Occupational hazards of a laparoscopic surgeon.pptx

hazards of lap surgeons

1. OCCUPATIONAL HAZARDS OF A LAPAROSCOPIC SURGEON 22.02.2024 Presenters: Dr. Vasanti, Dr. Gogul (Junior Residents) Moderator: Dr. Uday Shamrao Kumbhar (Professor, Dept. of Surgery) 1

2. INTRODUCTION One of the greatest advances in the field of surgery. 462% increase in laparoscopic cases by general surgery residents over the 18-year interval, 2000 to 2018. O verall operative volume has increased but the representation of open cases has steadily declined since the advent of MIS From 2003 to 2018, MIS representation increased in all studied procedures: cholecystectomy (88% to 94%), inguinal hernia repair (20% to 47%), appendectomy (38% to 93%), colectomy (8% to 43%). 2 Less pain Fewer wound infections Better cosmesis and functional recovery Reduced morbidity and mortality Radically shortened patient recovery times and reduced hospital stay Early return to work and improved overall quality of life

3. PROBLEM STATEMENT 81% of operating surgeons and 78% of camera holder assistants reported muscle pain/discomfort during the procedure. Intraoperative fatigue - 41.7% of operating surgeons and 51.7% of camera-holder assistants. The SAGES Task Force on Ergonomics- 8% to 12% frequent pain in the neck and upper extremities associated with laparoscopic surgery. Back pain - 15% more common in laparoscopy M inimally invasive surgeons are three to five times more likely to experience neck and shoulder pain than surgeons performing open surgery Significant proportion of surgeons regularly depend on analgesics Nearly a third (30.3%) of surgeons admit to giving consideration to their own discomfort when choosing an operative modality . Forty-seven percent of surgeons were concerned that musculoskeletal pain may shorten their career . 3

4. THE PROBLEM WITH LAPAROSCOPIC SURGERY Tedious and time consuming Long learning curve Static body postures Only four degrees of freedom Line of working and visual axis differ Two dimensional vision View not under surgeon’s control Loss of depth perception No tactile feedback Fulcrum effect Tremor enhancement, inversion and scaling of movements Problems with Workplace layout 4 Work related musculoskeletal disorders Laparoscopic vision and visual fatigue Sensory, cognitive and psychological challenges Laparoscopic Instrument related hazards Surgical smoke related hazards

5. WORK RELATED MUSCULOSKELETAL DISORDERS One of the most important occupational health issues among surgeons Back pain, neck pain, shoulder/arm muscle strain and pains/paresthesia in the hand and fingers The most affected anatomic region: shoulders for operating surgeons and the lower back for camera-holder assistants 5

6. 6 More static and upright posture Fewer moves of back Smaller range of motion Decreased mobility of the head Less anteroposterior weight shifting during laparoscopic manipulations Foot of the operating table, the foot pedals and cables on the floor- little space for the feet of surgical staff- static body position. Foot pedals - foot dorsiflexed over the pedals and loading of body weight on the other foot to prevent losing contact with the pedals – foot and leg pain/ discomfort NECK PAIN AND SPONDYLOSIS Long duration of static neck flexion, extension and rotation. Line of working and visual axis differ Positioning of the monitor BACK PAIN

7. 7 FULCRUM EFFECT INVERSION OF MOVEMENT FOUR DEGREES OF FREEDOM SHOULDER AND ARM MUSCLE STRAIN HAND INJURIES AND PECTORAL TENDONITIS Loss of haptic feedback Increased use of power morcellation, repeated insertion and removals of laparoscopic instruments through trocar-strain at the shoulder Uncomfortable, repetitive movements of the upper limbs. Longer instruments Amplification of arc of movement Tremor enhancement Substantially greater muscle forces and more awkward wrist movements. N eed to apply 4–6 times more force to complete the same task Instruments’ handles - fixed size for all surgeons and for all tasks. Abducted static position of the shoulder

8. Current laparoscopic instrument design- activation of the jaws by the proximal (thumb) instrument ring. The force to open and close the instrument- thumb apposition alone (countered by the other fingers) 8 Pistol grips with finger rings , which induce extreme ulnar deviation and wrist flexion Forced flexion at the wrist joint compressing the palmar cutaneous branch of the median nerve Carpal tunnel syndrome HAND INJURIES

