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PREFACE
Nowadays, most patients want to get operated on by minimally invasive surgery. One of these
is laparoscopic surgery. The main advantage of laparoscopic surgery is that instead of
operating patients through large incisions, patients get operated on through small incisions
with less trauma to the tissue. There is less postoperative pain, faster recovery, and shorter
hospital stays with sooner return to work. The chances of wound infection are less because of
less handling of tissue and better and acceptable cosmetic scar than traditional open surgery.
Also, there are fewer chances of postoperative adhesions and incisional hernia than in
traditional open surgeries. Laparoscopy is the word derived from the Greek word lapara,
which means “the soft part of the body between ribs and hip, loin, and flank” and scope
means to “look': Laparoscopic surgery, also called minimally invasive surgery (MIS) or
keyhole surgery, is a modern surgical technique in which operations are performed far from
their location through small incisions (usually 0.5–1.5 cm) elsewhere in the body.
●
Three Main Components include:
❍
Image production
❍
Pneumoperitoneum
❍
Laparoscopic instruments
Lamture Yeshwant Ramrao
Department of Surgery,
J.NMC Wardha
India
List of Contributors
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Aditya Patel Department of General Surgery JNMC, Sawangi (Meghe), Wardha, India
Ashirwad Sankhe Department of Surgery, Jawaharlal Nehru Medical College (D.M.I.M.S.),
Wardha, Maharashtra, India
Deepak Lamture Department of Surgery, J.NMC Wardha, India
Harshal Ramteke Department of Surgery, Jawaharlal Nehru Medical College (D.M.I.M.S.),
Wardha, Maharashtra, India
Lamture Yeshwant Ramrao
Meenakshi Yeola (Pate) Department of Surgery, A.I.I.M.S. Mangalagiri, India
Parmeshwar Ramesh Junare Department of Gastroenterology, Acharya Vinoba Bhave Rural Hospital,
Rajesh Domakunti Department of General Surgery, JNMC, Sawangi (Meghe), Wardha, India
Raju Kamlakarrao Shinde Department of Surgery J.N.M.C., D.M.I.M.S., Sawangi- Meghe, Wardha,
Resha Keshwani Meghe Institute of Higher Education and Research Centre, India
Rohini Bhoyar Department of Obstetrics and Gynaecology, N.K.P.S.I.M.S. & L.M.H.,
Sachin Gianchandani Meghe Institute of Higher Education and Research Centre, India
Sangita Devrao Jogdand Department of Surgery J.N.M.C., D.M.I.M.S., Sawangi- Meghe, Wardha,
Sanjeev Gianchandani Datta Meghe Institute of Higher Education and Research Centre, India
Sushanth R. Nayak Department of Surgery, A.I.I.M.S. Mangalagiri, India
Tushar Nagtode Department of General Surgery, JNMC, Sawangi (Meghe), Wardha, India
Venkatesh Rewale Department of General Surgery JNMC, Sawangi (Meghe), Wardha, India
Varsha P. Gajbhiye Department of Surgery, J.NMC Wardha, India
Vijendra Kirnake Department of Gastroenterology, Acharya Vinoba Bhave Rural Hospital,
Department of Surgery, J.NMC Wardha, India
Swangi, Wardha, India
Maharashtra, India
Nagpur, Maharashtra, India
Maharashtra, India
Swangi, Wardha, India
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Handbook of Laparoscopy Instruments, 2023, 1-12 1
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Ergonomics in Laparoscopy
CHAPTER 1
Meenakshi Yeola (Pate)
1
Department of Surgery, A.I.I.M.S, Mangalagiri, India
Abstract: Ergonomics studies aptly fitting a worker to his job or how the environment
is more conducive to a laparoscopic surgeon. In 1949, the phrase was fully defined and
benefited and protected many aspects of human activity [1]. In the context of
laparoscopy, the importance of ergonomics cannot be overstated. Suturing time can be
reduced by using proper ergonomics, according to studies [2]. Ergonomically designed
items have been found to alleviate pressure-related chronic discomfort in surgeons [3].
