Journal of Obstetrics and Gynaecology, January 2014; 34: 74–78 © 2014 Informa UK, Ltd. ISSN 0144-3615 print/ISSN 1364-6893 online DOI: 10.3109/01443615.2013.831048
GYNAECOLOGY
Prolonged laparoscopic surgery is associated with an increased risk of vertebral disc prolapse G. K. S. Cass1, S. Vyas2 & V. Akande2
J Obstet Gynaecol Downloaded from informahealthcare.com by Gazi Univ. on 01/06/15 For personal use only.
Department of Obstetrics and Gynaecology,1Musgrove Park Hospital, Taunton and 2Southmead Hospital, Bristol, UK
The benefits of laparoscopic surgery to the patient are well recognised, however it is more physically demanding on the surgeon. A survey was sent to members of the British Society of Gynaecological Endoscopy to ascertain musculoskeletal symptoms and vertebral disc prolapse thought to occur as a result of undertaking laparoscopic surgery. A total of 19 (15%) participants were diagnosed with a vertebral disc prolapse, for which one-third needed definitive treatment. There was a statistically significant association with length of practice and numbers of hours worked per week, with the risk of disc prolapse. There was a multitude of other musculoskeletal symptoms reported. These findings suggest that gynaecological laparoscopic surgery carries a high personal health risk to the surgeon, which is likely to increase as the capability and superiority of laparoscopic techniques develop. There is an urgent need to explore further the ergonomic impact of laparoscopic work to enable improvements to be made. Keywords: Ergonomics, gynaecology, laparoscopic surgery, musculoskeletal injuries, vertebral disc prolapse
work becomes more complex and lengthy, new patterns of injury are likely to evolve, yet injury related to this form of laparoscopic work has not been formally evaluated in our speciality. Furthermore, objective evidence of injury of vertebral disc prolapse has never been sought. Our objective was to explore the prevalence of musculoskeletal injury among gynaecological laparoscopic surgeons and the factors that may increase the risk, particularly caseload, complexity of surgery and length of practice.
Methods Data collection A survey, by e-mail, was sent to all members of the British Society for Gynaecological Endoscopy (BSGE), inviting a wide range of skilled and experienced laparoscopic surgeons to participate in the study. Completion of the survey was voluntary and an invitation was sent by a central source to the BSGE database of e-mail addresses. and the researchers were blinded to personal identifiers in the responses. A link in the e-mail was given to access the survey online. Three interval reminders were sent over the 3-month period of data collection.
Introduction The advantages of laparoscopic surgery to the patient such as reduced hospital stay, shorter recovery period and decreased postoperative pain, are some of the benefits to both the individual patient and healthcare system. However, laparoscopic surgery is more challenging and demanding for the surgeon (van der Schatte Olivier et al. 2008; Lee et al. 2009; Berguer et al. 1999). Several studies have investigated the prevalence of musculoskeletal symptoms in healthcare professionals, particularly focussing on lower back problems. Nursing is a prime example of a profession to suffer from the financial and personal burden of a high incidence of back pain, quoted as up to 60% in some studies (Smedley et al. 1995). Non-surgical doctors also endure musculoskeletal injury associated with work quoted as high as 44% in one survey among physicians (Smith et al. 2006). However, there are fewer studies examining the effect of the working environment on the surgical specialties. Recognition of the existence of morbidity from laparoscopic surgery is beginning to be documented and ‘minimal access surgery related morbidity syndromes’ is a term that has been used to include a range of these surgical related injuries (Reyes et al. 2008). There is, however, limited literature on these syndromes in gynaecological surgery and as gynaecological laparoscopic
Survey structure The survey was designed using SurveyMonkey® (www.surveymonkey.com/s/FLQKGV2) and consisted of questions seeking to address ergonomic issues surrounding gynaecological laparoscopic surgery. We specifically enquired about objective evidence of vertebral disc prolapse injury as a result of laparoscopic work. Advice was sought from neurosurgical colleagues to ensure relevant questions pertaining to disc prolapse were included. The survey was grouped into five categories (Table I): demographics; details and length of practice; occurrence of physical symptoms, to which surgeons were asked to grade as frequently, occasionally and never; incidence of vertebral disc prolapse thought secondary to laparoscopic work and free text for other ergonomic difficulties experienced and awareness of solutions to any problems described. Types of surgery undertaken were ranked according to complexity, in order to ascertain a correlation between complexity of surgery and vertebral disc prolapse. Total laparoscopic hysterectomy, myomectomy, sacrocolpopexy, pelvic floor repair and excision of endometriosis were classed as complex. Ovarian cystectomy, mild endometriosis treatment and adhesiolysis were classed as simpler procedures.
