Laparoscopic surgery can take quite a toll on a surgeon's body. A busy day in the OR leaves us with aches and pains from head to toe. Think about all the twisting of arms and turning of wrists needed to maneuver instruments into the right positions. Fingers ache if we don't hold the grips just so. The reward for staring at poorly placed monitors is a sore neck. But a few tweaks to your OR ergonomics can help reduce repetitive strain and other injuries.

Fits into my hand
Compared to open surgery, laparoscopy puts much more strain on the thumb, forearm flexor and deltoid muscles when doing a complex task such as tying a knot. Laparoscopic surgeons are much more likely to note pain in these body parts.1 This is hardly surprising when you consider the awkward devices we have to use, our limited access to the patient and our crowded workspaces.

Manufacturers have begun to realize that we prefer comfortable instruments (see "A Sampling of Ergonomic Instruments" on page 64). Look for these three features to make sure you're getting ergonomically designed instruments:

• smaller edges on trocars so they can easily penetrate the abdominal wall, which can reduce the stress that insertion puts on the muscles;
• plastic handles with large, smooth surfaces to reduce the pressure on fingers; and
• ratcheted handles to make gripping easier.

Take your surgeon's glove size into account when shopping for items such as laparoscopic staplers and scissors. People with a glove size of 6.5 or smaller tend to have a harder time using these instruments and this may put them at greater risk for musculoskeletal injuries.2 Instrument handles don't come in the variety of sizes we'd like to see, but hopefully this will change in the future.

What we really need is something that makes devices easier on our wrists. It's hard to get a dissector into the right position given the confines of the abdominal wall, which means we have to do a lot of twisting. Our choices are limited to pistol-grip handles or in-line handles with the controls on the shaft. While in-line grips make it easier to suture or grasp something at a 90-degree angle, they put the same amount of strain on the upper extremities.3 Instruments with adjustable handles that let a surgeon remain in a wrist-neutral position no matter what he's doing would be nice. I've seen a few prototypes that offered this option, but none have hit the market.

Robotic systems are definitely a big improvement to the ergonomics of surgeries. With these, the surgeon can sit, adjust his binoculars and control the procedure with six degrees of movement freedom. The result is a lot less arm stress for the surgeon.4 The downside, though, is that most facilities will need a heavy workload to justify the cost.

What the surgeon can do
Picking the right devices is a start, but many other factors can make a surgeon uncomfortable during laparoscopy. The typical surgeon spends hours in an unbalanced posture as he looks into a video screen while tapping foot pedals and maneuvering around cables. Most of the time he'll eventually settle into a static pose, and that can be more harmful to his body than if he were constantly moving. I have three points to offer you in these situations:

Properly position the display. The key is that the monitor should be in front of the surgeon and a little below eye level (as much as 45 degrees, but I prefer 25 degrees) so the surgeon doesn't strain his neck by looking up or to the side. The cheapest way to do this is to put the monitor on a lower mobile stand and move it into the right position. A more technical option is to install a boom-mounted screen and pull it around. There are also head-mounted displays, but these aren't very popular and are very expensive.

Set the table to the right height. Use a surgical table with lifts so the surgical handles are at the physician's elbow level and the patient is a little lower.5 In this setting, the surgeon will be able to operate without having his elbows flare out, which will reduce the stress on his arms and keep him from bumping into staffers or equipment. Simply put the patient down to the surgeon's mid-thigh level (you'll break the sterile field if the table gets to the knee level of any staffer).

Learn to reduce the strain from hand instruments. Surgeons may want to attend a conference to learn how to make procedures easier on themselves. One technique is "palming" the instrument, where you take your thumb out of the ring and hold the handle as you would a gun. You lose some dexterity when doing this and can't perform such fine motions as tissue dissections, but if all you're doing is grasping and holding tissue there's no reason to squeeze the ring anyway.

Surgeons may need reminders from the staff to take 30- to 60-second breaks every 15 to 20 minutes. It's not uncommon for physicians to freeze after they find a suitable spot to stand, particularly if they're concentrating on an intense procedure. That's exactly the sort of situation that worsens fatigue and could damage their joints over a few years.

Enlisting staff support
Getting the staff's support is an important part of getting these techniques implemented in your facility. Once you have the measurements for table height set and know what the best position for the monitor is, staff need to have a set protocol to put everything in its place for the surgeons.

Creating a written list of what goes where and at what height is also a good opportunity to optimize your OR space, such as where the arm boards and stands should be placed. For example, if you're doing upper abdominal surgery you may want to put the monitor near the patient's head so the surgeon can look straight ahead while operating.

Staffers and surgeons can also take this opportunity to clear the clutter of tubes and cables associated with endoscopes and other devices. If these get tangled, it could force everyone to assume more uncomfortable positions as they try to maneuver without pulling any plugs. Probably the best way to do this is by keeping each cord straight and close when in storage and reminding everyone to keep them separated when in use.

Since ORs dim the lights for laparoscopy, you need to find ways to tell the various instruments apart in the dark. One way to do this is to put brightly colored adhesive tape on the handles of their scissors and a different color of tape on their dissectors' handles. This way, staffers can tell what they're grabbing without resorting to trial-and-error.

Laparoscopy often takes a long time, so anything that you can do to shave a few minutes from the non-operating time will increase efficiency. This will cut down on the time your surgeon has to spend holding the instruments, which will reduce the strain on his body. Not only could this lengthen his career by a few years, but it can also reduce his chances of hurting a patient because his arms were too sore to control an awkward instrument.

References:
1. Berguer R, Chen J, Smith WD. "A Comparison of the Physical Effort Required for Laparoscopic and Open Surgical Techniques." Arch Surg. 2003;138:967-970.
2. Berguer R, Hreljac A. "The Relationship Between Hand Size and Difficulty Using Surgical Instruments: A Survey of 726 Laparoscopic Surgeons." Surg Endosc. 2004;18:508-512.
3. Berguer R, Gerber S, Kilpatrick G. "An Ergonomic Comparison of In-line vs. Pistol-grip Handle Configuration in a Laparoscopic Grasper." Surg Endosc. 1998;12:805-808.
4. Berguer R, Smith W. "An Ergonomic Comparison of Robotic and Laparoscopic Technique: The Influence of Surgeon Experience and Task Complexity." J Surg Res. 2006; 134:87-92.
5. Berguer R, Smith WD, Davis S. "An ergonomic study of the optimum operating table height for laparoscopic surgery." Surg Endosc. 2002;16:416-421.