Monitor position in laparoscopic 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.

A comparative study on trocar configurations and the use of steerable instruments in totally extraperitoneal inguinal hernia surgery training

BACKGROUND

Totally extraperitoneal (TEP) inguinal hernia surgery is a commonly performed but technically challenging procedure with a long learning curve. As TEP can be executed using two different trocar placements: a midline or a triangular configuration, the question remains which one is technically easier to master.

METHODS

In a multicenter crossover-study, medical students were randomised into two groups and executed tasks on a box trainer that measured time, volume and force parameters. Additionally, the study assessed whether the SATA instrument, a steerable laparoscopic instrument that articulates the instrument's tip, would reduce the difficulty of performing the tasks in the midline configuration. After training, all participants executed a first experiment using both trocar configurations, followed by a second experiment executed with steerable and non-steerable instruments in the midline configuration. Subjective and objective performances per condition and learning curves were assessed.

RESULTS

Participants were faster and showed lower peak forces in the triangulated configuration. Learning curve analysis showed a positive improvement in time and path length in the midline configuration. Although participants rated ergonomics and intuitiveness similarly between the instruments, they found the task easier with the SATA instruments, ranking the added value of the steering function as 5 out of 5. Objectively, time and path length showed no significant differences while exerted forces were lower when using conventional instruments.

CONCLUSION

Although the midline configuration is preferred in terms of comfort and posture, the findings indicate that, for inexperienced practitioners, performing TEP surgery in midline configuration is both subjectively and objectively more challenging, highlighting the need for extensive training to overcome its difficulties and possibly shorten its learning curve. Although instruments with additional steering functions were preferred over conventional instruments in the more challenging midline configuration, additional steering complexity did not result in better parameter outcomes, showing the need for more extensive training.

Promoting gender diversity and ergonomic equity in the cardiac surgery operating room

PURPOSE OF REVIEW

The operating room (OR) infrastructure and equipment such as gloves, were historically designed at a time when most surgeons were male. Today, there are increasing numbers of females in the OR and we should ensure that there is not a disproportionate risk of ergonomic stress and risk of work-related injuries. This review provides a perspective on the representation of female cardiac surgeons globally and examines the unique ergonomic challenges they may face.

RECENT FINDINGS

Female cardiac surgeons represent approximately 17% of practitioners in our sample of cardiac surgery centers, underscoring significant underrepresentation. Female cardiac surgeons report higher incidences of work-related musculoskeletal injuries and ergonomic challenges compared to their male colleagues. This could negatively impact their physical health and performance. Studies further highlight the inadequacy of standardized surgical tools and workstations in accommodating sex-specific anthropometry, contributing to the disproportionate strain experienced by female surgeons.

SUMMARY

To mitigate gender disparities in cardiac surgery, there is a need to optimize OR infrastructure and surgical instrumentation to accommodate sex-based anatomical differences. Implementing ergonomic solutions, such as adjustable workstations and gender-specific surgical tools, could reduce musculoskeletal injuries and improve overall surgeon performance. Addressing these disparities represents a critical step toward fostering an equitable and inclusive surgical workforce, enhancing both the health and career longevity of female cardiac surgeons.

Ergonomic endoscopy - Fundamentals of ergonomics and interventions for endoscopy-related musculoskeletal disorders

Recently, musculoskeletal disorders (MSDs) among endoscopists have attracted considerable attention. MSDs are caused by prolonged static postures, forceful manual exertions, and repetitive twisting maneuvers. Basic knowledge of ergonomics is useful for improving the posture, movements, and work environment of endoscopists, as well as developing equipment to prevent MSDs. This review discusses problematic endoscopic tasks from an ergonomic perspective, issues with MSD definitions, the prevalence of MSDs, local site interpretations, risk factors including working time and environment, and ergonomic evaluations. The evidence highlights the importance of multifaceted strategies for risk avoidance using the Hierarchy of Controls. Additionally, this review summarizes global trends and introduces the Ergonomic Endoscopy 7 Tips for MSD prevention, emphasizing a systems approach through collaboration with various stakeholders. Thus, it may serve as a guide for gastroenterologists and staff engaged in endoscopic procedures for prolonged periods.

Sensorimotor Challenges in Minimally Invasive Surgery: A Theoretically-Oriented Review

OBJECTIVE

This review surveys the literature on sensorimotor challenges impacting performance in laparoscopic minimally invasive surgery (MIS).

BACKGROUND

Despite its well-known benefits for patients, achieving proficiency in MIS can be challenging for surgeons due to many factors including altered visual perspectives and fulcrum effects in instrument handling. Research on these and other sensorimotor challenges has been hindered by imprecise terminology and the lack of a unified theoretical framework to guide research questions in the field.

METHOD

We conducted a systematic survey of the MIS literature, focusing on studies investigating sensorimotor challenges affecting laparoscopic performance. To provide a common foundation for cross-study comparisons, we propose a standardized taxonomy that distinguishes between different experimental paradigms used in the literature. We then show how the computational motor learning perspective provides a unifying theoretical framework for the field that can facilitate progress and motivate future research along clearer, hypothesis-driven lines.

RESULTS

The survey identified diverse sensorimotor perturbations in MIS, which can be effectively categorized according to our proposed taxonomy. Studies investigating monitor-, camera-, and tool-based perturbations were systematically analyzed, elucidating their impact on surgical performance. We also show how the computational motor learning perspective provides deeper insights and potential strategies to mitigate challenges.

CONCLUSION

Sensorimotor challenges significantly impact MIS, necessitating a systematic, empirically informed approach. Our proposed taxonomy and theoretical framework shed light on the complexities involved, paving the way for more structured research and targeted training approaches to enhance surgical proficiency.