Correspondence: G. K. S. Cass. Department of Obstetrics and Gynaecology, Musgrove Park Hospital, Taunton, TA1 5DA, UK. E-mail: gem_cass@ hotmail.com
Laparoscopic surgery and vertebral disc prolapse
75
Table I. Summary of questionnaire sent to members. Demographics Details of practice
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Longevity of practice Have you ever experienced the following during or after laparoscopic surgery? Please report as frequently, occasionally or never
Have you ever been diagnosed with a prolapsed disc secondary to laparoscopic work? If you have encountered other problems with laparoscopic surgery please comment
Job title Type of laparoscopic surgery Hours a week practising laparoscopic surgery Do you undertake complex procedures such as hysterectomy, excision of endometriosis? Number of years practising laparoscopic surgery Neck pain, stiffness Shoulder pain, stiffness Hand pain, stiffness Hand numbness Leg pain, stiffness Back pain Eye strain, reduced visual acuity Fatigue Agitation, frustration Difficulty visualising the operative field Difficulty manipulating instruments Prolonged set-up time of equipment Unfamiliarity of theatre staff with equipment Neck, thoracic or lumbar? Has this required treatment? Please suggest possible solutions
Statistical analysis Individual data responses were imported directly onto the data collection site on the SurveyMonkey website, to which there was password-secured access to the researchers. Once all responses were made, data was exported into the Microsoft Excel format and then analysed using SPSS. Data were analysed using binary logistic regression, Fisher–Freeman–Halton test and Pearson χ2-test of association.
Results In total, 506 e-mails were sent to a range of laparoscopic gynaecological surgeons, as identified from the BSGE database. There were 128 (24%) responses and the subsequent analyses is based on these. The demographics of the participants are detailed in Table II.
Physical symptoms The number of participants who reported experiencing pain or discomfort they believed attributable to carrying out laparoscopic procedures was 127 (99%). Shoulder pain and stiffness was experienced by 80% of participants, 28% reporting this on a frequent basis. Neck, back and hand pain was also reported in 74%, 77% and 70%, respectively. Details of other symptoms are outlined in Table III.
lumbar region and six (32%) of these needed definitive treatment for disc prolapse, including microdiscectomy, facet joint injections, nerve root block and manipulation. This occurrence was correlated with the amount of years practised and number of hours worked per week and both predicted an increased risk of disc prolapse. Binary regression analysis indicates there was a significant association between hours worked per week for laparoscopic surgery and injury of disc prolapse (p 0.005). Specifically, every additional hour spent in undertaking laparoscopic surgery would increase the chances of having an injury by a factor of 1.164 (95% CI, 1.046; 1.295). Similarly, there was a significant association between years of laparoscopic practice and injury (p 0.001). Every additional year of practice increased the chances of having an injury by a factor of 1.139 (95% CI 1.061; 1.222). Table IV summarises the association between length of laparoscopic and hysteroscopic work and years of practice with the incidence of disc prolapse. Our analysis revealed a significant association between more complex surgery and the rate of injury of disc prolapse (χ2 10.108, df 4, p 0.039). In relation to the occurrence of specific physical symptoms and incidence of disc prolapse, the frequency of experiencing neck pain and back pain was associated with a higher rate of injury of vertebral disc prolapse (χ2 6.509, df 2, p 0.039, χ2 8.822, df 2, p 0.012).
Vertebral disc prolapse Vertebral disc prolapse thought secondary to laparoscopic work was diagnosed in 19 (15%) participants, 11 of which were in the
Table III. Prevalence of symptoms reported. Frequency of symptom
Table II. General information and demographics of respondents (n 128). Demographics Consultant Associate specialist Clinical fellow Registrar Nurse laparoscopist Median number of years practising laparoscopic surgery Median hours a week practising laparoscopic surgery Complex procedures
n
(%)
108 1 6 12 1 1–40 1–24 77
84 1 5 9 1 11 4 60
Frequently
Shoulder pain/stiffness Neck pain/stiffness Back pain/stiffness Hand pain/stiffness Hand numbness Leg pain/stiffness Eye strain
Occasionally
Never
n
(%)
n
(%)
n
(%)
36 22 29 18 8 23 7
28.1 17.2 22.7 14.1 6.3 18.0 5.5
67 72 70 71 46 46 44
52.3 56.3 54.7 55.5 35.9 35.9 34.4
25 34 29 39 64 74 77
19.5 26.6 22.7 30.5 57.8 57.8 60.2
76
G. K. S. Cass et al.
Table IV. Association of vertebral disc prolapse with practice. 95% CI for OR OR
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Hours per week of laparoscopic surgery Hours per week of hysteroscopic surgery Years of practice
p value
Lower
Upper
1.164
0.005
1.046
1.295
0.956
0.720
0.748
1.222
1.139
0.001
1.061
1.222
Difficulty in manipulating laparoscopic instruments was also associated with the rate of injury of disc prolapse, suggestive of an important causative factor in injury (χ2 6.773, df 2, p 0.034). There was no statistical significant association found between the frequency of other musculoskeletal symptoms and the rate of injury of disc prolapse. An association between complexity of surgery and other musculoskeletal symptoms was only found to be statistically significant for hand numbness (χ2 18.562, df 8, p 0.017) and eye strain (χ2 21.349, df 8, p 0.006).
Other symptoms Other musculoskeletal symptoms and generalised complaints were reported by a high number of participants. A total of 104 (82%) reported fatigue and 80% reported prolonged set-up time of equipment, which exacerbated the slow turnover of patients and frustration. This correlated with similar reporting of unfamiliarity of equipment to theatre staff. Difficulty with manipulating instruments during operating was reported in 70% of participants, which echoes the prevalence of hand symptoms as seen earlier. Eye strain and visual acuity problems were less reported, at 40% and 25%, respectively. Survey questions 7 and 8 asked about physical injuries and other problems encountered during laparoscopic surgery that had not already been addressed. Several injuries were reported by more than one participant including: numbness of the digits (7); neurological symptoms in the upper limbs (4); numbness of the leg from pressure against the operating table (2) and pre-syncopal symptoms (2). Further details of symptoms are given in detail in Table V.
