Occupational Ergonomic Hazards of Minimal Access Surgery George Piligian, MD, MPH With Assistance Of Jae Lim and Andrew Yoon.

Occupational Ergonomic Hazards of Minimal Access

Surgery

George Piligian, MD, MPHWith Assistance Of Jae Lim and Andrew Yoon

Surgery The practice of treating disease or

illness through manual or operative means

Current Categorization of Surgical Performance

Methods Open Surgery Minimally Invasive Surgery

- Laparoscopy- NOTES- Robot Assisted

Open Surgery “Surgeons

traditionally require the 'eyes of a hawk' and the 'hands of a lady' when embarking on open surgical procedures”*

*O. Elhage, D. Murphy, B. Challacombe, A. Shortland, P. Dasgupta, 2007, Ergonomics in minimally invasive surgery, International Journal of Clinical Practice, v.61(2), p.186-188

Minimally Invasive Surgery: Laparoscopy

Surgical technique in which operations in the abdomen are performed through small incisions (usually 0.5-1.5cm) as compared to larger incisions needed in traditional surgical procedures

Minimally Invasive Surgery: Laparoscopy

Minimally Invasive Surgery: NOTES

Natural Orifice Transluminal Endoscopic Surgery

A new technique that uses natural orifices (e.g., the mouth) as access points and employs both endoscopic and laparoscopic methods with the endoscope as the main platform

Minimally Invasive Surgery: NOTES

Minimally Invasive Surgery: Robot Assisted

Surgery that involves the use of a robot under the direction and guidance of a surgeon*

*http://www.surgeryencyclopedia.com/Pa-St/Robot-Assisted-Surgery.html

Minimally Invasive Surgery: Robot Assisted

Ergonomics The concept of designing the working

environment to fit the worker*

Physicians are starting to take these factors into account when determining an operative approach**

**Aditya Bagrodia, Jay D. Raman, 2009, Ergonomics Considerations of Radical Prostatectomy: Physician Perspective of Open, Laparoscopic, and Robot-Assisted Techniques, Journal of Endourology, v.23(4), p. 627-633

*Nicholas Stylopoulos, MD, David Rattner, MD, 2003, Robotics and ergonomics, Surgical Clinics of North America, v.83(6), p. 1331-1337

Ergonomics of Open Surgery

Lacerations from Instrument Infection Overuse Syndrome*

Posture - forward flexed back and neck to lean over the operating field**

**Aditya Bagrodia, Jay D. Raman, 2009, Ergonomics Considerations of Radical Prostatectomy: Physician Perspective of Open, Laparoscopic, and Robot-Assisted Techniques, Journal of Endourology, v.23(4), p. 627-633

*Berguer R., 1999, Surgery and ergonomics, Archives of Surgery, v.134(9), p. 1011-1016.

Ergonomics of Laparoscopy

Increased Time/Fatigue Length of instruments

- Increased Tremor- Only about 4 Degrees of Freedom compared to human hands that provide 36 DOF and mechanical redundancy

Spatial disorientation/ instrument movement- Fulcrum Effect

Greater force required to grip instruments Only one size of instruments often

available

Ergonomics of Laparoscopy

Increased Time/Fatigue*

Reduced ability to sense tissue characteristics Surgical Fatigue Syndrome

- A four hour performance “wall” that is manifested by mental exhaustion, irritability, impaired surgical judgment, and reduced manual dexterity

Visual fatigue - long term effect is unknown

Possibly significant cardiovascular stress

*D. A. G. Reyes, B. Tang, A. Cuschieri, 2006, Minimal access surgery (MAS)-related surgeon morbidity syndromes, Surgical Endoscopy, v.20(1), p. 1-13

Ergonomics of Laparoscopy

Posture*

Overhead or side placement of monitor- Ideal placement is to the front, near the hands

There is an increase in the amount of equipment, which leads to a need to maneuver around them

Stiff upright with little movement- Less opportunity to shift weight

Requires raised arms placed in awkward positions for extended periods of time

*D. A. G. Reyes, B. Tang, A. Cuschieri, 2006, Minimal access surgery (MAS)-related surgeon morbidity syndromes, Surgical Endoscopy, v.20(1), p. 1-13

Berguer R., 1999, Surgery and ergonomics, Archives of Surgery, v.134(9), p. 1011-1016

Ergonomics Of NOTES No tactile response Visual fatigue Constant holding of the endoscope

induces fatigue Endoscopy can lead to

musculoskeletal pain in fingers, wrists and shoulders*

Young Hye Byun, Jun Haeng Lee, Moon Kyung Park, 2008, Procedure-related musculoskeletal

symptoms in gastrointestinal endoscopists in Korea, World J Gastroenterol, v.14(27)

Ergonomics Of Robotic Assisted Surgery

Effects of flexed neck, fixed seated position are unclear*

Fatigue from the use of polarizing head gear in some models**

Provides no tactile response High cost of production and

maintenance*Aditya Bagrodia, Jay D. Raman, 2009, Ergonomics Considerations of Radical Prostatectomy: Physician Perspective of Open, Laparoscopic, and Robot-Assisted Techniques, Journal of Endourology, v.23(4), p. 627-633

**D. A. G. Reyes, B. Tang, A. Cuschieri, 2006, Minimal access surgery (MAS)-related surgeon morbidity syndromes, Surgical Endoscopy, v.20(1), p. 1-13

Prostatectomy: A Case Study*

Prostatectomy is a relatively difficult open surgical procedure as regards ergonomics of the surgeon

For open prostate surgery, 50% of physicians reported pain, with neck pain being the most common, followed by back pain.

In comparison, for general open surgery, 30% of surgeons report pain, with pain being more common in the shoulders and lower back than the neck

*Aditya Bagrodia, Jay D. Raman, 2009, Ergonomics Considerations of Radical Prostatectomy: Physician Perspective of Open, Laparoscopic, and Robot-Assisted Techniques, Journal of Endourology, v.23(4), p. 627-633

Prostatectomy: A Case Study

Prostatectomy: A Case Study

106 Urologists were surveyed Chronic neck/back pain present in

43% of urologists surveyed Neck/back pain was experienced in

50%, 56%, and 23% of surgeons after open, laparoscopic and robot assisted prostatectomy, respectively

Recommendations For The Future

Shared surgical care and rest breaks to help avoid Surgical Fatigue Syndrome

Exoskeletal Support*

*D. A. G. Reyes, B. Tang, A. Cuschieri, 2006, Minimal access surgery (MAS)-related surgeon morbidity syndromes, Surgical Endoscopy, v.20(1), p. 1-13

The Ever Changing Future A New Endoscopic Microcapsule

Robot using Beetle Inspired Microfibrillar Adhesives*

* Proceedings of the 2005 IEEE/ASME International Conference on Advanced Intelligent MechatronicsMonterey, California, USA, 24-28 July, 2005

The Ever Changing Future Nanobots Operated by Clinician Engineers or

Surgeons?