APPLICATION

Understanding the sensorimotor challenges inherent to MIS can guide the design of improved training curricula and inform the configuration of setups in the operating room to enhance surgeon performance and ultimately patient outcomes. This review offers key insights for surgeons, educators, and researchers in surgical performance and technology development.

Ergonomics in bronchoscopy

PURPOSE OF REVIEW

This study examines ergonomic considerations in bronchoscopic procedures, surveying existing research, injury rates, contributing factors, and practical ergonomic controls.

RECENT FINDINGS

The field of ergonomics examines the relationship between workers and their workplace to enhance productivity and minimize injuries. Bronchoscopists may face ergonomic hazards due to extended periods of maintaining fixed positions, repetitive actions, and the design of both tools and procedure spaces. Studies on the ergonomics of bronchoscopy have revealed a wide range of musculoskeletal issues among practitioners. Those new to the field, including trainees and early-career professionals, may be particularly vulnerable to injuries compared to their more experienced counterparts. Implementing a systematic approach, such as that proposed by the National Institute for Occupational Safety and Health, could help reduce physical stress, discomfort, and the likelihood of musculoskeletal disorders for bronchoscopists.

SUMMARY

Bronchoscopists increasingly face ergonomic issues in their practice. Despite available measures to address these problems, the field lacks uniform ergonomic guidelines for bronchoscopy. To safeguard bronchoscopists' health and safety from the outset of their careers, more studies and training focused on ergonomics in bronchoscopy are needed.

Ergonomic and sustainable posture for gynecological laparoscopic surgeons determined based on images analyzed using artificial intelligence

Studies have reported the emergence of work-related musculoskeletal disorders (WMSD) due to surgery. In fact, the usfige of long-shafted instruments has been suspected to induce WMSD in laparoscopic surgery. The present study therefore investigated whether differences in the range of motion of the face and neck, and the shoulder, elbow and hand on the dominant hand side, existed when using short- and long-shafted laparoscopic coagulation shears (LCS) during a gynecological laparoscopic surgery, based on images analyzed using artificial intelligence. After identifying the corresponding body parts in the video, the range of motion was illustrated graphically for each joint coordinate, followed by statistical analysis for changes in the position of each part. The range of motion for the face and neck did not significantly differ, whereas those for the shoulder, elbow and hand became noticeably broader when using the 36-cm long-shafted LCS than when using the 20-cm short-shafted LCS. Overall, the shorter LCS promoted a narrower range of motion compared with the 36-cm LCS, suggesting its potential for reducing the physical strain placed on the surgeon's body during gynecological laparoscopic surgery.

Optimizing ergonomics during open, laparoscopic, and robotic-assisted surgery: A review of surgical ergonomics literature and development of educational illustrations

BACKGROUND

The surgical profession is plagued with a high prevalence of work-related musculoskeletal disorders. While numerous interventions have been tested over the years, surgical ergonomics education is still uncommon.

METHODS

The available literature on surgical ergonomics was reviewed, and with input from surgeons, recommendations from the review were used to create pictorial reminders for open, laparoscopic, and robot-assisted surgical modalities. These simple pictorial ergonomic recommendations were then assessed for practicality by residents and surgeons.

RESULTS

A review of the current literature on surgical ergonomics covered evidence-based ergonomic recommendations on equipment during open and laparoscopic surgery, as well as proper adjustment of the surgical robot for robot-assisted surgeries. Ergonomic operative postures for the three modalities were examined, illustrated, and assessed.

CONCLUSIONS

The resulting illustrations of ergonomic guidelines across surgical modalities may be employed in developing ergonomic education materials and improving the identification and mitigation of ergonomic risks in the operating room.

Ergonomics of bronchoscopy: good advice or a pain in the neck?

Interventional pulmonologists require a unique set of skills including precise motor abilities and physical endurance, but surprisingly the application of ergonomic principles in the field of bronchoscopy remains limited. This is particularly intriguing when considering the significant impact that poor ergonomics can have on diagnostic aptitude, income potential and overall health. It is therefore imperative to provide comprehensive education to physicians regarding the significance of ergonomics in their work, especially considering the introduction of advanced diagnostic and therapeutic procedures. By implementing simple yet effective measures (e.g. maintaining neutral positions of the wrist, neck and shoulder; adjusting the height of tables and monitors; incorporating scheduled breaks; and engaging in regular exercises), the risk of injuries can be substantially reduced. Moreover, objective tools are readily available to assess ergonomic postures and estimate the likelihood of work-related musculoskeletal injuries. This review aims to evaluate the current literature on the impact of procedure-related musculoskeletal pain on practising pulmonologists and identify modifiable factors for future research.

American Society for Gastrointestinal Endoscopy guideline on the role of ergonomics for prevention of endoscopy-related injury: summary and recommendations

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach to strategies to prevent endoscopy-related injury (ERI) in GI endoscopists. It is accompanied by the article subtitled "Methodology and Review of Evidence," which provides a detailed account of the methodology used for the evidence review. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline estimates the rates, sites, and predictors of ERI. Additionally, it addresses the role of ergonomics training, microbreaks and macrobreaks, monitor and table positions, antifatigue mats, and use of ancillary devices in decreasing the risk of ERI. We recommend formal ergonomics education and neutral posture during the performance of endoscopy, achieved through adjustable monitor and optimal procedure table position, to reduce the risk of ERI. We suggest taking microbreaks and scheduled macrobreaks and using antifatigue mats during procedures to prevent ERI. We suggest the use of ancillary devices in those with risk factors predisposing them to ERI.

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.