Environmental ergonomics When asked for other potential problems with laparoscopic surgery that may contribute to injuries sustained, a multitude of responses were given. Problems with the staff continuity (1), incorrect equipment (4) and junior camera assistants (1) were reported in a small number of participants. More common confounders were attributable to the operating room set-up; namely difficulties with optimising table height (11), positioning of ports (2) and display monitors (2). Poor posture was thought to be implicated in many injuries, as reported by 17 (13%) of participants. Table V. Other symptoms reported by respondents (n 18). Symptom
n
(%)
Numbness of digits Neurological symptoms in the upper limbs Numbness of leg Pre-syncope Stinging eyes Leg oedema Varicose veins
7 4 2 2 1 1 1
5.4 3.1 1.5 1.5 0.8 0.8 0.8
When asked how to minimise these problems or conditions encountered, 22 (17%) participants suggested improvement and solutions; 45% of these suggested financial investment to provide superior equipment, particularly a size range for handheld equipment and improved table ergonomics. However, some reported using a step to overcome the inability for the table to be at a lower level. Exercise, ipsilateral port site and avoidance of contralateral operating featured among the other responses. Robotics, mentioned by two participants, provided solutions to many ergonomic issues.
Discussion This study found that evidence of vertebral disc prolapse among those surveyed was 19 (15%), with over one-third of these surgeons requiring definitive treatment. This is in contrast to a 2% lifetime risk in the general population (Postacchini 1999). The longer the length of practice and the more hours practiced, significantly increased the likelihood of injury. This outcome is a new finding to the literature and is of concern. Furthermore, the study revealed that other ergonomic injuries to the gynaecological laparoscopic surgeon are prevalent. Musculoskeletal symptoms were reported in around 80% of respondents, most commonly pain and stiffness in the shoulder, back and neck. This is significantly higher than symptoms relating to non-healthcare workers, as well as other medical professionals (Xu et al. 1996; Oude Hengel et al. 2010). This distribution of pattern of injury is consistent with the findings by Berguer in the late 1990s, where laparoscopic surgeons were found to have reduced movement of the neck, trunk and awkward movements of the upper extremities (Berguer et al. 1997). Initial surveys conducted among laparoscopic surgeons during the infancy of research into ergonomics, suggested musculoskeletal injury occurred in around 8–12% (Berguer et al. 1999). However, more recent evidence reveals this prevalence to be appreciably higher (Esser et al. 2007; Gofrit et al. 2008; Wolf et al. 2000; Johnston et al. 2005; Stomberg et al. 2010). The prevalence of injury found in our study is comparable with a recent survey by Park et al. (2010) in the USA, conducted among general surgeons, where 87% of respondents reported a range of musculoskeletal complaints. Similarly, 83% of general surgeons studied in Germany, experienced musculoskeletal symptoms directly related to laparoscopic work (Szeto et al. 2009). Laparoscopy was pioneered by gynaecological surgeons and it is now time for the specialty to recognise its limitations in relation to surgeon wellbeing. With the advent of more complex procedures being undertaken laparoscopically, including many gynae-oncology cases, and the change in patient population such as obesity, the ergonomic and logistical challenges are evolving. Training in laparoscopy skills is likely to be introduced into the curriculum for trainees from the first year of training, hence the consultants of the future will have been exposed to the damaging ergonomics for longer, increasing their risk of injury. The personal costs and effects of this on service provision are unthinkable. It is therefore vital that the optimal working environment needs to be evaluated and incorporated into day-to-day practice. Some studies (Berguer et al. 1997; Nguyen et al. 2001; Manasnayakorn et al. 2008; El Shallaly and Cuschieri 2006; Lin et al. 2007; Emam et al. 2001; Manasnayakorn et al. 2009; Berguer et al. 2002; Berguer et al. 2000; van Det et al. 2009; Berguer et al. 2003; Supe et al. 2010) have been carried out to objectively assess the aetiology and underlying ergonomic risk factors that can precipitate these syndromes but this is still in its infancy.
