoulders (37.3 %). No participants had received formal ergonomics training and the majority (86.7 %) had not discussed pain with their supervisors. The focus group identified a culture of enduring pain without complaint and a reluctance to discuss it with mentors.

CONCLUSIONS

Musculoskeletal pain from operating was found to be a common issue in this cohort with the majority reporting distraction while operating. Ergonomics is not currently addressed by any formal training programmes and we have recommended a regional training initiative for trainees in KSS to address and prevent musculoskeletal injuries.

Work Related Pain in Gynecologic Surgeons - A National Survey

STUDY OBJECTIVE

This study aimed to: (1) ascertain the prevalence of work-related pain among gynecologic surgeons, (2) describe the risk factors and sequelae of pain, and (3) assess the need for an ergonomic curriculum.

DESIGN

Survey study.

SETTING

The survey was electronically administered.

PARTICIPANTS

Gynecologic surgery subspecialists and fellows in training, and Obstetrics and Gynecology specialists who performed gynecologic surgery were included.

MEASUREMENTS AND MAIN RESULTS

A 38-question anonymous survey was developed from the available ergonomic literature and had 3 main sections: (1) demographic information, (2) pain history, and (3) ergonomic education. A total of 305 gynecologic surgeons participated in the study. Of these, 76.7% were female. Most respondents were Minimally Invasive Gynecologic Surgeons (64.6%) with conventional laparoscopy as the primary surgical modality (65.6%). Of the respondents, 95.7% reported experiencing pain during or after surgery. Female surgeons (p = .018), shorter surgeons (OR = 2.4, 95% confidence interval [1.1, 5.4]), and those with a smaller gloves (p = .025) were more likely to report severe pain. Surgeons who reported worse pain were more likely to seek treatment (p = .007) and to take time off from operating (p <.001). Among the respondents, 79.4% reported engaging in various interventions to treat surgery-related pain. Due to pain, 23.9% reported changing the surgical modality, and 62.5% were concerned about their ability to operate in the future. Of the surgeons, 61.3% did not feel confident in their ability to set up their operating room ergonomically. 98.0% recommend formal ergonomic training for residents.

CONCLUSIONS

Surgeons are at risk of work-related pain. Gynecologic surgeons have been understudied and face specific ergonomic challenges. In this national survey of high-volume gynecologic surgeons of various subspecialties, we report a high rate of surgery-related pain and significant clinical and nonclinical sequelae of pain, and demonstrate the need to implement and improve ergonomic training for Obstetrics and Gynecology trainees.

A review of ergonomic positions to improve musculoskeletal distress in hepatobiliary pancreatic surgeons according to open, laparoscopic, and robotic surgeries

Advances in surgical ergonomics are essential for the performance, health, and career longevity of surgeons. Many surgeons experience work-related musculoskeletal disorders (WMSDs) resulting from various surgical modalities, including open, laparoscopic, and robotic surgeries. To prevent WMSDs, individual differences may exist depending on the surgical method; however, the key is to maintain a neutral posture, and avoid static postures. This review aims to summarize the concepts of ergonomics and WMSDs; identify the ergonomic challenges of open, laparoscopic, and robotic surgeries; and discuss ergonomic recommendations to improve them.

Ergonomics in the operating room and surgical training: a survey on the Italian scenario

Introduction

Surgical-related injuries are frequent, in fact the reported percentage of musculoskeletal disorders in surgeons is between 47% and 87%. These conditions are caused by long periods of standing, incorrect postures, repeated movements, little rest between operations, the lack of integrated operator rooms, the correct number and arrangement of monitors and the use of non-ergonomic instruments. This survey aims to assess the Italian overview both highlighting how prevalent surgical-related injury is in our surgeons and whether there is an operating room ergonomics education program in Italian surgical specialty schools.

Methods

An anonymous questionnaire was designed through SurveyMonkey© web application. This survey was composed of 3 different sections concerning the general characteristics of the participants, their surgical background and any training performed, and any injuries or ailments related to the surgical activity. The survey was carried out in the period 1th of December 2022 and the 6th of February 2023.

Results

At the close of our survey, 300 responses were collected. Among the participants, the two most represented specialties were Gynecology and Obstetrics (42.3%) and General Surgery (39.7%) and surgeons were mainly employed in the Northern regions of Italy (54.8%). Analyzing the participants' background, 61.7% of the respondents had laparoscopic training during their training and only 53.1% had a pelvic trainer during their residency. In accordance with 98.7% of the respondents, during surgery we have the feeling of being in an uncomfortable position that causes discomfort or muscle pain, and regarding the frequency of these discomforts, the majority of our study population experiences these problems monthly (46.2%), while in 29.6% it is experienced weekly, 12.1% annually and finally 12.1% daily. The surgical approach that is most correlated with these disorders is laparoscopy (62.7%) while the one that causes the least discomfort is robotic surgery (1.4%). These discomforts cause 43.9% of our population to take a break or do short exercises to reduce pain during surgery, and the body areas most affected are the back (61.6%), neck (40.6%) and shoulders (37.8%).

Conclusion

Despite this, our survey allows us to highlight some now-known gaps present in the surgical training program of our schools and the lack of protection toward our surgeons during their long career.

Ergonomic considerations for unique surgeon populations

PURPOSE OF REVIEW

Surgeons are rapidly diversifying as a population, introducing new ergonomic challenges. This review describes the challenges that are experienced by special populations of surgeons including small-handed surgeons, pregnant surgeons, and trainees, and evidence-based solutions to overcome them.