Enhancing Ergonomics in Pediatric Endoscopy Training and Practice

Pediatric endoscopists are at risk of work-related injuries from overuse and repetitive motions during endoscopy. Recently, there has been increasing appreciation for the importance of ergonomics education and training to help build long-term habits that prevent injury. This article reviews the epidemiology of endoscopy-related injuries in pediatric practice, describes methods for controlling exposures in the workplace, discusses key ergonomic principles that can be used to mitigate injury risk, and outlines tips for integrating education on endoscopy ergonomics during training.

Procedural and anthropometric factors associated with musculoskeletal injuries among gastroenterology endoscopists

BACKGROUND AND AIMS

Musculoskeletal (MSK) injuries among gastroenterologists are common. Our study describes risk factors and consequences of injury by comparing provider-specific anthropometric and objective procedural data to self-reported injury patterns.

METHODS

A validated MSK symptom survey was sent to gastroenterologists to gauge prevalence, distribution, and severity of active injury. Respondents' procedural activities over 7 years were collected via an endoscopic database.

RESULTS

64 surveys were completed. 54 respondents had active pain; 53.1% reported activity-limiting injury. Activity-limiting injuries lead to longer colonoscopy times (25.3 vs. 22.1 min, P = 0.03) and lower procedural volumes (532 vs. 807, P = 0.01). Hand/wrist injuries yielded longer colonoscopy insertion times (9.35 vs. 8.21 min, P = 0.03) and less hands-on scope hours (81.2 vs. 111.7 h, P = 0.04). Higher esophagogastroduodenoscopy volume corelated with shoulder injury (336.5 vs. 243.1 EGDs/year, P = 0.04). Females had more foot injuries (P = 0.04).

CONCLUSION

Activity-limiting MSK symptoms/injuries affect over 50% of endoscopists with negative impact on procedural volume and efficiency.

Endoscopy-related injury among gastroenterology trainees

Background and study aims  Endoscopy-related injury (ERI) is widespread among practicing gastroenterologists. However, less is known about the incidence among trainees. This study assesses the rate of self-reported ERI occurrence, patterns of injury, and knowledge of preventive strategies in a nationally representative sample of gastroenterology fellows. Methods  A 38-item electronic survey was sent to members of the American College of Gastroenterology. One hundred and sixty-eight gastroenterology fellows were included in analyses. Descriptive and univariate analyses evaluated the likelihood of ERI by workload parameters and gender. Results  ERI was reported by 54.8 % of respondents. ERI was most common in the thumb (58.7 %), hand/finger (56.5 %), and wrist (47.8 %). There was no significant difference in the reported occurrence of ERI between male and female gastroenterology fellows. However, female fellows were significantly more likely to report a greater number of body areas affected by ERI, and male fellows were more likely to report elbow pain. Most respondents (85.1 %) reported discussion about, or training in, ergonomic strategies during gastroenterology fellowship. Conclusions  ERI is reported to occur as early as gastroenterology fellowship. Results of this study support this finding and highlight the need for ongoing implementation and monitoring of a formal ergonomics training program as well as development of ergonomically appropriate instruments. Implications of these findings likely extend to trainees in other procedural related specialties like orthopedics and general surgery, though further research is required. Ergonomics training in gastroenterology fellowship and monitoring of its impact on trainees reported ERI is important due to negative effects on productivity and career longevity.

Gastrointestinal endoscopy and work-related injuries: an international survey

Background and study aims  Recently, the awareness of work-related musculoskeletal injuries (MSIs) among gastrointestinal endoscopists has increased because of their effect on the private and work life of clinicians as well as on the health care system. The high injury incidence (reported to range from 37 % to 89 %) has been correlated with the intensive muscular demand required during a procedure. Patients and methods  An online survey with 32 questions was conducted globally. Clinically active endoscopists (doctors and nurses) participated anonymously and voluntarily. The questionnaire included questions about endoscopist anthropometrics, experience of MSI, treatment, and preventive measures such as ergonomic training. Descriptive statistics were used to analyse the data. Results  Of 204 clinicians (78 % males; 81 % > 35 years of age), 107 (53 %) stated to have experienced a work-related MSI. The most frequent locations were in the neck (n = 49), shoulder and thumb (n = 39, both). Female clinicians resulted to be significantly more prone to develop MSI. In addition, endoscopists who performed more than 15 hours of endoscopy or more than 15 procedures per week reported a significantly higher rate of MSI. Conclusions  The high frequency of MSIs among gastrointestinal endoscopists highlights the importance of implementing ergonomic training. Including simple precautions before and during endoscopy may reduce the risk of developing an injury.

Effects of passive exoskeleton support on EMG measures of the neck, shoulder and trunk muscles while holding simulated surgical postures and performing a simulated surgical procedure

Exoskeletons have shown significant impact at reducing the biomechanical demand on muscles during repetitive lifting and overhead tasks in non-healthcare industries. However, the benefits of exoskeletons are yet to be realized in the operating room, particularly as work-related musculoskeletal disorders continue to be a concern for surgeons. This study quantified the effect of using neck, arm, and trunk exoskeletons on muscle activity while assuming typical postures held in the operating room. Fourteen participants were recruited to participate in this study. In this two-part experiment participants were asked to 1) hold a series of neck flexion, arm abduction and trunk flexion postures seen in surgical procedures, and 2) perform a simulated surgical task requiring five different trunk flexion posture levels. Participants were required to complete these tasks with and without passive exoskeleton(s). This study showed that even for postures held short time periods, exoskeletons are beneficial at reducing the demand on muscles; however, the reduction in muscle demand depends on body segment and postural angle, as intended with these passive exoskeletons. Furthermore, for the simulated surgical task with awkward trunk flexion postures (10-65°), the trunk exoskeletons showed a significant reduction in the rate of rise in back muscle sEMG (+1.365%MVC/min vs. +0.769%MVC/min for non-dominant lumbar extensor muscles, p = 0.0108; +1.377%MVC/min vs. +0.770%MVC/min for the dominant lumbar extensor muscles, p = 0.0196) over 25 min, consequently resulting in improved trunk subjective discomfort scores (7.34 vs. 4.30, p < 0.05), with no impact on the neck and shoulder biomechanical demand. The results from this study indicate that exoskeletons may be a potential intervention to reduce biomechanical loading during surgery.