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Laparoscopic surgery and vertebral disc prolapse Assessment of muscle workload, time for task completion and error rate during completion of a variety of laparoscopic procedures, has been studied in an attempt to define the optimal environment to enhance comfort and prevent injury in the surgeon. Another difficulty with laparoscopic surgery, is the poor design of instruments and this was a factor identified by our survey as a contributor to injury. Improved feedback and communication from the surgeon to the designers of the laparoscopic instruments may go some way to improving device ergonomics, as it has been suggested that economists and engineers cannot fully appreciate the finer actions and processes that the surgeons undertake in the operating room. Our survey demonstrated that only a small proportion of respondents provided suggestions to improve the ergonomic environment and occurrence of injury. It may be that awareness of this problem among our speciality is even lower, which further compounds anxiety about the future. Awareness of potential injuries is vital to ensure that time is taken to optimise the ergonomics of the operating room environment prior to commencement of the procedure. In industrial settings, the workplace is ergonomically designed to improve quantity and quality of work and enhance morale and comfort among workers. However, in the medical world, ergonomic interventions are rare. There are mandatory training sessions for manual handling techniques and an abundance of other occupational health advice regarding injury in the workplace, but guidance related to laparoscopic work is non-existent. Our findings suggest ergonomics in the operating room should be taught when laparoscopic training becomes part of the curriculum for junior trainees. The low response to our survey invitation may have occurred for a number of reasons. However, the response rate is comparable and, in many cases, superior to the surveys conducted in other specialities (Berguer et al. 1997; Stomberg et al. 2010; Berguer and Hreljac 2004). Invitations to the survey were only sent by e-mail and to improve recruitment into the study; interval reminders were sent to account for busy work schedules and absence from access to e-mail. Reporting and self-selection bias is a recognised limitation associated with survey responses. Although this was unavoidable, it was reduced by sending the survey to all members of the BSGE and a range of experience, complexity of surgery and length of practice was achieved among the respondents. Furthermore, this does not invalidate the results that a significant number of injuries occurred. This survey did not record demographics such as age or sex. These variables may arguably be attributable to many of the musculoskeletal complaints in isolation. With older age, surgeons are likely to have longer operating years of practice, which we found to be a significant risk for disc prolapse. Nonetheless, in comparison with other surveys with other specialists, it seems that laparoscopic surgery itself is the factor that increases risk of musculoskeletal symptoms rather than individual demographics. It has been demonstrated that sex may be implicated in the prevalence of hand injury, as female surgeons typically have smaller hands (Berguer and Hreljac 2004; Smith et al. 2006). The one-size-fits-all design of laparoscopic instruments means that manipulation is more difficult for smaller hand sizes. Furthermore, a glove size of 6.5 confers an increased likelihood of hand pain and numbness. Although we did not record sex and glove size, we do not envisage that the reported frequency of symptoms would have altered, only that a correlation may have been shown between smaller glove size and symptom prevalence.
77
Conclusion Our findings suggest that gynaecological laparoscopic surgery carries a high personal health risk to the surgeon. Our analysis shows that it is the length of practice and number of hours worked per week that are the strong predictors of significant injury. Nevertheless, the lack of formal guidance on optimal practice, the ever increasing capability and superiority of laparoscopic techniques and the longer length of time surgeons will be performing this type of surgery, means that our rate of injury to the surgeons providing the service will be a gross underestimate. The personal health burden on the surgeon is not the only illeffect from such increases in injury. The rate of case cancellation and reduction in surgical careers lengths is likely to have adverse consequences for not only patient care but increase the strain on the arduous financial challenges on publicly funded health services. Our findings have highlighted the need to explore further the ergonomic impact of laparoscopic work on the surgeon. Such research will hopefully ensure improvements are made to perfect the operating room environment and increase awareness within the field of gynaecological surgery, so that a pandemic of injury does not occur.
Acknowledgements Our thanks go to Alianu Kingsly, Statistician, Bristol Institute of Technology, University of the West of England, for contributing to the statistical analysis of original data. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Berguer E, Hreljac A. 2004. The relationship between hand size and difficulty using surgical instruments: a survey of 726 laparoscopic surgeons. Surgical Endoscopy 18:508–512. Berguer R, Rab GT, Abu-Ghaida H, Alarcon A, Chung J. 1997. A comparison of surgeons’ posture during laparoscopic and open surgical procedures. Surgical Endoscopy 11:139–142. Berguer R, Forkey DL, Smith WD. 1999. Ergonomic problems associated with laparoscopic surgery. Surgical Endoscopy 13:466–468. Berguer R, Forkey DL, Smith WD. 2000. The effect of laparoscopic instrument working angle on surgeons’ upper extremity workload. Surgical Endoscopy 15:1027–1029. Berguer R, Smith WD, Davis S. 2002. An ergonomic study of the optimum operating table height for laparoscopic surgery. Surgical Endoscopy 16:416–421. Berguer R, Chen J, Smith WD. 2003. A comparison of the physical effort required for laparoscopic and open surgical technique. Archives of Surgery 138:967–970. El Shallaly G, Cuschieri A. 2006. Optimum view distance for laparoscopic surgery. Surgical Endoscopy 20:1879–1882. Emam TA, Franks TG, Hanna GB, Cuschieri A. 2001. Influence of handle design on the surgeon’s upper limb movements, muscle recruitment and fatigue during endoscopic suturing. Surgical Endoscopy 15:667–672. Esser AC, Koshy JG, Randle HW. 2007. Ergonomics in office-based surgery: a survey-guided observational study. Dermatologic Surgery 33:1304–1314. Gofrit ON, Mikahail AA, Zorn KC, Zagaja GP, Steinberg GD, Shalhav AL. 2008. Surgeons’ perceptions and injuries during and after urologic laparoscopic surgery. Urology 71:404–407. Johnston WK, Hollenbeck BK, Wolf JS. 2005. Comparison of neuromuscular injuries to the surgeon during and-assisted and standard laparoscopic urologic surgery. Journal of Endourology 19:377–381. Lee G, Lee T, Dexter D, Godinez C, Meenaghan N, Catania R et al. 2009. Ergonomic risk associated with assisting in minimally invasive surgery. Surgical Endoscopy 23:182–188. Lin DW, Bush RW, Earle DB, Seymour NE. 2007. Performance and ergonomic characteristics of expert surgeons using face-mounted display
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during virtual reality-simulated laparoscopic surgery: an electromyographically based study. Surgical Endoscopy 21:1135–1141. Manasnayakorn S, Cuschieri A, Hanna GB. 2008. Ideal manipulation angle and instrument length in hand-assisted laparoscopic surgery. Surgical Endoscopy 22:942–949. Manasnayakorn S, Cuschieri A, Hanna GB. 2009. Ergonomic assessment of optimum operating table height for hand-assisted laparoscopic surgery. Surgical Endoscopy 23:783–789. Nguyen NT, Ho HS, Smith WD. 2001. An ergonomic evaluation of surgeons’ axial skeletal and upper extremity movements during laparoscopic and open surgery. American Journal of Surgery 182:720–724. Oude Hengel KM, Visser B, Sluite JK. 2010. The prevalence and incidence of musculoskeletal symptoms among hospital physicians: a systematic review. International Archives of Occupational and Environmental Health 84:115–119. Park A, Lee G, Seagull FJ, Meenaghan N, Dexter, D. 2010. Patients benefit while surgeons suffer: an impending epidemic. Journal of the American College of Surgeons 210:306–313. Postacchini F. 1999. Lumbar disc herniation. New York: Springer Wien. p. 151–152. Reyes DAG, Tang B, Cuschieri. 2008. Minimal access surgery (MAS)-related surgeon morbidity syndromes. Surgical Endoscopy 20:1–13. Smedley J, Egger P, Cooper C, Coggon D. 1995. Manual handling activities and risk of low back pain in nurses. Occupational and Environmental Medicine 52:160–163.