RECENT FINDINGS

Small-handed and female surgeons report more musculoskeletal complaints compared with their male counterparts. Pregnant surgeons frequently report development or worsening of musculoskeletal disorders such as carpal tunnel syndrome and low back pain. Trainees also report high rates of musculoskeletal complaints with minimal autonomy to alter their environment. Limited objective data exists regarding the ideal instruments currently available for special populations. Several small, randomized studies have proposed exercise regimens targeting the upper extremities and pregnancy-related pain syndromes with improvements in symptoms. Various methods of ergonomic education have been studied in trainees with improvements in operating room posture and performance.

SUMMARY

Limited objective data is available to recommend specific surgical instruments for high-risk surgeon populations. Beneficial exercise regimens have been described for musculoskeletal disorders commonly plaguing surgeons but have yet to be studied explicitly in small-handed or pregnant surgeons and trainees.

Assessing Muscular Pain and Ergonomics Among Robotic Surgeons in China: A Validation

INTRODUCTION

Robotic surgery has transformed minimally invasive procedures, offering precision and efficiency. However, the ergonomic aspects of robotic consoles and their impact on surgeon health remain understudied. This review investigates the burden of ergonomics and muscle fatigue among robotic surgeons in China, comparing the findings to a multinational study.

METHODOLOGY

A literature review identified themes related to physical discomfort in robotic surgery. A questionnaire was administered to Chinese robotic surgeons, yielding 40 responses. The study assessed demographic characteristics, surgeon experience, ergonomic practices, reported discomfort, and pain-relief mechanisms.

RESULTS

The study revealed that most surgeons experienced shoulder and neck pain, with mixed opinions on whether robotic surgery was the primary cause. Stretching exercises were commonly used for pain relief. Surgeons believed that case volume and surgery duration contributed to discomfort. Comparisons with a multinational study suggested potential demographic and experience-related differences.

CONCLUSION

While the study has limitations, including a small sample size and potential translation issues, it underscores the importance of addressing ergonomic concerns and providing proper training to robotic surgeons to ensure their well-being and longevity in the field. Further research with larger cohorts and platform-specific analyses is warranted.

Skill assessment based on clutch use in cross-platform robot-assisted surgery

BACKGROUND

Many studies have investigated the transfer of skills between laparoscopic and robot-assisted surgery (RAS). These studies have considered time, error, and clinical outcomes in the assessment of skill transfer. However, little is known about the specific operations of the surgeon. Clutch control use is an important skill in RAS. Therefore, the present study aimed to propose a novel objective algorithm based on computer vision that can automatically evaluate a surgeon's clutch use. Additionally, the study aimed to evaluate the correlation between clutch metrics and surgical skill on different surgical robot platforms.

METHODS

The robotic surgery training center of Wuhan University trained 30 laparoscopic surgeons as the study group between 2023 and 2024. Laparoscopic surgeons were trained by combining robotic simulator exercises and RAS animal experiments. During the training, video and hand movement data were collected. Hand movements identified by a skin-color model were combined with labeling information to classify clutch use. The metrics were validated on different robotic platforms (dv-Trainer, EDGE MP1000, Toumai™ MT1000, and DaVinci Xi system) and among surgeons with different surgical skill levels.

RESULTS

On the robotic simulator, clutch accuracy in the expert group was significantly higher than in the study group for all tasks. No significant differences were observed in the number of clutches between the expert and study groups. In the RAS experiment, the number of clutches decreased significantly for both study and expert groups. The accuracy was maintained at a high level in the expert group but decreased rapidly in the study group.

CONCLUSIONS

We proposed a new objective assessment of surgical skills, clutch use metrics, in cross-platform RAS. Additionally, we verified that the metrics significantly correlated with the surgical skill levels of the surgeons.

Ergonomic interventions to reduce upper limb musculoskeletal pain during robotic surgery: a narrative review

There is a high prevalence of upper limb musculoskeletal pain among robotic surgeons. Poor upper limb ergonomic positioning during robotic surgery occurs when the shoulders are abducted, and the elbows are lifted off the console armrest. The validated rapid upper limb assessment can quantify ergonomic efficacy. Surface electromyography and hand dynamometer assessment of strength are the most common methods to assess muscle fatigue. A literature review was performed to find evidence of ergonomic interventions which reduce upper limb musculoskeletal pain during robotic surgery. There is a paucity of studies which have reported on this topic. In other occupations, there is strong evidence for the use of resistance training to prevent upper extremity pain. Use of forearm compression sleeves, stretching, and massage may help reduce forearm fatigue. Microbreaks with targeted stretching, active ergonomic training, improved use of armrest, and optimal hand controller design have been shown to reduce upper limb musculoskeletal pain. Future studies should assess which interventions are beneficial in reducing surgeon upper limb pain during robotic surgery.

Physical and psychological impact of surgery on the operating surgeon

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

Human Factors Integration in Robotic Surgery

OBJECTIVE

Using the example of robotic-assisted surgery (RAS), we explore the methodological and practical challenges of technology integration in surgery, provide examples of evidence-based improvements, and discuss the importance of systems engineering and clinical human factors research and practice.

BACKGROUND

New operating room technologies offer potential benefits for patients and staff, yet also present challenges for physical, procedural, team, and organizational integration. Historically, RAS implementation has focused on establishing the technical skills of the surgeon on the console, and has not systematically addressed the new skills required for other team members, the use of the workspace, or the organizational changes.

RESULTS

Human factors studies of robotic surgery have demonstrated not just the effects of these hidden complexities on people, teams, processes, and proximal outcomes, but also have been able to analyze and explain in detail why they happen and offer methods to address them. We review studies on workload, communication, workflow, workspace, and coordination in robotic surgery, and then discuss the potential for improvement that these studies suggest within the wider healthcare system.