Human factors in pelvic surgery

In the pelvis, anatomic complexity and difficulty in visualization and access make surgery a formidable task. Surgeons are prone to work-related musculoskeletal injuries from the frequently poor design and flow of their work environment. This is exacerbated by the strain of surgery in the pelvis. These injuries can result in alterations to a surgeons practice, inadvertent patient injury, and even early retirement. Human factors examines the relationships between the surgeon, their instruments and their environment. By bridging physiology, psychology, and ergonomics, human factors allows a better understanding of some of the challenges posed by pelvic surgery. The operative approach involved (open, laparoscopic, robotic, or perineal) plays an important role in the relevant human factors. Improved understanding of ergonomics can mitigate these risks to surgeons. Other human factors approaches such as standardization, use of checklists, and employing resiliency efforts can all improve patient safety in the operating theatre.

Ergonomics and Surgeon Comfort During Flexible Ureteroscopy

The technological advancements of flexible ureteroscopy (FURS) and its accessories have resulted in broadening its indications to include the management of complex renal stones, with long operative time. The surgeon's understanding about the ergonomics of the ureteroscopes and their cognizance of the operation theatre layout helps to improve their performance, including the surgical outcomes. This paper will describe the ergonomics that are involved in conducting FURS which in turn will aid in developing a more conducive surgical environment for the surgeon during the procedure, based on scientific literature review and expert opinions in high-volume centres. Proper surgeon position, well-arranged operation theatre layout, monitor and pedal position, anaesthesia type, and surgical team are important factors to decrease musculoskeletal strains for surgeons and increase work efficiency. Different types of flexible ureteroscope have different characters and knowing these special characters leads to better ergonomics during surgery. Robotic-assisted FURS have shown good safety and ergonomics in clinical application.

Ergonomics in Endoscopic Transsphenoidal Surgery: A Survey of the North American Skull Base Society

Objective Different surgical set-ups for endoscopic transsphenoidal surgery (ETS) have been described, but studies on their ergonomics are limited. The aim of this article is to describe present trends in the ergonomics of ETS.

Design and Participants A 33-question, web-based survey was sent to North American Skull Base Society members in 2018 and 116 responded to it (16% of all members). Most respondents were from North America (76%), in academic practice (87%), and neurosurgeons (65%); they had more than 5 years of experience in ETS (73%), had received specific training (66%), and performed at least 5 procedures/mo (55%).

Results Mean reported time for standard and complex procedures were 3.7 and 6.3 hours, respectively. The patient's body is usually positioned in a straight, supine position (84%); the head is in a neutral position (46%) or rotated to the side (38%). Most surgeons perform a binostril technique, work with a partner (95%), and operate standing (94%), holding suction (89%) and dissector (83%); sometimes the endoscope is held by the primary surgeon (22–24%). The second surgeon usually holds the endoscope (72%) and irrigation (42%). During tumor removal most surgeons stand on the same side (65–66%). Many respondents report strain at the dorsolumbar (50%) or cervical (26%) level. Almost one-third of surgeons incorporate a pause during surgery to stretch, and approximately half exercise to be fit for surgery; 16% had sought medical attention for ergonomic-related symptoms.

Conclusion Most respondents value ergonomics in ETS. The variability in surgical set-ups and the relatively high report of complaints underline the need for further studies to optimize ergonomics in ETS.

Effects of endoscopy-related procedure time on musculoskeletal disorders in Japanese endoscopists: a cross-sectional study

Background and study aims  There has been little evidence assessing the prevalence of musculoskeletal disorders (MSDs) among endoscopists performing recent diagnostic and therapeutic endoscopic procedures requiring prolonged procedural times. We evaluated the prevalence and identified the risk factors for developing MSDs, focusing on procedural time. Methods  An electronic survey of endoscopists (n = 213) employed at the Nagoya University Hospital and its affiliated hospitals was developed by a multidisciplinary group.  Results  Of the 110 endoscopists (51.6 %) who responded to the survey, eighty-seven endoscopists (79.1 %) had experienced endoscopy-related MSDs during the previous 1 year, and 49 endoscopists (44.5 %) had experienced these MSDs during the previous week. Nineteen endoscopists (17.3 %) reported absence from work due to severe MSDs. The most frequent sites of MSDs were neck, low back, and shoulders. Logistic regression analyses showed that longer upper endoscopic submucosal dissection ESD, (odds ratio: 5.7; 95 %CI: 1.3-25.0), lower ESD (odds ratio 4.9; 95 %CI: 1.1-22.0), and lower gastrointestinal treatment (odds ratio: 5.6; 95 %CI: 2.3-13.3) were significantly associated with the development of MSDs in the low back area. Moreover, longer lower ESD (odds ratio: 5.0; 95 % CI: 1.2-20.2) was a risk factor for symptoms in the left shoulder. Conclusion  This study suggests a correlation between the volume of therapeutic endoscopic procedures including ESD and the risk of MSDs mainly low back area and left shoulder. Managing monthly total endoscopic time, in light of organizational ergonomics, could contribute to minimizing such risks of endoscopy-related MSDs.

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.

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.

