Surgical ergonomics. Analysis of technical skills, simulation models and assessment methods

Safety and Optimizing Ergonomics for Cardiothoracic Surgeons

Cardiothoracic surgery, demanding in nature, often results in surgeons suffering from musculoskeletal injuries, causing chronic pain and leading to premature retirement. A significant majority report experiencing pain, exacerbated by minimally invasive techniques such as video-assisted thoracoscopic surgery. Despite this, many surgeons delay seeking medical assistance. To mitigate these risks, preventative strategies such as strength exercises, stretching during operations, and taking brief breaks are crucial. However, the surgical community faces a shortage of institutional support and comprehensive ergonomic education. Advancements in technology, including artificial intelligence and virtual reality, could offer future solutions.

Exploring the Role of Simulation Training in Improving Surgical Skills Among Residents: A Narrative Review

The role of simulation in medical education is crucial to the development of surgeons' skills. Surgical simulation can be used to improve surgical skills in a secure and risk-free environment. Animal models, simulated patients, virtual reality, and mannequins are some types of surgical simulation. As a result, feedback encourages students to reflect on their strengths and weaknesses, enabling them to focus on improvement. Healthcare simulation is a strong educational instrument, and the main goal of this is to give the students an opportunity to do a practical application of what they have learned through theory. Before taking it to the patients, they will already have certain tools they have previously acquired during the practice. This makes it easier for students to identify the knowledge gaps that they must fill to improve patient outcomes. Moreover, simulation brings a wonderful opportunity for students to acquire skills, gain confidence, and experience success before working with real patients, especially when their clinical exposure is limited. The use of simulation to teach technical skills to surgical trainees has become more prevalent. The cost of setting up a simulation lab ranges from $100,000 to $300,000. There are several ways to evaluate the effectiveness of simulation-based surgical training. Repetitive surgical simulation training can improve speed and fluidity in general surgical skills in comparison to conventional training. Few previous studies compared learners who received structured simulation training to a group of trainees who did not receive any simulation training in single-center randomized control research. Significantly faster and less time-consuming skill proficiency was noticeable in simulated trainees. Despite being anxious in the operating room for the first time, simulated trainees completed the surgery on time, demonstrating the effectiveness of surgical simulation training. Traditional surgical training involves senior-surgeon supervision in the operating room. In simulation-based training, the trainees have full control over clinical scenarios and settings; however, guidance and assessment are also crucial. Simulators allow users to practice tasks under conditions resembling real-life scenarios. Simulators can be compared with traditional surgical training methods for different reasons. For example, intraoperative bleeding may occasionally show up not only visibly on the screen but also by shaking the trocars erratically. Without haptics, training on virtual simulators can cause one's pulling and pushing forces, which are frequently greater than what the tissue needs, to be distorted. A good method of simulation training is using virtual reality simulators with haptics and simulated patients. The availability of these facilities is limited, though, and a typical session might include an exercise involving stacking sugar cubes and box trainers. The degree of expertise or competency is one area that needs clarification as medical education transitions to a competency-based paradigm. The article aims to provide an overview of simulation, methods of simulation training, and the key role and importance of surgical simulation in improving skills in surgical residents.

The Impact of Perioperative and Operative Variables on Early Postoperative Complications Following Primary Hypospadias Repair

OBJECTIVES

To evaluate possible risk factors for complications following primary hypospadias repair relative to factors associated with timing of hypospadias repair in terms of case order, morning or afternoon scheduling, perioperative delays, and surgeon's daily work schedule as well as individual operative techniques.

METHODS

We retrospectively reviewed charts of 422 boys undergoing primary hypospadias repair with a sutured urethroplasty by one of three surgeons over a 10-year period and the surgeon's daily schedule.

