Keywords
ergonomics - occupational injury - surgeon health
Case Example by Justin Maykel, MD
Case Example by Justin Maykel, MD
Earlier in my career, I never considered the impact surgery would have on my own musculoskeletal
(MSK) health. As I progressed into my late thirties, I started to experience back
and hip pain so severe that I could barely walk after long days in the operating room.
I started wearing a back brace while operating. I began taking naproxen on a regular
basis. I never told anyone out of fear of stigma. I wanted to keep building my practice
and not slow down. At first, I assumed it would just get better. Eventually, as my
symptoms progressed, I tried everything—stretching, braces, massage therapy, acupuncture,
physical therapy, chiropractor, steroid injections.
A magnetic resonance imaging (MRI) revealed torn cartilage around my hip. This resulted
from years of repetitive, positional trauma working in the operating room without
regard for proper ergonomics. It required surgery and an associated 6-week recovery,
during which I was sidelined out of work.
I was shocked to learn that nearly all of my colleagues had chronic MSK conditions
related to the physical demands of our job. Surgeons are like professional athletes,
who require conditioning to keep them performing at the top of their game. We need
to improve our working environment and maintain our physical health to make sure that
we can perform optimally and maintain career longevity. Step 1 is to recognize the
reality of the situation. Step 2 is to do something about it, and therefore we welcome
you to keep reading.
Introduction
At the conclusion of medical school, young physicians embark upon their professional
journey with the acceptance of the Hippocratic Oath, affirming they will do no harm.
As admirable as this pledge may be, surgeons rarely consider the personal harm that
may ensue from years of operating in hazardous conditions. A recent report from the
American College of Surgeons' Surgery News Bulletin has addressed the mounting health
concerns of surgeons, declaring “This has to change, for how can we provide excellent
care to the patient if we cannot maintain our own health and safety.”[1]
Surgeons are conditioned and trained in a high-paced, productivity-driven environment,
where the thoughts or complaints related to stress and fatigue are often discouraged
or simply ignored. Medical students and residents are generally young, flexible, and
limber. Their senior surgeons would be unlikely to admit or address any personal weakness
or limitations to their trainees. This flawed relationship represents a critical barrier
to open dialog and progress. The consequences are severe and relate to both physical
and mental health.[2]
Despite all the advances in medical technology, operating rooms are still not designed
ergonomically nor with the surgeon's health in mind. Operating tables have limited
mobility, floor surfaces are hard, and monitors are positioned incorrectly. Furthermore,
the complexity and duration of operations have evolved, often related to the epidemic
of morbid obesity in our population. The surgeon stands and operates in awkward positions
for multiple hours. As a consequence, reports have demonstrated that 50 to 85% of
practicing surgeons worldwide experience regular MSK discomfort in the neck, shoulders,
and back. Endoscopic procedures are another risk factor for the incidence of hand
and finger injuries (42%), as well as neck pain (11%). These symptoms may all lead
to chronic disorders over time.[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
Those at a greater risk of injury include surgeons with a history of preexisting neuromuscular
disorders such as carpal tunnel syndrome, tendonitis, and arthritis.[11]
[12] In addition, case volume, duration, and disproportionate hand size to instrumentation
are associated with a greater rate of neurapraxia.[13]
[14]
[15] Maintaining a static position for an extended period of time, especially when operating
in the extremes of quadrants of the abdominopelvic cavity, increases the physical
workload endured by the MSK system. Davis et al have reported that more than 40% of
surgeons experienced one or more injuries in the workplace. These injuries affect
operative performance in half of these surgeons, whereas 20 to 30% missed work or
reduced the number of operations performed as a direct result of their injury. Sadly,
only 20% of surgeons officially reported their injury.[16] As a result, the cost for medical treatment of occupational related injuries have
exceeded 100 billion dollars annually, a significant economic burden on society.[17]
[18]
It is critical that our profession focuses not only on the patient but also on improving
the physical and mental well-being of the provider. Surgeons are not invincible and
should be encouraged to reveal their limitations and recognize the potential risks
related to performing surgery. Failing to embrace these issues will affect a surgeon's
ability to function, resulting in diminished career satisfaction, fatigue, and burnout.[8]
[19] Unfortunately, many surgeons never receive a formal education or are even aware
that guidelines exist to help prevent these prevalent occupational injuries.[9]
[20]
[21] Even more disappointing, when properly trained and educated, only 60% of surgeons
actually incorporate appropriate ergonomic designs in their surgical practices.[21]
Human Factors and Ergonomics
Human Factors and Ergonomics
To master surgeon safety in the operating room, one must understand the science of
ergonomics. The word ergonomics stems from the Greek words “ergon,” meaning work,
and “nomos,” meaning natural laws or arrangements. It is the study of people at work
and how the working environment is designed to suit the worker.[22] Ergonomics relates to the interaction between person and machine, and the subsequent
interaction the machine plays on the person, with the goal of optimizing how technology
is used.[11]
[23]
[24] Combined as a complete system, the principles of ergonomics use anatomy, physiology,
psychology, and engineering to create a favorable environment that mitigates MSK complaints
and optimizes performance and efficiency.[24]
The conditions that surgeons withstand have been compared with those of certain industrial
workers.[25] Unfortunately, little basic science research has been implemented to address and
evaluate the ergonomics in the operating room.[15]
[26] Integrating the field of ergonomics into medicine, especially surgery, can be challenging
as multiple factors cannot be manipulated. These include the patient's body habitus
or the necessity to remain within the constraints of a sterile surgical field.
