Ergonomics in the operating room

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.

Minimally Invasive Approaches to Spinal Cerebrospinal Fluid Leak Repair: Current Strategies and a Novel Technique

Spinal cerebrospinal fluid (CSF) leaks can be caused by tears in the dura and are challenging to treat. Traditional methods of treating spinal CSF leakage include nonsurgical management, epidural blood patches (EBP), and direct surgical repair. Minimally invasive surgery (MIS) is rapidly progressing within neurosurgery due to its advantages for patient safety and comfort. Existing MIS techniques to spine surgery utilize a rigid endoscope, which has limitations when reaching smaller areas requiring greater degrees of visualization. The simultaneous use of a flexible endoscope and wearable heads-up display (wHUD) improves access and visualization in these small areas while allowing the surgeon to maintain optimal ergonomics. In this article, we review minimally invasive approaches to spine surgery and the management of spinal CSF leaks. We also demonstrate a novel minimally invasive technique utilizing flexible endoscopy and a wHUD to treat a case of recurrent CSF leak. We describe the successful utilization of this technology and provide the groundwork for future practitioners to incorporate this approach into their practice.

Opinion, uptake and current practice of robot-assisted upper gastrointestinal and oesophagogastric surgery in the UK: AUGIS national survey results

INTRODUCTION

The uptake of upper gastrointestinal (GI) robotic surgery in the United Kingdom (UK), and Europe more widely, is expanding rapidly. This study aims to present a current snapshot of the practice and opinions of the upper GI community with reference to robotic surgery, with an emphasis on tertiary cancer (oesophagogastric) resection centres.

METHODS

An electronic survey was circulated to the UK upper GI surgical community via national mailing lists, social media and at an open-invitation conference on robotic upper GI surgery in January 2023. The survey included questions on surgeons' current practice or planned adoption (if any) of robotics at individual and unit level, and their opinions on robotic upper GI surgery in general. Priority ranking and Likert-scale response options were used.

RESULTS

In total, 81 respondents from 43 hospitals were included. Thirty-four resectional centres responded, including 30 of 31 (97%) recognised upper GI cancer centres in England. Respondents reported performing robotic surgery in 21 of 34 (61.8%) resectional centres, with a median of 65 procedures per centre performed at the time of the survey (range 0-500, interquartile range 93.75). Every centre without a robotic programme expressed a desire or had active plans to implement one. Respondents ranked surgeon ergonomics as the most important reason for pursuing robotics, followed by improvements in patient outcomes and oncological efficacy.

CONCLUSIONS

Robotic upper GI practice is nascent but rapidly growing in the UK with plans for uptake in almost all tertiary centres. There is growing opinion that this is likely to become the predominant surgical approach in future with benefits to both patients and surgeons. This snapshot offers a point of reference to all stakeholders in upper GI surgery.

Preventing Surgeon Work-Related Musculoskeletal Disorders: A Pilot Study of the Comprehensive Operating Room Ergonomics (CORE) Program

IMPORTANCE

Work-related musculoskeletal disorders (WMSDs) among surgeons are markedly increasing. Several proposed interventions to reduce WMSDs among surgeons have been studied, but few follow an occupational therapy-oriented approach addressing biomechanical, psychophysical, and psychosocial risk factors.

OBJECTIVE

To design, implement, and assess the potential of the Comprehensive Operating Room Ergonomics (CORE) program for surgeons, a holistic evidence-based ergonomics and wellness intervention grounded in occupational therapy principles.

DESIGN

Mixed-methods pilot study with the quantitative strand embedded in the qualitative strand.

SETTING

University-affiliated hospital.

PARTICIPANTS

Six laparoscopic surgeons.

OUTCOMES AND MEASURES

CORE program outcomes were assessed using qualitative and quantitative data to indicate changes in posture, physical discomfort, sense of wellness, and operating room (OR) ergonomic performance. The Rapid Upper Limb Assessment (RULA) was used to quantify surgeons' WMSD risk level before and after intervention.

RESULTS

There were 12 baseline observations (two for each participant), and two or three post-CORE implementation observations. A statistically significant difference, F(1, 6) = 8.57, p = .03, was found between pre- and post-occupational therapy intervention RULA scores. Thematic analysis of surgeon feedback, which was overwhelmingly positive, identified five themes: postural alignment, areas of commonly reported physical pain or discomfort, setup of the OR environment, surgical ergonomics training, and ergonomics in everyday life.

CONCLUSIONS AND RELEVANCE

The CORE program effectively decreased ergonomic risk factors to optimize surgeons' occupational performance in the OR. This study demonstrates a potential solution to how occupational therapists can holistically support surgeons and health care providers who are at risk for WMSDs. Plain-Language Summary: By 2025, a surgeon shortage is expected, partly because of the increase in surgeons' work-related musculoskeletal disorders, which affect their health and job continuity. This pilot study shows that the Comprehensive Operating Room Ergonomics program effectively addresses these problems. The study also serves as a framework for occupational therapy professionals to work with health care providers on ergonomics, benefiting population health. Results suggest that this approach could enhance surgeons' work conditions, supporting the American Occupational Therapy Association's Vision 2025 to improve health and quality of life.

Worker and work-related factors influence on musculoskeletal symptoms among veterinary surgeons

Worker and work-related musculoskeletal symptoms are prevalent among surgeons operating on human patients. Despite incidence rates for accidents among veterinarians and their staff being 2.9 times higher than that of general practitioners of human medicine, little is known about musculoskeletal symptoms among veterinary surgeons. In this study, 212 board-certified members of the American College of Veterinary Surgeons responded to a survey regarding various work-related activities and their experience with musculoskeletal symptoms in 10 different body regions. Across all body regions, reported pain increased from before to after a typical day of surgery (p <.01). Gender, weight, age, and years performing surgery were worker factors that were related to pain (p <.05), while number of procedures, practice focus, and proportion of minimally invasive surgery were work factors related to pain (p <.05). Our findings suggest that musculoskeletal symptoms are prevalent among veterinary surgeons and may help provide evidence for guidelines for minimising musculoskeletal injuries in veterinary surgery.Practitioner summary: Little is known about the risk factors for musculoskeletal symptoms (MSS) among veterinary surgeons. This cross-sectional survey of veterinary surgeons investigates worker and work factors related to MSS. We show that MSS are prevalent and identify key factors providing evidence that MSS are a concern in veterinary surgery.

Ergonomics appraisals in operating rooms

This document presents the ergonomic assessments carried out by Spanish surgeons on the materials used within an operating room. With the objective of disseminating and raising awareness of the importance of ergonomics, this working group has compiled information from a previously conducted survey on musculoskeletal disorders associated with surgical work from the year 2022, obtaining feedback from 131 surgeons from 17 distinct specialties. A noteworthy 80.2 % of surveyed surgeons reported having experienced forced postures during surgery, and 96.9 % believe that their physical discomfort is a result of the posture adopted during operations. Such postures can result in the development of pathologies and may have a direct impact on work performance and even in extreme cases, it can lead to sick leave or early retirement. By providing their insights on electronic devices, surgical furniture, and instrumentation, surgeons can help identify areas for improvement in the practice of their profession.

Fixing Hands, Breaking Backs: The Ergonomics and Physical Detriment of the Hand Surgeon

BACKGROUND

Work-related musculoskeletal disorders in surgeons have been well documented. Hand surgeons, however, represent a unique population of surgical subspecialists due to frequent use of operative magnification. Thus, we aim to examine the contributing factors, types, and frequencies of work-related musculoskeletal injuries experienced by hand surgeons.

METHODS

A Research Electronic Data Capture survey including 12 demographic and 13 Nordic Musculoskeletal Injury Questionnaire questions was emailed twice to all active members of the American Association for Hand Surgery (AAHS). Data collection remained open for 30 days.