CONCLUSION

There is a growing need to understand and develop approaches to safety and quality improvement through human-systems integration at the frontline of care.Precis: The introduction of robotic surgery has exposed under-acknowledged complexities of introducing complex technology into operating rooms. We explore the methodological and practical challenges, provide examples of evidence-based improvements, and discuss the implications for systems engineering and clinical human factors research and practice.

Tips and tricks in gynaecological robotic surgery

It was the dawn of a new era for robotic surgery when the Food and Drug Administration (FDA) approved da Vinci robotic surgical system for general laparoscopic procedures in 2000. The surgical practice saw a transformative breakthrough towards minimally invasive approach with the ever-increasing uptake of advanced robots proven to benefit patients and surgeons in various ways. However, these innovative machines only complement and enhance a surgeon's operating skills, and with such privilege come responsibilities and new challenges. Heavy reliance on such advanced devices while operating on humans necessitates thorough training and supervision to ensure safe and efficient applications. It is the surgeon's responsibility to direct the procedure constantly and lead other team members who assist during the surgery. In this chapter, we provide miscellaneous tips and tricks that can help beginners navigate through robotic surgery with more confidence and enthusiasm.

Ergonomic hand positioning overcomes visual perception mismatch in nonsimulated robotic colorectal surgery

The aim of the study was to compare the internal instrument and external surgeon hand positions to determine whether visual perception mismatch (VPM) is a factor during robotic colorectal surgery. Continuous video footage of 24 consecutive robotic colorectal surgery cases were analysed concurrently with sagittal video recordings of surgeon hand positions. Separated sagittal hand positions would indicate nonergonomic positioning without clutching of the robotic controls, either matching the on-screen up/down instrument tip positions (no VPM) or in the opposite direction (true VPM). Variables (30-min surgery time blocks, anatomic target, and task performed), which resulted in hand separation or VPM, were analysed. Operating with the presence of VPM for more than one duration occurred 51 times and nonergonomic sagittal hand positioning occurred 22 times. For an experienced robotic surgeon, ergonomic positioning of the hands is favoured over adjustment for VPM despite the potential higher mental workload.

Factors affecting upper limb ergonomics in robotic colorectal surgery

The aim of the study was to examine the factors which may influence suboptimal ergonomic surgeon hand positioning during robotic colorectal surgery (RCS). An observational study of 11 consecutive RCS cases from June 2022 to August 2022 was performed. Continuous video footage of RCS cases was analysed concurrently with video recordings of surgeon's hand positions at the console. The outcome studied was the frequency with which either hand remained in a suboptimal ergonomic position outside the predetermined double box outlines, as marked on the surgeon's video, for >1 min. Situations which resulted in poor upper limb ergonomics were dissection in the peripheral operating field location, left-hand use, use of the stapler, dissection of the main mesenteric blood vessels, and multi-quadrant surgery. Being aware of situations when suboptimal ergonomic positions occur can allow surgeons to consciously compensate by using the clutch or pausing to take a rest break.

What does this paper add to the literature?

The study is important because it is the first to look at factors which may influence poor upper limb ergonomics during non-simulated RCS. By recognizing these factors and compensating for them, it may improve surgeon ergonomics with resultant better performance.

Muscle fatigue and physical discomfort reported by surgeons performing robotic-assisted surgery: a multinational survey

Robotic surgery has revolutionized surgical procedures and has provided many advantages over traditional laparoscopic and open surgeries. Despite the benefits, there are concerns about the physical discomfort and injuries that may be experienced by surgeons during robotic surgeries. This study aimed to identify the most common muscle groups implicated in robotic surgeons' physical pain and discomfort. A questionnaire was created and sent to 1000 robotic surgeons worldwide, with a response rate of 30.9%. The questionnaire consisted of thirty-seven multiple-choice questions, three short answer questions, and one multiple-option question pertaining to the surgeon's workload as well as their level of discomfort while and after performing surgery. The primary endpoint was to identify the most common muscle groups implicated in robotic surgeons' physical pain and discomfort. Secondary endpoints were to highlight any correlation between age group, BMI, hours of operation, workout regimen, and significant pain levels. The results showed that the most common muscle groups implicated in physical pain and discomfort were the neck, shoulders, and back, with many of the surgeons attributing their muscular fatigue and discomfort to the ergonomic design of the surgeon console. Despite the level of surgeon comfort the robotic console provides when compared to other conventional forms of surgery, the findings suggest the need for better ergonomic practices during robotic surgeries to minimize physical discomfort and injuries for surgeons.

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.

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.

Augmenting Career Longevity: An Analysis of Ergonomics Training Among 134 Neurological Surgeons

BACKGROUND

Work-related pain among neurosurgeons remains understudied, yet can have long-term consequences which affect operative efficiency and efficacy, career longevity, and life outside of work.

OBJECTIVE

This study provides insight into the extent of pain experienced by neurosurgeons and the effect of ergonomics training on pain.

METHODS

An online survey pertaining to ergonomics and pain was sent to all neurosurgeons on the Council of State Neurosurgical Societies (CSNS) email distribution list. Statistical comparisons of age groups against pain levels and ergonomics training against pain levels, as well as multivariate linear regression of demographics, training, and operating factors against pain levels were performed.