The discipline of ergonomics has evolved significantly since its inception in the
early 1900s.[27]
[28] Research has been performed and employed in large industrial companies, the military,
and sports training to maximize performance while reducing errors and injury.[11] More recently, focus has been drawn to the medical environment. Methods to mobilize
and care for patients in intensive care units, gastrointestinal endoscopy suites,
and medical-surgical wards have been implemented to specifically minimize back injuries.[29] As the incidence of cervicobrachial injuries rose in the dental profession, this
encouraged the redesign of equipment and techniques to mitigate further health risks
to the provider.[30]
[31] Similar responses are more complex in the field of surgery. The wide variety of
operative techniques, disease locations, and patient position all alter the operating
room environment. These factors contribute to how the operative field is visualized,
the way surgical instruments are manipulated, and, ultimately, surgeon stance and
posture.[11]
[26] These variables span open, laparoscopic, and robotic approaches.
Body Positioning
“Posture” is defined as the spatial arrangements of body parts as they align to perform
a task. This is an interface between segmental joints of the body and muscles crossing
these joints to protect the body's support structures and prevent damage in any position.
These factors are influenced by the task, environment, working tools, and biologic
characteristics of the worker.[32] A healthy, stable posture occurs when one is standing upright without a rounded
back. The spine should remain straight to maintain the natural lordotic and kyphotic
curves of the vertebrae. The elbows should be facing outward, the shoulder blades
brought down and inward, while tucking in the core and buttocks. Focus on a line of
gravity transecting all the spinal curves, and this will provide a stable structure
and base of support ([Fig. 1]). The best means of preventing work-related injuries are understanding and recognizing
how a stable posture feels and understanding the downsides of a faulty posture that
will lead to MSK injuries.[33]
[34] This understanding is not innate and requires coaching and training to develop muscle
memory.
Fig. 1 Optimal ergonomic position.
One must not underestimate the physical exertion and mechanical load placed on the
body while operating. An alteration in body mechanics when placed in constrained,
asymmetric, and prolonged positions results in tissue stress and injury due to overexertion
or imbalance. Improper working postures place muscles, tendons, and ligaments at risk.
Abnormal loads and strains result in damage to bones, joints, and cartilage. Furthermore,
neurapraxia may occur because of nerve compression or ischemia.[35] In more than 50% of surgeons, posture alone has contributed to their symptoms.[4]
Rosenblatt et al described the three most common errors in ergonomic posture: excessive
forward head position, sustained uncomfortable elevations, and asymmetry in weight-bearing.[36] When the head is maintained in a too far forward posture, it results in tension
and pain in the upper torso, ultimately causing degenerative changes in the cervical
spine and shoulder girdle. For every inch that the head moves forward in space, the
relative weight on the spine increases by 10 pounds, resulting in an increased demand
on the joints supporting the head. Regrettably, many of these positions are performed
subconsciously from poor habits that are adopted overtime. Failure to become aware
of these positions increases the workload placed on the spinal column, and microtrauma
accumulates in the tissue.[37] In addition, the frequent uncoordinated and repetitive motions of the upper extremities
and prolonged static head and back postures inflict unnecessary stress on the spinal
column.[38] During open surgery, a common posture employed by the surgeon is a head- and back-bent
position, with a twisted torso.[10] Laparoscopic operations require a head- and back-straight stance with an upright
skeleton to allow the eyes to focus on the display screen, whereas the arms are commonly
placed in a continuous abducted and internally rotated position, a position associated
with increased shoulder pain. Open procedures require more dynamic movements as compared
with the relatively static nature of laparoscopy.[10]
A static uninterrupted posture will increase the risk of long-term back pain through
a sustained isometric contraction of the lumbar extensor muscle group.[26] Even if a force is generated at 2% of the muscle's maximum voluntary contraction,
this results in decreased tissue oxygenation and risks subsequent injury.[7] Further injury occurs as muscles and tendons accumulate lactic acid and toxins secondary
to the compression of veins and capillaries when maintained in these static positions.[38]
[39] This further exacerbates tissue trauma due to decreased oxygenation and lack of
nutrition.[40] During minimally invasive procedures, 70% of surgeons tend to maintain a static
posture, as these operations require less back flexion compared with open procedures.
These infrequent changes in position over time will result in muscular strain and
fatigue.[38]
[41]
[42] As procedural time increases, forward flexion of the torso intensifies. This position
increases the compressive load on the spine, resulting in fatigue, stress, and pain.