RESULTS

Ninety-six of 1228 AAHS members (8%) responded. Respondents were predominantly attendings (88, 91.7%), male (67, 69.8%), in academic practice (48, 50%), and in the age range of 35 to 44 years (34, 35.4%). Sixty-nine respondents (71.9%) attribute discomfort to their profession. Pain (56, 82.4%) and stiffness (46, 67.6%) were the most frequent symptoms, most common in the neck and wrist/hand regions. Fifty-nine (61.5%) respondents had acute (<1 week) discomfort, with onset most frequently reported after surgery (45, 48.9%). Thirty-two (34.8%) of the respondents state they worry these symptoms will hinder their ability to perform surgery in future. Sixteen (16.7%) respondents sustained a musculoskeletal injury directly related to work. Exercise was the most popular nonmedical therapy, while over-the-counter medications were the most popular medical therapy.

CONCLUSION

The unique ergonomics of hand surgery, including frequent use of loupes and microscopes, appear detrimental to the surgeons' health and career longevity. Further research will allow for the development of preventative measures, with the goal of facilitating longer, more productive careers for hand surgeons.

Use of the spider limb positioner for fibular free flap reconstruction of head and neck bony defects

BACKGROUND

Osseous and osteocutaneous fibular free flaps are the workhorse of maxillomandibular reconstruction over 30 years after the initial description. Since 2019, we have routinely used the Spider Limb Positioner, adapted from its use in shoulder orthopedic procedures, for fibular free flap harvest. Herein, we describe this novel technique in our cohort.

METHODS

We describe our intraoperative setup and endorse the versatility and utility of this technique in comparison to other reported fibular free flap harvest techniques.

RESULTS

The Spider Limb Positioner was used 61 times in 60 different patients to harvest osseous or osteocutaneous fibular free flaps. Median (range) tourniquet time for flap harvest was 90 (40-124) minutes. No iatrogenic nerve compression injuries or complications related to lower extremity positioning occurred.

CONCLUSION

We describe a novel approach to fibular free flap harvest utilizing the Spider Limb Positioner, which affords optimal ergonomics, visibility, and patient repositioning. There were no nerve injuries or complications related to positioning in our series.

Effect of laparoscopic handle size on surgical performance: A randomized crossover trial

Laparoscopic instrument handles design and dimensions are crucial to determine the configuration of surgeons' hand grip and, therefore, can have a deleterious effect on overall surgical efficiency and surgeons' comfort. The aim of this study is to investigate the impact of laparoscopic handle size and hand surface area on surgical task performance. A single-blind, randomized crossover trial was carried out with 29 novice medical students. Participants performed three simulated tasks in "black box" simulators using two scissor-type handles of different sizes. Surgical performance was assessed by the number of errors and time required to complete each task. Hand anthropometric data were measured using a 3D scanner. Execution time was significantly higher when cutting and suturing tasks were performed with the smaller handle. In addition, hand surface area was positively correlated with peg transfer task time when performed with the standard handle and was correlated with cutting task time in small and standard handle groups. We also found positive correlations between execution time and the number of errors executed by larger-handed participants. Our findings indicate that laparoscopic handle size and hand area influence surgical performance, highlighting the importance of considering hand anthropometry variances in surgical instrument design.

Prevalence of disability secondary to work-related musculoskeletal injuries among orthopaedic surgeons

Background

Orthopaedic surgeons encounter many work-place hazards that can lead to musculoskeletal injuries (MSI) and their clinical sequelae. This study aims to evaluate musculoskeletal injuries among orthopaedic surgeons and compare their rates of disability claims and time off work. Additionally, this study provides a perspective on the financial impact of work-related injuries among orthopaedic surgeons.

Methods

An electronic survey was developed to assess work-place hazards among orthopaedic surgeons. The survey included questions on demographics, musculoskeletal injuries, and disabilities. Electronic surveys were emailed to all current members of the American Academy of Orthopaedic Surgeons (AAOS) between March and April 2021 in the United States. Descriptive statistics were run for all variables and chi-squared and t-tests when applicable.

Results

1645 members of the AAOS completed the survey (7.03 % response rate), and 243 (14.9 %) reported a work-related injury to their place of employment at some point during their career. Of the respondents, 1129 (76.4 %) reported having active disability insurance, and 61 (3.7 %) orthopaedic surgeons filed a disability claim secondary to a work-related injury at some point during their career. Of the surgeons that claimed disability, 39 (66.1 %) returned to work, and 20 (33.9 %) had an early retirement. Foot/ankle injuries led to the highest rates of early retirement overall (62.5 %).

Conclusion

This study captures the prevalence of disability claims made by orthopaedic surgeons due to work-place hazards. To our knowledge, this is the first study to broadly compare disability claims amongst orthopaedic surgeons. This data should be used to implement changes in the orthopaedic community to decrease injuries and disability claims.

Continuous training based on the needs of operating room nurses using web application: a new approach to improve their knowledge

INTRODUCTION

Since university education and intensive and limited pre-service training do not provide an acceptable level of performing the duties of operating room nurses, and considering the limitations of traditional training methods in the field of operating room; This study was conducted with the aim of determining the effect of using the electronic education approach based on web application, leveled, personalized and based on the needs of nurses on their level of knowledge and satisfaction.

MATERIALS AND METHODS

This research is a quasi-experimental type of single-group multi-center pre-test-post-test, which during that, four stages of educational needs assessment, educational content design, web application design for training and evaluation of operating room nurses and determining the effectiveness of this method are included. Based on their knowledge and satisfaction, during this period, 36 nurses from the operating rooms that met the study criteria were included in the study by stratified random sampling based on the determined sample size. The data collection includes a four-choice test to measure the knowledge of operating room nurses in heart anatomy (score range 0-20), the principles of movement, transferring and positioning of the patient in the operating room (score range 0-15), the principles of ergonomics in the operating room (score range score 0-10) and satisfaction questionnaire (score range 0-28). Data collected using descriptive statistical tests (percentage of frequency and frequency, mean and standard deviation) and analytical tests (paired sample t-test, independent samples t-test, ANOVA, Pearson correlation, chi-square) with the software SPSS version 16 was analyzed.

RESULTS

Generally, the average knowledge scores of operating room nurses before and after the intervention were 5.96 ± 3.96 vs. 13.6 ± 3.77, in the course of principles of moving, transferring and positioning the patient in the operating room were 6.3 ± 3.42 vs. 13.3 ± 1.32, respectively 8.7 ± 3.97 vs. 18.1 ± 1.07 (in heart anatomy), 1.57 ± 2.6 vs. 0.73 ± 9.1 (in the principles of ergonomics in the operating room) and the average Knowledge scores after the intervention were significantly higher than before the intervention (P<0.001). Also, the average satisfaction score of nurses was 21.3 ± 5.83 and 22 nurses (64.7%) were satisfied with the e-learning course.

CONCLUSION

The use of the electronic education approach based on the web application, leveled, personalized and based on the needs of the nurses, led to the improvement of the level of knowledge and satisfaction of the operating room nurses. E-learning can be used as a complementary educational tool and method for continuous training of operating room nurses in other specialized fields of operating room and surgery.

HIGHLIGHTS

• Educational content in the form of educational videos taught by professors of medical sciences universities on each of the topics of heart anatomy (28 episodes of 5-10 minutes), principles of ergonomics in the operating room (7 episodes of 5-25 minutes) and movement principles. The transfer and positioning of the patient in the operating room (16 episodes of 10-20 minutes) were designed in three primary, intermediate and advanced levels. • The results of this study showed that the use of an electronic education approach based on the web application, levelled, personalized and based on the needs of nurses, led to the improvement of the knowledge of operating room nurses. Also, operating room nurses were delighted with electronic training courses. E-learning can be used as a complementary educational tool and method for continuous training of operating room nurses in other specialized fields of operating room and surgery. • Based on the results of this study, the use of an electronic education approach based on the needs of operating room nurses can be used as a complementary tool to conventional continuous education. Since this method allows interactive, personalized education is levelled, and asynchronous. It can be used at any time and place on a laptop, tablet or mobile phone; a wide range of operating room nurses in the hospitals of the Islamic Republic of Iran can use it for educational justice to Many borders should be established in the country. However, there are studies to evaluate the generalizability and the effect of using the e-learning approach on the clinical skills of operating room nurses and to compare the effect of e-learning with other methods and educational tools on the knowledge and skills of the learners and the extent of consolidating the learned material in their memory.