Ergonomics of Endoscopic Skull Base Surgery: A Systematic Review

OBJECTIVE

There has been a significant expansion in endonasal endoscopic skull base surgery (EES) that has been used to address a wide range of intracranial and sinonasal pathologies. Although there exists a large amount of literature on approaches and patient outcomes, there is a paucity of data describing ergonomics in this field. Our goal was to evaluate and summarize the literature on ergonomics in EES.

METHODS

We systematically reviewed all published, peer-reviewed, English language literature in the PubMed and Web of Science databases as screened by multiple reviewers describing ergonomics as related to EES.

RESULTS

A total of 50 articles were found that described significant conclusions and descriptions on ergonomics in EES. We found and summarized the different technical aspects of ergonomics as pertaining to EES and provided evidence-based suggestions on operating room and surgeon setup.

CONCLUSIONS

There are several improvements in EES ergonomics that can decrease fatigue, improve efficiency, and overall surgeon well-being.

3D Exoscope System in Neurosurgery-Comparison of a Standard Operating Microscope With a New 3D Exoscope in the Cadaver Lab

BACKGROUND

For decades, the operating microscope has been the "gold standard" visualization device in neurosurgery. The development of endoscopy revolutionized different surgical disciplines, whereas in neurosurgery, the endoscope is commonly used as an additional device more than as single visualization tool. Invention of a 3D exoscope system opens new possibilities in visualization and ergonomics in neurosurgery.

OBJECTIVE

To assess the prototype of a 3D exoscope (3D exoscope, year of manufacture 2015, FA Aesculap, Tüttlingen, Germany) as neurosurgical visualization device in comparison to a standard operating microscope.

METHODS

A pterional approach was performed in 3 ETOH-fixed specimens (6 sides). A standard operating microscope was compared to a 3D exoscope prototype. Dimensions like visual field, magnification, illumination, ergonomics, depth effect, and 3D impression were compared.

RESULTS

In all approaches, the structures of interest could be clearly visualized with both devices. Magnification showed similar results. The exoscope had more magnification potential, whereas the visual quality got worse in higher magnification levels. The illumination showed better results in the microscope. Surgeons felt more comfortable with the 3D exoscope, concerning ergonomic considerations. Depth effect and 3D impression showed similar results. None of the surgeons felt uncomfortable using the exoscope.

CONCLUSION

The operating microscope is the gold standard visualization tool in neurosurgery because of its illumination, stereoscopy, and magnification. Nevertheless, it causes ergonomic problems. The prototype of a 3D exoscope showed comparable features in visual field, stereoscopic impression, and magnification, with a clear benefit concerning the ergonomic possibilities.

Ergonomics and musculoskeletal symptoms in surgeons performing endoscopic procedures for benign prostatic hyperplasia

BACKGROUND AND PURPOSE

Benign prostatic hyperplasia (BPH) is the most common urologic disorder affecting older men, necessitating medical or surgical intervention. Limited data exists regarding the effect these surgeries have on the endourologist's musculoskeletal system following the surgery because of the required difficult posture, prolonged procedures, repetitive movements, and the settings of an adjustable visual display terminal workstation. The aim of our study was to survey the prevalence and possible causes of musculoskeletal disorders among endourologists performing transurethral resection of the prostate (TURP) or laser prostatectomy using either holmium laser enucleation or thulium laser enucleation.

MATERIALS AND METHODS

An email inviting all members of the Endourological Society to participate in the survey was sent. The questionnaire included different demographic and practice characteristics, with concern regarding performing either TURP or laser prostatectomy and the incidence and type of musculoskeletal incidents following these surgeries. All responses were collected by a commercially available internet based survey host (www.surveymonkey.com) over a period of 6 weeks.

RESULTS

Of the 121 complete responses, 84 (69%) of endourologists complained of a musculoskeletal disorder following TURP or laser prostatectomy. The most frequent complaint was for neck (64%), followed by back (57%), shoulder (48%), hand (40%), and elbow (18%). The average prostate volume turned out to be the most compelling predictor for musculoskeletal disorder occurrence with an average prostate volume of 76 g operated on by the complaining group compared with 59 g in the noncomplaining group. Those with more severe symptoms were linked to a mean prostate size of 80 g (60-146) and constantly complained of shoulder, neck, or back trouble compared with the less-severely complaining group.

CONCLUSIONS

A high prevalence of musculoskeletal complaints among urologists performing endourologic prostatectomy was confirmed and was found to be proportionally related to the size of the prostate. The integration of an ergonomic specialist inside the operation room to watch and correct the surgeon's position during endourologic procedures may reduce the endourologist's exposure to these occupational hazards.

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 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.

Master-slave motion alignment for an open surgical console

BACKGROUND

Open surgical consoles widely employed in minimally invasive surgery have better ergonomics than closed consoles. To enhance surgical robots' ergonomics, operational efficiency, and safety, an effective master-slave motion alignment model should be established.

METHODS

The kinematic model of the robot system based on laparoscopic camera coordinate system is built in the first place. Then, the relative pose between the operator's eyes and the display is measured by Tobii Eye Tracking Sensor and is subsequently used to improve the master-slave motion alignment model.

RESULTS

Robot threading experiments are conducted by two doctors and three testers to verify the kinematic model. As a result, in contrast to the original model, the improved model reduces both operation time and the number of collisions.

CONCLUSIONS

The improved master-slave motion alignment model, in which the transformation matrix between the operator's eyes and the display is employed, raises the ergonomics, operational efficiency, and safety.

Physical and Mental Impact of Laparoscopic Sleeve Gastrectomy on the Surgeon: French vs. American Positions. A Randomized and Controlled Study

PURPOSE

To determine the physical and mental impact on the primary surgeon, by the patient's and surgical staff's dispositions at the operating table, during laparoscopic vertical sleeve gastrectomy.