RESULTS

One hundred and thirty-four neurosurgeons responded to the survey. The mean average severity of pain across respondents was 3.3/10 and the mean peak severity of pain was 5.1/10. Among the reported peak pain severity scores, neurosurgeons with 21-30 years of operating experience had significantly higher pain scores than those with 11-20 years of experience (mean 6.2 vs. 4.2; P < 0.05), while neurosurgeons with more than 30 years of experience had significantly less pain than those with 21-30 years of experience (mean 4.4 vs. 6.2, P = 0.005). Training in ergonomics did not significantly improve respondents' reported peak or mean pain severities (17.9% reported having ergonomics training).

CONCLUSIONS

Ergonomics training did not appear to make a difference in neurosurgeons' pain severities. This may signify a need to optimize ergonomics pedagogy to achieve observable benefits.

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.

Ergonomics in Otolaryngology: A Systematic Review and Meta-analysis

OBJECTIVES

To determine the proportion of otolaryngologists with work-related musculoskeletal discomfort (WRMD) and to review objective ergonomic data that contribute to WRMD.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A comprehensive search of the literature identified 1121 articles for initial review of which 19 (3563 participants) met criteria for qualitative discussion and eight (2192 participants) met criteria for meta-analysis. Random effects meta-analyses were used to estimate the proportion of otolaryngologists reporting WRMD.

RESULTS

The overall proportion (95% confidence intervals [CI]) of general otolaryngologists reporting WRMD was 0.79 (0.66, 0.88) for any symptoms; 0.54 (0.40, 0.67) for neck symptoms; 0.33 (0.20, 0.49) for shoulder symptoms; and 0.49 (0.40, 0.59) for back symptoms. Surgeons performing primarily subspecialty cases had a lower estimated overall prevalence of WRMD versus those performing general ENT cases, however the odds ratio (OR) was not statistically significant (OR [95% confidence interval] 0.53 [0.22, 1.25]). 23%-84% of otolaryngologists underwent medical treatment for WRMD. 5%-23% took time off work and 1%-6% stopped operating completely as a result of WRMD. 23%-62.5% of otolaryngologists believed WRMD negatively impacted their quality of life. Objective measures of ergonomic posture indicate moderate to severe risk of injury during the routine clinic and surgical procedures with none found to be low risk.

CONCLUSIONS

Ergonomic stressors among otolaryngologists contribute to a high rate of WRMD across all subspecialties with notable impact on productivity, longevity, and quality of life. Laryngoscope, 133:467-475, 2023.

Ergonomic Assessment of the Surgeon's Physical Workload During Robot-Assisted Versus Standard Laparoscopy in a French Multicenter Randomized Trial (ROBOGYN-1004 Trial)

BACKGROUND

Standard laparoscopy (SL) is responsible for musculoskeletal disorders in surgeons because of poor ergonomic positions, which could be reduced by robot-assisted laparoscopy (RAL) owing to the surgeons' seated position. One of the aims of the ROBOGYN-1004 study (NCT01247779) was to evaluate surgeons' workloads during real-time procedures of gynecological oncological surgery.

METHODS

Patients with gynecological cancer eligible for minimally invasive surgery were recruited from 13 French centers between December 2010 and December 2015. Physical workload was evaluated using the Borg scale every hour over the surgery duration and the perception of workload evaluated using NASA-TLX at the end of surgery.

RESULTS

A total of 369 patients were recruited, of whom 176 underwent RAL and 193 underwent SL (per-protocol analysis). Posture during SL was significantly more challenging for all body parts except the back. There was an increase in discomfort over time (up to 4 h) for the hands and arms, neck, and legs in SL compared with RAL. Perceived physical activity and abilities were rated higher in SL than in RAL (p < 0.01), whereas perceived personal performance was higher in SL (p < 0.01). Perceived physical effort during surgery was lower in RAL than in SL.

CONCLUSIONS

RAL improves the perception of physical workload. Compared with SL, the perceived effort is lower in RAL regardless of the complexity of the surgery.

Ergonomics Workshop Improves Musculoskeletal Symptoms in General Surgery Residents

INTRODUCTION

Poor operative ergonomics can lead to muscle fatigue and injury. However, formal ergonomics education is uncommon in surgical residencies. Our study examines the prevalence of musculoskeletal (MSK) symptoms, baseline ergonomics knowledge, and the impact of an ergonomics workshop in general surgery residents.

METHODS

An anonymous voluntary presurvey and postsurvey was distributed to all general surgery residents at a single academic residency, assessing resident characteristics, MSK symptoms, and ergonomic knowledge before and after an ergonomics workshop. The workshop consisted of a lecture and a personalized posture coaching session with a physiatrist.

RESULTS

The presurvey received 33/35 (94%) responses. Of respondents, 100% reported some degree of MSK pain. Prevalence of muscle stiffness and fatigue decreased with increasing height. Females reported higher frequencies of MSK pain (P = 0.01) and more muscle fatigue than males (100% versus 73%, P = 0.03). All residents reported little to no ergonomics knowledge with 68% reporting that ergonomics was rarely discussed in the operating room. The postsurvey received 26/35 (74%) responses. Of respondents, 100% reported the workshop was an effective method of ergonomics education. MSK symptom severity improved in 82% of residents. Reports that ergonomics was rarely discussed in the operating room significantly decreased to 22.8% of residents (P < 0.01).

CONCLUSIONS

Surgical resident ergonomics knowledge is poor and MSK symptoms are common. Resident characteristics are associated with different MSK symptoms. Didactic teaching and personalized posture coaching improve ergonomics knowledge and reduce MSK symptom severity. Surgical residencies should consider implementing similar interventions to improve resident wellbeing.

Course Design and Learning Outcomes of a Practical Online Ergonomics Course for Surgical Residents

OBJECTIVE

Course content was designed and the learning outcomes assessed for an online ergonomics course for surgical residents. This course could fulfill an optional Surgical Council on Resident Education (SCORE) curriculum on Surgical Ergonomics.