Ergonomics in Craniofacial Surgery: Can We Do Better? A Quality Improvement Study

OBJECTIVE

Many plastic surgeons experience musculoskeletal strain and injury from poor ergonomics during surgery. This is associated with reduced performance, shortened careers, and decreased quality of life. This study compared the ergonomics of the conventional operating table headrest and the Mayfield headrest in craniofacial surgery.

METHODS

A prospective cohort study of patients undergoing craniofacial operations between November 20, 2022 and April 26, 2023, within a single craniofacial surgeon's practice. The authors obtained data on the total duration of the operation and Rapid Entire Body Assessment (REBA) scores for the primary surgeon and assistant.

RESULTS

Four operations (mean: 147 ± 60.9 min) were included in the regular headrest group, and 8 in the Mayfield headrest group (mean: 61±53.4 min). Four hundred fifty-five regular headrest time points and 851 Mayfield time points were recorded. Eight hundred thirty-five regular headrest time points and 538 Mayfield time points were recorded. The mean REBA score for the regular headrest was 5.79 ± 1.9, which was higher than the Mayfield (5.01 ± 2.0; P < 0.0001). Subgroup analysis showed the mean REBA score for the primary surgeon (5.89 ± 2.0) was higher than the assist (5.48 ± 1.6) in the regular headrest group ( P < 0.0001), whereas the converse was true for the Mayfield headrest (primary surgeon: 4.67 ± 1.8, assist: 5.65 ± 2.15, P < 0.0001).

CONCLUSIONS

Ergonomic scores were better using the Mayfield headrest than the regular headrest. The primary surgeon scored better with the Mayfield headrest, whereas the assists had better scores with the regular headrest.

Exposure to inclined trunk postures in surgical staff

In surgical staff, low-back pain (LBP) is prevalent and prolonged trunk inclination is hypothesized to be one of its potential causes. The aim of this study was to evaluate the magnitude and duration of trunk inclination in the sagittal plane of surgical assistants during surgical procedures. The three-dimensional trunk orientation was measured in 91 surgical assistants across four medical facilities during surgical procedures using an inertial measurement unit on the thorax. Per participant, Exposure Variation Analysis was used to evaluate the percentage of the total time of trunk inclination (< -10° (backward inclination); -10-10° (upright posture); 10-20° (light inclination); 20-30° (moderate inclination); >30° (strong inclination)) taking into account posture duration (< 10 s; 10-60 s; 60-300 s; > 300 s). Participants reported their LBP history and perceived low-back load during the procedure via a questionnaire. Participants were in an upright posture for 75% [63-84%] (median [interquartile range]) of the total surgery time (average surgery time: 174 min). Trunk inclination was beyond 20° and 30° for 4.3% [2.1-8.7%] and 1.5% [0.5-3.2%] of the surgery time, respectively. In most of the participants, the duration of trunk inclination beyond 20° or 30° was less than 60 s. Questionnaire response rate was 81%. Persistent or repeated LBP was reported by 49% of respondents, and was unrelated to the exposure to inclined trunk postures. It is concluded that other factors than prolonged trunk inclination, for instance handling of loads or prolonged standing may be causally related to the reported LBP in the investigated population.

Impact of preferred surgical modality on surgeon wellness: a survey of workload, physical pain/discomfort, and neuromusculoskeletal disorders

BACKGROUND

We compared surgeons' workload, physical discomfort, and neuromusculoskeletal disorders (NMSDs) across four surgical modalities: endoscopic, laparoscopic, open, and robot-assisted (da Vinci Surgical Systems).

METHODS

An electronic survey was sent to the surgeons across an academic hospital system. The survey consisted of 47 questions including: (I) Demographics and anthropometrics; (II) The percentage of the procedural time that the surgeon spent on performing each surgical modality; (III) Physical and mental demand and physical discomfort; (IV) Neuromusculoskeletal symptoms including body part pain and NMSDs.

RESULTS

Seventy-nine out of 245 surgeons completed the survey (32.2%) and 65 surgeons (82.2%) had a dominant surgical modality: 10 endoscopic, 15 laparoscopic, 26 open, and 14 robotic surgeons. Physical demand was the highest for open surgery and the lowest for endoscopic and robotic surgeries, (all p < 0.05). Open and robotic surgeries required the highest levels of mental workload followed by laparoscopic and endoscopic surgeries, respectively (all p < 0.05 except for the difference between robotic and laparoscopic that was not significant). Body part discomfort or pain (immediately after surgery) were lower in the shoulder for robotic surgeons compared to laparoscopic and open surgeons and in left fingers for robotic surgeons compared to endoscopic surgeons (all p < 0.05). The prevalence of NMSD was significantly lower in robotic surgeons (7%) compared to the other surgical modalities (between 60 and 67%) (all p < 0.05).

CONCLUSIONS

The distribution of NMSDs, workload, and physical discomfort varied significantly based on preferred surgical approach. Although robotic surgeons had fewer overall complaints, improvement in ergonomics of surgery are still warranted.

Does surgeon sex and anthropometry matter for tool usability in traditional laparoscopic surgery? A systematic review and meta-analysis

INTRODUCTION

Hand size, strength, and stature all impact a surgeon's ability to perform Traditional Laparoscopic Surgery (TLS) comfortably and effectively. This is due to limitations in instrument and operating room design. This article aims to review performance, pain, and tool usability data based on biological sex and anthropometry.

METHODS

PubMed, Embase, and Cochrane databases were searched in May 2023. Retrieved articles were screened based on whether a full-text, English article was available in which original results were stratified by biological sex or physical proportions. Article quality was discussed using the Mixed Methods Appraisal Tool (MMAT). Data were summarized in three main themes: task performance, physical discomfort, and tool usability and fit. Task completion times, pain prevalence, and grip style results between male and female surgeons formed three meta-analyses.

RESULTS

A total of 1354 articles were sourced, and 54 were deemed suitable for inclusion. The collated results showed that female participants, predominantly novices, took 2.6-30.1 s longer to perform standardized laparoscopic tasks. Female surgeons reported pain at double the frequency of their male colleagues. Female surgeons and those with a smaller glove size were consistently more likely to report difficulty and require modified (potentially suboptimal) grip techniques with standard laparoscopic tools.

CONCLUSIONS

The pain and stress reported by female or small-handed surgeons when using laparoscopic tools demonstrates the need for currently available instrument handles, including robotic hand controls, to become more size-inclusive. However, this study is limited by reporting bias and inconsistencies; furthermore, most data was collected in a simulated environment. Additional research into how anthropometric tool design impacts the live operating performance of experienced female surgeons would further inform this area of investigation.

Musculoskeletal injuries in cross-speciality surgeons: a survey of UK-based doctors

Musculoskeletal disorder (MSD) rates amongst surgeons are as high as 80% and injuries within the healthcare setting are an impending epidemic with a distinct lack of intervention to prevent it. The career-shortening impact this has on the cohort of highly trained workers within the National Health Service must be highlighted. This study was designed to be the first UK-based cross-speciality survey to establish the prevalence and impact of MSDs. A quantitative survey from the standardised Nordic Questionnaire was distributed compromising questions assessing the prevalence of musculoskeletal complaints in all anatomical zones. 86.5% of the surgeons reported musculoskeletal discomfort over the last 12 months, with 92% of respondents detailing issues over the last 5 years. 63% state this had an impact on their home life, with a further 86% believing their symptoms are related to posture at work. 37.5% of surgeons admitted to altering or stopping work due to MSDs. This survey demonstrates high rates of MSK injuries in surgeons with a certain subsequent impact on occupational safety and career length. Robotic surgery may be a solution to the impending problem however further research is needed with policies developed to protect our health workers.