All factors associated with a reduction in performance.[43]
Improper head and neck angles result in cervical discomfort and have also been associated
with posture fatigue. Numbness, stiffness, and pain in the shoulders, neck, arm, and
wrists have been reported by 8 to 18% of surgeons.[26] During open procedures, surgeons have a propensity to create a forward flexed neck
angle of 60 to 90 degrees, and intraoperative electromyography (EMG) studies have
demonstrated a greater amplitude in the cervical erector spinal muscles with this
posture. This results in a greater workload on the cervical extensor muscle group
to stabilize the head.[10] In addition to neck and back pain, this anterior tilt of the neck is correlated
with MSK symptoms in the trapezius and the temporomandibular joint. This posture is
accentuated in those with preexisting symptoms, further worsening pain and discomfort
over time.[44]
Standing upright places an intermediate amount of compression on the spinal column,
which ultimately results in lower back pain.[32] Due to the force of gravity, improper posture will accentuate cervical lordosis
and thoracic kyphosis to maintain lumbar lordosis. This effect on the spinal column
results in an altered biomechanical loading on muscles, ligaments, and joints that
can trigger long-term injuries. This abnormal compensation in position may ultimately
result in a decrease in truncal height.[32] These hazards are directly related to the duration of exposure and underscore the
importance of surgeons being mindful of their posture and performing corrective measures
periodically while operating.
Laparoscopy
The advent of laparoscopy has been associated with considerable benefit in patient
outcomes. This approach has been correlated with decreased postoperative pain, less
wound complications, and a shorter length of hospital stay.[45] However, minimally invasive surgery is technically demanding and imposes a significant
physical demand on the surgeon. Park et al report that 87% of surgeons who regularly
perform minimally invasive operations have succumbed to work-related symptoms and
injuries directly related to this approach.[21] The greatest stress on the body during laparoscopy has been reported to be on both
the cervical and lumbar spine, in addition to the shoulders, wrists, and hands. MSK
disorders in these body segments are secondary to both static positions and awkward
postures.[39]
[46]
[47] Furthermore, internal rotation movements of the shoulder, as well as supination,
ulnar, and radial deviations occur more frequently in laparoscopic procedures compared
with open procedures, which are associated with a greater rate of discomfort in these
regions.[38]
Laparoscopy requires a substantial amount of focus, and the degree of concentration
endured by these procedures is reportedly greater than that by open surgery.[38] It is important that the surgeon understands the risks of operating laparoscopically,
and although there are multiple barriers to ergonomic efficiency, success begins with
surgeon awareness and recognition of existing obstacles.[24] Ergonomic guidelines for laparoscopic equipment have also been developed and will
benefit the surgeon when implemented ([Table 1]).[48] Reports have demonstrated that as few as 9% of surgeons are even aware of any formalized
recommendations, and only 3% apply them routinely.[49] One of the fundamental concerns with poor ergonomics in the operating room is associated
with the surgeon's nonneutral body position, and this is often driven by their equipment
and a failure to be mindful of their posture. As surgeons progress through the early
laparoscopic learning curve, they should be encouraged to maintain a comfortable and
natural body posture to avoid the fatigue and pain that occur as a result of cumulative
bad habits ([Fig. 1]).[22]
[50]
Table 1
Ergonomics principles and recommendations for laparoscopic procedures
|
Ideal working posture
|
|
Stand upright
|
|
Avoid static positions
|
|
Arm and elbow angle between 90 and 120 degrees
|
|
Forearm in a neutral horizontal position
|
|
Slight inward rotation of the arms
|
|
Mild wrist extension and finger flexion
|
|
Table height
|
|
Table between 66 and 77 cm above the floor
|
|
Purchase of tables that can be lowered adequately
|
|
Adjust for a neutral posture
|
|
Instruments and elbows aligned
|
|
Image display screen position
|
|
Request ceiling-mounted screens
|
|
Unobstructed and in-direct view of the operator
|
|
Distance between 0.9 and 3 m from the surgeon
|
|
Viewing angle to monitor: 15- to 45-degree downward gaze
|
|
Cautery and insufflation setting in the surgeon's view
|
|
Separate monitor for assistant
|
|
Instrument handle design and usage
|
|
Ring handles: avoid excess pressure on fingers while activating
|
|
Avoid excess ulnar or radial deviation
|
|
Locking mechanism prevents tissue slippage or excessive force
|
|
Locking mechanism should rotate on/off
|
|
Avoid friction between the instrument and the abdominal wall
|
|
Handle manipulation for the left and right hands
|
|
Avoid pressure on the thenar eminence or the palm activating instruments
|
|
Use rotational handles
|
|
Ideal instrument manipulation angle: 45–60 degrees in reference to the patient
|
|
Trocar placement
|
|
Triangulate toward the target anatomy
|
|
Target organ 1520 cm from the center trocar
|
|
Remaining trocars arranged in 15–20 cm arc, 5–7 cm apart
|
|
Avoid placement that requires excess reach over the patient
|
There are inherent differences between the ergonomics of open and laparoscopic equipment,
which imposes varying constraints on the operator. The use of open surgical instruments
provides multiple degrees of freedom, allowing for dynamic movements, with dissection
performed in a three-dimensional space in line with the target organ. In contrast,
during laparoscopy, the surgeon is typically found in a static posture limited by
a two-dimensional view, with the loss of physical contact with the surgical field.