MATERIALS AND METHODS

This is a randomized and controlled study that included 18 laparoscopic sleeve gastrectomy procedures performed by two surgeons in a private and academic hospital. The cases were randomized for the American or French position. After surgery, the National Aeronautics and Space Administration - Task Load Index (NASA-TLX) and the Body Part Discomfort (BPD) scales were applied to the primary surgeon.

RESULTS

An increased workload and more discomfort were reported when using the French position. The NASA-TLX was 28 ± 8 vs. 57 ± 18 (p = 0.001), and the BPD was 2 vs. 8 (p = 0.001).

CONCLUSIONS

The American position resulted in a lower physical and mental impact on the surgeon when performing a laparoscopic sleeve gastrectomy.

Ergonomics in Surgery: A Review

OBJECTIVE

Work-related musculoskeletal disorders (WMSDs) are prevalent among surgeons and may result in practice modification. We aimed to perform a comprehensive review of the English-language literature regarding ergonomic risk, prevalence of WMSDs, and unique ergonomic considerations by route of surgery.

METHODS

Multiple searches were performed of PubMed and University library resources to access English-language publications related to surgeon ergonomics. Combinations of keywords were used for each mode of surgery, including the following: "ergonomics," "guidelines," "injury," "operating room," "safety," "surgeon," and "work-related musculoskeletal disorders." Each citation was read in detail, and references were reviewed.

RESULTS

Surgeon WMSDs are prevalent, with rates ranging from 66% to 94% for open surgery, 73% to 100% for conventional laparoscopy, 54% to 87% for vaginal surgery, and 23% to 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, it remains associated with trunk, wrist, and finger strain. Surgeon WMSDs often result in disability but are under-reported to institutions. Additionally, existing research tools face limitations in the operating room environment.

CONCLUSIONS

Work-related musculoskeletal disorders are prevalent among surgeons but have received little attention owing to 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 to protect surgeons from preventable, potentially career-altering injuries.

Sources of pain in laparoendoscopic gynecological surgeons: An analysis of ergonomic factors and proposal of an aid to improve comfort

Minimally invasive surgery (MIS) offers cosmetic benefits to patients; however, surgeons often experience pain during MIS. We administered an ergonomic questionnaire to 176 Korean laparoscopic gynecological surgeons to determine potential sources of pain during surgery. Logistic regression analysis was used to identify factors that had a significant impact on gynecological surgeons’ pain. Operating table height at the beginning of surgery and during the operation were significantly associated with neck and shoulder discomfort (P <0.001). The ability to control the operating table height was the single factor most significantly associated with neck (P <0.001) and shoulder discomfort (P <0.001). Discomfort of the hand/digits was significantly associated with the trocar site (P = 0.035). The type of electrocautery activation switch and foot pedal were significantly related to surgeons’ foot and leg discomfort (P <0.001). In evaluating the co-occurrence of pain in 4 different sites (neck, shoulder, back, hand/digits), the neck and shoulder were determined to have the highest co-occurrence of pain (Spearman’s ρ = 0.64, P <0.001). These results provide guidance for identifying ergonomic solutions to reduce gynecological laparoscopic surgeons’ pain. Based on our results, we propose the use of an ergonomic surgical step stool to reduce physical pain related to performing laparoscopic operations.

Muscle activity and hand motion in veterinarians performing laparoscopic training tasks with a box trainer

OBJECTIVE

To evaluate muscle activity and hand motion in veterinarians performing a standard set of laparoscopic training tasks.

SAMPLE

12 veterinarians with experience performing laparoscopic procedures.

PROCEDURES

Participants were asked to perform peg transfer, coordination, precision cutting, and suturing tasks in a laparoscopic box trainer. Activity of the right biceps brachii, triceps brachii, forearm flexor, forearm extensor, and trapezius muscles was analyzed by means of surface electromyography. Right hand movements and wrist angle data were registered through the use of a data glove, and risk levels for the wrist joint were determined by use of a modified rapid upper limb assessment (RULA) method. One-way repeated-measures ANOVA with a Bonferroni post hoc test was performed to compare values between tasks.

RESULTS

Activity in the biceps muscle did not differ significantly among the 4 tasks. Activity in the triceps, forearm flexor, and forearm extensor muscles was significantly higher during precision cutting than during the coordination task. Activity in the trapezius muscle was highest during the suturing task and did not differ significantly among the other 3 tasks. The RULA score was unacceptable (score, 3) for the coordination, peg transfer, and precision cutting tasks but was acceptable (score, 2) for the suturing task.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated that the ergonomics of laparoscopic training depended on the tasks performed and the design of the instruments used. Precision cutting and suturing tasks were associated with the highest muscle activity. Acceptable wrist position, as determined with the RULA method, was found with the suturing task, which was performed with an axial-handled instrument.

Combining of ETHOS Operating Ergonomic Platform, Three-dimensional Laparoscopic Camera, and Radius Surgical System Manipulators Improves Ergonomy in Urologic Laparoscopy: Comparison with Conventional Laparoscopy and da Vinci in a Pelvi Trainer

BACKGROUND

Posture, vision, and instrumentation limitations are the main predicaments of conventional laparoscopy.

OBJECTIVE

To combine the ETHOS surgical chair, the three-dimensional laparoscope, and the Radius Surgical System manipulators, and compare the system with conventional laparoscopy and da Vinci in terms of task completion times and discomfort.