Can a Wireless Full-HD Head Mounted Display System Improve Knee Arthroscopy Performance? - A Randomized Study Using a Knee Simulator

INTRODUCTION

Our prototype wireless full-HD Augmented Reality Head-Mounted Display (AR-HMD) aims to eliminate surgeon head turning and reduce theater clutter. Learning and performance versus TV Monitors (TVM) is evaluated in simulated knee arthroscopy.

METHODS

19 surgeons and 19 novices were randomized into either the control group (A) or intervention group (B) and tasked to perform 5 simulated loose-body retrieval procedures on a bench-top knee arthroscopy simulator. A cross-over study design was adopted whereby subjects alternated between devices during trials 1-3, deemed the "Unfamiliar" phase, and then used the same device consecutively in trials 4-5, to assess performance in a more "Familiarized" state. Measured outcomes were time-to-completion and incidence of bead drops.

RESULTS

In the unfamiliar phase, HMD had 67% longer mean time-to-completion than TVM (194.7 ± 152.6s vs 116.7 ± 78.7s, P < .001). Once familiarized, HMD remained inferior to TVM, with 48% longer completion times (133.8 ± 123.3s vs 90.6 ± 55s, P = .052). Cox regression revealed device type (OR = 0.526, CI 0.391-0.709, P < .001) and number of procedure repetitions (OR = 1.186, CI 1.072-1.311, P = .001) are significantly and independently related to faster time-to-completion. However, experience is not a significant factor (OR = 1.301, CI 0.971-1.741, P = .078). Bead drops were similar between the groups in both unfamiliar (HMD: 27 vs TVM: 22, P = .65) and familiarized phases (HMD: 11 vs TVM: 17, P = .97).

CONCLUSION

Arthroscopic procedures continue to be better performed under conventional TVM. However, similar quality levels can be reached by HMD when given more time. Given the theoretical advantages, further research into improving HMD designs is advocated.

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.

Prevalence and Impact of Musculoskeletal Pain Due to Operating Among Surgical Trainees

OBJECTIVE

Upwards of 79%-88% of practicing surgeons report musculoskeletal pain due to operating. However, little is known about when these issues begin to become clinically significant. This survey evaluates the prevalence and impact of musculoskeletal pain among surgical residents.

DESIGN

After IRB approval, an anonymous 19-question survey based on Cornell Musculoskeletal Discomfort Questionnaire was sent to current surgical residents measuring frequency and degree of pain at 5 sites (neck, shoulder, upper back, lower back, and elbow/wrist) as well as impact on activities both at work and outside of work. Chi square analysis was used to identify differences between groups.

SETTING

Single academic medical center.

PARTICIPANTS

Trainees in all surgical-based specialties.

RESULTS

Fifty-three residents responded from 8 different specialties (38% response rate). Respondents were a representative balance of male (53%)/female (47%) with a mean age of 30 ± 2 years. Residents in all specialties and all years of clinical training responded, with the greatest number from general surgery (the largest program with 48% of respondents), second year of clinical training (30%) and an overwhelming 96% of residents reported experiencing pain they felt was due to operating. The most common sites of pain were the neck (92%) and lower back (77%). This pain was a frequent issue for most with 74% reporting multiple times per month and 26% reporting pain nearly every day. Nearly half of residents reported that pain slightly to substantially interfered with their ability to work (44%) and with activities outside of work (47%). Most residents (75%) sought no treatment. No residents missed work despite reporting pain.

CONCLUSIONS

Musculoskeletal pain begins during training, occurs regularly, and affects function. Neck pain is the most frequent, severe, and disabling site. This provides a target for interventions to reduce the impact of chronic pain on patient care, surgeon wellness, and career longevity.

Surgical stress: the muscle and cognitive demands of robotic and laparoscopic surgery

Introduction

Surgeons are among the most at-risk professionals for work-related musculoskeletal decline and experience high mental demands. This study examined the electromyographic (EMG) and electroencephalographic (EEG) activities of surgeons during surgery.

Methods

Surgeons who performed live laparoscopic (LS) and robotic (RS) surgeries underwent EMG and EEG measurements. Wireless EMG was used to measure muscle activation in four muscle groups bilaterally (biceps brachii, deltoid, upper trapezius, and latissimus dorsi), and an 8-channel wireless EEG device was used to measure cognitive demand. EMG and EEG recordings were completed simultaneously during (i) noncritical bowel dissection, (ii) critical vessel dissection, and (iii) dissection after vessel control. Robust ANOVA was used to compare the %MVC_RMS and alpha power between LS and RS.

Results

Thirteen male surgeons performed 26 laparoscopic surgeries (LS) and 28 robotic surgeries (RS). Muscle activation was significantly higher in the right deltoid (p = 0.006), upper trapezius (left, p = 0.041; right, p = 0.032), and latissimus dorsi (left, p = 0.003; right, p = 0.014) muscles in the LS group. There was greater muscle activation in the right biceps than in the left biceps in both surgical modalities (both p = 0.0001). There was a significant effect of the time of surgery on the EEG activity (p <0.0001). A significantly greater cognitive demand was observed in the RS than in the LS with alpha, beta, theta, delta, and gamma (p = 0.002 - p <0.0001).

Conclusion

These data suggest greater muscle demands in laparoscopic surgery, but greater cognitive demands in robotic surgery.

Prevalence of Work-Related Musculoskeletal Symptoms in Veterinary Surgeons - A Cross-Sectional Survey

OBJECTIVES

 The aim of this study was to determine the prevalence of work-related musculoskeletal symptoms (MSS) in veterinary surgeons using an online survey.

METHODS

 An online survey was distributed to 1,031 diplomates of American College of Veterinary Surgeons. Responses were collected with data regarding surgical activities, experience with various types of MSS in 10 different body sites and attempts to reduce MSS.

RESULTS

 Two hundred and twelve respondents (21% response rate) completed the distributed survey in 2021. Ninety-three per cent of respondents had experienced MSS associated with surgery in at least one body part, with the neck, lower back and upper back frequently affected. Musculoskeletal discomfort and pain worsened with prolonged surgical hours. Forty-two per cent of them suffered from chronic pain persisting longer than 24 hours after surgeries. Musculoskeletal discomfort was common regardless of practice emphasis and procedure types. Forty-nine per cent of respondents with musculoskeletal pain had taken medication, 34% sought physical therapy for MSS and 38% ignored the symptoms. Over 85% of respondents showed more than some concern regarding career longevity due to musculoskeletal pain.

CLINICAL SIGNIFICANCE

 Work-related MSS are common in veterinary surgeons, and the results of this study warrant longitudinal clinical studies to determine risk factors and attention to workplace ergonomics in veterinary surgery.

An Early Prospective Clinical Study to Evaluate the Safety and Performance of the Versius Surgical System in Robot-Assisted Cholecystectomy

OBJECTIVE

The aim of this study was to demonstrate the ability of the Versius Surgical System to successfully and safely complete cholecystectomy.

BACKGROUND

The system has been developed in-line with surgeon feedback to overcome limitations of conventional laparoscopy to enhance surgeon experience and patient outcomes. Here we present results from the cholecystectomy cohort from a completed early clinical trial, which was designed to broadly align with Stage 2b of the Idea, Development, Exploration, Assessment, Long-term follow-up framework for surgical innovation.

METHODS

Procedures were performed between March 2019 and September 2020 by surgical teams consisting of a lead surgeon and operating room (OR) assistants. Male or female patients aged 18 years and over and requiring cholecystectomy were enrolled. The primary endpoint was the rate of unplanned conversion from robot-assisted surgery to conventional laparoscopic or open surgery. Adverse events (AEs) and serious AEs were adjudicated by video review of the surgery and patient study reports by an independent Clinical Expert Committee.

