Chief of anesthesiology and Medical Director, OLV Clinic Aalst, Belgium
Surgery has grown ever more high-tech in the past 30 years, which may be good news for patients, but technological advance has ironically brought with it bad news for surgeons.
Minimally invasive surgery (MIS) has become ‘the standard’ for a still growing number of procedures in abdominal surgery, gynaecology, urology, even in orthopedic and cardiac surgery.
While the advantages for the patient are obvious – less trauma, less pain, less blood loss, shorter hospital stay – MIS confronts the surgical team with challenges in ergonomics.
With MIS, surgeons and their team lose contact with the surgical field. Visual feedback is provided by a monitor often set on a trolley position far to the side of the field of action.
Tactile feedback is compromised by the length of the shaft of the surgical instruments. In addition, the freedom of movement of video camera and instruments is limited because these are fixed in the different keyholes.
Keyhole surgery has thus led to a loss of hand-to-eye co-ordination, as the operating team is not able to situate the monitor in an ergonomically preferable position.
This situation is exacerbated by the fact that operating tables, constructed for open surgery where surgeons use short instruments, are too high for laparoscopic procedures, where surgeons use long-shafted instruments.
In short, technological advances in operating equipment that benefit the patient have caused a whole generation of surgeons to stoop, bend and twist into uncomfortable positions that they have to maintain for long periods, causing muscle ache, tension and musculoskeletal damage.
Unresponsive fixtures and fittings
This has come about because surgeons have been compelled to integrate new equipment and ways of working into standard operating theatres with their unresponsive fixtures and fittings designed for old methods of ‘open surgery’.
But innovative manufacturers have, over the last ten years, recognized this problem and have been developing designs of operating room (OR) equipment that allow surgeons to work in more natural positions which avoid ergonomic stress.
A landmark in the quest to free surgeons from poor posture was passed in September 2010 when one of the world’s leading medical equipment manufacturers, Maquet of Rastatt, Germany, installed its 1,000th Magnus operating table system.
The recipient was our OLV Clinic in Aalst, Belgium, which already uses five (and another five are underway) of these highly manoeuverable tables, which can tilt and twist in any direction, to perform all kinds of minimally invasive surgery, including robot-aided cardiac surgery and urology – the clinic performs 350 laparoscopic robot-assisted prostatectomies a year.
Ideal upright position
Highly adaptable operating table systems such as the Magnus are ideal for solving posture problems for surgeons, as its individual adjustment options enable the surgeon to perform the procedure in an ideal upright standing posture and thus ensure relaxed and safe work processes, especially for laparoscopic surgery.
In the past, surgeons have used footstools to gain the height necessary to manipulate their hand-held keyholes instruments into the correct position. But, apart from the obvious trip hazard, the use of foot-operated switches in laparoscopic surgery makes this option often impossible. A study1 in 2006 revealed that 45% of the surgeons interviewed had to use a step during surgery to compensate for the height of the operating table. And about 33% of doctors and 56% of surgical nursing staff reported that problems with operating tables and steps have caused hazardous situations in the operating theatre (OT) on several occasions.
But tables such as the Magnus eradicate such violations of health and safety law by their ability to offer unlimited patient positioning options, a capability much needed in many areas of minimally invasive surgery. Especially in MIS, extreme positions are often required to provide an optimum exposure area using gravity. With slope angles up to 80°, Magnus allows easier laparoscopic bariatric surgery and robot-assisted prostatectomy. The excellent access to the surgical field and the optimum patient care enabled by the table ensure a better workflow.
Bernhard Kulik, head of product management for operating tables at Maquet, explains: “The correct use of medical equipment not only relieves the burden on surgeons and the operating team – it also has an effect on efficiency and therefore on profitability.
As a high-performance centre, the operating room is particularly prone to complications and risks resulting from non-ergonomic equipment. This can have major monetary implications for a hospital.”
The OLV Clinic, after originally investing in five dedicated MIS suites in 1999, installed a further five in 2010. These are operating rooms with permanently installed laparo- or thoracoscopic equipment. This equipment, attached to a ceiling-mounted suspension system, consists of multiple flat-screen monitors that can be positioned all around the operative field and are height adjustable. The freedom of monitor positioning provides an improved ergonomic posture for the entire surgical team and prevents extreme head and neck angulations in the axial and sagittal plane.2
Concern for the surgeons back, neck and arms is not the only consideration for hospitals building MIS suites. Efficiency and safety are improved. The room is always ‘ready’, facilitating efficient OT scheduling and reducing expensive theatre time. Permanently installed equipment reduces connection errors. Having most cables – power supply, network connections, gases – coming through the ceiling-mounted power beams, creates more free space in the OT, safer floor conditions and easier cleaning.
In 1999, the OLV Clinic also started a successful robot (da Vinci®Surgical System) programme, first in cardiac surgery and later on in urology, gynaecology and abdominal surgery. The da Vinci Surgical System is comprised of four major components: an ergonomically designed surgeon’s console, a patient cart with four interactive robotic arms, a high-performance vision System and patented EndoWrist instruments.
The surgeon operates while seated comfortably on the console, viewing a highly magnified 3-D image of the body’s interior. To operate, the surgeon uses master controls that work like forceps. As well as having a high-definition 3-D vision system, the robotic cart placed by the side of the patient has four robotic arms that can be manipulated by the surgeon from the console.
Three of the robotic arms are mounted with the surgical instruments, which are controlled by the operating doctor through the console. The fourth robotic arm is used to hold the camera. While the robotic arms move according to the movements of the surgeon’s hands, the camera provides a high-definition video of the procedure being carried out. The surgeon has the benefit of viewing a three-dimensional, magnified, video image and can rotate his hands more freely than with the conventional technique.
Different kinds of instruments can be attached to the robotic arms according to the procedure to be performed. Additionally, the robotic arms are capable of performing a full circular movement generally not possible by non-robotic arms. Thus robotic surgery has improved ergonomic conditions for the operating surgeon as well as advancing patient care.
The increased awareness of hospitals of both the human and financial cost of having surgeons operating in unergonomic positions can be measured by the increasing customer demand made on manufacturers. For instances, Maquet recorded a 50% increase in demand for its Magnus system between 2008 and 2009. Another example of this awareness is that fact that, in Belgium, there was just one robot programme in 2000, but now there are 23.
Versatile operating tables, dedicated MIS suites, robot programmes are enhancing ergonomics in the OR. However, declaring the OR the most ergonomic place to work today is far from the truth. Many additional problems exist and need to be addressed in the near future, but several initiatives are tackling it.
In 2006, Tübingen University in Germany established its ‘Experimental Operating Room (OR) and Ergonomics’ facility, which is a unique, world-wide, open and interdisciplinary laboratory that any institute or company is invited to use for research and development. They have built a real OT in one to one scale in a former industrial hall where future developments and relevant processes can be tested out – whether it is the height of an operating table or the development of smooth work processes within a surgical team.3
At the OLV Clinic, the OLV Robotic Surgery Institute was set up in 2010. This institute addresses all aspects of robot surgery, including ergonomics, by teaching, hands-on sessions, wet lab, dry lab and dual console practice.
Through such forward-thinking initiatives, the health of surgeons and their co-workers are being cared for, not just that of the patient.
- Matern U et al. Arbeitsbedingungen und Sicherheit im Arbeitsplatz OP. Deutsche Ärtzteblatt 2006, vol 103, issue 47
- van Det MJ et al. Surg Endosc 2008;22: 2421-2427
- Matern U. Ergonomic deficiencies in the operating room: Examples for minimally invasive surgery. Work 2009;33:165-168