DESIGN

The online course included five 5-minute modules within the residents' learning system, each ending with an ungraded knowledge question, and a final 5-question multiple-choice retention quiz that allowed infinite attempts. The course was designed by ergonomists and surgeons at a quaternary academic hospital system. Participants were given two weeks to complete the modules. An electronic survey with questions assessing ergonomics knowledge and understanding on a 5-point Likert scale (strongly disagree - strongly agree) was distributed both before and after the course. The post-course survey included three additional questions to elicit feedback regarding learning experience and course design. Descriptive statistics and nonparametric paired comparisons were used to evaluate learning outcomes.

SETTING

General surgery residency program at an academic medical center in the U.S.

PARTICIPANTS

Twenty-two general surgery post graduate year 1 residents (PGY1s) were recruited to participate and completed the pre-course survey. Eight out of the 22 participants (36%) completed the online course and quiz; seven (32%) completed the course, quiz, and the post-course survey.

RESULTS

Participants had high pre-course awareness of the importance of surgical ergonomics, benefits of work-related musculoskeletal disorder (WMSD) prevention, as well as awkward intraoperative postures being an WMSD risk factor. Participants' confidence increased significantly from pre- to post-course in ability to assess risk (p = 0.021), but not in ability or willingness to mitigate risky surgical postures. Participants who completed the quiz answered a median of 4 (IQR: [4, 5]) questions correctly. All participants indicated that they would recommend this course to other residents.

CONCLUSIONS

These short practical ergonomics online learning modules increased surgical residents' confidence in assessing surgical WMSD risks.

A comparison of laparoscopic and robotic ergonomic risk

INTRODUCTION

Work related injuries in minimally invasive surgery (MIS) are common because of the strains placed on the surgeon's or assistant's body. The objective of this study was to compare specific ergonomic risks among surgeons and surgical trainees performing robotic and laparoscopic procedures.

MATERIALS AND METHODS

Ergonomic data and discomfort questionnaires were recorded from surgeons and trainees (fellows/residents) for both robotic and laparoscopic procedures. Perceived discomfort questionnaires were recorded pre/postoperatively. Intraoperatively, biomechanical loads were captured using motion tracking sensors and electromyography (EMG) sensors. Perceived discomfort, body position and muscle activity were compared between robotic and laparoscopic procedures using a linear regression model.

RESULTS

Twenty surgeons and surgical trainees performed 29 robotic and 48 laparoscopic procedures. Postoperatively, increases in right finger numbness and right shoulder stiffness and surgeon irritability were noted after laparoscopy and increased back stiffness after robotic surgery. Further, the laparoscopic group saw increases in right hand/shoulder pain (OR 0.8; p = 0.032) and left hand/shoulder pain (0.22; p < 0.001) compared to robotic. Right deltoid and trapezius excessive muscle activity were significantly higher in laparoscopic operations compared to robotic. Demanding and static positioning was similar between the two groups except there was significantly more static neck position required for robotic operations.

CONCLUSION

Robotic assisted surgeries led to lower postoperative discomfort and muscle strain in both upper extremities, particularly dominant side of the surgeon, but increased static neck positioning with subjective back stiffness compared with laparoscopy. These recognized ergonomic differences between the two platforms can be used to raise surgeon awareness of their intraoperative posture and to develop targeted physical and occupational therapy interventions to decrease surgeon WMSDs and increase surgeon longevity.

The Current State of Surgical Ergonomics

OBJECTIVE

Work-related musculoskeletal disorders are widespread among surgeons, causing significant disability and career modification. Gender plays a role, as female surgeons have a two-fold greater risk for discomfort during certain operations due to generally smaller hand sizes and height as compared to male surgeons. There is a lack of appropriate surgical instrumentation geared toward smaller hand sizes. Maintaining a neutral position while operating, frequent changes in position, and increased awareness can contribute to decreasing the detrimental impact on surgeons' bodies from performing operations.

Minimally invasive surgery and the risk of work-related musculoskeletal disorders: Results of a survey among Israeli surgeons and review of the literature

BACKGROUND: Minimally invasive surgery (MIS) has many advantages for patients, however, it places surgeons at risk for Work-related musculoskeletal disorders (WMSD). Recently, the importance of prevention of such injuries and improvement of the ergonomics of the operating room is increasing. OBJECTIVES: To assess the prevalence of WMSD among minimally invasive surgeons in Israel, discuss the contributing factors and the overall awareness for ergonomic training. In addition, a review of the literature on the topic was conducted. METHODS: An online questionnaire was sent to the members of the Israeli Society of Endoscopic Surgery. The results were analyzed and summarized. For literature review, PubMed was used to search for English-language publications related to the issue. RESULTS: Of 83 respondents, the majority (77%) have considerable experience in MIS (more than 10 years). The prevalence of WMSD was 12% before beginning the practice of laparoscopy compared to 78% after 15–20 years of practice. Injury sites included back pain, neck and upper extremity (shoulder pain, tennis elbow and carpal tunnel syndrome) in 41%, 25% and 34% respectively. More than two thirds of responders unaware of possible ergonomic solutions and didn’t consider adopting any appropriate preventive measures. CONCLUSIONS: The incidence of WMSD among MIS surgeons is high and underestimated. There is a desperate need to prevent such morbidity among surgeons by increasing awareness and providing the means to improve their work environment. Surgeons should adhere to ergonomic recommendations for positioning of monitors, table height, posture, foot pedal placement and laparoscopic devices use.