RESULTS

Overall, 134/143 (93.7%) cholecystectomies were successfully completed using the device. Of the 9 (6.3%) conversions to another surgical modality, 7 were deemed to be related to the device. A total of 6 serious AEs and 3 AEs occurred in 8 patients (5.6%), resulting in 4 (2.8%) readmissions to hospital within 30 days of surgery and 1 death.

CONCLUSIONS

This study demonstrates cholecystectomy performed using the device is as safe and effective as conventional laparoscopy and supports the implementation of the device on a wider scale, pending instrument modifications, in alignment with Idea, Development, Exploration, Assessment, Long-term follow-up Stage 3 (Assessment).

Feasibility of transthoracic esophagectomy with a next-generation surgical robot

Robot-assisted minimal access surgery (MAS), compared with conventional MAS, has shown a number of benefits across several therapeutic indications but its use for transthoracic esophagectomy (TTE) requires further evaluation. Here, we report the first-in-human series of major esophageal resections performed using a next-generation tele-operated robotic surgical system in a single center. Robot-assisted TTE was performed using the Versius Surgical System by a single surgeon to assess the robotic system's ability to achieve tumor clearance (measured by R0 resection rates) whilst reducing anastomotic leakage rates. Intra- and post-operative outcomes such as median operative time, length of hospitalization, intra-operative blood loss, and the number of complications were also assessed. Fifty-seven patients underwent robot-assisted TTE between August 2019 and June 2021. All procedures were completed successfully with no unplanned conversions to alternative surgical methods. Estimated blood loss was minimal, and no adverse events, complications or deaths were reported. Our experience with the Versius Surgical System demonstrates its safe adoption and implementation for TTE.

Ergonomics in the OR: Electromyographic Evaluation of Common Muscle Groups Used During Simulated Flexible Ureteroscopy - a Pilot Study

OBJECTIVE

To assess the effects of different surgeon positions and ureteroscope types on muscle activation as measured by surface electromyography (sEMG) during simulated ureteroscopy in an endourology box-trainer model and kidney phantom.

METHODS

For this exploratory study, sEMG was used to quantify muscle activation of three endourology fellows during various ureteroscopic tasks. Electrodes were placed on the ureteroscope-holding side of the following muscles: thenar, forearm flexor, forearm extensor, biceps, triceps, deltoid, and trapezius. Subjects wore fitted lead aprons in an operating room and used a cystoscopy table with surgical drapes and an endoscopic video tower. Trials were completed with a disposable and reusable ureteroscope, both in the standing and sitting positions. Each subject performed an identical set of tasks in a phantom silicone kidney and ureteroscopy box trainer to recreate the procedural components of basketing, navigating a renal collecting system, and dusting. Raw EMG data for each task was processed and normalized as a percent of each subject's maximum voluntary contraction to allow comparison.

RESULTS

The forearm extensor was the most heavily utilized muscle. The trapezius and deltoid muscles were activated more during sitting whereas the forearm flexors had increased activity during standing. The heavier reusable ureteroscope had increased forearm extensor activation compared to the disposable ureteroscope.

CONCLUSIONS

Preliminary data show measurable differences in muscle activation based on both surgical posture and type of ureteroscope used. This highlights the need for more extensive EMG studies to identify techniques and equipment to optimize ergonomics and potentially minimize injury during flexible ureteroscopy.

The first international Delphi consensus statement on Laparoscopic Gastrointestinal surgery

BACKGROUND

Laparoscopic surgery has almost replaced open surgery in many areas of Gastro-Intestinal (GI) surgery. There is currently no published expert consensus statement on the principles of laparoscopic GI surgery. This may have affected the training of new surgeons. This exercise aimed to achieve an expert consensus on important principles of laparoscopic GI surgery.

METHODS

A committee of 38 international experts in laparoscopic GI surgery proposed and voted on 149 statements in two rounds following a strict modified Delphi protocol.

RESULTS

A consensus was achieved on 133 statements after two rounds of voting. All experts agreed on tailoring the first port site to the patient, whereas 84.2% advised avoiding the umbilical area for pneumoperitoneum in patients who had a prior midline laparotomy. Moreover, 86.8% agreed on closing all 15 mm ports irrespective of the patient's body mass index. There was a 100% consensus on using cartridges of appropriate height for stapling, checking the doughnuts after using circular staplers, and keeping the vibrating blade of the ultrasonic energy device in view and away from vascular structures. An 84.2% advised avoiding drain insertion through a ≥10 mm port site as it increases the risk of port-site hernia. There was 94.7% consensus on adding laparoscopic retrieval bags to the operating count and ensuring any surgical specimen left inside for later removal is added to the operating count.

CONCLUSION

Thirty-eight experts achieved a consensus on 133 statements concerning various aspects of laparoscopic GI Surgery. Increased awareness of these could facilitate training and improve patient outcomes.

Endoscopic surgery suturing techniques: a randomized study on learning

BACKGROUND

Surgeons have widely adopted endoscopic suturing techniques using conventional laparoscopic instruments and the more advanced robotic systems. The FlexDex is a novel articulating laparoscopic needle driver providing enhanced dexterity in laparoscopic surgery. This study evaluates and compares the learning curve of endoscopic suturing with conventional laparoscopy, the FlexDex and robotic suturing in novices.

METHODS

Participants performed a minimal invasive suturing task in three different ways in a randomized order: with a conventional laparoscopic needle driver, using the FlexDex needle driver and third, using the Da Vinci Si surgical system. Primary outcome was suturing task time. Secondary outcome parameters were assessment of suturing quality and workload perception.

RESULTS

A total of 10 novice participants were included and completed a total of 300 sessions. Median (IQR) suturing time of the first 5 sessions was 231 s (188-291) in the laparoscopic group versus 378 s (282-471) in the FlexDex group versus 189 s (160-247) in the DaVinci Si group. The last 5 sessions showed significant reduction of median suturing time of 143 s (120-190), 232 s (180-265) and 172 s (134-199) respectively. Analysis identified that the learning curve for the laparoscopic needle driver and Da Vinci Si was reached in 5 sessions, compared to 8 sessions for the Flexdex. The laparoscopic needle driver and Da Vinci Si showed a significant shorter median suturing time compared to the FlexDex (p = 0.00). The FlexDex quality assessment scores were significantly lower compared to the laparoscopic (p = 0.00) and robotic (p = 0.00) scores and perceived workload remains high for the FlexDex users.

CONCLUSIONS

Ex vivo endoscopic suturing with the FlexDex demonstrated a prolonged learning curve compared to laparoscopic and robotic suturing. The learning curve of the FlexDex is fundamentally different from conventional laparoscopic and robotic instruments. This study provides further insights in the implementation and training of endoscopic suturing techniques.

The burden of performing minimal access surgery: ergonomics survey results from 462 surgeons across Germany, the UK and the USA

This international study aimed to understand, from the perspective of surgeons, their experience of performing minimal access surgery (MAS), to explore causes of discomfort while operating and the impact of poor ergonomics on surgeon welfare and career longevity across different specialties and techniques. A quantitative online survey was conducted in Germany, the UK and the USA from March to April 2019. The survey comprised 17 questions across four categories: demographics, intraoperative discomfort, effects on performance and anticipated consequences. In total, 462 surgeons completed the survey. Overall, 402 (87.0%) surgeons reported experiencing discomfort while operating at least ‘sometimes’. The peak professional performance age was perceived to be 45–49 years by 30.7% of surgeons, 50–54 by 26.4% and older than 55 by 10.1%. 86 (18.6%) surgeons felt it likely they would consider early retirement, of whom 83 were experiencing discomfort. Our findings highlight the continued unmet needs of surgeons performing MAS, with the overwhelming majority experiencing discomfort, frequently in the back, neck and shoulders, and many likely to consider early retirement consequently. Innovative solutions are needed to alleviate this physical burden and, in turn, prevent economic and societal impacts on healthcare systems resulting from MAS limiting surgeon longevity.