This article discusses fundamental principles and procedures such as triangulation,
ideal coaxial alignment, doctor-patient drawbacks, and how to forego these challenges
with recent technological breakthroughs.
1,*
and Sushanth R. Nayak
1
Keywords: Ergonomics, Hawthorne effect, Ideal position, Posture, Sectorisation,
Tactile sensation, Table height, Triangulation.
INTRODUCTION
Over the last 20 years, the use of laparoscopy has grown dramatically. Compared
to laparotomies, the advantages of laparoscopic surgeries are a smaller incision,
fewer post-operative complications and pain, a reduced hospital stay, a speedy
recovery, and, sometimes, better access. The latter differs from the former in
terms of the required tools, instruments, and psychomotor abilities.
This ergonomics essay covers the fundamental principles and methodologies,
such as triangulation, ideal coaxial arrangement, surgeon and patient
disadvantages, and how to solve these obstacles using the most recent
technological advances.
What is Ergonomics?
●
The term comes from the Greek terms “ergon,” which means “labour,” and
“nomos,” which means “natural laws or organization.” [1].
*
Corresponding author Meenakshi Yeola (Pate): Department of Surgery, A.I.I.M.S, Mangalagiri, India;
E-mail: dr.meenakshiyeola@gmail.com
All rights reserved-© 2023 Bentham Science Publishers
Lamture Yeshwant Ramrao (Ed.)
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●
“The scientific study of people at work in terms of equipment design, workplace
layout, the working environment, safety, productivity, and training,” according
to ergonomics [1].
In layperson's terms, it's the science of matching the right specialist to the right
job or creating the optimum atmosphere and environment for a doctor. The term
was initially mentioned in 1949, and it has benefited and protected a broad
spectrum of endeavours [1].
Ergonomics Significance
●
Reduction of suture time [2].
●
Chronic pain with pressure relieved [3].
The Hawthorne Effect
●
It is a well-known fact that when an individual is aware that he is being observed
and assessed, he does a task better and with more extraordinary precautions.
This tends to distort the results in favour of better scores than would be received
if the candidate being assessed was uninformed about the examination.
●
This is the “Hawthorne effect,” which has been shown to apply to most
scientific evaluations of human functioning. Hence, a grasp of it is crucial for
ergonomic purposes [4].
●
Surgeons can use ergonomic metrics to assess laparoscopy as a surgical skill that
requires dexterity and coordination. Although private assessments are needed to
avoid the Hawthorne effect's bias, doing so would bring many ethical and
analytical concerns.
Lack of Tactile Sensation
●
As learners, we are taught to “see” with our hands and eyes while acquiring
those skills, as in laparotomies [1].
●
The tactile feedback is sorely lost while transitioning from open to laparoscopic
procedures.
●
The surgeon's hands are replaced by long graspers manoeuvred through trocars,
which significantly diminishes efficiency and lengthens the dissection time [5].
The Reduced Degree of Freedom of Movement
●
During surgical intervention, doctors have a lot of freedom and can operate
together linearly with the visible polarity. There's still direct three-dimensional
vision as well as immediate tactile feedback.
●
At the time, just four degrees of freedom are available. Increasing the degree
from 4 to 6 enhances dexterity by 1.5 times, according to Falk et al. [6].
Ergonomics in Laparoscopy Handbook of Laparoscopy Instruments 3
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●
Tremor augmentation also has a fulcrum effect. The main disadvantage is that
the surgeon has no control over the vision [7].
Decoupling of the Visual (Monitor) & Motor axis
●
The 'failure of spatial awareness' caused by inadvertent visual stimuli is
explored, as is the 'failure of surrounding field of vision' or 'Binocular effect'
caused by the limited browsing spectrum.
●
Overcoming the spatial separation of the axial direction of eyesight and the axis
of the process's physical element is among the significant cognitive obstacles for
the practitioner in his metamorphosis into a minimally invasive surgeon.
