Ergonomics in the OR: Protecting Your Surgeons

Surgeons come in all shapes, sizes and sexes with individual ergonomic needs. Those instruments designed for the burly 6-foot-6 surgeon who played middle linebacker in college aren't ideally suited for the petite 5-foot-4 mother of two, who possesses just as much grit but not as much grip. It's important for you and your surgeons to keep their comfort in mind so they can continue to operate, and operate well, instead of succumbing to debilitating repetitive stress injuries.

Erica Sutton, MD, was nearly a victim of her chosen profession. She was too young of a surgeon for her shoulders to ache and her hands to throb. Or so she thought. "The pain began during my residency — I hadn't even begun my laparoscopic fellowship," recalls the associate professor of general surgery at University of Louisville (Ky.) School of Medicine. "It became obvious that I had to figure out how to operate comfortably so my career wasn't over before it started."

Like many surgeons, Dr. Sutton focused on patient care at the expense of her own well-being. That attitude, thankfully, is changing as more surgeons are realizing that in order to take care of their patients, they must first take care of themselves.

Surgeons spend years learning surgical techniques — how to handle instruments, how to make a stitch, how to expose tissue — with very little instruction or emphasis placed on proper ergonomics and posture, according to Michael Lidsky, MD, a gastrointestinal surgeon at Duke Cancer Center in Durham, N.C. "We're taught how to be a surgeon, but not how to be a healthy surgeon," he says. "Physical discomfort has long been viewed as part of the job."

During his residency, Dr. Lidsky sat in on an ergonomic workshop that completely changed his outlook about the physical demands of surgery. "I had been experiencing lower neck pain, and checked all the boxes for an ergonomic injury," he explains.

The ergonomics expert who ran the workshop later observed Dr. Lidsky performing surgery and offered useful tips for improving his posture. Your surgeons might not have access to an ergonomics expert, but their colleagues can offer a knowing perspective on how to maintain proper posture beside the OR table.

"Surgeons can ask one of their partners to watch how they perform surgery to assess and tell them if there are things they could change," says Dr. Lidsky. "Another perspective can provide insights on techniques and postures that surgeons can't possibly have on their own."

You can also take pictures of how surgeons stand at the table or position their instruments. After surgery, surgeons can review the images to see how their form compares to how they think they're operating. John Jarstad, MD, an ophthalmologist affiliated with the University of Missouri in Columbus, had photos taken of himself performing cataract surgery. What he saw made him cringe: His neck was extended too far forward, and he was leaning off to the side instead of centering himself at the microscope's oculars.

Dr. Jarstad, and countless ophthalmologists like him, sit hunched behind microscopes for hours on end during busy days of surgery, unable to move their arms and shoulders more than a couple inches as they perform some of surgery's most intricate maneuvers. Even the relatively brief cataract procedures can cause lasting injuries to necks, backs and shoulders.

In 2006, Dr. Jarstad found out just how physically damaging his chosen career was when he ended up on the other end of the knife. "A bulging disk in my back caused numbness and weakness in my legs," he says. "I put up with it for a long time and tried everything — physical therapy, seeing a chiropractor — but nothing provided relief. I finally had to resort to undergoing a microdiscectomy."

Dr. Jarstad says he's amazed by how many ophthalmologists he's spoken to who've also had back surgery. Eye surgeons being forced into retirement because of repetitive strain injuries is "not an uncommon story," says Dr. Jarstad.

Surgery cured Dr. Jarstad's aching back, but it was the steps he took, some seemingly simple, to improve his posture that helped make surgery more tolerable.

"I'm now much more cognizant of my posture, making sure I'm sitting [square to] the patient," says Dr. Jarstad. He also raises the OR table, allowing him to sit up higher and extend his legs, a posture that puts less strain on his back. Plus, some surgical microscope manufacturers offer ocular extensions, allowing surgeons to operate in a more upright posture with their spines in a neutral position.

Placing video monitors in ergonomically advantageous positions around the OR table also impacts surgeon posture. Monitors mounted on floor-based towers are often placed at the foot of the bed, according to Dr. Sutton. "And that would mean I'm constantly looking over my left shoulder, putting strain on my neck and shoulders." ?

Boom-mounted monitors provide the versatility surgeons need to operate in comfort. Dr. Sutton positions the center of a monitor on the opposite side of the surgical site in a direct line with her nose, so she can track the movement of her instruments on the screen without turning her head.

She also steps on lifts to make sure her elbows are properly positioned, especially while operating on obese patients, who make up a higher percentage of the patient population than when she was in training. "Laparoscopic surgeons need to be able to comfortably manipulate instruments with their elbows at their sides and hands extended directly in front of them," she says.

Dr. Lidsky agrees. "Surgeons need to get the table low enough — or themselves high enough — to relax the shoulders," he says, "which offloads the wrists."

Posture is important, but there are technologies and products available that are designed to make surgery more comfortable for surgeons.

• Comfortable headgear. The ergonomics expert who worked with Dr. Lidsky noticed the loupes he used were antiquated and ill-fitting. He wasn't aware newer, more comfortable models were available until he tried on a new pair sized to his specifications. The new loupes have a steeper declination angle — the angle at which the magnifier comes off the glass — which saved about 17 degrees of neck flexion to help keep it within the comfortable threshold of 25 degree or less.

Newer headlights are lightweight and balanced for added comfort, and cordless battery-powered LED headlights let surgeons move around the OR table freely and position themselves with comfort in mind.

• Foot protection. Dr. Lidsky says his lower back and legs benefit from standing on anti-fatigue mats during surgery. And don't ignore the benefits of a comfortable pair of shoes. Dr. Jarstad likes to slip on athletic footwear that feature spring-loaded heels and stabilizing supports to relieve some pressure off his joints.
• Video upgrades. Three-dimensional, heads-up displays, which are growing in popularity in ophthalmic ORs, eliminate the need for surgeons to view surgery through a microscope's oculars, freeing them up to sit comfortably. "That's most likely the future of cataract surgery," says Dr. Jarstad, although he acknowledges the full transition will require residency hospitals to adapt the technology so up and coming surgeons can train with the technology before using it as they begin their careers.

That doesn't mean experienced surgeons should shy away from trialing the technology. "I've found it to be an easy transition," says Dr. Jarstad.

• Improved instrumentation. Dr. Sutton points out that women surgeons tend to be shorter and smaller, and therefore have hand and wrist issues from trying to manipulate instruments traditionally designed for their male counterparts. She also finds it difficult to rotate the knobs on flexible endoscopes with one hand.

Surgeons are very good at concentrating on the task at hand and ignoring the physical pain they're feeling. That attitude, thankfully, is changing. "We gear up for the surgery, much like athletes do for the big game, and decompress when it's over," says Dr. Jarstad, who visits a sports massage therapist and trains to handle the rigors of surgery. He's mindful to take care of his body through proper diet, regular exercise and rest. "I encourage other surgeons to do the same," he says. "Those things certainly helped to extend my career." OSM