This disconnect between visual and motor sensations alters the efficiency of the procedure.
The loss of tactile feedback alters depth perception and adds to the complexity of
the operation.
The ability to move laparoscopic instruments is restricted to only four degrees of
freedom: rotational, up/down, left/right, in/out.[51]
[52] In addition, the force necessary to grasp laparoscopic instruments is almost six
times greater than what is required in open surgery. Accordingly, the surgeon grips
the instruments harder, which is a less efficient transfer of energy from the handle
to the tip. Holding the instruments in this fashion increases pain and discomfort
throughout the hand.[15]
[22]
[26] When laparoscopic instruments are used, they are passed through trocars fixed at
the abdominal wall, and this creates a paradoxical fulcrum effect, where the intracorporeal
aspect of the instrument moves in the opposite direction of the surgeon's hand. Stationary
trocar positions will prohibit the surgeon from adjusting their body posture around
the instruments, resulting in awkward working angles.[51] Harmful forces may be exerted on the surgeon's torso when contorting his/her body
around a morbidly obese patient or one with a thick abdominal wall. In addition, if
trocars are skived, or not placed in a perpendicular direction between the skin and
peritoneal cavity, excessive force to be exerted on the instruments will be required
and may result in upper extremity discomfort. Operating laparoscopically is not intuitive.
This alteration in spatial recognition overtime can affect surgeon performance. This
approach requires a focused and learned coordination of movements to maintain mental
stamina and prevent harm to the surgeon ([Table 2]).[15]
[22]
Table 2
Factors contributing to mental fatigue
|
Fulcrum effect of instruments causes visualization of inverted movements
|
|
Increased level of hand–eye coordination
|
|
Two-dimensional images
|
|
Loss of depth perception
|
|
Effects of light reflection and shadows
|
|
Lack of efficiency in movement around the operative field
|
|
Duration of surgery
|
Instrument length has also been associated with an increased risk of shoulder discomfort.
The maneuverability of these instruments becomes increasingly difficult when the ratio
of the intracorporeal to extracorporeal length is <1. A greater degree of extracorporeal
length increases the distance of instrument movement, which creates a wider elbow-to-shoulder
angle and is associated with muscle fatigue and joint pain.[53] Laparoscopy is also associated with an increased risk of uncomfortable wrist positions
and may lead to increased pain, numbness, and fatigue in the hand.[38] In addition, laparoscopic handles are generally not adjustable, and some are created
with cumbersome locking mechanisms. Opening and closing many of these instruments
require an excessive and disproportionate amount of force on the thumb and differs
based on hand size. Instruments are rarely manufactured in varying sizes to fit the
hand dimensions of the surgeon, and this may result in discomfort, nerve compression,
and limited maneuverability.[54]
[55]
Proper surgeon location at the operating room table and trocar placement both affect
posture. Trocars should be triangulated, with the target organ approximately 15 to
20 cm from the center port. Additional trocars are placed in a semicircular pattern,
with each trocar approximately 5 to 7 cm apart. Correct placement facilitates instrument
working angles between 60 and 90 degrees and avoids excessive extracorporeal instrument
length and friction from the abdominal wall.[22]
[56] If trocar positioning is too far from the target organ, it may cause the surgeon
to push on the abdominal wall to gain a closer distance, causing muscle strain. In
general, a laparoscopic procedure is performed with the surgeon on the opposite side
of the patient's pathology. Reaching over or across the patient for trocar access
is indicative of incorrect port placement. Standing between the patient's legs may
force the surgeon to lean over the patient, placing excess stress on the back.[38] However, an evaluation of laparoscopic cholecystectomies identified that operating
while standing between the patient's legs may be more ergonomically suitable, as standing
on the patient's left side was associated with increased stress on the upper arms,
neck, and trunk due to a high rate of upper arm flexion, abduction, shoulder elevation,
neck flexion, and torso rotation.[57] These findings serve as an example that one position does not fit all operations,
and, more importantly, the surgeon must be aware and knowledgeable of beneficial ergonomic
and positioning options.
