CONTORTIONIST Laparoscopy can be a painful way for your surgeons to practice, sometimes causing debilitating repetitive stress injuries.

Try holding your shoulders, elbows and wrists like the surgeon in this picture. Awkward, right? After just a few minutes, you'd likely be sore and fatigued. Now imagine holding instruments in that weird, spread-eagle position, gripping and guiding those long chopstick-like tools that don't bend like your wrists and don't move in the same direction as your hand movements — the surgeon's hand moves left, and the instrument tip moves right. To top off our ergonomic exercise, you'll have to crane your neck and squint your eyes to view the procedure on a monitor that's up and over to the right and too far away.

"Do that 3 times a day for 20 years, and you'll really be sore," says Howard Ross, MD, chief of colon and rectal surgery at Temple University Hospital in Philadelphia, Pa. "You think of surgery as a gentle art, but surgeons can be very, very sore by day's end."

Patients love the reduced pain and smaller incisions of minimally invasive surgery, but a day of laparoscopy can be a grueling total body workout for your surgeons. How are your surgeons coping with the physical pain of practicing?

When his pinky and ring finger go numb during a longer case like a colon resection, it feels like your hand fell asleep and you hit your funny bone, says Sean Harbison, MD, a general surgeon at the Hospitals of the University of Pennsylvania-Penn Presbyterian in Philadelphia, Pa. In clinical terms, it's a median or an ulnar neuropraxia from overstressing your wrists. In reality, it's just one of laparoscopy's many aches and pains that can leave your surgeons feeling sore, stiff or worse — pain can incapacitate surgeons, limit their practice or shorten their careers.

"I know several surgeons who had to stop doing surgery because of cervical disc problems," says Dr. Harbison. "They had to change their whole professional trajectory. One became an ICU doctor."

After a day of 2 colon resections and 3 hemorrhoidectomies, Dr. Ross can remember plenty of days when it hurt to lift his head or turn to the side, when he had numb spots that lasted a week because he was holding the instruments for so long.

Nowadays, he's much more aware of ergonomics in the OR. He takes the time to set up the room so that his posture is good and his body position is comfortable at all times during an operation — his shoulder girdle relaxed, a slight bend in the elbow, a natural position of his hands and fingers so nothing is contorted.

If your ORs were designed for traditional open surgery, they may not be set up to perform laparoscopic procedures.

"If you're not set up correctly and focused so intently on the act, 2 hours will go by and you can't move your neck. Or you're stiff and your shoulders are cramped. Why? Because you weren't correctly positioned when you set up," says Dr. Ross. "You can hold an awkward position for a few minutes, but you'll say, 'Man, I can't move' when you release that tension."

Dr. Ross positions the monitor across from the patient at eye level so he's not hunched over or looking up or sideways to see. "Set up the screen so that the surgeon's neck is not strained to one side," he says. "You want him standing in a straight-up position so the natural curve in the back is preserved."

Surgeons should take a break to stretch during longer procedures, adds Dr. Ross. One study found that surgeons who take 90-second breaks to perform a variety of stretching exercises during procedures reported improvements in their physical and mental well-being.

But it's difficult for surgeons to maintain a good posture while working in the 3D space of the closed abdomen and looking at it in 2D on a TV screen. When cutting or grasping with a rigid, fixed-length instrument that doesn't bend, the body wants to move to the beat of the maneuver, says Dr. Ross, who likens it to a bowler who contorts his body after he releases the ball in an effort to alter its path.

An occupational hazard
The University of Texas MD Anderson Cancer Center in Houston conducted a survey of the workplace injuries suffered by oncologic surgeons. Researchers concluded that ergonomic issues in the OR are serious and that surgeons may need the assistance of ergonomic experts to improve their posture to avoid lower back injuries. The industry has answered the call for help by designing handles that fit the surgeon's hand better and instruments of different lengths. Thanks to HD optics, surgeons no longer have to squint to see what's in front of them on the video monitor.

Sharona B. Ross, MD, FACS, the director of minimally invasive surgery and surgical endoscopy at Florida Hospital Tampa, preaches and practices perfect ergonomic positioning. Whenever she performs single-incision laparoscopy, "everything ergonomically is perfect." For a gallbladder removal, after she sets the patient in a slight reverse Trendelenburg, she raises the bed so that her back is not flexed and she positions the screen at the right height for her neck.

"Adjust the environment to suit your needs," she says. "Ergonomics is everything. It's your future as a surgeon. If you're not taking care of your back and neck "

Before Dr. Ross started paying attention to ergonomics, she needed a massage twice a month for upper back and neck pain. Now that her shoulders, arms, neck, back and wrists no longer ache after she leaves the OR, "I haven't seen my masseuse for months and months."

Laparoscopic procedures are beneficial for patients, and clearly, the technique is here to stay, but surgeons need to look out for their own well-being as well. OSM