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The issue of ergonomics is easily overlooked in the surgical arena. Surgeons and staff are driven to start cases and get them done, and may be distracted from taking a few moments before surgery to consider equipment placement, patient positioning and potential obstructions. But ergonomic factors must be taken seriously, or else surgical staff will end up paying the price. Here's an overview of some common concerns and how to avoid the achy wrists and tight backs that can turn into debilitating injuries if ignored.
Posture and movement play big roles in occupational ergonomics, and long stretches of surgery can take a toll on any OR staffer's body. But laparoscopic procedures can be particularly grueling. I've observed surgical situations where five to eight minutes pass without movement of any kind by the surgeon. This is rarely true of open surgery or, for that matter, of any industrial setting.
Open surgery may be performed standing up or sitting down, but there's always some movement going on, even if it's just shifting around. In comparison, laparoscopy is, hour by hour and minute by minute, more stressful on the body, given its miniaturized devices, limited access to the surgical site, crowded workspace and higher incidence of static postures.
While a half-hour of neck, back and trunk strain may not be a terribly urgent issue, such stress repeated regularly or sustained for longer procedures can result in soreness and fatigue over the short term and musculoskeletal damage, tendonitis or other repetitive stress injuries and chronic back pain over the long term.
The height of the OR table is a major factor in laparoscopic ergonomics. Physicians must be sure to adjust the table to a suitable height before the procedure begins. In general, the table and the patient should be positioned at a lower height than what the physician is used to for open surgery. When the table is at the normal open surgery height, the instrumentation may raise a physician's hands to shoulder or neck height, which will create substantial stress on his arms over the course of a procedure. To reduce that stress, the hands should be at elbow height or lower. Note that the design of the instruments should be taken into account as well: Instruments with pistol-grip-style handles may be easier to hold at a higher level than those with axial, or in-line, handles.
Be aware, of course, that it might not always be possible to attain the ideal table height. Perhaps your table doesn't descend low enough, or the patient's body size won't allow the desired level. It's always possible for a physician to stand on lifts at the table, but this solution contains its own problems. The surgeon might accidentally fall off the lifts, or if some instruments for the procedure are pedal-driven, you'll also need to arrange lifts for the pedals.
Don't forget the possibilities that patient positioning might offer in easing the surgeon's work stance. A lithotomy position, for instance, may let a surgeon stand between the patient's legs to comfortably operate on the abdomen.
Point of view
Another important factor is the proper positioning of display monitors. For most surgeons working in laparoscopy and other image-guided surgeries, the monitor is too high. While this isn't a problem for 15- to 20-minute cases, it's unsuitable for procedures of an hour or longer. Surgeons continually looking up and to the side to see what they're doing will end up with serious neck pain.
A monitor should be in front of a surgeon, so he's facing it directly as he works. It's also recommended that the monitor be positioned so that the display is 15 degrees to 25 degrees below the viewer's eye level. This lets the surgeon view the image in a natural posture and prevents the strain resulting from a continually twisted and craned neck.
In many ORs, the monitor stands at the top of a tall cart over all the other laparoscopic equipment, presumably under the impression that a high monitor is easier to see. But placing it on a lower cart or mobile stand is a better option for your surgeons' well-being. If your budget and infrastructure allow, mounting monitors on the articulated arms of an equipment boom is an even more ergonomic solution and one that's quicker to adjust to each individual surgeon. If you're planning to invest in a boom system, though, make sure ahead of time that it will actually enable monitors to be placed below eye level during surgery.
Tools on hand
The design of surgical instruments also weighs heavily on the ergonomics of laparoscopic procedures. They're generally constructed from a standpoint of "one size fits all," but for a physician whose glove size is 6.5 or smaller, they can prove awkward to handle and present a higher risk for wrist pain, nerve compression and other musculoskeletal injuries with prolonged use.
Surgeons have some choice of instrument design. When trialing the options, they need to do more than just weigh it in their hand and give it a cursory test. Many sales are conducted in break rooms and physicians' offices, but the best choices are made in a realistic setting.
Instruments featuring handles with broad, smooth, rounded-off contact surfaces accommodate different-sized fingers and reduce pressure on them. Handles with ratcheting or locking mechanisms provide forceful, continuous traction on the instrument with less effort from the surgeon's hand.
In terms of technique, surgeons may be able to reduce hand strain by occasionally "palming" an instrument. To do this, they remove their thumb from the ring on the instrument's handle and wrap their hand around the handle. While this position offers less dexterity to perform some complex tasks, it straightens the wrist and allows a rest when simply grasping and holding. For some tasks, such as suturing, axial instruments are generally easier to use.
Surgeons may find it helpful to take a 30- or 60-second break every 15 or 20 minutes, since they have a tendency to freeze up in concentration during intense procedures and may be unaware of how long they're holding a static and potentially straining position.
While sharps injuries and patient transfer mishaps tend to garner the most attention in safety discussions, slips, falls and collisions are also serious hazards. Besides the basic causes, such as fluids or other foreign matter on floors and inattentive hurrying through a facility's workspaces, a leading factor in these accidents is equipment storage, or rather, a lack of space for it.
It's a design issue. Most hospitals and surgery centers are built without adequate storage space. Coupled with the explosion of equipment and devices involved in modern surgery, we're seeing more and more ORs and hallways choked with equipment pushed up against the walls. This leaves insufficient space for free movement and increases the likelihood of falls or collisions. Make sure that equipment is stored safely by keeping workflow patterns in mind and requiring everything to be returned to its proper place after use.
Another common complaint is the aches and pains that staff suffer as a result of moving heavy items in and out of the OR, whether that means pushing mobile equipment or lifting and carrying trays of sterilized instruments. It's a standard industrial ergonomic problem that nurses face, but the usual advice is of little help here. "Lift with your legs, not with your back," is moot when you're hefting items down long hallways and backing through doors into the OR. Help from lifting belts and hand trucks isn't always compatible with sterile environments. The best advice is to remind staff to be aware of their needs in transporting equipment and to seek assistance when necessary.
In laparoscopic surgery, the first assistant holds the camera and scope. It's a critical task in that he's responsible for the surgeon's visualization, but it's also a boring task in that not much is happening, minute to minute. It's likely that he's also leaning across the table with his arm extended to support a two-pound instrument for long periods of time, which can cause back and shoulder fatigue.
To ease this burden, a laparoscopic camera holding system is recommended. You have two options in this area: Passive camera holders are clamped to the OR table, moved and fixed into position, then manually moved when necessary, but motorized voice- or pedal-activated camera holders are available as well.
Staff may find it helpful to record, preference-card-style, each surgeon's preferred table height and monitor patient positions used for different procedures in order to ensure quick, efficient and ergonomic room setups. They should also make an effort to keep equipment cords and tubes organized, before and during a procedure, in order to allow free movement and to prevent tripping and the accidental pulling out of plugs.