9. LAPAROSCOPI ST’S THUMB 9 Ring-handled instruments NON-DOMINANT HAND- retraction and unnatural position for prolonged periods Damage to the lateral digital nerve of the thumb (superficial branch of the radial nerve in the region). Increased paresthesia and numbness of fingers Neurapraxia/ Axonotemesis R eversible nerve injury Potential for permanent damage . Trophic skin changes A ringed silicon rubber attachment has been proposed to prevent laparoscopic thumb

10. Complaining of fatigue and stress related to surgical procedures- considered inelegant and attributed to surgeon inefficiency Many surgeons seek treatment for WRMDs but comparatively few report them to their workplace Changing position, limiting the number of cases, spreading the cases throughout a week, treatment in the form of physical therapy, medications, surgery, time off work Rising patient volume, work intensity and increasingly complex patients - develop into unhealthy behaviors, emotional and physical burnout Implications - attrition of more experienced surgeons (who may be retiring earlier than planned), - reduced patient access to more surgeon-strenuous operative approaches - suboptimal patient outcomes - reduced retention of trainees in an already demanding field 10

11. ERGONOMICS 11 Ergonomic adjustments – decrease fatigue and injuries, make surgeries safer, improve efficiency and patient outcome Critical Adjustments for Improving Ergonomics in Laparoscopic Surgery 1. Work place lay out 2. Tool (instrument) design and use 3. Work environment modification 4. Training of staff

12. INTEGRATED LAPAROSCOPIC THEATRE Average general operating theater - not designed to house laparoscopic equipment Laparoscopic operations tripled the number of cables and tubes touching the surgeon or assistant. Hinderance to movement and a potential source of breaks in aseptic technique Monitor is placed on top of a trolley with fixed height The integrated theater is a state-of-the-art system in which the laparoscopic equipment and multiple flat-screen monitors are permanently installed Ceiling-mounted suspension system that facilitates versatile positioning away from the monitors. Wiring - concealed The laparoscopic equipment can be remotely controlled - touch panel at a control station. 12

13. 13 Important bearing on shoulder and hand muscle strain Effective working height increases - p neumo-peritoneum distends the abdominal wall Long laparoscopic working instrument Ideal operating table level should be such that: (1) elbow angle is between 90° and 120° to the working surface (i.e., patient body habitus) (2) handles - roughly at, or slightly below the level of the surgeon’s elbows (3)Table height should be dictated by the tallest person Best Practices for Laparoscopic Surgery. Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved TABLE HEIGHT

14. POSITIONING OF ASSISTANT A surgeon in two different positions can perform laparoscopic cholecystectomy - Standing on the left side of patients (preferred by Americans) - Standing between the legs (preferred by Europeans) American position – uncomfortable , high physical demand, more effort in 2-handed manoeuvering French position- more flexion of thoracolumbar spine S witching sides of the table - avoid prolonged static posture 14 Fig.1: (A) French position (B) American position

15. MONITOR POSITION Multiple monitors ( a minimum of two monitors of at least 24 inches ) P laced straight in front of each person and aligned with motor axis of forearm instruments in the horizontal plane and in the sagittal plane at 15–40° below eye level A cceptable distance between the surgeon and monitor can vary- commonly suggested distance is 140–305 ​cm Good display characteristics (contrast, detail, brightness, lighting uniformity, focusing uniformity, sharpness and color). 15

16. FOOT PEDALS Placed close to the foot Aligned in the same direction as the instruments i.e. towards the target quadrant of surgery and principal laparoscopic monitor L imit foot dorsiflexion to below 25° over the pedal U tilize shoes with a maximum external width below 10.8 ​cm Pedal with a built-in foot rest - preferable. Disc-Shaped Foot Control: flat round disc pedal. Weight spread evenly over both feet Switch activation : clockwise rotation activates the coagulation function, and counterclockwise rotation activates the cutting function. Alternative: ESU operated by hand controls 16

17. 17 EXOSUITS Decrease pain and fatigue without significant interference in dexterity of performance ETHOS

18. 18 The handle of the instrument – greatest discomfort Ring Shank handle Precision grip = pinch grip = finger grip Advantageous when work with precision (like fine grasping or dissecting) Palm grip handle Power grip = pistol grip = palm grip Power grip handles with large smooth surface and pistol type handle shaft alignment- preferred while using heavy instruments like staplers Shaft- angulated/ in line The angle between the handle and shaft should be between 14° and 50° to facilitate comfortable posture of the hand and arm