Surgeon Strength: Ergonomics and Strength Training in Cardiothoracic Surgery

With the high prevalence of musculoskeletal pain in surgeons and interventionalists, it is critical to analyze the impact of ergonomics on cardiothoracic surgeon health. Here, we review the existing literature and propose recommendations to improve physical preparedness for surgery both in and outside the operating room. For decades, cardiothoracic surgeons have suffered from musculoskeletal pain, most commonly in the neck, and back due to a lack of proper ergonomics during surgery. A lack of dedicated ergonomics curriculum during training may leave surgeons at a high predisposition for work-related musculoskeletal disorders. We searched PubMed, Google Scholar, and other sources for studies relevant to surgical ergonomics and prevalence of musculoskeletal disease among surgeons and interventionalists. Whenever possible, data from quantitative studies, and meta-analyses are presented. We also contacted experts and propose an exercise routine to improve physical preparedness for demands of surgery. To date, many studies have reported astonishingly high rates of work-related pain in surgeons with rates as high as 87% in minimally-invasive surgeons. Several optimizations regarding correct table height, monitor positioning, and loupe angles have been discussed. Lastly, implementation of ergonomics training at some programs have been effective at reducing the rates of musculoskeletal pain among surgeons. Surgical work-related stress injuries are more common than we think. Many factors including smaller incisions and technological advancements have led to this plight. Ultimately, work-related injuries are underreported and understudied and the field of surgical ergonomics remains open for investigative study.

EFFECT OF MUSCULOSKELETAL DISORDERS AND ORGANIZATIONAL CLIMATE ON WELL-BEING OF DENTAL HYGIENISTS

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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.

Incorporating Surgical Ergonomics Education into Surgical Residency Curriculum

BACKGROUND

Education on surgical ergonomics during residency training is lacking. This study aimed to determine the feasibility and impact of incorporating surgical ergonomics lectures into residency curriculum.

METHODS

A survey was distributed to 42 residents with questions regarding demographics, surgical factors, prevalence of musculoskeletal (MSK) symptoms, and awareness of ergonomic recommendations. The residents then received 2 lectures on ergonomics in surgery. A follow up survey was distributed to evaluate the impact of the lectures.

RESULTS

Twenty-two residents completed the presession survey. Ninety-one percent reported MSK symptoms attributed to their training. Seventeen residents completed the follow up survey. All reported increased awareness of their own habits while operating and improved understanding of methods to prevent and/or treat work-related injuries. All residents recommended incorporating the lectures as an adjunct to their regular curriculum.

CONCLUSIONS

The rates of MSK symptoms and/or injury are high among surgeon trainees. Residency is an opportune time to educate on principles of ergonomics and may prevent future injuries.

Ergonomics in Interventional Radiology: Awareness Is Mandatory

Ergonomics in interventional radiology has not been thoroughly evaluated. Like any operators, interventional radiologists are exposed to the risk of work-related musculoskeletal disorders. The use of lead shielding to radiation exposure and the lack of ergonomic principles developed so far contribute to these disorders, which may potentially affect their livelihoods, quality of life, and productivity. The objectives of this review were to describe the different situations encountered in interventional radiology and to compile the strategies both available to date and in development to improve ergonomics.

Using Wearable Technology to Measure the Association Between Neck Posture and Neck Pain During Urologic Open and Robotic Surgery

PURPOSE

Chronic neck pain is the most prevalent work-related musculoskeletal injury among surgeons. Urologists may be at higher risk of neck injury due to extended time spent operating in deep anatomical structures during open surgery. Our goal was to use wearable technology to quantify the relationship between neck posture and pain during open and robotic surgery.

MATERIALS AND METHODS

Urologic attendings and residents who spent at least 1 day per week performing surgery for over 6 hours took part in this study. Neck posture was measured in real time during surgery using inertial measurement devices attached at the occipital protuberance and 7th cervical vertebrae. Self-reported neck pain scores were obtained throughout their workday.

RESULTS

30 participants and 202 hours of surgery were included in the study (21 attendings, 9 residents). There was a significant association between neck posture and pain (p = 0.04). Surgeons performing open procedures spent on average 147 minutes with their head in neck flexion postures of 30° or greater compared to 68 minutes for those performing robotic procedures (p =0.007). Surgeons performing open procedures reported a mean change in neck pain of 2.0 on the numeric analogue scale, compared to 1.3 for those performing robotic procedures (p = 0.04).

CONCLUSIONS

Real time measurements of neck flexion during urologic surgery shows that greater duration and higher degree of neck flexion were associated with increased neck pain. Raising awareness about ergonomics in the operating room during residency will enable future generations of surgeons to make conscious decisions regarding their neck posture in surgery.

Surgical ergonomics for urologists: a practical guide

Poor ergonomics in the operating room can have detrimental effects on a surgeon's physical, psychological and economic well-being. This problem is of particular importance to urologists who are trained in nearly all operative approaches (open, laparoscopic, robotic-assisted, microscopic and endoscopic surgery), each with their own ergonomic considerations. The vast majority of urologists have experienced work-related musculoskeletal pain or injury at some point in their career, which can result in leaves of absence, medical and/or surgical treatment, burnout, changes of specialty and even early retirement. Surgical ergonomics in urology has been understudied and underemphasized. In this Review, we characterize the burden of musculoskeletal injury in urologists and focus on various ergonomic considerations relevant to the urology surgeon. Although the strength of evidence remains limited in this space, we highlight several practical recommendations stratified by operative approach that can be incorporated into practice without interrupting workflow whilst minimizing injury to the surgeon. These recommendations might also serve as the foundation for ergonomics training curricula in residency and continuing medical education programmes. With improved awareness of ergonomic principles and the sequelae of injury related to urological surgery, urologists can be more mindful of their operating room environment and identify ways of reducing their own symptoms and risk of injury.