Smith DR, Wei N, Zhang YJ, Wang RS. 2006. Musculoskeletal complaints and psychosocial risk factors among physicians in mainland China. International Journal Industrial Ergonomics 36:599–603. Stomberg MW, Tronstad SE, Hedberg K, Bengtsson J, Jonsson P, Johansen L et al. 2010. Work related musculoskeletal disorders when performing laparoscopic surgery. Surgical Laparoscopy, Endoscopy and Percutaneous Techniques 20:49–53. Supe AN, Kulkarni GV, Supe PA. 2010. Ergonomics in laparoscopic surgery. Journal of Minimal Access Surgery 6:31–36. Szeto GP, Ho P, Ting AC, Poon JT, Cheng SW, Tsang RC. 2009. Work-related musculoskeletal symptoms in surgeons. Journal of Occupational Rehabilitation 19:175–184. van der Schatte Olivier RH, Van’t Hulenaar CD, Ruurda JP, Broeders IA. 2008. Ergonomics, user comfort, and performance in standard and robot-assisted laparoscopic surgery. Surgical Endoscopy 23:1365–1371. van Det MJ, Meijerink WJ, Hoff C, Totte ER, Pierie JP. 2009. Optimal ergonomics for laparoscopic surgery in minimally invasive surgery suites: a review and guidelines. Surgical Endoscopy 23:1279–1285. Wolf JF, Marcovich R, Gill IS, Sung GT, Kavoussi LR, Clayman RV et al. 2000. Survey of neuromuscular injuries to the patient and surgeon during urologic laparoscopic surgery. Urology 55:831–836. Xu Y, Bach E, Orhede E. 1996. Occupation and risk for the occurrence of low-back pain (LBP) in Danish employees. Occupational Medicine 26:131–136.
GYNAECOLOGY
Prolonged laparoscopic surgery is associated with an increased risk of vertebral disc prolapse G. K. S. Cass1, S. Vyas2 & V. Akande2
J Obstet Gynaecol Downloaded from informahealthcare.com by Gazi Univ. on 01/06/15 For personal use only.
Department of Obstetrics and Gynaecology,1Musgrove Park Hospital, Taunton and 2Southmead Hospital, Bristol, UK
The benefits of laparoscopic surgery to the patient are well recognised, however it is more physically demanding on the surgeon. A survey was sent to members of the British Society of Gynaecological Endoscopy to ascertain musculoskeletal symptoms and vertebral disc prolapse thought to occur as a result of undertaking laparoscopic surgery. A total of 19 (15%) participants were diagnosed with a vertebral disc prolapse, for which one-third needed definitive treatment. There was a statistically significant association with length of practice and numbers of hours worked per week, with the risk of disc prolapse. There was a multitude of other musculoskeletal symptoms reported. These findings suggest that gynaecological laparoscopic surgery carries a high personal health risk to the surgeon, which is likely to increase as the capability and superiority of laparoscopic techniques develop. There is an urgent need to explore further the ergonomic impact of laparoscopic work to enable improvements to be made. Keywords: Ergonomics, gynaecology, laparoscopic surgery, musculoskeletal injuries, vertebral disc prolapse
work becomes more complex and lengthy, new patterns of injury are likely to evolve, yet injury related to this form of laparoscopic work has not been formally evaluated in our speciality. Furthermore, objective evidence of injury of vertebral disc prolapse has never been sought. Our objective was to explore the prevalence of musculoskeletal injury among gynaecological laparoscopic surgeons and the factors that may increase the risk, particularly caseload, complexity of surgery and length of practice.
Methods Data collection A survey, by e-mail, was sent to all members of the British Society for Gynaecological Endoscopy (BSGE), inviting a wide range of skilled and experienced laparoscopic surgeons to participate in the study. Completion of the survey was voluntary and an invitation was sent by a central source to the BSGE database of e-mail addresses. and the researchers were blinded to personal identifiers in the responses. A link in the e-mail was given to access the survey online. Three interval reminders were sent over the 3-month period of data collection.
