Ergonomic assessment of the da Vinci console in robot-assisted surgery

Understanding the challenges of robotic-assisted surgery adoption: Perspectives from stakeholders and the general population on human-interaction, built environment, and training

This study aims to explore adoption barriers from three aspects critical to facilitating robotic-assisted-surgery (RAS) adoption: the human-robot-interaction, built-environment, and training. Guidelines for research and design are identified from these perspectives. This study consisted of three phases: 1) surveys to RAS stakeholders and a crowd-sourcing survey; 2) stakeholder focus groups; and 3) a workshop with subject-matter experts to prioritize future research for RAS. Barriers from the human-robot-interaction perspective include hesitancy among clinicians to trust automation and physical discomfort during prolonged RAS. Barriers impeding communication and workflow disruptions were identified considering the built-environment. Training barriers were exemplified by varying curriculums from formal (courses) to informal (peer training) for surgeons. Crowd-sourced survey results suggest socio-economic status plays a role in RAS perception. Design guidelines include: 1) improved ergonomics; 2) deliberate introduction of automation; 3) sufficient in-room storage for prospective operating rooms; and 4) the development of compact RAS devices for older/smaller rooms.

Cologne ergonomic measurement for robotic surgery (CEMRobSurg) using the Hugo™ RAS System

BACKGROUND

The ergonomic advantages and potential challenges that robotic surgery poses to the well-being of surgeons are mainly unexplored. The most recent surgical robot introduced on the European market is the Hugo™ RAS System by Medtronic. This study aims to evaluate the ergonomic benefits of the Hugo™ RAS System, which is available in our training laboratory, CeMIT (Center for Medical Innovation and Technology Cologne).

METHODS AND PROCEDURES

Using the previously established Cologne Ergonomic Measurement Setup for Robotic Surgery (CEMRobSurg), we measured three parameters related to ergonomic posture from subjects with different levels of surgical expertise (laypeople, medical students, surgical residents, and expert robotic surgeons). The heart rate was measured continuously using a polar band. The noise level was measured while using the Hugo™ RAS System, and automated photographs using our locally developed methodology were captured of the participant every 2 s to assess body posture. The ergonomic measurements were conducted while the subject performed the same standardized robotic training exercises (Peg Board, Rope Walk, and Ring Walk).

RESULTS

A total of 53 participants were enrolled in this study. The average noise level during all measurements was 54.87 dB. The highest stress level was measured in surgical residents with a sympathetic nervous system index (SNS index) of 1.15 (min - 1.43, max 3.56). The lowest stress level was measured in robotic experts with an SNS index of 0.23 (min - 0.18, max 0.91). We observed a risk-prone positioning of the neck and elbow in medical students (mean 39.6° and 129.48°, respectively). Robotic experts showed a risk positioning in the knee and hip region (mean 107.89° and 90.31°, respectively).

CONCLUSION

This is the first study to analyze and objectify the ergonomic posture of medical students, surgical trainees, surgeons, and laypeople using the open console, modular Hugo™ RAS System. Our findings offer recommendations for operating surgeons and allow for a comparative analysis between the different robotic systems. Further evaluations in real-time operative scenarios will follow.

A multimodal virtual vision platform as a next-generation vision system for a surgical robot

Robot-assisted surgery platforms are utilized globally thanks to their stereoscopic vision systems and enhanced functional assistance. However, the necessity of ergonomic improvement for their use by surgeons has been increased. In surgical robots, issues with chronic fatigue exist owing to the fixed posture of the conventional stereo viewer (SV) vision system. A head-mounted display was adopted to alleviate the inconvenience, and a virtual vision platform (VVP) is proposed in this study. The VVP can provide various critical data, including medical images, vital signs, and patient records, in three-dimensional virtual reality space so that users can access medical information simultaneously. An availability of the VVP was investigated based on various user evaluations by surgeons and novices, who executed the given tasks and answered questionnaires. The performances of the SV and VVP were not significantly different; however, the craniovertebral angle of the VVP was 16.35° higher on average than that of the SV. Survey results regarding the VVP were positive; participants indicated that the optimal number of displays was six, preferring the 2 × 3 array. Reflecting the tendencies, the VVP can be a neoconceptual candidate to be customized for medical use, which opens a new prospect in a next-generation surgical robot.

The evidence behind robot-assisted abdominopelvic surgery: a meta-analysis of randomized controlled trials

BACKGROUND

Despite recent advancements, the advantage of robotic surgery over other traditional modalities still harbors academic inquiries. We seek to take a recently published high-profile narrative systematic review regarding robotic surgery and add meta-analytic tools to identify further benefits of robotic surgery.

METHODS

Data from the published systematic review were extracted and meta-analysis were performed. A fixed-effect model was used when heterogeneity was not significant (Chi2 p ≥ 0.05, I2 ≤ 50%) and a random-effects model was used when heterogeneity was significant (Chi2 p < 0.05, I2 > 50%). Forest plots were generated using RevMan 5.3 software.

