GastrointestinalErgonomic analysis of primary and assistant surgical roles
Introduction
Adoption of laparoscopic surgery has led to a variety of benefits for surgical patients. When compared with comparable open procedures, many laparoscopic approaches are associated with shorter hospital stays,1 less postoperative pain,2 and lower postoperative complication rates.3 However, laparoscopic procedures are associated with significant ergonomic challenges to operating surgeons. In a recent survey, a majority of surgeons reported musculoskeletal pain in the neck, back, shoulders, or hands during or after laparoscopy.4 Another report showed that the presence of subjective musculoskeletal symptoms was most closely associated with laparoscopic case volume.5 The operating room is a workplace with a variety of potential ergonomic challenges including improperly positioned monitors, suboptimal table height, and poor instrument design. Although these challenges have been recognized by a growing body of research on operating surgeons,6, 7, 8 they may also impact surgical assistants during procedures. To date, there have been few studies of subjective or objective ergonomic stress associated with surgical assisting.
Our group is undertaking a line of research into the quantitative ergonomic assessments of laparoscopic surgery using surface electromyography (sEMG). sEMG allows muscle activation to be quantified as a voltage in a standardized, noninvasive way. This technology is well accepted in the study of ergonomics and has been used in a variety of industrial fields.9 Several recent reports have described the use of sEMG to study surgical ergonomics in dry lab models.8, 10, 11, 12 Our group has also performed the first evaluations of muscle activation during operative task performance, identifying ergonomic differences between laparoscopic and robotic surgical platforms as well as differences between basic and advanced laparoscopic procedures.13, 14 We have also performed the first evaluation of the impact of patient factors on surgical ergonomics.15 Most research to date, however, has focused on primary surgical tasks, rather than assistant tasks. Surgical assistance is often thought of as a passive task. However, it is often comprised of prolonged periods of static or isometric muscle contraction in a fixed position such as when holding the laparoscope or retracting. This may result in significant ergonomic stress to the assistant. Lee et al. performed the only known quantitative assessment of ergonomics during surgical assistance in a dry lab model, using force plates, and identified some evidence of postural instability during camera driving.12 To date, however, a direct examination of muscle activation during surgical assisting in the operating room has not been reported in the literature. In this study, we sought to compare the activation of bilateral biceps, triceps, deltoid, and trapezius muscle groups between primary surgery and assisting, as quantified by sEMG data obtained from a single expert laparoscopic surgeon during various operative procedures in which they performed either or both roles. We hypothesize that muscle activation in all muscle groups tested will be significantly higher during primary surgical task performance when compared with surgical assistance.
Section snippets
Subject recruitment
Under an institutional review board-approved protocol, a general surgeon with fellowship training in minimally invasive surgery and an experience of more than 1200 laparoscopic procedures was recruited to participate in this study.
Operative procedures
Data were collected during 13 laparoscopic procedures performed at Barnes-Jewish Hospital. All procedures were performed using instruments and materials listed on the participating surgeon's preference card. There were no procedures that were converted from
Results
Thirteen laparoscopic procedures were used in this study (Table 1). A total of 222 min of primary surgery and 476 min of assisting were included in analysis. In nine of the cases, the subject alternated between primary surgeon and assistant roles. One procedure included only primary surgery, and three procedures included only assisting.
Muscle activation (Fig.) was significantly higher during primary surgery compared with assisting in the right biceps (primary: 5.47 ± 0.21 %MVC, assistant:
Discussion
The ergonomic challenges associated with laparoscopic surgery have gained increased attention in recent years. To date, however, most subjective and objective investigations of surgical ergonomics have focused on operating surgeons and primary operative tasks. Little data exist regarding the ergonomic challenges associated with surgical assistance. In this study, we performed the first quantitative comparison of ergonomic stress associated with primary operative tasks and surgical assisting.
Acknowledgment
The authors thank Gyusung Lee, PhD of the Department of Surgery at Johns Hopkins University (Baltimore, MD) for his valuable advice.
Author's contributions: Study conception and design was done by A.Z., J.A.C., I.O., S.C., and M.M.A. Acquisition of data was carried out by A.Z., I.O., J.A.C., and M.M.A. Analysis and interpretation of data done with the help of A.Z., I.O., J.A.C., and M.M.A. Drafting of manuscript was done by A.Z., J.A.C., and M.M.A. Critical revision was carried out by A.Z.,
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2017, Journal of Surgical ResearchCitation Excerpt :Four series of measurements were carried out more than 2 mo. All the quantitative values presented are averages deduced from a statistical analysis because it has been demonstrated that medical staff are subjected to largely equivalent ergonomic stresses whatever the task.15 As an example, Figure 4 represents the front and back view thermal images of four subjects (two males and two females) after the reference situation, after 3 h spent in the classical endoscopy service, and after 3 h spent in the operating room with lead aprons, respectively.