Sensorial ergonomics requires optimizing visualization to allow for precision, accuracy,
and dexterity to manipulate tissue.[22] Positioning of the displayed monitor will affect visual orientation, neck position,
and stance throughout a procedure.[24] When feasible, the surgeon should request for operating rooms that are designed
for laparoscopy. This typically entails multiple ceiling mounted screens that allow
for easy manipulation and height adjustment. The main laparoscopic console should
be in direct view of the surgeon or assistant to prevent rotation or poor posture
to visualize equipment settings.[24]
[58] The monitor height should be in front of the operator and approximately 10 to 25
degrees below the horizontal plane of the eye with a downward gaze ([Fig. 1]). This promotes a neutral position of the cervical muscles and lowers the degree
of neck strain while providing an optimal height for visualization.[59]
[60] When the monitor is too high, this requires the surgeon to compensate by placing
an excess amount of extension in the cervical and lumbar spine.[36] The recommended distance between the image and the surgeon should be between 0.9
and 3 m, a space that allows for ideal accommodation of the ocular lens ([Fig. 1]). When the screen is too close, it increases eye strain; however, this measurement
may be slightly altered based on the size of the screen.[15] The assistant should have a separate screen, as even camera holding is a risk factor
for work-related injuries.[22]
[24]
[61] Spending dedicated time to adjust the visual display screen will develop an environment
conducive to operating safely, minimizing surgeon fatigue, and reducing the risk of
adverse outcomes.[24]
Table height is critical to maintaining a neutral posture, and this applies to both
laparoscopic and open procedures. The table should be at the height of the surgeon's
elbow.[38] When standing comfortably, the angle of the arm and elbow should be between 90 and
120 degrees, with the forearm in a neutral and horizontal position at a point between
supination and pronation ([Fig. 1]). The wrists should be placed in a slightly extended position, with a slight bend
of the fingers.[26]
[50] The surgeon should also be mindful of the height of his/her assistance or cosurgeon,
as the ergonomic safety of all involved staff is critical to the efficiency and outcome
of the operation.
When the table is too high, the surgeon is forced to raise his/her arms and change
the angle of forearm and wrist to compensate for grip on the instruments. This causes
fatigue and pain in the wrist and shoulders due to excessive extension in these joints.
This discomfort makes fine dissection and suture placement challenging. It is common
to rely on outdated equipment with limited motion, particularly in table height. The
purchase of updated operating room tables may be necessary, requiring a capital investment
by the hospital.
In addition, a table adjusted too high often requires a surgeon to stand on a step
stool. This confines the surgeon to a smaller working area. When this space is cluttered
by cables or a foot pedal, this could offset surgeon balance and cause unintentional
motion and subsequent injury to the patient. Furthermore, the surgeon may succumb
to an injury if one should fall off the platform.[50] If a foot pedal is used for electrocautery, this should be at the same level as
the surgeon's foot and aligned with the working instrument toward the targeted anatomy
([Fig. 1]). This will prevent any unnecessary shift in the legs or feet, or an awkward position
during cauterization of tissue. For extra protection, consider always placing two
platforms adjacent to each other, as well as two platforms behind, to prevent an inadvertently
fall off the back side of the stool.
Patient positioning on the table requires careful consideration. When the arms are
placed at 90 degrees to the bed, it may interfere with the surgeon's stance in relation
to the target intra-abdominal quadrant. In these circumstances, the patient's arms
should be tucked to allow the surgeon to take a comfortable stance at the operating
table. Any position that results in the surgeon twisting his/her upper extremity,
lower extremity, or back should be avoided.[36] Developing a comfortable work environment by incorporating these ergonomic principles
and recommendations will minimize physical fatigue, help avoid injury, and reduce
the additive mental stress experienced during lengthy laparoscopic procedures.
Robotic Surgery
Offering an advantage over the ergonomic limitations of laparoscopy, robot-assisted
surgery provides a different perspective of the operative field. The da Vinci robotic
surgery system (Intuitive Surgical, Sunnyvale, CA) was introduced in 2003 and has
become increasingly popular throughout multiple surgical disciplines.[62] This system allows the operation to be conducted at a console away from the patient,
with the surgeon in a seated position. The robotic arms require little mechanical
effort to activate. The wristed instruments allow for seven degrees of freedom, which
aids in fine manipulation. In addition, the camera display is three-dimensional and
set up with a downward gaze, minimizing potential eyes strain and fatigue. The console
itself can be adjusted to a personalized optimal ergonomic position, and a supportive
chair can be employed as well.