RESULTS

The median age and IQR of the patients at time of operation was 0.79 (0.57) years, and median follow-up was 259 (664) days. A significant increase in the rate of any complication was noted with morning versus afternoon cases for the group overall with morning cases having a hazard 2.3 times higher than afternoon cases (p=0.012). Additionally, there was a significant increase in hazard of complication with increasing difference in time between actual procedure duration versus scheduled duration, with hazard of complication increasing 5% for each increase of 15 minutes of surgical time (p=.043).

CONCLUSIONS

A variety of previously identified potential risk factors for hypospadias complications were identified. Our analysis also demonstrated variability in level of risk of different factors between surgeons, reinforcing the utility of surgeons monitoring their own results in response to changes in technique. Novel potential risk factors for some surgeons identified in our study included an increased risk of complications when the hypospadias was done in the morning rather than the afternoon and when the procedure lasted longer than scheduled.

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.

What Are "Microergonomics," "Penization," and "Electronics Integrated with Surgical Instruments"?

BACKGROUND

Most microsurgical instrument designs concentrate on manipulating the targeted tissue more than the detailed design of the user's hand. Microergonomics is a new area of study on hand design in order to redesign the instruments in a better way for the surgeon's hand.

METHODS

The article describes how the concept of microergonomics could improve the design of microinstruments. The penization concept is introduced, too. This involves converting the instruments available to the shape of a pen, making these instruments manipulated just like the writing process.

RESULTS

A new design of pen needle holder is suggested, along with a new concept of integrating electronics with the instruments, revealing many possible future devices.

CONCLUSIONS

The future perspectives of designing neurosurgical instruments will be directed toward microergonomics, penization, and electronics integrated with surgical instrument principles.

Obliterated Posterior Cul-de-sac Laparoscopic Surgical Simulation

BACKGROUND

Obliteration of the posterior cul-de-sac is a challenging, often unexpected surgical finding. Developing the dissection skills required to manage this finding during laparoscopy is essential for optimizing treatment of many pain disorders during hysterectomy or ovarian surgery; however, exposure of trainees to cul-de-sac dissection is variable. Currently, there are no widely available simulation models for teaching and practicing this technique.

METHOD

Our aim is to design a low-cost and high-fidelity laparoscopic simulation model that represents key anatomical structures and emphasizes skills for laparoscopic dissection of an obliterated posterior cul-de-sac.

EXPERIENCE

A three-dimensional model was created and is described. Nine experts (gynecologic surgery fellows and attendings) and 17 residents completed a single 30-minute simulation session and completed several assessments to begin establishing the face validity of this model.

CONCLUSION

Experts and residents rated the obliterated cul-de-sac simulation as highly realistic and useful. Residents showed a statistically significant increase in comfort with the dissection, from a median Likert score of 1 out of 5 (interquartile range 1-1) to 3 out of 5 (interquartile range 2-3) (P<.001). Experts scored better than residents on blinded video grading of model performance (P<.001). This low-cost and easily reproducible model fills a critical gap in gynecologic surgery education.

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.

How to stich? 90 degrees: The perfect angle

OBJECTIVE

This is a discussion about correct suturing techniques and implications that follow inappropriate suturing. We deconstruct the suturing needle angles and methods to be adopted to acquire the perfect needle angle to the tissue being sutured. A study of angles confirms that 90° is perceptible to the naked eye and easy to identify, making it an appropriate foundation to explain, communicate and teach the concepts in the wet-lab and the operating room.

BACKGROUND

There is a lack of robust teaching regarding entry of the needle orthogonal to the tissue planes. In addition, objective methods of assessing angles of the needle relative to the tissue and consequences of inaccuracy are lacking. The authors aim to deconstruct the steps of suturing with the aim of demonstrating ninety degrees is the perfect suturing angle.

STUDY DESIGN

We conducted a study to identify 90° (the perfect suturing angle) as an angle easy to identify with the naked eye. Angles from 86° to 94° and 41° to 49° were printed and presented to volunteers with the instruction to identify the angles of 90° and 45°.