19. PALMING THE INSTRUMENT GRASPING FOR PROLONGED PERIODS 19 Locking or ratchet mechanism

20. 20 Manipulation angle: angle between two working instruments Azimuth angle: angle between one side instrument & telescope considered as a horizontal projection Elevation angle: angle between the instrument and patients body If manipulation angle is of 60°, optimal elevation angle is 60° Wide manipulation angles - higher elevation angles for optimal performance and task efficiency. Manipulation angle : 45°- 75°. Ideal: 60°. Equal azimuth angles improve task efficiency. The 90° optical axis target view angle is said to have the best accuracy i.e. optical axis is at 90° to surface of the target to be viewed

21. Principles- Triangulation, avoiding reverse alignment, avoiding crossing of equipment and limiting scissor 21 Ratio of intrabdominal length equals external length : 1 Excessive grasping force with increasing angle A rms should be held in comfortable, slightly inwardly rotated positions, putting the working angle between instruments when suturing and tying at around 60° A notable exception is in the case of intracorporeal suturing, as it is most efficient when the angle between the instruments and the horizontal line is ​< ​55°, while the angle between the instruments should “form an isosceles triangle between 25° and 45°”.

22. Most laparoscopic instruments are designed for a hand size of 6.5 or more Handle- adequate gripping width- reduce excessive pressure. Increasing intracorporeal mobilities by placing various joints at the distal end of the instrument Articulating end pieces Innovations in the Handle Designs - Adjustable handle shaft angles, rotatory handles, self-righting instruments and provision of power grasping Haptic enhancement 22 MODIFICATION OF INSTRUMENT DESIGN

23. LAPAROSCOPIC VISION Indirect view Image transmission, clarity, focusing, zooming, color alteration View not under the control of the operating surgeon Restricted field of view Limited degree of freedom of camera movement Two dimensional vision Rotational distortion Visual fatigue and Eye strain – more common in junior surgeons Deterioration of visual acuity and function of the ocular muscles responsible for fixation-refixation of the eyeballs 23 Multiple 2D cameras S hadow introduction A utomatic image realignment system L eft to right mirror image correction for assistants H ead mounted cameras A utostereoscopic monitors 3D stereoscopic vision - less visual fatigue and cognitive workload. R efocussing problems

24. SENSORIAL ERGONOMIC CHALLENGES Perceptual and sensorial ergonomic problems in visual displays (e.g., monitors), tactile displays (e.g., force feedback in the handle), and auditory displays (e.g., beeps and alarms in the OR) Cautery pedals are situated under operating table and covered by sterile sheets. Sensory feedback for commercially available instruments was low compared to bare fingers Longer operating times Increased concentration COGNITIVE ERGONOMIC CHALLENGES Two dimensional viewing of the three-dimensional field Viewing direction of the surgeon differs from the viewing direction of the camera Fulcrum effect - internal movement to the right is displayed as a movement to the left on the monitor Continuous reflection on an interpretation of the images Significantly higher mental stress in inexperienced surgeons Comparing laparoscopic and open surgical techniques with regard to performing knot tying tasks, the laparoscopic approach resulted in fewer tied knots 24

25. MENTAL HEALTH CHALLENGES For operating surgeons- Long-term operations, unsmooth operation procedures, changes in the difficulty of operations, team cooperation. For camera-holder assistants- 55.2% of camera-holder assistants reported verbal scolding from the operating surgeons, primarily attributed to lapses in laparoscope movement coordination Mental health impairments often underestimated The SURGTLX results showed that the distributions of mental, physical, and situational stress for operating surgeons and camera-holder assistants were comparable 25

26. OTHER MEASURES ‘Work hardening’ or physical conditioning through physiotherapy and exercise Published data on its application in surgeons - scarce. Work-based yoga programmes - effective for symptoms of lower back pain, reducing stress and improving emotional wellbeing. Training programmes on ergonomics and proper work practices STRATEGICAL REST BREAKS Frequent pauses are effective, if they are taken before the onset of appreciable fatigue Targeted stretch microbreaks – standardized 1.5min at 20-40min interval, improved physical performance and mental focus without lengthening operating time Longer breaks- patient position should be changed into supine position, all the CO2 gas should be out take out all the instrument, patient will be under anesthesia - prevent DVT, microatelectasis , slow growing cerebral edema and respiratory acidosis A systematic review of music - in laparoscopic surgery -improve performance related to efficient transferring of instrument and decreased mental workload 26