●
Working in different coordinate systems has been proven in studies to reduce
performance, resulting in increased technique mistakes [8].
Assuming A Relatively Stable Posture
•While staring at the surgical field, the surgeon cannot direct his sight straight at
the instruments or his hands. Working in multiple coordinate systems has been
shown in studies to lower performance and increase the rate of technique errors
Fig. (1.1) [8].
• Greatconcentrationandskillisutmost required for performing the complex laparo
scopic surgeries.
• Hence, it has been observed that as compared to the open approach,the operating
surgeon assumes a more static posture during laparoscopic procedures.
• These static postures have been demonstrated to bemore disabling and harmful
than dynamic postures are as muscles and tendons build up lactic acid and toxins
when held for prolonged periods in same postures [9 - 11].
• Sensorial ergonomics (manipulations and visualization) improve precision,
dexterity, and confidence, while physical ergonomics provide comfort for
surgeon. Together, these two element sofergonomics increase safety, have better
outcome, and reduce the stressof the operating surgeon (Fig. 1.1) [12].
More Crowd
• Overcrowding operating room (OR) [13] due to increased equipment may pose a
physical danger to the staff in OR.
• The abundance of equipment in the operational field forms a “Spaghetti” of
connections that reduces the efficiency [14].
• A ceiling-mounted system helps eliminate chaos on the floor.
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Fig. (1.1). The surgeon's strength during laparoscopic versus open surgery.
Dim-lit Room
Since OR lights get switched off during the procedure, the remainder staff has to
operate during dim light, increasing the chance of selecting the incorrect tools and
creating collision dangers.
Drawbacks for The Surgeon
●
Unsuspecting surgeons doing many laparoscopic surgeries in greater volume
centres reported numerous complications related to hands, vision and spine [15,
16] Fig (1.2).
Fig. (1.2). Faulty posture and awkward thumb grip reducing the desired efficiency.
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Setbacks to The Patient
Carpal tunnel syndrome, visual strain, and spine issues have all been reported by
surgeons doing several laparoscopic surgeries in tertiary care centres [15].
Because of the uncomfortable thumb grips used with laparoscopic pistol-grip
devices, there have been reports of thenar neuropathy [16].
Ideal Position
Reasons Hindering An Ideal Position
1. Operating table's height
2. Visual display's location (Monitor)
3. Placement of the foot pedal
4. Location of the port
5. Instrumentation-related
6. Surgeon & Team location
7. Innovations in technology
Operative Table Height
●
The elbow joint should be 90 - 120 degrees, or at /slightly lower than the elbow
level, as in open surgery.
●
To attain this purpose, the table's height should be modified.
●
Due to the long laparoscopic tools and the inclination of the table, considerably
more than open surgery, the table height may have to be significantly reduced. If
the procedure is prolonged, this produces shoulder and neck discomfort.
●
If the surgeon cannot lower the table below a specific position, they must stand
on an elevated platform [17].
Monitor Location
●
The line of vision ≤ 25 degrees from an ergonomic standpoint is ideal [18, 19].
According to studies, this results in the least amount of neck strain.
●
Conventional Displays are set on a reduced position to stand except the OR gear
used for the best results. The surgeon shouldn't be in a “chin-up” position [19].
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●
The 2nd one is required when the operating doctor changes the previous set-up,
such as a complete colectomy. The addition of a second monitor for assistance
relieves neck strain.
1. Foot Pedal Location.
2. During laparoscopic surgery, foot pedals operate devices like the cautery. These
get frequently misplaced and require difficult and uncomfortable postures.
3. The pedals should be near the foot and pointed toward the target quadrant and
the main laparoscopic display.
4. A pedal with a built-in footrest is preferable to the surgeon [20].
5. Port Placement.
The three angles of port placement:
• “Manipulation”
• “Azimuth”
• “Elevation”
Manipulation Angles for Instrumentation
●
Manasnayakorn et al. [21] examined task efficiency and performance quality in
animal models and found that a specific manipulative angle of 45° - 60° has the
superior outcome.
