Ergonomics of laparoscopic surgery surgery

The slide discusses ergonomics of laparoscopic surgery

1. ERGONOMICS OF LAPAROSCOPIC SURGERY DR. AMJAD SAYEED JUNIOR RESIDENT GS UNIT-II

2. INTRODUCTION 1901: Kelling introduced visualizing scope in the peritoneum of dog- ‘ celioscopy ’ 1983: Kurt Semm did first lap appendectomy 1985: Erich Muhe of Germany, performed first laparoscopic cholecystectomy Last 2-3 decades laparoscopy has prevailed Advancement in instrument and devices Still ergonomics is a big challenge: 1) ill effects on surgeon 2) patient is the victim Chronological Advances in Minimal Access Surgery. Prof. R.K. Mishra. World Laparoscopy Hospital

3. ADVANTAGES OF LAPAROSCOPIC SURGERY Wound related Decreased wound size and trauma Decreased wound infection and dehiscence Low incidence of herniation Reduced post operative pain Improved post op mobility Reduced intra operative heat loss and fluid loss No use of abdominal wall retractors Improved visualization Less handling of bowel loops and early return of bowel functionality in post op Less incidence of post op adhesions Bailey & Love’s short practice of surgery, 28 th edition, Principles of Minimal Access Surgery, Page-164

4. OPEN SURGEY: High degree of freedom Work in line with visual axis 3-dimensional direct vision Direct tactile feedback OPEN VS LAPAROSCOPIC SURGERY LAPAROSCOPIC SURGERY: 4 degrees of freedom 2 dimensional vision Loss of peripheral vision Loss of depth perception Decoupling of visual motor axes View not under the control of surgeon Fulcrum effect Static posture

5. ERGONOMICS “Ergon” means work “Nomos” means natural laws or arrangement Science of best suiting the worker to his workspace Mastering Endo-Laparoscopic and Thoracoscopic surgery: ELSA manual

6. ERGONOMIC PRINCIPLES IN LAPAROSCOPIC SURGERY Body posture and positioning Workstation setup Instrument design and Handling Minimizing repetitive movements Team communication and coordination Physical environment control Surgeon workload and fatigue management

7. SURGEON BODY POSTURE Laparoscopic surgery can lead to significant fatigue to surgeon due to abnormal posturing Ideal position: Relaxed stance Arms slightly abducted, retroverted and rotated inward Elbow bent at 90 – 120 angle Neck slightly flexed with a downward gaze No clamps/instruments between surgeon and OT table Mastering Endo-Laparoscopic and Thoracoscopic surgery: ELSA manual

8. HEIGHT OF OPERATING TABLE Usually 0.8 times the elbow height of the surgeon, facilitating elbow angle of 90 – 120 . Ergonomics and Patient Safety in  Gynaecological Endoscopic Surgery. Page 69

9. PHYSICAL CONSTRAINTS TO SURGEON Neck pain and spondylosis Shoulder pain, backache Hand, finger and joint pain Tenosynovisitis Burning eyes Stress exhaustion

10. American: Stand by the left side of the patient European: Stand between the legs Both positions are convenient, one may find one more ergonomically better OT POSITION

11. POSITION OF DISPLAY Positioned lower than eyes of the surgeon (15-40 such that it facilitates eye-hand-target axis and gaze down view. Straight line concept On the side of target organ Standard LCD monitors placed on low cart separate from operating room equipment Second monitor: when surgeon changes ports and position Distance: 3-10 feet between monitor and surgeon 5 times the diagonal length of the monitor Ergonomics and Patient Safety in  Gynaecological Endoscopic Surgery. Page 69

12. MONITOR POSITION

13. TROCAR PLACEMENT Triangulation Placement of the trocars in a triangular manner Target organs should be ~ 15 cm from the camera port which is placed in the middle Other trocars to be placed in an arc ~ 5-7 cm on either side of the camera port This allows instruments to work freely at 60 to 90 angle and to prevent clashing

14. Sectorization – when endo-laparoscope is situated lateral to the working ports. Mastering Endo-Laparoscopic and Thoracoscopic surgery: ELSA manual

15. Baseball Diamond Concept Textbook of Practical Laparoscopic Surgery by Prof. R K Mishra, Chapter 7: Principles of Laparoscopic Port Position

16. MANIPULATION ANGLES Mastering Endo-Laparoscopic and Thoracoscopic surgery: ELSA manual

17. MANIPULATION ANGLE Angle between two working instruments Ideal angles is between 45 to 60 Should be equal to Elevation Angle for best ergonomics Yeola M.,  Gode D. and Bora A.Ergonomics in Laparoscopy. IJRSMS. 2017 Dec; 03 (02): 102-108. It is 30 in sectorization

18. AZIMUTH ANGLE Angle between the scope and working instrument Ideally it should be equal on both sides Half of manipulation angle Yeola M.,  Gode D. and Bora A.Ergonomics in Laparoscopy. IJRSMS. 2017 Dec; 03 (02): 102-108. It is 30 with nearest instrument and 60 with next instrument in sectorization

19. ELEVATION ANGLE Angle of the instrument with the horizontal line. Ideally 30 It should be equal to manipulation angle for shortest execution time and optimal performance. Yeola M.,  Gode D. and Bora A.Ergonomics in Laparoscopy. IJRSMS. 2017 Dec; 03 (02): 102-108.