Zihni et al performed the first quantitative analysis comparing ergonomic stress between
laparoscopic and robotic procedures. The authors used surface EMG to compare the activation
of the bicep, triceps, deltoid, and trapezius muscle groups during both laparoscopic
and robotic procedures. Results demonstrated a significantly elevated level of muscle
activation in all muscle groups, except for the trapezius muscle, during laparoscopy
when compared with robotic surgery.[63] The suggested etiology of increased trapezius muscle activation during robotic surgery
may be secondary to the anterior tilt of the head and neck while looking down into
the console. In a smaller pilot study, Lawson et al demonstrated postural advantages
during robotic procedures. The authors identified decreased discomfort in the arm,
forearm, and wrists; however, there was a greater rate of neck strain due to the position
of the upper torso.[47] Overall, these findings concluded that laparoscopy had a higher degree of ergonomic
challenges based on a greater measurement of muscle activation compared with a robotic
approach.[63] In a recent study by Franasiak et al, 45% of surveyed surgeons reported experiencing
strain while performing a robotic operation, with >70% of these surgeons reporting
neck discomfort. The authors identified that only 16% of surgeons underwent any formal
ergonomic training; however, when an educational program was implemented, 74% noted
a decrease in strain when implementing the recommended positions.[20] Although the robotic surgical platform addresses and alleviates many of the ergonomic
deficiencies associated with conventional laparoscopy, this modality has not fully
alleviated the risk of MSK discomfort among surgeons.[64]
During robotic procedures, the surgeon should always focus on a neutral position to
avoid static loading on the body.[65] Once this is established, the surgeon must continuously reevaluate themselves to
ensure that no pain or discomfort develops. At the console, the surgeon's chair should
be on lockable wheels and have adjustable height and depth, as well as lumbar support.
The feet should rest comfortably on the ground in front of the pedals, with the knees
at a 90-degree angle or greater. The arms should be perpendicular to the floor, and
the elbows should be at 90 degrees resting comfortably on the armrest while keeping
the elbows tucked in closely to off-load pressure and reduce discomfort along the
torso. Frequent clutching of the mechanical arms is imperative to maintain the elbows
in this position. The optical camera display should be placed at a comfortable height
for viewing. The ocular height should be adjusted to prevent or relieve neck, shoulder,
and upper back strain. There should be no arching or straightening of the back or
neck to increase height. The neck should be at a downward angle of approximately 20
degrees, without any excess bending. When positioned, the surgeon should avoid placing
unnecessary tension or force on the headrest, as this can increase forehead pain and
neck discomfort. No longer constrained by a sterile field, if strain or discomfort
is recognized, the surgeon can stand, flex, and/or stretch for small periods of time.
This can be performed routinely during small breaks for instrument or suture exchanges.
The chair and console height can be readjusted at any time to provide a more comfortable
position.[20]
[65] Due to the paucity of research comparing the ergonomics of robot-assisted surgery
versus conventional laparoscopy, further investigations are required to fully elucidate
the surgeon's risk of work-related injury when using this technology.[66]
Musculoskeletal Therapy
Surgeons who suffer from MSK injuries employ multiple options to address their symptoms,
including nonsteroid anti-inflammatory medications, muscle relaxants, and additional
treatments such as massage, acupuncture, and physical therapy.[67] The risk of narcotic use and dependence should not be ignored.[68] Surgeons who suffer from a work-related injury may require an increased amount of
sick leave, variations or limitations to their practice, temporary assignments to
nonsurgical tasks, or early retirement.[4]
[19]
[69] Self-medication or analgesic usage may alleviate symptoms, but these treatment options
do not target the underlying cause. The ultimate goal would be to recognize causative
factors at early stages and employ countermeasures to minimize pain and disability
while promoting career longevity.
Spinal instability is one of the most common etiologies of lower back pain and one
of the primary disorders affecting surgeons. Improving stability decreases the mechanical
irritation of the spinal column and reduces symptoms.[70]
[71] Surgeons may require orthopedic footwear, spinal braces, and exoskeletons to maintain
stability and posture while operating.[69] Devices including ergonomic body supports and headrests have been piloted to assist
in creating a more stable and natural posture to alleviate strain on the cervical,
thoracic, and lumbar spine during both open and laparoscopic procedures.[72]
[73] The implementation of standing on a Gel Mat (Gelpro, Austin, TX) has been evaluated,
and surgeons reported an improved operative posture and less back, knee, and foot
pain with this intervention. The overall subjective perception of physical discomfort
and fatigue was significantly less, and surgeons also reported a lower rate of intraoperative
errors when standing on the Gel Mat.[74]
The ergonomics of surgery need not solely rely on equipment, as there are several
measures a surgeon can employ in the operating room that will protect his/her MSK
health. For example, alternating surgeon participation during complex and lengthy
operations allows for periodic rest breaks. Cuschieri recommended routine 10-minute
breaks every 2 hours where the operating team and surgeon leave the room.[52] While this might appear extreme, the concept and benefits of microbreaks have been
well established. A multicenter study performed by Hallbeck et al implemented the
use of 1- to 2-minute exercise-guided breaks spaced every 20 to 40 minutes of operative
time or when medically appropriate. These activities focused on rotational movements
and activation of muscle groups in the neck, back, hands, and lower extremities during
procedures lasting between 2 and 12 hours. Results demonstrated that microbreaks did
not increase operative duration, disrupt the workflow of the procedure, or cause any
distractions. Surgeons reported a 34% improvement in mental focus and a 57% improvement
in physical performance, and following this investigation, almost 90% of surgeons
desired to incorporate microbreaks into their practice.[75] Park et al further investigated the effects of targeted stretching microbreaks using
similar time intervals. These exercises preserved sterility and involved neck flexion,
extension, and lateral rotation; backward shoulder roll and chest stretch; upper back
and hand stretch; low back flexion and extension; gluteus maximus contractions; and
foot and heel lifts for lower extremity and ankle stretches. Encouraging results were
demonstrated with an improvement in both physical and mental performance, with no
impact on case duration. Furthermore, the majority of surgeons planned to continue
this routine regularly.[8] These two studies clearly demonstrate a safe, effective, and efficient method to
reduce MSK discomfort during the conduct of surgery.[8]
[75]
Simple postural rests, even if these are not formal procedure breaks, should be implemented
to readjust the body to a neutral stance and alleviate tension on the torso and extremities.[61] Additional sterile intraoperative stretches and exercises may be performed to offset
strain on the body. The upper extremity can be mobilized with bilateral or unilateral
arm raises. This allows for full shoulder elevation, external rotation, scapular depression,
and retraction to reduce strain on this location. The scapula is drawn down and the
back while the sternum is lifted slightly to allow the shoulder girdle to be stretched
and mobilized. Squatting is another movement that offsets pressure on the torso. This
multifunctional exercise engages the large muscles of the lower extremity and recapitulates
symmetrical weight-bearing and a neutral spine. This can be performed without compromising
the sterility of the operation.[36]
Furthermore, it is important to avoid any excessive or sustained shoulder abduction
and internal rotation. This position is suboptimal as it requires the greatest workload
on the deltoid and trapezius muscles, predisposing surgeons to fatigue and injury.