DESIGN, SETTING, AND PARTICIPANTS

Fifteen trainees performed the three main laparoscopic suturing tasks of the Heilbronn training program (IV: simulation of dorsal venous complex suturing; V: circular suturing of tubular structure; and VI: urethrovesical anastomosis) in a pelvi trainer. The tasks were performed conventionally, utilizing the three devices, and robotically. Task completion times were recorded and the surgeon discomfort was evaluated using questionnaires.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Task completion times were compared using nonparametric Wilcoxon signed rank test and ergonomic scores were compared using Pearson chi-square test.

RESULTS AND LIMITATIONS

The use of the full laparoscopic set (ETHOS chair, three-dimensional laparoscopic camera, Radius Surgical System needle holders), resulted in a significant improvement of the completion time of the three tested tasks compared with conventional laparoscopy (p<0.001) and similar to da Vinci surgery. After completing Tasks IV, V, and VI conventionally, 12 (80%), 13 (86.7%), and 13 (86.7%) of the 15 trainees, respectively, reported heavy total discomfort. The full laparoscopic system nullified heavy discomfort for Tasks IV and V and minimized it (6.7%) for the most demanding Task VI. Especially for Task VI, all trainees gained benefit, by using the system, in terms of task completion times and discomfort. The limited trainee robotic experience and the questionnaire subjectivity could be a potential limitation.

CONCLUSIONS

The ergonomic laparoscopic system offers significantly improved task completion times and ergonomy than conventional laparoscopy. Furthermore, it demonstrates comparable results to robotic surgery.

PATIENT SUMMARY

The study was conducted in a pelvi trainer and no patients were recruited.

Comparing McGRATH® MAC, C-MAC®, and Macintosh Laryngoscopes Operated by Medical Students: A Randomized, Crossover, Manikin Study

We hypothesized that the McGRATH MAC would decrease the time of intubation compared to C-MAC for novices. Thirty-nine medical students who had used the Macintosh blade to intubate a manikin fewer than 3 times were recruited. The participants performed sequential intubations on the manikin in two simulated settings that included a normal airway and a difficult airway (tongue edema). The intubation time, success rate of intubation, Cormack-Lehane grade at laryngoscopy, and difficulty using the device were recorded. Each participant was asked to identify the device that was most useful. The intubation time decreased significantly and by a similar amount to the McGRATH MAC and C-MAC compared to the Macintosh blade (P < 0.001 and P = 0.017, resp.). In the difficult airway, the intubation times were similar among the three devices. The McGRATH MAC and C-MAC significantly increased the success rate of intubation, improved the Cormack-Lehane grade, and decreased the difficulty score compared to the Macintosh blade in both airway settings. The majority of participants selected the McGRATH MAC as the most useful device. The McGRATH MAC and C-MAC may offer similar benefits for intubation compared to the Macintosh blade in normal and difficult airway situations.

Methodological Infrastructure in Surgical Ergonomics: A Review of Tasks, Models, and Measurement Systems

Though in its infancy, the discipline of surgical ergonomics is increasingly valued. Still, little has been written regarding this field's tasks, models, and measurement systems. These 3 critical experimental components are crucial in objectively and accurately assessing joint and postural control as exhibited by expert laparoscopic surgeons. Such assessments will establish characteristic patterns important for surgical training. In addition, risk factors associated with both minimally invasive surgical instruments and the operating room environment can be identified and minimized. Our review focuses on evidence-based experimental ergonomic studies undertaken in the field of laparoscopic surgery. Publications were located through PubMed and other database and library searches. This article describes tasks, models, and measurement systems and considers their specific applications and the types of data obtainable with the use of each. Advantages and limitations, especially those of measurement systems, are compared and discussed. Future trends and directions believed necessary for optimal investigation and results are also addressed.

The ergonomics of laparoscopic surgery: a quantitative study of the time and motion of laparoscopic surgeons in live surgical environments

BACKGROUND

Laparoscopic surgery presents multiple ergonomic difficulties for the surgeon, requiring awkward body postures and prolonged static muscle loading that increases risk of musculoskeletal strain and injury. This prospective study quantitatively measures the biomechanical movements of surgeons during laparoscopic procedures to determine at-risk movements from prolonged static muscle loading and repetitive motions that may lead to injury.

METHODS

A total of 150 video recordings of 18 surgeons, standing at the patient's left, were captured from three fixed camera positions during live gynecological laparoscopic surgery. Postoperative processing quantified surgeon movements at the neck, shoulders and elbows using computer software to measure extreme joint angles and time spent within defined joint angle ranges.

RESULTS

Surgeons spent a median of 98 % (range 77-100 %) of surgical time with their neck rotated at 21° (range 0°-52°). The non-dominant arm was subjected to more extreme positions for significantly longer periods of time compared to the dominant, with shoulder flexion at 45°-90° for 35 vs. 0 % (p < 0.001) and elbow flexion at >120° for 31 vs. 0 % (p < 0.001) of total surgical time. Procedures involving power morcellation required significantly greater number of instrument insertion/removals-119 (range 56-182) compared with 12 (range 2-122) when morcellation was not used (p < 0.001). Shorter surgeons maintained significantly greater degrees of neck rotation when viewing the monitor (p < 0.003) and surgeons with shorter arm lengths spent longer in extreme positions with their non-dominant shoulder at >90° (p = 0.04) and elbow at >120° (p < 0.001) compared with taller surgeons. No significant correlations were found between BMI or surgical experience and more extreme joint positions.

CONCLUSIONS

Four primary areas have been identified where surgeons are consistently demonstrating movements that increase their risk of harm: (1) extended periods of neck rotation; (2) asymmetrical loading between the dominant and non-dominant shoulders; (3) power morcellation and frequent insertions/removals of laparoscopic instruments resulting in repetitions of the most extreme shoulder positions and (4) a negative correlation between height and percentage time spent in more extreme positions.

