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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?