The surgeon should remember to drop the shoulders and relax the hands, as this will
off load the pressure on these muscle groups. To avoid unnecessary shear force on
the pelvis and lower spine, one should refrain from any positions that shift weight
onto one leg. This typically occurs when using a foot pedal at varying elevations
to the ground, causing an asymmetrical load on the lower extremity. To further protect
the torso and lower extremities, place the feet shoulder width apart, do not lock
the knees, and abstain from shifting weight in the hips. If a circumstance arises
that requires weight to be shifted, it should be countered by engaging the deep muscles
of the trunk and pelvis to maintain a neutral position. Consideration of the operating
room setup, maintaining a stable posture while standing or sitting, and repeatedly
employing a practice of postural adjustments are critical to maintaining a long, healthy,
and injury-free career in surgery.[36]
Prevention through Conditioning
Prevention through Conditioning
Physical fitness is often correlated with strength and physiological variables such
as heart rate, blood pressure, and oxygen consumption. However, joint flexibility
and range of motion are often discordant with physical endurance, and when not conditioned
properly, this results in injury.[76]
[77] High-intensity functional training (HIT) programs have been rapidly expanding throughout
all communities due to the benefits seen in body composition and strength. Even though
advantages in health and wellness may be gained through these activities, it is imperative
that novice athletes enroll in a well-organized and monitored introductory program
to avoid injury and time away from work.[78]
Although multiple modalities exist that aid in reducing symptoms of lower back pain
and MSK discomfort, establishing a program of injury prevention is of even greater
importance. The spine is naturally unstable, and it is the interplay of multiple muscles
groups that allows for coordinated contractions to sustain a functional position.[70] Pain from mechanical stress, tension, lack of joint mobility, an imbalance of muscular
length, strength, and endurance, lack of stabilization, and decreased cardiopulmonary
stamina will all impact posture. Interventions often addressed through physical therapy
involve techniques to foster spinal and extremity movements, limb stretching, and
joint mobilization, as well as stabilization exercises with progression to strength,
functional, and aerobic training. Furthermore, muscle groups from the suboccipital
region down to the gastrocnemius are interrelated in the development of a strong,
stable spine. Functional, stretching, and strengthening exercises can all be applied
to each specific body region that requires conditioning and should be tailored to
the individual surgeon in relation to his/her work environment and demands.[34]
There are various programs, resources, and routines that can be implemented to manage
MSK injuries as well as prevent them in the healthy surgeon. These should be customized,
as the mechanical etiology of instability and pain will vary among individuals. Although
the breadth of techniques to prevent and improve MSK disorders cannot all be discussed
here, it is important that before adopting any functional movement or strengthening
program, one should receive appropriate education from an accredited therapist. Improving
the strength and stability of the lumbopelvic hip complex or core provides stabilization
to the torso and spine. This requires balance, plyometric, and strengthening routines
to focus on a neutral spine with optimal trunk positioning to transfer weight-bearing
loads without harm. Any program should be performed in a stepwise fashion beginning
with local muscle recruitment, then stabilization postures, and, finally, dynamic
body exercises.[79] Training of the deep trunk muscles has been associated with a reduction in chronic
lower back pain. However, McGill and Karpowicz recommend the use of a stability training
program that places minimal force on the spine, as many people who require these routines
have compromised stability at baseline.[80]
[81]
Suni et al evaluated the effectiveness of conditioning and strengthening the normal
lordotic curve of the spine, referred to as the “neutral zone.” Targeting this region
facilitates the prevention of lower back pain by decreasing the effects of harmful
loads placed on the lower back and subsequent ligamentous injuries. The studied exercises
focused on the lumbar neutral zone and included balance, abdominal curl-up maneuvers,
hip joint and hip flexor stretches, squat exercises, trunk muscle balance exercises
on the hands and knees, upper body rotation with a rubber band, and upper body rotation
while side-lying. These movements were initially guided by a physical therapist; however,
patients had to demonstrate a commitment to the program, with graduated increments
in activity, and expectations that these drills would be incorporated into the patients'
daily schedule. The authors demonstrated a 39% reduction in lower back pain in the
treatment arm at 12 months. Additionally, at the conclusion of the study, those in
the treatment group had an improved outlook on their future ability to work.[82]
In addition to standard strengthening activities, maximizing the effects of intra-abdominal
pressure through the coordination of trunk and respiratory muscles directly affects
pelvic stability and torso stabilization. Exhalation workouts target an increase in
intra-abdominal pressure, resulting in the activation of abdominal and trunk muscles.