20. EQUIPMENT RELATED CHALLENGES Half of 1.3 million instrument-related injuries occur in US hospitals- poor instrument design (US FDA) Only 4 degrees of freedom Reduced efficiency: Surgeon has to work six times harder Generally available in one standard size

21. DEGREES OF FREEDOM Potential for movement of the instrument either in one direction or around the instrument axis. Open surgery: 6 degrees of freedom Laparoscopic instruments possess a motion constraint of four DoFs • 1st DoF —up/down (heave) • 2nd DoF —rotation around instrument axis (roll) • 3rd DoF —left/right (sway) • 4th DoF —forward/backward (surge) The limitation in the DoFs with laparoscopic instruments makes handling of the target organ more difficult. ESPES Manual of Pediatric Minimally Invasive Surgery. Chapter 2: Ergonomics in Minimally Invasive Surgery

22. DEGREES OF FREEDOM ESPES Manual of Pediatric Minimally Invasive Surgery. Chapter 2: Ergonomics in Minimally Invasive Surgery

23. INSTRUMENT DESIGN AND HANDLING Laparoscopic instruments are long and require precise manipulation- hand and wrist pain Instruments should be: -Lightweight -Rotating handles -Appropriate grip size -Balance and weight distributation -Ergonomic design -Locking system -Variable length

24. Fulcrum Laparoscopic instruments work on Type 1 Lever action For optimal functioning ½ to 2/3 rd of the instrument should be inside the cavity Length of adult laparoscopic instruments is 36 cm Textbook of Practical Laparoscopic Surgery by Prof. R K Mishra, Chapter 7: Principles of Laparoscopic Port Position

25. Ergonomics and Patient Safety in  Gynaecological Endoscopic Surgery. Page 71,72

26. OR SETUP Setup of laparoscopic equipment – monitors, insufflator, energy source, light source, mayo stand Localization and positioning of team members – surgeon, assistants, anaesthesia, scrub nurse Instrumentation – size, length, specific instruments required in procedure, scope type, size and length Mastering Endo-Laparoscopic and Thoracoscopic surgery: ELSA manual

27. INTEGRATED OR Connects the OT environment including patient information, audio, visual, lights and other aspects All the aspects can be controlled from a single console Mastering Endo-Laparoscopic and Thoracoscopic surgery: ELSA manual Devices mounted on movable arms/carts for better space utilization Facilitate interaction with external parties

28. 3D LAPAROSCOPY Newer generation 3D cameras significantly improve the laparoscopic precision Provides perception of depth

29. MINIMIZING REPETITIVE MOVEMENTS Alternating tasks: engage different muscle groups Optimizing instrument design Short breaks and micro-pauses Instrument placement: frequently used within easy reach Use of energy devices: reduces number of instrument changes Delegate tasks: distribute simple and repetitive tasks to assistant Use of multifunctional instruments

30. TEAM COMMUNICATION AND COORDINATION Clear communication protocols Clear defined roles Thorough preoperative briefing Good camera operator-surgeon coordination Efficient instrument passing Minimizing verbal distractions during critical steps

31. PHYSICAL ENVIRONMENT CONTROL Optimal lighting: Bright, adjustable and shadow-free lighting Only dimmed not completely switched off Complete darkness have negative impact: handling of instruments and needles Temperature regulation Noise control Adjustible surgical table Space management in OR: prevent crowding around surgeon and table Ventilation and air quality Standing comfort: Anti-fatigue mats

32. SURGEON WORKLOAD AND FATIGUE MANAGEMENT Scheduling and case management: Planning longer and complex surgeries earlier in the day Regular breaks during long procedures Mental fatigue management: Practicing mindfulness or relaxation techniques before surgery Rotating roles Physical fitness and conditioning Hydration and nutrition

33. TAKE HOME MESSAGE Appropriate OR setup and ergonomics are required for optimal performance 7 Ps to be kept in mind: Position Posture Proper knowledge of devices and instruments Pre-operative planning Port placement Patient safety Part of surgical training

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