Evaluating the Ergonomics of Surgical Residents During Laparoscopic Simulation: A Novel Computerized Approach

BACKGROUND

Assessment of residents' body positioning during laparoscopy has not been adequately investigated. This study presents a novel computer vision technique to automate ergonomic evaluation and demonstrates this approach through simulated laparoscopy.

METHODS

Surgical residents at a single academic institution were video recorded performing tasks from the Fundamentals of Laparoscopic Surgery (FLS). Ergonomics were assessed by 2 raters using the Rapid Upper Limb Assessment (RULA) tool. Additionally, a novel computer software program was used to measure ergonomics from the video recordings. All participants completed a survey on musculoskeletal complaints, which was graded by severity.

RESULTS

Ten residents participated; all performed FLS in postures that exceeded acceptable ergonomic risks as determined by both the human and computerized RULA scores (P < .001). Lower-level residents scored worse than upper-level residents on the human-graded RULA assessment (P = .04). There was no difference in computer-graded RULA scores by resident level (P = .39) and computer-graded scores did not correlate with human scores (P = .75). Shoulder and wrist position were the greatest contributors to higher computer-graded scores (P < .001). Self-reported musculoskeletal complaints did not differ at resident level (P = .74); however, all residents reported having at least 1 form of musculoskeletal complaint occurring "often."

CONCLUSIONS

Surgery residents demonstrated suboptimal ergonomics while performing simulated laparoscopic tasks. A novel computer program to measure ergonomics did not agree with the scores generated by the human raters, although it concluded that resident ergonomics remain a concern, especially regarding shoulder and wrist positioning.

Ergonomics for surgeons - prototype of an external surgeon support system reduces muscular activity and fatigue

BACKGROUND

Since the unergonomic postures cannot be changed during a surgery, it seems reasonable to externally support the surgeon's posture in order to relieve the musculature. To evaluate this matter, we conducted a pilot study to investigate if a prototype of an external surgeon support system (S3) relieves the musculature in an objectively measurable manner.

METHODS

Simultaneous surface electromyography (EMG) was used alongside a combination of a laser Doppler flowmeter and a tissue spectrometer to record back and leg muscles during a simulated surgical situation.

FINDINGS

With S3, muscle activity was significantly lower (p < 0.05) and also fatigue decreased when compared to without S3. Muscle blood flow and oxygenation were relatively close to baseline with S3, but increased without S3.

INTERPRETATION

An ergonomic S3 is a possible approach to reduce muscle activity and fatigue and may therefore prevent chronic back pain amongst surgeons in the long term.

A Comparative Study of the Ergonomic Risk to the Surgeon During Vesicoscopic and Robotic Cross-Trigonal Ureteric Reimplantation

Background: Maintenance of the body posture and precise repetitive movements during minimally invasive surgeries predispose the surgeons to the risk of musculoskeletal disorders (MSDs). The present study was designed to estimate the ergonomic risk of MSDs in a single surgeon while performing vesicoscopic ureteric reimplantation. Materials and Methods: All children with primary vesicoureteric reflux (VUR) undergoing vesicoscopic ureteric reimplantation through the laparoscopic (Group 1) or robotic (Group 2) approaches from July 2015 to October 2019 were included. Data, including age at the time of surgery, gender, the severity of VUR (grade), number of ureters involved (unilateral or bilateral), and procedural details, were recorded. Rapid Entire Body Assessment (REBA) tool was used for the ergonomic risk assessment of each procedure. The REBA scores were graded as negligible (1), low (2-3), medium (4-7), high (8-10), and very high (11 or more). The risk index was considered as normal (1 or less) and high (>1). The ergonomic risk associated with both approaches was compared. Results: A total of 16 patients (Male:Female = 9:7) were included in the present study. Groups 1 and 2 had 11 and 5 patients, respectively. The average (range) age of the children belonging to Group 1 was significantly lesser than Group 2 (3 versus 7.5 years; P = .0004). The average duration of surgery was significantly longer in Groups 1 versus 2 (P = .03). The average REBA scores associated with the laparoscopic and robotic approaches were 13 and 5, respectively (P = .0006). The risk indices in both approaches were 3.25 and 1.25, respectively. Conclusion: In a limited cohort of patients, we observed an overall high risk of MSD to the surgeon while performing vesicoscopic ureteric reimplantation. The associated ergonomic risk was significantly less with the robotic (medium risk category) versus laparoscopic approach (very high risk category).

A systematic review of biomechanical risk factors for the development of work-related musculoskeletal disorders in surgeons of the head and neck

BACKGROUND

Previous studies have shown high rates (47-72%) of self-reported work-related musculoskeletal disorders (WRMDs) in surgeons of the head and neck. Physical requirements in the workplace, individual factors (e.g. poor posture, obesity) and psychosocial factors have been identified as risk factors. Establishing biomechanical risk factors may help prevent further development of WRMDs in this population.

OBJECTIVE

The purpose of this critical review was to source studies that identified the biomechanical risk factors for WRMDs in this surgical sub-specialty.

METHODS

Searches were conducted of Medline, CINAHL, and AMED databases from 1980 until September 2018.

RESULTS

A total of 182 article were identified. Exclusion criteria lead to 163 full-text articles being screened, generating a total of 6 articles for review. The aims of the included studies varied significantly. Surgeons spend the majority of operating time in static, asymmetrical positions. Surgical loupes/headlamps significantly increased cervical spine loading. Articulated surgical arm supports provided optimal ergonomic conditions. Performing surgical operations with the surgeon in standing or sitting had no effect on task performance or demand. Physical fatigue was also measured in both positions.

CONCLUSIONS

A combination of equipment-based and patient/surgeon position-based factors predispose surgeons to biomechanical risk factors. Studies of greater methodological quality are required.

Postural ergonomics and work-related musculoskeletal disorders in neurosurgery: lessons from an international survey

Background

Work-related musculoskeletal disorders (WMSDs) affect a significant percentage of the neurosurgical workforce. The aim of the current questionnaire-based study was to examine the prevalence of WMSDs amongst neurosurgeons, identify risk factors, and study the views of neurosurgeons regarding ergonomics.

Methods

From June to August 2020, members of the “European Association of Neurosurgical Societies,” the “Neurosurgery Research Listserv,” and the “Latin American Federation of Neurosurgical Societies” were asked to complete an electronic questionnaire on the topics of WMSDs and ergonomics.

Results

A total of 409 neurosurgeons responded to the survey, with a 4.7 male to female ratio. Most of the surgeons worked in Europe (76.9%) in academic public hospitals. The vast majority of the participants (87.9%) had experienced WMSDs, mainly affecting the shoulder, neck, and back muscles. The most common operations performed by the participants were “Craniotomy for convexity/intrinsic tumors” (24.1%) and “Open lumbar basic spine” (24.1%). Neurosurgeons agreed that ergonomics is an underexposed area in the neurosurgical field (84.8%) and that more resources should be spend (87.3%) and training curricula changes should be made (78.3%) in order to alleviate the burden of WMSDs on neurosurgeons. Univariate analysis did not reveal any associations between the development of WMSDs and age, gender, tenure, average duration of operation, operating time per week, type of operation, and surgical approach.

Conclusions

The problem of WMSDs ought to be more closely addressed and managed by the neurosurgical community. More studies ought to be designed to investigate specific ergonomic parameters in order to formulate practice recommendations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00701-021-04722-5.

Ergonomic advantage of pistol-grip endoscope in the ENT practice

OBJECTIVES

Recent technology manufactured a nasopharyngeal videoscope with pistol-shaped grip (PG). This study aimed to assess the ergonomic feasibility of this novel device in daily ENT practice.