Introduction The advantages of laparoscopic surgery to the patient such as reduced hospital stay, shorter recovery period and decreased postoperative pain, are some of the benefits to both the individual patient and healthcare system. However, laparoscopic surgery is more challenging and demanding for the surgeon (van der Schatte Olivier et al. 2008; Lee et al. 2009; Berguer et al. 1999). Several studies have investigated the prevalence of musculoskeletal symptoms in healthcare professionals, particularly focussing on lower back problems. Nursing is a prime example of a profession to suffer from the financial and personal burden of a high incidence of back pain, quoted as up to 60% in some studies (Smedley et al. 1995). Non-surgical doctors also endure musculoskeletal injury associated with work quoted as high as 44% in one survey among physicians (Smith et al. 2006). However, there are fewer studies examining the effect of the working environment on the surgical specialties. Recognition of the existence of morbidity from laparoscopic surgery is beginning to be documented and ‘minimal access surgery related morbidity syndromes’ is a term that has been used to include a range of these surgical related injuries (Reyes et al. 2008). There is, however, limited literature on these syndromes in gynaecological surgery and as gynaecological laparoscopic
Survey structure The survey was designed using SurveyMonkey® (www.surveymonkey.com/s/FLQKGV2) and consisted of questions seeking to address ergonomic issues surrounding gynaecological laparoscopic surgery. We specifically enquired about objective evidence of vertebral disc prolapse injury as a result of laparoscopic work. Advice was sought from neurosurgical colleagues to ensure relevant questions pertaining to disc prolapse were included. The survey was grouped into five categories (Table I): demographics; details and length of practice; occurrence of physical symptoms, to which surgeons were asked to grade as frequently, occasionally and never; incidence of vertebral disc prolapse thought secondary to laparoscopic work and free text for other ergonomic difficulties experienced and awareness of solutions to any problems described. Types of surgery undertaken were ranked according to complexity, in order to ascertain a correlation between complexity of surgery and vertebral disc prolapse. Total laparoscopic hysterectomy, myomectomy, sacrocolpopexy, pelvic floor repair and excision of endometriosis were classed as complex. Ovarian cystectomy, mild endometriosis treatment and adhesiolysis were classed as simpler procedures.
Correspondence: G. K. S. Cass. Department of Obstetrics and Gynaecology, Musgrove Park Hospital, Taunton, TA1 5DA, UK. E-mail: gem_cass@ hotmail.com
Laparoscopic surgery and vertebral disc prolapse
75
Table I. Summary of questionnaire sent to members. Demographics Details of practice
J Obstet Gynaecol Downloaded from informahealthcare.com by Gazi Univ. on 01/06/15 For personal use only.
Longevity of practice Have you ever experienced the following during or after laparoscopic surgery? Please report as frequently, occasionally or never
Have you ever been diagnosed with a prolapsed disc secondary to laparoscopic work? If you have encountered other problems with laparoscopic surgery please comment
Job title Type of laparoscopic surgery Hours a week practising laparoscopic surgery Do you undertake complex procedures such as hysterectomy, excision of endometriosis? Number of years practising laparoscopic surgery Neck pain, stiffness Shoulder pain, stiffness Hand pain, stiffness Hand numbness Leg pain, stiffness Back pain Eye strain, reduced visual acuity Fatigue Agitation, frustration Difficulty visualising the operative field Difficulty manipulating instruments Prolonged set-up time of equipment Unfamiliarity of theatre staff with equipment Neck, thoracic or lumbar? Has this required treatment? Please suggest possible solutions
Statistical analysis Individual data responses were imported directly onto the data collection site on the SurveyMonkey website, to which there was password-secured access to the researchers. Once all responses were made, data was exported into the Microsoft Excel format and then analysed using SPSS. Data were analysed using binary logistic regression, Fisher–Freeman–Halton test and Pearson χ2-test of association.
Results In total, 506 e-mails were sent to a range of laparoscopic gynaecological surgeons, as identified from the BSGE database. There were 128 (24%) responses and the subsequent analyses is based on these. The demographics of the participants are detailed in Table II.
Physical symptoms The number of participants who reported experiencing pain or discomfort they believed attributable to carrying out laparoscopic procedures was 127 (99%). Shoulder pain and stiffness was experienced by 80% of participants, 28% reporting this on a frequent basis. Neck, back and hand pain was also reported in 74%, 77% and 70%, respectively. Details of other symptoms are outlined in Table III.
lumbar region and six (32%) of these needed definitive treatment for disc prolapse, including microdiscectomy, facet joint injections, nerve root block and manipulation. This occurrence was correlated with the amount of years practised and number of hours worked per week and both predicted an increased risk of disc prolapse. Binary regression analysis indicates there was a significant association between hours worked per week for laparoscopic surgery and injury of disc prolapse (p 0.005). Specifically, every additional hour spent in undertaking laparoscopic surgery would increase the chances of having an injury by a factor of 1.164 (95% CI, 1.046; 1.295). Similarly, there was a significant association between years of laparoscopic practice and injury (p 0.001). Every additional year of practice increased the chances of having an injury by a factor of 1.139 (95% CI 1.061; 1.222). Table IV summarises the association between length of laparoscopic and hysteroscopic work and years of practice with the incidence of disc prolapse. Our analysis revealed a significant association between more complex surgery and the rate of injury of disc prolapse (χ2 10.108, df 4, p 0.039). In relation to the occurrence of specific physical symptoms and incidence of disc prolapse, the frequency of experiencing neck pain and back pain was associated with a higher rate of injury of vertebral disc prolapse (χ2 6.509, df 2, p 0.039, χ2 8.822, df 2, p 0.012).