RESULTS

Fifty-one volunteers replied to the 90° angle study and sixty-five volunteers replied to the 45° study. 92% correctly identified at least one 90° angle and 72% identified both the 90° angles. 63% identified at least one 45° angle and only 27% identified both the 45° angles presented to them. This supported our hypothesis that 90° is an angle that is readily identifiable to the human eye.

CONCLUSIONS

Objective assessment of surgical skills and training should focus on the basic needle skills with particular emphasis on suturing angles, progressing to higher skills using low and intermediate fidelity models and correlating practice alongside the trainees' operative progress.

The Current State of Surgical Ergonomics Education in U.S. Surgical Training: A Survey Study

OBJECTIVE

The aim of this study was to characterize the current state of surgical ergonomics education in the United States.

BACKGROUND

The burden of work-related musculoskeletal disorders (MSDs) in surgeons is high and no overarching strategy for redress exists. Twelve distinct specialties describe an unmet need for surgical ergonomics education (SEE). This study aimed to define the current state of SEE in U.S. surgical training programs.

METHODS

We performed a descriptive analysis of a 20-item questionnaire of ACGME-certified program directors from 14 surgical and interventional medical specialties. Formal SEE was defined as any organized education module that reviewed the occupation-specific burden of common work-related MSDs and described a framework for prevention via occupation-specific applied ergonomics. Program directors were queried regarding SEE provision, characteristics, and perceived trainee attitude toward the education.

RESULTS

Questionnaires were received from 130 of 441 (29.5%) program directors. Two (1.5%) provided formal SEE and 33 (25.4%) provided informal SEE, which consisted of unstructured intraoperative directives and isolated lectures. Two programs previously provided SEE but discontinued the effort due to lack of an evidence-based framework and instructors. Trainees appeared to think that learning surgical ergonomics skills was a worthwhile time investment in 100% and 76.7% of current formal and informal SEE, respectively.

CONCLUSION

SEE is rarely provided in any capacity (25.4%), let alone in a consistent or evaluable fashion (1.5%). Impediments to sustainable SEE include lack of an evidence-based framework for education and instructors. An evidence-based, reproducible, and accreditation council-compliant SEE module would be a valuable resource for the surgical and interventional medical communities.

Comprehensive and Integrative Experimentation Setup for Large Animal Hybrid Valvular Heart Surgery

BACKGROUND

Experimental surgical procedures for atrioventricular valves present promising translational capabilities, and preclinical studies are necessary to assess their applicability and to train young enthusiastic heart teams. Here, we present a synopsis of experimental surgical procedures on porcine models for mitral valvular (MV) and tricuspid valvular (TV) interventions; mitral valve-in-valve implantation (MViV), transapical cardioscopic (TAC) MV replacement (MVR), TAC-MV annuloplasty, and tricuspid valve-in-a-ring (TViR) procedures.

METHODS

Twenty-five (n = 25) female Yorkshire pigs of 55-65 kg is the total number used in the four approaches; seven animals underwent MViV, six TAC-MVR, six TAC-MV annuloplasty, and six TViR, respectively. All were subjected to a first conventional valvular surgery (bioprosthetic valve replacement and/or prosthetic ring repair). Then, after 4 wk, a less-invasive second surgery was performed using the transcatheter approaches under investigation. Except for the TAC-MVR and annuloplasty procedures, all animals were followed up for additional 4 wk.