METHODS

To assess the ergonomic impact of grip shape on ENT physicians, conventional grip videoscope (CG) and PG were utilized in this study. Surface electromyography (sEMG) was recorded to assess the muscle activity in the upper limb during endoscopy on a training model. Bilateral sEMG recordings were performed including thenar muscle, pronator teres muscle, brachioradialis muscle, and biceps brachii muscle. Mean value of the mean sEMG amplitude throughout the task in triplicated examinations (mMA) with each electrode, total values of four mMAs in both of the grip-side and the insertion tube-side limb muscles, and total value of all eight mMAs were calculated, and compared between CG and PG. Subgroup analyses were also performed in the experienced ENT physicians and the residents.

RESULTS

PG provided significantly lower mMA values in thenar muscle and brachioradialis muscle of the grip-side limb compared with CG. Total value of four mMAs in PG was significantly lower compared with that in CG in the grip-side limb, and total value of all eight mMAs in PG was significantly lower compared with that in CG. Furthermore, total value of four mMAs in PG was significantly lower compared with that in CG in the grip-side limb, in both of the subgroups.

CONCLUSION

This is the first study to support the idea that the newly designed pistol-grip endoscope may have an ergonomic advantage over conventional endoscope for otolaryngologists in daily practice.

LEVEL OF EVIDENCE

4.

Assessing Risks Awareness in Operating Rooms among Post-Graduate Students: A Pilot Study

Background: In this study, we promote a global approach to occupational risk perception in order to improve occupational health and safety training programs. The study investigates the occupational risk perception of operating room healthcare workers using an Analytic Hierarchy Process approach. Methods: A pilot study was carried out through a cross-sectional survey in a university hospital in Southern Italy. An ad hoc questionnaire was administered to enrolled medical post-graduate students working in the operating room. Results: Fifty medical specialists from seven fields (anaesthetists, digestive system surgeons, general surgeons, maxillofacial surgeons, thoracic surgeons, urologists, and gynaecologists) were questioned about perceived occupational risk by themselves. Biological, ionizing radiation, and chemical risks were the most commonly perceived in order of priority (w = 0.300, 0.219, 0.210). Concerning the biological risk, gynaecologists unexpected perceived this risk as less critical (w = 0.2820) than anaesthesiologists (w = 0.3354), which have the lowest perception of the risk of ionizing radiation (w = 0.1657). Conclusions: Prioritization methods could improve risk perception in healthcare settings and help detect training needs and perform sustainable training programs.

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

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

Surgical Ergonomics and Musculoskeletal Pain in Orthopaedic Surgery Residents: A Multicenter Survey Study

Owing to the nature of orthopaedic surgery, occupational hazards and musculoskeletal pain (MSP) are inherent. These hazards have been well-documented among practicing orthopaedic surgeons, but there remains a paucity of data regarding MSP among orthopaedic surgery residents. The purpose of this study was to identify the prevalence and quantify the extent of work-related MSP among orthopaedic surgical residents. We also sought to analyze resident attitudes, beliefs, and behaviors regarding surgical ergonomics.

Gender equity in ergonomics: does muscle effort in laparoscopic surgery differ between men and women?

BACKGROUND

Women surgeons may experience more ergonomic challenges while performing surgery. We aimed to assess ergonomics between men and women surgeons.

METHODS

Laparoscopic surgeons from a single institution were enrolled. Demographics and intraoperative data were collected. Muscle groups were evaluated objectively using surface electromyography (EMG; TrignoTM, Delsys, Inc., Natick, MA), and comprised upper trapezius (UT), anterior deltoid, flexor carpi radialis (FCR), and extensor digitorum (ED). Comparisons were made between women (W) and men (M) for each muscle group, assessing maximal voluntary contraction (MVC) and median frequency (MDF). The Piper Fatigue Scale-12 (PFS-12) was used to assess self-perceived fatigue. Statistical analyses were performed using SPSS v26.0, α = 0.05.

RESULTS

18 surgeries were recorded (W:8, M:10). Women had higher activation of UT (32% vs 23%, p < 0.001), FCR (33% vs 16%, p < 0.001), and ED (13% vs 10%, p < 0.001), and increased effort of ED (90.4 ± 18.13 Hz vs 99.1 ± 17.82 Hz). Comparisons were made between W and M for each muscle group, assessing MVC and MDF.

CONCLUSIONS

After controlling for surgeon's height and duration of surgery, an increase in muscle activation was seen for women laparoscopic surgeons. Since poor ergonomics could be a major cause of work-related injuries, we must understand differences in ergonomics between men and women and evaluate which factors impact these variations.

Improving IR Ergonomics Using a Flexible C-Arm System

PURPOSE

To evaluate the impact of a versatile flexible ceiling-mounted C-arm on active table and gantry repositioning during interventions and its effect on operator discomfort, system usability, and patient safety compared with a traditional ceiling-mounted system.

MATERIALS AND METHODS

There were 100 IR procedures studied: 50 in a traditional IR system (standard group) and 50 with a novel multiaxis ceiling-mounted system (test group). FlexArm was capable of multiple gantry rotation points allowing increased access to the patient in addition to 236 cm of lateral x-ray detector travel. For each procedure, both the table and the gantry repositioning were measured. Patient safety, patient/equipment repositioning effort, and physical discomfort were evaluated through an operator survey.

RESULTS

Table repositioning was reduced from 42 to 16 instances per procedure (P < .001) in the test group compared with the standard group. The operators perceived less table and gantry repositioning effort (P < .0001) and decreased risks of equipment collisions, displacement of vascular access, and dislodgment of tubes/lines with the test group (P < .0001). Operator discomfort was reduced for all body areas in the test group over the standard group (P < .0001).

CONCLUSIONS

The FlexArm system geometry enhances operator ergonomics, as there was a decrease need to move the table, leading to a perceived decrease in patient risk and decrease operator physical discomfort when compared to a traditional imaging system.

The Selection of Main Surgical Work Factors in Operating Rooms

The main component of error minimization in operating rooms (ORs) is to maintain high reliability of surgical teams. The analysis of adverse events in the OR reveals deficiencies in cognitive and interpersonal skills as the main factors influencing surgeons’ errors. Therefore, research of these additional factors is necessary, besides factors related to surgeons’ clinical knowledge and technical skills. In this paper, the key factors for evaluating activities in surgical operating rooms are identified. Fuzzy analytic hierarchy process is used for identification of key factors. Fifteen key factors are identified for evaluating activities in surgical operating rooms to improve the efficiency of surgical operations. For each group of activities (surgical “capabilities,” operating room characteristics, and non-technical skills), five factors are identified. As the most important, the following factors are obtained: communication, indoor environment standardization, and tool handle design. The aim of the analysis of these key factors is surgeons’ work capability enhancement, rational design of operating rooms, and advancement of operators’ cognitive and interpersonal skills.

Surgeon-Powered Robotics in Thoracic Surgery; An Era of Surgical Innovation and Its Benefits for the Patient and Beyond

Following its introduction in 1992, the growth of minimally invasive thoracic surgery was initially hampered by the lack of specialized instruments, impeded visualization and stapling. However, in subsequent years these challenges were somewhat overcome and video-assisted thoracoscopic surgery (VATS) became the preferred modality of many centers. More recently, robotic surgery has come to the fore. Whilst it offers outstanding precision via robotic wristed instruments, robotic surgery is expensive and has safety implications as the surgeon is away from the patient's side. Wristed VATS instruments offer a new, exciting alternative. By placing the robotic-like wristed instruments in the hands of the surgeon, a concept we call surgeon-powered robotics, the benefits of robotic surgery can be achieved by the patient's side. We describe our experience of the ArtiSential® wristed instruments and discuss the benefits and challenges of this technology. By combining wristed instruments with the latest surgeon-controlled 3D camera technology, surgeon-powered robotics is an affordable reality.

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.

The Impact of Lead Aprons on Posture of Orthopaedic Surgeons

BACKGROUND

Surgeons working in orthopedics and trauma surgery are frequently exposed to repetitive actions and non-ergonomic positions in their operative activities with the regular use of lead aprons. Musculoskeletal complaints of the neck and back among surgeons are reported in the literature as up to 80%. In this study, the effects of lead aprons on the posture of surgeons are examined using videorasterstereography, foot pressure measurement and questionnaires.