Vertebral disc prolapse Vertebral disc prolapse thought secondary to laparoscopic work was diagnosed in 19 (15%) participants, 11 of which were in the
Table III. Prevalence of symptoms reported. Frequency of symptom
Table II. General information and demographics of respondents (n 128). Demographics Consultant Associate specialist Clinical fellow Registrar Nurse laparoscopist Median number of years practising laparoscopic surgery Median hours a week practising laparoscopic surgery Complex procedures
n
(%)
108 1 6 12 1 1–40 1–24 77
84 1 5 9 1 11 4 60
Frequently
Shoulder pain/stiffness Neck pain/stiffness Back pain/stiffness Hand pain/stiffness Hand numbness Leg pain/stiffness Eye strain
Occasionally
Never
n
(%)
n
(%)
n
(%)
36 22 29 18 8 23 7
28.1 17.2 22.7 14.1 6.3 18.0 5.5
67 72 70 71 46 46 44
52.3 56.3 54.7 55.5 35.9 35.9 34.4
25 34 29 39 64 74 77
19.5 26.6 22.7 30.5 57.8 57.8 60.2
76
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Table IV. Association of vertebral disc prolapse with practice. 95% CI for OR OR
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Hours per week of laparoscopic surgery Hours per week of hysteroscopic surgery Years of practice
p value
Lower
Upper
1.164
0.005
1.046
1.295
0.956
0.720
0.748
1.222
1.139
0.001
1.061
1.222
Difficulty in manipulating laparoscopic instruments was also associated with the rate of injury of disc prolapse, suggestive of an important causative factor in injury (χ2 6.773, df 2, p 0.034). There was no statistical significant association found between the frequency of other musculoskeletal symptoms and the rate of injury of disc prolapse. An association between complexity of surgery and other musculoskeletal symptoms was only found to be statistically significant for hand numbness (χ2 18.562, df 8, p 0.017) and eye strain (χ2 21.349, df 8, p 0.006).
Other symptoms Other musculoskeletal symptoms and generalised complaints were reported by a high number of participants. A total of 104 (82%) reported fatigue and 80% reported prolonged set-up time of equipment, which exacerbated the slow turnover of patients and frustration. This correlated with similar reporting of unfamiliarity of equipment to theatre staff. Difficulty with manipulating instruments during operating was reported in 70% of participants, which echoes the prevalence of hand symptoms as seen earlier. Eye strain and visual acuity problems were less reported, at 40% and 25%, respectively. Survey questions 7 and 8 asked about physical injuries and other problems encountered during laparoscopic surgery that had not already been addressed. Several injuries were reported by more than one participant including: numbness of the digits (7); neurological symptoms in the upper limbs (4); numbness of the leg from pressure against the operating table (2) and pre-syncopal symptoms (2). Further details of symptoms are given in detail in Table V.
Environmental ergonomics When asked for other potential problems with laparoscopic surgery that may contribute to injuries sustained, a multitude of responses were given. Problems with the staff continuity (1), incorrect equipment (4) and junior camera assistants (1) were reported in a small number of participants. More common confounders were attributable to the operating room set-up; namely difficulties with optimising table height (11), positioning of ports (2) and display monitors (2). Poor posture was thought to be implicated in many injuries, as reported by 17 (13%) of participants. Table V. Other symptoms reported by respondents (n 18). Symptom
n
(%)
Numbness of digits Neurological symptoms in the upper limbs Numbness of leg Pre-syncope Stinging eyes Leg oedema Varicose veins
7 4 2 2 1 1 1
5.4 3.1 1.5 1.5 0.8 0.8 0.8
When asked how to minimise these problems or conditions encountered, 22 (17%) participants suggested improvement and solutions; 45% of these suggested financial investment to provide superior equipment, particularly a size range for handheld equipment and improved table ergonomics. However, some reported using a step to overcome the inability for the table to be at a lower level. Exercise, ipsilateral port site and avoidance of contralateral operating featured among the other responses. Robotics, mentioned by two participants, provided solutions to many ergonomic issues.
