Optimizing the environment can measurably reduce physical strain
The demands of surgery often take a significant mental and physical toll, so it is important that the surgical environment is optimized for safety, effectiveness and quality of life. Awareness of the issue has led to a growing interest in improving surgical ergonomics as a way to address these issues.
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Ergonomics focuses on designing the environment to fit the worker rather than forcing the worker to fit the environment. These principles can be applied to the surgical setting in a variety of ways, including operating room layout and equipment design as well as the personal posture and techniques of the surgeon.
“Surgeons require mental acuity, physical dexterity and skill, and situational awareness, similar to high performance athletes,” notes Amy Park, MD, Section Head of Female Pelvic Medicine & Reconstructive Surgery at Cleveland Clinic’s Ob/GYN & Women’s Health Institute. “At the same time, we are also manual laborers, facing physically arduous work, long periods of ergonomic strain, and harsh working environments while paying little attention to our positions and focusing on the patient, not ourselves.”
Dr, Park is a founding member of the Society for Surgical Ergonomics. She says the implications of these ongoing stressors are significant, not just for the surgeon, but also their patients and the health care community at large.
There are a number of work-related musculoskeletal disorders associated with poor ergonomics, which can have a significant, long-term impact, including carpal tunnel syndrome, epicondylitis, neck tension syndrome, shoulder tendonitis and rotator cuff injury.
Overexertion and repetitive use injury can lead to decreased productivity and absenteeism, as well as the related costs, Dr. Park explains.
“In one survey, 40 percent of surgeons had sustained at least one work-related injury,” she says. “Fifty percent of these surgeons received medical care for these injuries and only 19 percent reported the injuries to their institutions.”
There are three stages to work-related musculoskeletal disorders, according to Dr. Park. They are:
These injuries can have a significant impact on a surgeon’s career. In addition to missed work, surgeons may face decreased caseload or other changes to their operating practice, and in some cases, forced retirement. “At-risk physicians make up about 20 percent of the active workforce,” notes Dr. Park. “We are expected to face a shortage by 2025, and disability is one of the contributing factors. “A culture of silent suffering exacerbates poor ergonomics and pain among surgeons, while also perpetuating a lack of understanding around the issue,” she adds. “We are seeing increased momentum and recognition across the field, but more education and awareness is needed.”
Ergonomic training has been shown to be effective. In one study, Dr. Park notes, 88% of surgeons changed their practice after in-person training and 74% reported decreased strain.
“Ergonomic adjustments include proper chair position allowing for 90-degree flexion at the knee, forearm placement parallel to the ground with elbows tucked at the side, head flexion less than 20 degrees, and
placing little to no forehead pressure on headrest,” Dr. Park outlines. “You want to be in a neutral position, and also focus on relaxing your hands instead of always clutching.
“We have found that these interventions do work,” she adds. “There is a decrease in lost workdays or sick leave, and it improves efficiency, reduces costs, decreases waste of materials and equipment, enhances corporate image, and increases employee satisfaction.”
Best practices include keeping extremities as close to the body as possible, using a compliant mat to decrease the impact of prolonged standing to the spinal discs, and alternating between sitting and standing. The monitor and height of the table are also important.
“The laparoscopic screen should be placed so that the neck is held in approximately 20 degrees of flexion,” she explains. “Table heights should be adjusted to accommodate the tallest surgeon with step stools used for other team members.”
Microbreaks can also be a beneficial intervention. “Every 20 to 40 minutes during a procedure, take a break and stretch for 1.5 minutes,” Dr. Park recommends. “This is associated with improvements in mental focus and physical performance with no difference in OR time.”
Surgeons can use the Microbreak Stretch app, which demonstrates the appropriate stretches. It is also important to perform neck, hamstring and back stretches immediately after breaking scrub, notes Dr. Park. There is also value in incorporating stretching and flexibility exercises into personal fitness routines and to undergoing regular massage therapy.
“Institutions also have a critical role to play. We should be creating a culture where it is OK to acknowledge that injuries occur and that emphasizes the importance of protective measures,” says Dr. Park. “We should communicate with surgeons at every level of training, and we should correlate symptoms of pain or discomfort with findings of ergonomic assessments and tissue level damage in affected surgeons and surgical assistants. Institutions must do their best to protect surgeons from these preventable, potentially career altering or career ending injuries.”
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