RESULTS

Robotic surgery had comparable overall complications compared to laparoscopic surgery (p = 0.85), which was significantly lower compared to open surgery (odds ratio 0.68, p = 0.005). Compared to laparoscopic surgery, robotic surgery had fewer open conversions (risk difference - 0.0144, p = 0.03), shorter length of stay (mean difference - 0.23 days, p = 0.01), but longer operative time (mean difference 27.98 min, p < 0.00001). Compared to open surgery, robotic surgery had less estimated blood loss (mean difference - 286.8 mL, p = 0.0003) and shorter length of stay (mean difference - 1.69 days, p = 0.001) with longer operative time (mean difference 44.05 min, p = 0.03). For experienced robotic surgeons, there were less overall intraoperative complications (risk difference - 0.02, p = 0.02) and open conversions (risk difference - 0.03, p = 0.04), with equivalent operative duration (mean difference 23.32 min, p = 0.1) compared to more traditional modalities.

CONCLUSION

Our study suggests that compared to laparoscopy, robotic surgery may improve hospital length of stay and open conversion rates, with added benefits in experienced robotic surgeons showing lower overall intraoperative complications and comparable operative times.

Robotic assisted surgery reduces ergonomic risk during minimally invasive colorectal resection: the VOLCANO randomised controlled trial

PURPOSE

Minimally invasive surgery benefits patients but poor operating ergonomics causes musculoskeletal injuries in surgeons. This randomised controlled trial aims to assess whether robotic-assisted surgery with the open-console Versius® system can reduce surgeons' ergonomic risks during major colorectal resections.

METHODS

Prospectively registered at ClinicalTrials.gov (NCT05262296) in March 2022. Adult patients requiring a minimally invasive colorectal resection were potentially eligible. Photographs taken at 2-min intervals were analysed using the objective Rapid Entire Body Assessment (REBA) posture analysis scale to calculate intraoperative surgeon ergonomic risk. Secondary outcomes included team communication (Oxford NOTECHS II), surgeon cognitive strain (modified NASA-TLX scale), and clinical outcomes.

RESULTS

Sixty patients were randomised in a 2:1 ratio (40 robot, 20 laparoscopic). Mean age was 65yrs and 34 (57%) were male. Body Mass Index did not differ between the 2 groups (overall mean 29.0 ± 5) and there were equal proportions of left and right-colonic resections. REBA was significantly lower in the robotic arm (median robot REBA score 3 vs lap REBA 5 [p < 0.001]), equating to an injury risk category drop from "medium" to "low risk". There were no significant differences in team communication, operative duration, or patient outcomes. Surgeon cognitive strain was lower in robotic cases (mean robot 32.4 ± 10.3 vs lap 45.6 ± 14.3 [p < 0.001]).

CONCLUSIONS

This trial demonstrates that robotic surgery with an open-console system reduces ergonomic risk scores and cognitive strain during colorectal resections, with no apparent detriment to team communication. This may therefore be a safe & feasible solution to the increasing problem of work-related musculoskeletal injuries in surgeons.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Surgical ergonomics for urologists: a practical guide

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Ergonomic assessment of the first assistant during robot-assisted surgery

The use of the da Vinci robot in minimal invasive surgery comes with numerous advantages. Recent papers describe improvements in the ergonomic environment and benefits for the surgeon's posture in the console. Ergonomics for first assistants or scrub nurses at the OR table during robot-assisted procedures, however, have gained minor attention. The aim of this study, therefore, is to analyse the ergonomic environment specifically for first assistants during robot-assisted surgery. Three techniques were used to evaluate body posture and ergonomics during three discriminated actions. First of all, a questionnaire was conducted. Second, sagittal and dorsal photographs of all first assistants were shot. From these photographs, joint angles of the trunk, neck, shoulder, elbow, pelvic girdle and spine were calculated and rapid upper limb assessment (RULA) scores were determined. In addition, intra-observer variability was assessed to determine the robustness of the results. Lastly, the number of obstructions during the surgery was registered by an observer present at the operation theatre. The questionnaires displayed that 73% of the first assistants were in uncomfortable working positions for longer periods of time. Twenty percent of the participants even report pain or visible bruising due to hinderance of the robot arm. Furthermore, an average of 2.8 obstructions per surgical procedure was registered, mainly affecting the lower arm (60%). The photographs demonstrated that all joint angles, except for the elbow joint, are potentially harmful when assisting during robot-assisted surgery. RULA scores revealed high-risk ergonomic risk scores for all measured actions. Tissue traction was recognized as the action with the highest physical workload. During robot-assisted surgery, first assistants experience non-ergonomic trunk, neck and shoulder angles. These recordings are supported by posture analysis. Tissue traction is reported as the most intensive action by the nurses. Tacking, however, can lead to the most unfavourable RULA score. The surgeon's awareness of the position of the robot arms could reduce the number of obstructive moments for the first assistant. Lowering the number of instrument replacements is plausible to lead to better ergonomic postures for first assistant.