RESULTS

(1) MViV (n = 7): Standard MVR was successfully performed in all animals. Transvalvular pressure gradients and flow velocities were (P_max 3.77 ± 0.8 mmHg; P_mean 2.1 ± 0.6 mmHg, V_max 97 ± 13 cm/s; V_mean 68 ± 21 cm/s). Effective MViV followed (P_max 16.7 ± 1.8 mmHg; P_mean 6.2 ± 1.2 mmHg, V_max 216 ± 32 cm/s; V_mean 110 ± 24 cm/s). (2) TAC-MVR (n = 6): The overall bypass time was 177.2 ± 44.2 min. Transprosthetic P_mean was 4.6 ± 2.4 mmHg; no paravalvular leaks in all animals. (3) TAC-MV annuloplasty (n = 6): The implantation time was 47 ± 6 min. MV was competent, left ventricular ejection fraction (LV-EF%) was 63 ± 4%. (4) TViR (n = 6): Conventional TV ring repair was performed in all animals (P_max 2.42 ± 0.7 mmHg; P_mean 1.3 ± 0.6 mmHg, V_max 82 ± 10.4 cm/s; V_mean 65.4 ± 21 cm/s). All TViRs were implanted efficiently (P_max 4.7 ± 1.6 mmHg; P_mean 2.7 ± 0.8 mmHg, V_max 105 ± 31 cm/s; V_mean 81 ± 16 cm/s). A mild paravalvular leak was observed in one animal (16%).

CONCLUSIONS

All studied experimental valvular interventions are feasible, within the context of well-trained cardiac surgery specialists, and all possibilities should be considered when treating a patient to determine which one suits best his individual challenges and scope.

Wrist Motion Variation between Novices and Experienced Surgeons Performing Simulated Airway Surgery

Objective

To determine whether wrist motion measured by a smartphone application can be used as a performance metric for a simulated airway procedure requiring both wrist and finger dexterity. We hypothesized that this accelerometer application could detect differences between novices and experienced surgeons performing simulated cricothyrotomy.

Setting

Academic medical center.

Study Design

Prospective pilot cohort study.

Methods

Voluntary surgeons and nonsurgeons were recruited. After viewing a training video, smartphones with accelerometer applications were attached to both wrists while subjects performed a cricothyrotomy on a validated task trainer. Procedure time and motion parameters, including average resultant acceleration (ARA), total resultant acceleration (TRA), and suprathreshold acceleration events (STAEs), were collected for dominant and nondominant hands. Subjects were stratified by prior experience. Blinded experts scored each performance using Objective Structured Assessment of Technical Skills (OSATS), and t tests were used to compare performance.

Results

Thirty subjects were enrolled. Median age was 26 years, and 20 subjects were male. In the dominant hand, significant differences were seen between novice and experienced surgeons in TRA (P = .005) and procedure time (P = .006), while no significant differences were seen in STAEs (P = .42) and ARA (P = .33). In the nondominant hand, all variables were significantly different between the 2 groups: STAEs (P = .012), ARA (P = .007), TRA (P = .004), and procedure time (P = .006).

Conclusions

Wrist motion measured by a low-cost smartphone application can distinguish between novice and experienced surgeons performing simulated airway surgery. This tool provides cost-effective and objective performance feedback.

A study of the prevalence of musculoskeletal disorders in surgeons performing minimally invasive surgery

INTRODUCTION

Minimally invasive surgery (MIS) has shown significant benefits for patients and healthcare systems. However, due to the poor ergonomic adaptation of operating rooms and surgical instruments, most surgeons suffer from pain caused by musculoskeletal disorders (MSDs).

METHODS

A descriptive survey on MIS surgeons working in different surgical specialties has been carried out in Hospital Valdecilla (Spain). The aim is to determine the prevalence of MSDs using a personal interview and the standardized Nordic questionnaire. The study determines the prevalence of MSDs in different parts of the body and their relationship with epidemiological and labor variables. A questionnaire was filled out by 129 surgeons.

RESULTS

90% of surgeons reported MSDs. The higher prevalence appears in the most experienced surgeons. The most affected zones are the lower back (54%), neck (51%), upper back (44%), lower extremities (42%), right shoulder (29%) and right hand (28%).

CONCLUSIONS

The prevalence of MSDs is higher in MIS surgeons than in any other occupational group. The most vulnerable group is experienced surgeons and there is a potential risk that symptoms will be increased in the future. Muscle strength is revealed as a protective factor against MSDs.