Body posture during simulated tracheal intubation: GlideScope(®) videolaryngoscopy vs Macintosh direct laryngoscopy for novices and experts

Tracheal intubation requires the anaesthetist to adopt an awkward body posture. To investigate how posture may be improved, we compared the effects of laryngoscopy technique (GlideScope(®) vs Macintosh blade) and experience (novices vs experts) on body posture angles and the Rapid Entire Body Assessment postural analysis score. Novices (25 medical students) and experts (26 anaesthetists) were video-recorded performing intubation in a manikin using both devices. The GlideScope resulted in smaller deflections for all analysed posture angles (all p values < 0.001) except the wrist compared with the Macintosh blade. Novices showed more trunk (p < 0.001) and neck (p = 0.002) flexion than experts. Using the GlideScope resulted in a lower Rapid Entire Body Assessment score compared with using the Macintosh blade (p < 0.001), indicating that the GlideScope resulted in body posture less likely to induce musculoskeletal injuries. From an ergonomic point of view, the GlideScope should be the preferred technique for laryngoscopy.

Video display during laparoscopy - where should it be placed?

Introduction

During laparoscopy, the monitor is usually placed near the operating table, at eye level, which significantly affects hand-eye coordination. First, it is impossible for the surgeon to simultaneously observe the operative field and hand movement. Second, the axis of view of the endoscope rarely matches the natural axis of the surgeon's sight: it resembles a direct view into the operative field. Finally, as the arms of the tools act as levers with a fulcrum at the site of the skin incision, the action of the tool handles is a mirror image of the movement of the tool tips seen on the monitor. Studies have shown that a neutral position with the head flexed at 15–45° is the most ergonomically suitable.

Aim

To evaluate whether the level of monitor placement exerts an influence on laparoscopic performance.

Material and methods

A group of 52 students of medicine were asked to pass a thread through 9 holes of different sizes, placed at different levels and angles, using a self-made laparoscopic simulator. Each student performed the task four times in two monitor positions: at eye level, and placed on a simulator. The order of monitor placement was randomized.

Results

The task was performed more quickly when the monitor was placed on the simulator and the sight was forced downwards. Lower placement was also found to be more beneficial for students with experience in laparoscopy.

Conclusions

New technologies which place the display on the patient, thus improving the ergonomics of the operation, should be developed.

Monitor height ergonomics: A comparison of operating room video display terminals

A surgeon's eyes should be positioned 1 meter (m) distant and no more than 15° below the top of an operating monitor (0.27 m). We sought to determine which operating room video display terminal can best accommodate ergonomically optimized gaze during surgery. Floor to eye height was measured for surgeons in seated, perched, and standing positions. These ranges were then compared to vertical displacement ranges for monitors measured from floor to top of the screen. Eye height was measured for standing (1.56-1.80 m), perched (1.40-1.65 m), and seated (1.10-1.32 m) positions. The minimum distance (min) between the floor and the top of the monitor and the vertical mobility range (VR) of the monitor were measured throughout a tertiary medical center including towers with boom arms (TcB) (min: 1.58 m, VR: 0.37 m), towers without booms (TsB) (min: 1.82 m, VR: 0.025 m), ceiling mounted booms (CMB) (min: 1.34 m:, VR: 1.04 m), and portable monitors (PM) (min: 1.73 m, VR: 0.04 m). The tangent of 15° declination was used to calculate a correction factor to determine the minimum optimal ergonomic display height. The correction factor was subtracted from the eye height at each position to determine the lowest target height and the highest target floor to eye distance for each position. Analysis of variance with least significant difference post hoc testing identified all minimum distances and vertical ranges to be statistically different (p < 0.001). Monitor vertical displacement varied between styles of carts. CMB video display terminal systems can accommodate standing, perched and the tallest seated surgeons. TcB, TsB and PM systems cannot adequately accommodate all standing, perched or seated surgeons.

Prevalence and risk factors for musculoskeletal injuries related to endoscopy

BACKGROUND

There are limited data regarding work-related injury among endoscopists.

OBJECTIVE

To define the prevalence of endoscopy-related musculoskeletal injuries and their impact on clinical practice and to identify physician and practice characteristics associated with their development.

DESIGN

Survey.

SETTING

Electronic survey of active members of the American Society for Gastrointestinal Endoscopy with registered e-mail addresses.

PARTICIPANTS

Physicians who currently or ever performed endoscopy and responded to the survey between February 2013 and November 2013.

INTERVENTION

A 25-question, self-administered, electronic survey.

MAIN OUTCOME MEASUREMENTS

Prevalence, location, and ramifications of work-related injuries and endoscopist characteristics and workload parameters associated with endoscopy-related injury.

RESULTS

The survey was completed by 684 endoscopists. Of those, 362 (53%) experienced a musculoskeletal injury perceived definitely (n = 204) or possibly (n = 158) related to endoscopy. Factors associated with a higher rate of endoscopy-related injury included higher procedure volume (>20 cases/week; P < .001), greater number of hours per week spent performing endoscopy (>16 hours/week; P < .001), and total number of years performing endoscopy (P = .004). The most common sites of injury were neck and/or upper back (29%) and thumb (28%). Only 55% of injured endoscopists used practice modifications in response to injuries. Specific treatments included medications (57%), steroid injection (27%), physiotherapy (45%), rest (34%), splinting (23%), and surgery (13%).

LIMITATIONS

Self-reported data of endoscopy-related injury.

CONCLUSION

Among endoscopists there is a high prevalence of injuries definitely or potentially related to endoscopy. Higher procedure volume, more time doing endoscopy per week, and cumulative years performing endoscopy are associated with more work-related injuries.