Discussion This study found that evidence of vertebral disc prolapse among those surveyed was 19 (15%), with over one-third of these surgeons requiring definitive treatment. This is in contrast to a 2% lifetime risk in the general population (Postacchini 1999). The longer the length of practice and the more hours practiced, significantly increased the likelihood of injury. This outcome is a new finding to the literature and is of concern. Furthermore, the study revealed that other ergonomic injuries to the gynaecological laparoscopic surgeon are prevalent. Musculoskeletal symptoms were reported in around 80% of respondents, most commonly pain and stiffness in the shoulder, back and neck. This is significantly higher than symptoms relating to non-healthcare workers, as well as other medical professionals (Xu et al. 1996; Oude Hengel et al. 2010). This distribution of pattern of injury is consistent with the findings by Berguer in the late 1990s, where laparoscopic surgeons were found to have reduced movement of the neck, trunk and awkward movements of the upper extremities (Berguer et al. 1997). Initial surveys conducted among laparoscopic surgeons during the infancy of research into ergonomics, suggested musculoskeletal injury occurred in around 8–12% (Berguer et al. 1999). However, more recent evidence reveals this prevalence to be appreciably higher (Esser et al. 2007; Gofrit et al. 2008; Wolf et al. 2000; Johnston et al. 2005; Stomberg et al. 2010). The prevalence of injury found in our study is comparable with a recent survey by Park et al. (2010) in the USA, conducted among general surgeons, where 87% of respondents reported a range of musculoskeletal complaints. Similarly, 83% of general surgeons studied in Germany, experienced musculoskeletal symptoms directly related to laparoscopic work (Szeto et al. 2009). Laparoscopy was pioneered by gynaecological surgeons and it is now time for the specialty to recognise its limitations in relation to surgeon wellbeing. With the advent of more complex procedures being undertaken laparoscopically, including many gynae-oncology cases, and the change in patient population such as obesity, the ergonomic and logistical challenges are evolving. Training in laparoscopy skills is likely to be introduced into the curriculum for trainees from the first year of training, hence the consultants of the future will have been exposed to the damaging ergonomics for longer, increasing their risk of injury. The personal costs and effects of this on service provision are unthinkable. It is therefore vital that the optimal working environment needs to be evaluated and incorporated into day-to-day practice. Some studies (Berguer et al. 1997; Nguyen et al. 2001; Manasnayakorn et al. 2008; El Shallaly and Cuschieri 2006; Lin et al. 2007; Emam et al. 2001; Manasnayakorn et al. 2009; Berguer et al. 2002; Berguer et al. 2000; van Det et al. 2009; Berguer et al. 2003; Supe et al. 2010) have been carried out to objectively assess the aetiology and underlying ergonomic risk factors that can precipitate these syndromes but this is still in its infancy.
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Laparoscopic surgery and vertebral disc prolapse Assessment of muscle workload, time for task completion and error rate during completion of a variety of laparoscopic procedures, has been studied in an attempt to define the optimal environment to enhance comfort and prevent injury in the surgeon. Another difficulty with laparoscopic surgery, is the poor design of instruments and this was a factor identified by our survey as a contributor to injury. Improved feedback and communication from the surgeon to the designers of the laparoscopic instruments may go some way to improving device ergonomics, as it has been suggested that economists and engineers cannot fully appreciate the finer actions and processes that the surgeons undertake in the operating room. Our survey demonstrated that only a small proportion of respondents provided suggestions to improve the ergonomic environment and occurrence of injury. It may be that awareness of this problem among our speciality is even lower, which further compounds anxiety about the future. Awareness of potential injuries is vital to ensure that time is taken to optimise the ergonomics of the operating room environment prior to commencement of the procedure. In industrial settings, the workplace is ergonomically designed to improve quantity and quality of work and enhance morale and comfort among workers. However, in the medical world, ergonomic interventions are rare. There are mandatory training sessions for manual handling techniques and an abundance of other occupational health advice regarding injury in the workplace, but guidance related to laparoscopic work is non-existent. Our findings suggest ergonomics in the operating room should be taught when laparoscopic training becomes part of the curriculum for junior trainees. The low response to our survey invitation may have occurred for a number of reasons. However, the response rate is comparable and, in many cases, superior to the surveys conducted in other specialities (Berguer et al. 1997; Stomberg et al. 2010; Berguer and Hreljac 2004). Invitations to the survey were only sent by e-mail and to improve recruitment into the study; interval reminders were sent to account for busy work schedules and absence from access to e-mail. Reporting and self-selection bias is a recognised limitation associated with survey responses. Although this was unavoidable, it was reduced by sending the survey to all members of the BSGE and a range of experience, complexity of surgery and length of practice was achieved among the respondents. Furthermore, this does not invalidate the results that a significant number of injuries occurred. This survey did not record demographics such as age or sex. These variables may arguably be attributable to many of the musculoskeletal complaints in isolation. With older age, surgeons are likely to have longer operating years of practice, which we found to be a significant risk for disc prolapse. Nonetheless, in comparison with other surveys with other specialists, it seems that laparoscopic surgery itself is the factor that increases risk of musculoskeletal symptoms rather than individual demographics. It has been demonstrated that sex may be implicated in the prevalence of hand injury, as female surgeons typically have smaller hands (Berguer and Hreljac 2004; Smith et al. 2006). The one-size-fits-all design of laparoscopic instruments means that manipulation is more difficult for smaller hand sizes. Furthermore, a glove size of 6.5 confers an increased likelihood of hand pain and numbness. Although we did not record sex and glove size, we do not envisage that the reported frequency of symptoms would have altered, only that a correlation may have been shown between smaller glove size and symptom prevalence.
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Conclusion Our findings suggest that gynaecological laparoscopic surgery carries a high personal health risk to the surgeon. Our analysis shows that it is the length of practice and number of hours worked per week that are the strong predictors of significant injury. Nevertheless, the lack of formal guidance on optimal practice, the ever increasing capability and superiority of laparoscopic techniques and the longer length of time surgeons will be performing this type of surgery, means that our rate of injury to the surgeons providing the service will be a gross underestimate. The personal health burden on the surgeon is not the only illeffect from such increases in injury. The rate of case cancellation and reduction in surgical careers lengths is likely to have adverse consequences for not only patient care but increase the strain on the arduous financial challenges on publicly funded health services. Our findings have highlighted the need to explore further the ergonomic impact of laparoscopic work on the surgeon. Such research will hopefully ensure improvements are made to perfect the operating room environment and increase awareness within the field of gynaecological surgery, so that a pandemic of injury does not occur.
Acknowledgements Our thanks go to Alianu Kingsly, Statistician, Bristol Institute of Technology, University of the West of England, for contributing to the statistical analysis of original data. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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