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Surgical digest

Surgical ergonomics

Bobby VM Dasari MS,MScEd,FRCS

Consultant Liver Transplant and HPB Surgeon and Honorary Associate Professor,
Queen Elizabeth Hospital / University of Birmingham
Birmingham, UK

Surgical training and standards are often compared to those used in the aviation industry. Surgeons and pilots must go through similar stringent, arduous training to achieve certain high standards and maintain them, lest human life at risk. Once trained, skilled and experienced surgeons need to be protected from wear and tear so they continue to deliver precise and flawless care. However, surgeons are often affected by musculoskeletal disorders such as degenerative spine disease, carpal tunnel syndrome, and tendinitis. In a meta-analysis, Epstien et al reported the overall 12-month prevalence of musculoskeletal disorders among surgeons and interventional specialists. The results were astonishing: neck pain in 60%, shoulder pain in 52%, back pain in 49%, and upper extremity pain in 35%1.

Surgeons spend many of their early years learning anatomy from head to toe, and master the physical and physiological aspects of the structures in the areas of their expertise. The relevant knowledge enables them to prevent damage to any of these structures while operating. But what do they do to prevent injuries to themselves, while executing these procedures? Surgeons wear a scrub gown, and gloves, maybe goggles, to save themselves from needle pricks and contact with body fluids. And they often adjust the height of the operating table at the very start of a procedure. What else do they take care of?

The surgeon ensures that a patient is positioned well on the cushion-padded operating table, takes appropriate care to prevent pressure sores, and nerve compression, and that the joints are not overstretched.  If the surgeon overlooks this, the theatre staff and anaesthetist will make sure these issues are addressed. But how many operating theatre staff know about the musculoskeletal injuries a surgeon becomes a victim of by standing and operating for long hours that involve repetitive movements, in static and awkward postures?  How often do they take precautions to prevent the stress on their neck muscles, back muscles, and nerve injuries? How many of the non-surgical staff are aware of the ergonomic risks and offer the surgeon a support system to avoid these injuries? Indeed, are there any such support systems?

It is a significant incident if the patient does not receive measures to prevent venous thromboembolism, but what about the venous stasis in the legs of the surgeon? We are now lucky to have self-retaining retractors in operating theatres but it was not long ago that trainees had to retract the abdominal wall with the best possible, yet awkwardly designed metal retractors. A trainee surgeon accepts it as part of their job, a vocation, and hopes they made a meaningful contribution while learning the surgical steps. But are the trainees aware of the musculoskeletal injuries they can sustain in the short term and long run while delivering their job? Some 80% of trainees are reported to have experienced postsurgical muscular pains, with 25% requiring rehabilitation or massage therapy for injuries sustained at work2. At the time of writing this, I reviewed the ISCP curriculum for surgical trainees and did not find any reference to surgeon ergonomics and musculoskeletal injuries in the general surgery curriculum. Nor is there much on the RCS England website. Will there be any on individual healthcare Trust websites?

Surgeons and the surgical environment very rightly focus on patient safety which is the primary goal of the profession. But in the process, they fail to take adequate care of themselves. It is high time that all surgical societies ensure their members are protected from work-related injuries before their discs get worn out and the nerves get entrapped. About 10% of surgeons require a leave of absence, practice modification, or early retirement because of work-related muscular injuries. Without protecting surgeons’ health and well-being, additional workforce shortages, and burnout will be around the corner.

Education on workplace safety and ergonomics is effective at increasing awareness and reducing risk factors.  It is not sufficient on its own but is probably a good starting point. The minimum we should do straight away is to include ergonomics in the curriculum of surgical trainees. The theatre infrastructure should support surgeon ergonomics; micro- and macro breaks for prolonged operations should be encouraged. In one study including 103 injured surgeons, only 19% reported their injury, even though 35% performed fewer operations due to the injury3. To address such underreporting, and help early identification of these preventable problems, annual visits to occupational therapists and to physiotherapists could be made part of mandatory training. Preventative exercise and yoga programmes specifically for surgeons to prevent symptoms of lower back pain, and chronic neck pain are beneficial. These need to be utilised by surgeons and supported by healthcare Trusts. As a liver transplant and HBP surgeon with another marathon two decades of surgical career ahead of me, I have benefitted to an extent from some of these practices. It is not enough though. The industry should make an effort to make lightweight ergonomic instruments (including loupes and headlamps), and that are suitable for a diverse group of surgeons, rather than the current practice of one size fits all.

Surgeons in the US seem to be ahead of the pain and the game. The Society of Surgical Ergonomics has taken initiatives to increase awareness on the subject and such efforts should be welcomed. Other societies and importantly individual surgeons have to follow suit. Such groups must encourage research at different levels to a) develop immediate, pragmatic steps to reduce the injuries, b) help the victims of the injuries and c) bring sustainable changes to the theatre infrastructure by collaborating with industry.


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