During breathing exercises, the contraction of the abdominal wall is controlled and
spinal stabilization can be accomplished.[83]
[84] This method of breathing allows for the relaxation of lumbar muscles and an improvement
in pelvic mobility, and may effectively relieve and prevent back pain.[85] When trained properly, the surgeon should feel empowered to practice all these exercises
routinely to improve mobility, enhance flexibility, and, ultimately, decrease pain.
Besides muscle-directed exercises, additional activities have demonstrated benefit
in core strength and posture improvement. Yoga has been reported to promote both physical
and psychological health.[86]
[87] Isha hot yoga is a practice of unique poses performed in a warm environment. This
particular subset of yoga has been correlated with an improvement in spinal flexibility
and overall functional capacity.[88]
[89] In a review of more than 100 patients participating in a hot yoga training schedule,
Kumar et al demonstrated a significant progression in core stability and single-leg
balance. This was analyzed through assessing a patient's ability to stand on one leg
while keeping the opposite foot on the inside of their knee for support, as well as
a plank test that involves placement in the prone position, with a rise up on the
toes, and bending the forearms while keeping the entire body stiff as a plank. This
particular routine has been validated to assess core stability. This form of hot yoga
appears to develop muscle activity and improve the muscular endurance responsible
for controlling these dynamic postures.[90]
Pilates has also been used in the treatment and prevention of lower back pain. This
method of conditioning focuses on improving posture through lumbopelvic stability
exercises and breath control. The activation of the body's core muscles, the diaphragm,
and pelvic floor muscles will develop the mobility and flexibility associated with
spinal support and may reduce lower back and hip pain.[91] Furthermore, Pilates teaches the correct timing of muscle activation, another factor
that, when not optimized, contributes to pain syndromes. Valenza et al randomized
participants to an 8-week trial of Pilates where this intervention group attended
class twice a week for 45 minutes, performing 14 various floor exercises at basic,
intermediate, and advanced levels. Participants evaluated after Pilates had a significant
reduction in chronic pain and disabilities scores, in addition to an improvement in
flexibility and balance.[92]
Osteopathic manipulation and targeted manual therapies have also been implemented
with the goal of alleviating the underlying etiology of pain. This area of medicine
focuses on the entire body as a system and provides a hands-on technique to alleviate
discomfort, restore function, and promote health. Cruser et al evaluated the effects
of manipulative therapy on a military population with acute lower back pain. Interventions
were performed weekly over 1 month and included a mixture of high- and moderate-velocity
thrusts, soft tissue stretching, kneading and pressure, myofascial release and stretching,
positional treatments of myofascial tender points, and muscle energy techniques. These
patients were found to have a greater reduction in pain, with a higher rate of self-improvement
and treatment satisfaction.[93] Myofascial release has also been directed to treat lower back pain among a cohort
of nurses. This technique uses the application of a low-load long-duration stretch
to the muscle's fascia with the purpose of restoring length to improve function and
reduce pain. This safe and effective technique can be administered by most therapists.
Nurses were found to have a 53% reduction in pain and a 30% reduction in disability
following 8 weeks of therapy.[94] These treatment methods, when received as an adjunct to a regular exercise program
for spinal strength and stability, may significantly improve long-term health and
wellness.
Conclusion
Across all surgical approaches and platforms, the conduct of an operation may put
the surgeon at risk for developing chronic MSK injuries. In such a physically demanding
profession, injury prevention is critical. This can be achieved through a combination
of optimizing operating room ergonomics and health maintenance through tailored training
regimens. Most surgeons lack awareness and proper training related to operative posture,
ergonomics, and risk mitigation through practice changes, modifications of the working
environment, and prevention strategies. The risk to MSK health is cumulative and rarely
recognized until injury occurs, impacting productivity, job satisfaction, and, ultimately,
career longevity. Through awareness and advocacy, we can enhance surgeon health and
maintain a productive workforce that is prepared and conditioned to provide surgical
care for our patients.