METHODOLOGY

All subjects (n = 31) were examined before and after exposure to wearing lead aprons during surgery using videorasterstereography and pedography. In addition, a survey with a separately created questionnaire and the Cornell Musculoskeletal Discomfort Questionnaire (CMDQ) was carried out.

RESULTS

An average duration of lead apron use of 102.6 min showed an increase in forefoot load (p = 0.002) especially in the elderly subjects and thoracic kyphosis (p < 0.001) especially in the younger doctors with a significant lateral deviation (p = 0.006). In addition, the lateral deviation was shown to correlate with an increasing body size or a shorter period of employment (p = 0.008; r = 0.51/p = 0.026; r = - 0.44). Significantly fewer surgeons experienced back complaints on working days without lead apron use in the operating room compared to days in the OR (p = 0.011).

CONCLUSION

The impact of wearing front covered lead aprons during operations in the field of orthopaedics and trauma surgery leads to more frequent back complaints, even among young and healthy doctors. Under an average duration of surgery of 102 min a temporary postural deviation occurs that can be demonstrated by means of videorasterstereography and foot pressure measurement. The subjects showed a shifted weight distribution on the forefoot, a gain in thoracic kyphosis and an increase in lateral deviation, which also correlated with an increasing height and shorter length of employment.

Interventions to improve ergonomics in the operating theatre: A systematic review of ergonomics training and intra-operative microbreaks

Musculoskeletal occupational injury is prevalent within the surgical community. This is a multi-factorial issue, but is contributed to by physical posture, environmental hazards and administrative deficiency. There is growing awareness of this issue, with several behavioural, educational and administrative techniques being employed. The literature on this topic is, however, sporadic and difficult to access by healthcare practitioners. The aim of this systematic review was to evaluate the literature on the current interventions used to minimise musculoskeletal occupational injury in surgeons and interventionalists. This review will focus on administrative and human factor interventions, such as intra-operative microbreaks and ergonomics training.

Improving ergonomics in the operating room for orthopaedic surgeons in order to reduce work-related musculoskeletal injuries

Introduction

Orthopaedic surgery is characterized by surgical tasks that are physical, repetitive and require some degree of stamina from the surgeon. Occupational injuries are alarmingly common in orthopaedic surgery with two-thirds of all surgeons reporting a work-related musculoskeletal (MSK) injury during their career. One of the leading causes of the high level of MSK injuries among orthopaedic surgeon is lack of ergonomics of the operating room. Implementing an ergonomic process has been shown to be effective in reducing the risk of developing MSK disorders in other high-risk industries. We reviewed well-established and effective ergonomic guidelines from the industrial workplace and determined the pertinent principles that could be transferred to the operating room to help reduce the number and severity of common orthopaedic work-related MSK injuries.

Methods

We reviewed the ergonomic guidelines, primarily from the Occupational Safety and Health Administration (OSHA), that specifically address minimizing the risk of these work-related injuries and that are transferable to the operating room. In addition, the ergonomic guidelines from the Canadian Center for Occupational Health and Safety (CCOHS), the National Institute for Occupational Safety and Health (NIOSH) and the Centers for Disease Control and Prevention (CDC) were reviewed.

Results

Many of the guidelines to avoid work-related injuries in industry are transferable to the operating room. The pertinent guidelines clearly indicated how to adjust the height of the operating table, the proper design of hand and power tools and the modifications to the operating room environment that can help prevent injury. These guidelines from industry include maintaining a neutral posture and joint alignment, working with the appropriate hand tools and minimizing the lower extremity fatigue by using the proper footwear and floor mats.

Discussion

Optimizing the occupational environment and utilizing well-established ergonomic principle from industry is both feasible and practical in the operating room to decrease the incidence of musculoskeletal injuries among this high-risk profession. These guidelines are simple, effective and are easy to implement by orthopaedic surgeons in order to minimize their risk of sustaining a work-related injury.

The comparison of the process of manual and robotic positioning of the electrode performing radiofrequency ablation under the control of a surgical navigation system

This study is aimed at the comparison of the process of manual and robotic positioning of the electrode performing radiofrequency ablation under the control of a surgical navigation system. The main hypothesis of this experiment was that the use of a collaborative manipulator (KUKA iiwa) will allow to position the active part of the electrode relative to the center of the tumor more accurately and from the first attempt. We also monitor the stability of the electrode′s velocity during insertion and consider some advantages in ergonomics using the robotic manipulator. We use three more criteria to compare the surgeon's and robotic performance, unlike other studies, where only the target point's accuracy criterion is observed. The main idea is to examine the movement parameters of the electrode that can lead to potential patient trauma. Sphere-shaped tumor phantoms measuring 8 mm in diameter were filled with contrast and inserted in bovine livers. 10 livers were used for the robotic experiment and an equal quantity for manual surgery. The livers were encased in silicone phantoms designed to imitate the liver position in a real patient's abdominal cavity. Analysis of CT data gave the opportunity to find the entry and the target point for each tumor phantom. This data was loaded into a surgical navigation system that was used to track and record the position of the RF-electrode during the operation for further analysis. The standard deviation of points from the programmed linear trajectory totaled in the average 0.3 mm for the robotic experiment and 2.33 mm for the manual operation with a maximum deviation of 0.55 mm and 7.99 mm respectively. Standard deviation from the target point was 2.69 mm for the collaborative method and 2.49 mm for the manual method. The average velocity was 2.97 mm/s for the manipulator and 3.12 mm/s for the manual method, but the standard deviation of the velocity relative to the value of the average velocity was 0.66 mm/s and 3.05 mm/s respectively. Thus, in two criteria out of three, the manipulator is superior to the surgeon, and equality is established in one. Surgeons also noticed advantages in ergonomics performing the procedure using the manipulator. This experiment was produced as part of the work on the developing of a robotic multifunctional surgical complex. We can confirm the potential advantages of using collaborative robotic manipulators for minimally invasive surgery in case of practice for cancer treatment.

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

OBJECTIVE

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

APPLICATION

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

[Musculoskeletal disorders among urologists-is there an association with open pelvic surgery? : Results of a national survey]

BACKGROUND

In urology, the health implications of open pelvic surgery (OPS) on the patient have been the subject of numerous studies. However, health effects on the surgeon have not yet been sufficiently considered. The present study investigates the relationship between musculoskeletal disorders in urological surgeons and their activity in OPS.

MATERIALS AND METHODS

From the point of view of occupational physiology, exemplary operations in OPS were examined using the key indicator method (KIM). In addition, a web-based survey among German clinicians was carried out. From the collected variables, models for the prediction of the endpoints pain and disc herniation (DH) were generated by multivariate logistic regression.

RESULTS

Risk assessment of the operations with KIM could show that OPS presents a significantly increased physical workload and thus potential physical overstraining. Of the 605 participants in the survey, 35.4% were urologists performing OPS, 32.0% were urologists not performing OPS and 32.6% were gastroenterologists (control groups). Activity in OPS had an odds ratio (OR) of 1.09 (confidence interval [CI]: 0.72-1.66, p = 0.69) for predicting pain, and an OR of 1.14 for prediction of DH CI: 0.66-1.94; p = 0.64). Statistically significant factors influencing the perception of pain were BMI, gender and work ability index (WAI), whereas age and WAI were significant for the occurrence of DH.

CONCLUSION

Our survey could not show that surgeons practicing OPS have a significantly increased rate of musculoskeletal disorders or, in particular, an increased rate of DH in comparison to the control groups. Nevertheless, the rate of reported complaints among all clinicians surveyed is high, and the random risk assessment of the examplary OPS operations could also demonstrate the risk of physical overstraining. Further considerations should therefore be made as to how reduce the strain on the musculoskeletal system.