27. SURGICAL SMOKE - Aromatic hydrocarbons, unsaturated hydrocarbons, aldehydes, alcohols and ketones, as well as dioxins. - Mutagenic, teratogenic and carcinogenic. - Manipulation of laparoscopic tools - leak through trocars from the peritoneal cavity into the operating room. - Most of these compounds are absorbed easily into the respiratory tract and by the skin. - Symptoms of exposure are: irritation and inflammation of the airways, coughing, headaches, dizziness, nausea and vomiting, irritation of eyes and conjunctivitis. - Exposure for an average of 7 hours per day, 5 days a week over a period of many years. - Calculated risk of developing cancer is negligible. Repeated exposure increases the possibility of developing effects. - Minimized by sucking out the fumes through suction cannula rather than opening the direction away from the operating team 27

28. ROBOTIC SURGERY Better alternative. G enerally considered more ergonomic than laparoscopic surgery L ower postoperative discomfort and muscle strain in both upper extremities, particularly dominant side of the surgeon Advantages in visualization - b etter exposure, stereopsis, surgeon camera control, and line of sight screen location L ess likely than open or laparoscopic surgery to lead to neck, back, hip, knee, ankle, foot, and shoulder pain, elbow and wrist pain. M ore likely than either open or laparoscopic surgery to lead to eye pain, and more likely than open surgery to lead to finger pain. F ixed position of the console viewer - inadequate spinal posture, i ncreased static neck positioning with subjective back stiffness compared with laparoscopy. (41.2%) reported musculoskeletal disorders, by since their first use of the robot which significantly persisted during the daily surgical activity  Longer robotic operating times - risk of visual fatigue from constant viewing of the video display through the binoculars. C omputer vision syndrome - blurred vision, dry eyes, eyestrain (asthenopia), and headache. 28

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30. REFERENCES Safety considerations in laparoscopic surgery: A narrative review The Rise of Minimally Invasive Surgery: 16 Year Analysis of the Progressive Replacement of Open Surgery with Laparoscopy Risk assessment of the ergonomic aspects of laparoscopic theatre A Review of the Ergonomic Issues in the Laparoscopic Operating Room Neuropraxia following laparoscopic procedures: An occupational injury Most surgeons in pain after surgery, Mayo research finds Physical and mental health impairments experienced by operating surgeons and camera holding assistants during laparoscopic surgery: a cross sectional survey Laparoscopist's Thumb: An Occupational Hazard Lap Burn A New Platform Improving the Ergonomics of Laparoscopic Surgery: Initial Clinical Evaluation of the Prototype Ergonomic assessment of neck posture in the minimally invasive surgery suite during laparoscopic cholecystectomy Effect of Assisted Surgery on Work-Related Musculoskeletal Disorder Prevalence by Body Area among Surgeons: Systematic Review and Meta-Analysis A comparison of operating room crowding between open and laparoscopic operations Strategic Rest Break in Laparoscopic Surgery: A Need International Hazard Datasheets on Occupation 30

31. REFERENCES 15. Laparoscopic Procedures Hurting Surgeons 16. The trainees’ pain with laparoscopic surgery: what do trainees really know about theatre set-up and how this impacts their health 17. The pain of surgery: Pain experienced by surgeons while operating 18. Surgical smoke may be a biohazard to surgeons performing laparoscopic surgery 19. Surgical smoke and occupational health 20. Occupational hazards of surgical smoke and achieving a smoke free operating room environment: Asia- Pacific Consensus statement on practice recommendations Comparison of surgeons’ posture during laparoscopic and open surgical procedures Work related musculoskeletal pain in general surgical trainees: extent of the problem and strategies for injury prevention Are Smoke and Aerosols Generated During Laparoscopic Surgery a Biohazard? A Systematic Evidence-Based Review Direction of gaze and comfort: discovering the relation for the ergonomic optimization of visual tasks Textbook - Art of laparoscopic surgery by C. Palanivelu Effect of laparoscopic surgery on surgeons’ health Surgeon symptoms, strain, and selections: Systematic review and meta-analysis of surgical ergonomics 28. Intraoperative “Micro Breaks” With Targeted Stretching Enhance Surgeon Physical Function and Mental Focus: A Multicenter Cohort Study. Annals of Surgery 265(2):p 340-346, February 2017 29. Optimizing ergonomics during open, laparoscopic, and robotic-assisted surgery: A review of surgical ergonomics literature and development of educational illustrations 31

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