Work-system interventions in robotic-assisted surgery: a systematic review exploring the gap between challenges and solutions

BACKGROUND

The introduction of a robot into the surgical suite changes the dynamics of the work-system, creating new opportunities for both success and failure. An extensive amount of research has identified a range of barriers to safety and efficiency in Robotic Assisted Surgery (RAS), such as communication breakdowns, coordination failures, equipment issues, and technological malfunctions. However, there exists very few solutions to these barriers. The purpose of this review was to identify the gap between identified RAS work-system barriers and interventions developed to address those barriers.

METHODS

A search from three databases (PubMed, Web of Science, and Ovid Medline) was conducted for literature discussing system-level interventions for RAS that were published between January 1, 1985 to March 17, 2020. Articles describing interventions for systems-level issues that did not involve technical skills in RAS were eligible for inclusion.

RESULTS

A total of 30 articles were included in the review. Only seven articles (23.33%) implemented and evaluated interventions, while the remaining 23 articles (76.67%) provided suggested interventions for issues in RAS. Major barriers identified included disruptions, ergonomic issues, safety and efficiency, communication, and non-technical skills. Common solutions involved team training, checklist development, and workspace redesign.

CONCLUSION

The review identified a significant gap between issues and solutions in RAS. While it is important to continue identifying how the complexities of RAS affect operating room (OR) and team dynamics, future work will need to address existing issues with interventions that have been tested and evaluated. In particular, improving RAS-associated non-technical skills, task management, and technology management may lead to improved OR dynamics associated with greater efficiency, reduced costs, and better systems-level outcomes.

Ergonomics in IR

Ergonomic research in the field of interventional radiology remains limited. Existing literature suggests that operators are at increased risk for work-related musculoskeletal disorders related to the use of lead garments and incomplete knowledge of ergonomic principles. Data from existing surgical literature suggest that musculoskeletal disorders may contribute to physician burnout and female operators are at a higher risk of developing musculoskeletal disorders. This review article aims to summarize the existing ergonomic challenges faced by interventional radiologists, reiterate existing solutions to these challenges, and highlight the need for further ergonomic research in multiple areas, including burnout and gender.

A kinematic posture analysis of neurological assistants in their daily working practice-a pilot study

Background

The aim of this pilot study was to analyze postures during the work of neurologists with respect to their occupational activities.

Methods

A total data material of 64.8 h (3885.74 min) of nine (three m/six f) neurologists (assistant physicians) was collected. Kinematic data were collected using the CUELA system (electro-goniometry). In addition, the occupational tasks performed on-site were subject to a detailed objective activity analysis. All activities were assigned to the categories “Office activities” (I), “Measures on patients” (II) and “Other activities” (III). The angle values of each body region (evaluation parameters) were evaluated according to ergonomic ISO standards.

Results

Only 3.4% of the working hours were spent with (II), while 50.8% of time was spent with (I) and 45.8% with (III). All tasks of category (II) revealed an increased ergonomic risk to the head, neck, trunk and back areas. During category (I) especially neck and back movements in the sagittal plane showed higher ergonomic risk levels.

Conclusion

Despite frequently performed awkward body positions in (II), the ergonomic risk is considered as rather low, since the percentage time share totaled only 3.4%. As a result, “Office activities” have been detected as high predictor to cause stress load on the musculoskeletal system in the daily work of neurologists.

An analysis of the ergonomic risk of surgical trainees and experienced surgeons during laparoscopic procedures

BACKGROUND

Work-related musculoskeletal injuries have been increasingly recognized to affect surgeons. It is unknown whether such injuries also affect surgical trainees. The purpose of this study was to assess the ergonomic risk of surgical trainees as compared with that of experienced surgeons.

METHODS

Ergonomic data were recorded from 9 surgeons and 11 trainees. Biomechanical loads during surgery were assessed using motion tracking sensors and electromyography sensors. Demanding and static positions of the trunk, neck, right/left shoulder, as well as activity from the deltoid and trapezius muscles bilaterally were recorded. In addition, participants reported their perceived discomfort on validated questionnaires.

RESULTS

A total of 87 laparoscopic general surgery cases (48 attendings and 39 trainees) were observed. Both trainees and attendings spent a similarly high percentage of each case in static (>60%) and demanding positions (>5%). Even though residents reported overall more discomfort, all participants shared similar ergonomic risk with the exception of trainees' trunk being more static (odds ratio: -11.42, P = .006).

CONCLUSION

Surgeons are prone to ergonomic risk. Trainees are exposed to similar postural ergonomic risk as surgeons but report more discomfort and, given that musculoskeletal injuries are cumulative over time, the focus should be on interventions to reduce ergonomic risk in the operating room.

A systematic review of the true benefit of robotic surgery: Ergonomics

BACKGROUND

Ergonomics, as defined by the optimization of one's physical environment to enhance work performance, is an important consideration in surgery. While there have been reviews on the ergonomics of laparoscopy, this has not been the case for robotic surgery despite the rising number of publications.

METHODS

This study was performed in accordance to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. A search was performed on main databases to identify relevant articles.

RESULTS

Twenty-nine articles were included, comprising 3074 participants. Studies employing objective measurement tools showed that robotics conferred superior ergonomic benefits and reduced work load compared to laparoscopy, for both surgeons and trainees. Survey studies also demonstrated that self-reported discomfort was lower in robotic procedures compared to laparoscopy and open surgery. Compared to other subspecialities, gynecological procedures seem to be associated with greater surgeon-reported strain.