●
Manipulative angles ranging from 45° to 75° with identical azimuth angles are
advised.
●
Task efficiency was reported to be better with equal azimuth angles than with
unequal azimuth angles.
●
Manipulation and elevation angles have a direct relationship.
●
For best performance and work efficiency, broader angles of manipulation need
wider angles of elevation.
●
For endoscopic surgery, the most ergonomic configuration is an angle of
manipulation, 45°- 75° with equal azimuth angles [22].
Triangulation
●
There is no universal agreement on port placement for complex laparoscopic
surgeries. Currently, surgeons' preferences based on individual experience
determine where ports are placed. Trocars are frequently positioned in a
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triangular pattern to assist with easy instrument manipulation and optimal
visibility during laparoscopy.
●
The desired site should be 10-25 cm away from the central part of the optical
trocar. 2 remaining additional trocars are inserted at 5–7 cm on each side of the
imaging port in the same arc, avoiding problems with long handles caused by
too far or too close port placement, as well as abdominal wall interference. To
minimize instrument conflicts, two more retractable ports might be placed in the
same arc but further laterally if necessary.
Sectorisation
●
Sectorisation refers to placing an optical trocar as one of the lateral port trocars.
●
This is commonly done after appendicectomy when a 10mm trocar is implanted
as an optical trocar in the infraumbilical region. Two extra trocars are positioned
laterally beneath these trocars.
●
Beginners should avoid sectoring devices since it needs a higher level of
comprehension and expertise with the laparoscopic view, as well as drastically
different hand-eye coordination.
●
Limited instrument length.
EQUIPMENT RELATED CHALLENGES
●
According to the US FDA, improper equipment design may blame for half of
the 1.3 million instrument-related injuries in U.S. hospitals yearly [23, 24].
Limited View
●
During laparoscopy, the surgeon usually watches a 2-d video of the surgical
domain on a screen set some feet away from their vision. Even with excellent
monitoring equipment, image definition and resolution detail do not equal direct
viewing.
●
The loss of peripheral vision, one of the cornerstones of the laparoscopist's
surgical skills in open procedures, is another limiting factor that the
laparoscopist must deal with.
●
In challenging situations, angulated scopes provide a better view. Regularly, 0
and 30 degrees are utilized. However, higher angulation can be employed with
additional angulation requiring the surgeon's orientation, resulting in a restricted
visual aspect.
Reduced Proficiency of The Instruments
●
Laparoscopic instruments are limited to work through small openings. As a
result, the internal mechanical linkages become more complex, reducing the
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transfer efficiency from the surgeon's hand to the instrument tip.
●
Compared to a Hemostat, a standard disposable laparoscopic grasper distributes
the force of the surgeon's hand from the handle to the tip in a 1:3 ratio. As a
result, a laparoscopist must labour six times more to achieve the same outcomes
[25].
●
Furthermore, due to the standardization of size, surgeons of different builds use
the same ones, reducing efficacy. Instruments that are customized are costly.
Shapes are Not Aptly Designed
●
According to Mattern and Waller [26], incorrectly designed instrument forms
inflict problems on vitally working parts of the hand.
●
The direct transfer of pronation and supination to the instrument effector is
possible due to the instrument's longitudinal axis.
Limited Instrument Mobility
●
The fixed-position entry ports in laparoscopic surgery reduce the capacity of the
operator.
●
Wrongly located ports make the whole procedure much more complex.
Instrument Exchanges
●
Are time-consuming and distracting for the surgeon, necessitating the use of
multifunctional equipment and reducing exchanges.
Intracorporeal Suturing
●
Skills play an essential role in the final result.
●
Due to the lack of triangulation, these issues arise from the need to suture at
unusual port positions.
●
Suturing at variable angles to the tissue.
Surgeon and Team Position
●
Usually, two different positions are preferable. One should stand to the person's
side and the other among their lower limbs.
●
Even though the port placement is similar, each position differs somewhat.
Recent Advances
One Port Laparoscopy
A single port entry is used to gain access to the peritoneum.
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