CONCLUSION

Robotic surgery is ergonomically superior to open and laparoscopic surgery. However, rates of physical strain remain significant and should be addressed by formal ergonomic training and adequate console familiarization.

Muscle activation during traditional laparoscopic surgery compared with robot-assisted laparoscopic surgery: a meta-analysis

BACKGROUND

The repetitive and forceful motions used by operating surgeons increase the risk of developing musculoskeletal disorders. Most ergonomists consider the surgical environment to be incredibly harsh for its workers. Traditional Laparoscopic Surgery (TLS) in particular has a number of physical and mental challenges associated with it, and while Robotic-Assisted Laparoscopic Surgery (RALS) provides several features that improve upon TLS, some surgeons have still reported musculoskeletal symptoms they attribute to RALS. In this paper, we endeavored to systematically review muscle activation for both TLS and RALS, to compare the modalities and present the results as a meta-analysis.

METHODS

A literature search was conducted using Pubmed, Embase, and Cochrane databases in November 2018 with the following inclusion criteria: full text was available in English, the paper contained original data, EMG was one of the primary measurement techniques, and the paper included EMG data for both TLS and RALS. Results from studies were compared using standardized mean difference analysis.

RESULTS

A total of 379 papers were found, and through screening ten were selected for inclusion. Sample populations ranged from 1 to 31 surgeons, and a variety of study designs and metrics were used between studies. The biceps were the only muscle group that consistently and significantly demonstrated lower muscle activation for RALS for all included studies.

CONCLUSIONS

The results may support the belief that RALS is ergonomically superior to TLS, shown through generally lower muscle activation scores. However, these results must be interpreted with caution due to the heterogeneity between the studies and multiple potential sources for bias within studies. This analysis would be strengthened with a higher number of homogenous, high-quality studies examining larger sample sizes.

An Ergonomic Assessment Of Four Different Donor Nephrectomy Approaches For The Surgeons And Their Assistants

Introduction

Open surgery is increasingly being replaced by laparoscopic approaches that are more demanding for the surgical team. The physical and mental workload of these approaches have not been quantified.

Materials and methods

A multicenter prospective study was performed evaluating the physical and mental stresses of 4 surgical approaches (open surgery [OS], standard laparoscopy [SL], hand-assisted laparoscopy [HAL], and robot-assisted laparoscopy [RAL]) for donor nephrectomy for the surgeon and their assistant. The Borg Scale was used to evaluate exertion in different body parts every 30 mins during surgery and the NASA-TLX score was used to evaluate overall workload.

Results

264 nephrectomies were performed over a 33-month period and 258 questionnaires evaluating these surgeries were obtained. Surgeons experienced less left shoulder and arm exertion and left forearm and hand exertion, but greater lower back exertion, as measured by the Borg scale, with RAL. Leg exertion was significantly greater with OS. Assistant surgeons experienced increased exertion in the back, right shoulder and arm, and right forearm and hand with RAL. NASA Task load index (TLX) surgeon scores showed mental demand was similar for all 4 surgical approaches. Physical demand was lower and overall performance was higher with RAL.

Discussion

Four different nephrectomy surgical approaches were evaluated in a multicenter setting. Surgeon and assistant scores of physical exertions were generally in the "easy" range but confirmed that robotic surgery is an ergonomic progress compared to other techniques, except for the axial skeleton. Further, it degrades the working conditions for the assistant.

Ergonomics and Musculoskeletal Health of the Surgeon

Surgeons face hazardous working conditions due to ergonomic deficiencies found throughout the operating room. More than 80% of surgeons have succumbed to a work-related injury or illness as a consequence of sustaining awkward or static positions throughout lengthy operations over a career. While the focus of the procedure is directed to the patient, there is little concurrent regard for proper posture or spinal stability. Even when symptoms of discomfort are experienced, they are often ignored. This results in decreased production and may ultimately threaten surgical careers. Surgeons are often unaware of recommendations or guidelines designed to improve their comfort while operating. Furthermore, there is a significant lack of any formal ergonomic education, especially for minimally invasive procedures. Several modifiable risk factors can be adjusted in the operating room to provide a safer working environment. In addition, strengthening, stability, and exercise programs directed by a trained therapist may be employed to improve the surgeon's musculoskeletal health.

Ergonomics in gynecologic surgery

PURPOSE OF REVIEW

Work-related musculoskeletal disorders (WMSDs) are prevalent among surgeons and result in significant disability. We aimed to review the English-language literature regarding ergonomic risk, prevalence of WMSDs, and unique ergonomic considerations of gynecologic surgery.

RECENT FINDINGS

Surgeon WMSDs are prevalent, with rates ranging from 66 to 94% for open surgery, 73-100% for conventional laparoscopy, 54-87% for vaginal surgery, and 23-80% for robotic-assisted surgery. Risk factors for injury in open surgery include use of loupes, headlamps, and microscopes. Unique risks in laparoscopic surgery include table and monitor position, long-shafted instruments, and poor instrument handle design. In vaginal surgery, improper table height and twisted trunk position create injury risk. Although robotic surgery offers some advantages in neck and shoulder strain, it remains associated with trunk, wrist, and finger strain.

SUMMARY

WMSDs are prevalent among surgeons but have received little attention because of under-reporting of injury and logistical constraints of studying surgical ergonomics. Future research must aim to develop objective surgical ergonomics instruments and guidelines and to correlate ergonomics assessments with pain and tissue-level damage in surgeons with WMSDs. Ergonomics training should be developed and implemented in order to protect surgeons from preventable, potentially career-altering injuries.