Ergonomic Interventions

- SECOND Toolkit

WHAT?                                                                                                                                                   

The goal of this intervention is to:

WHY?                                                                                                                                                     

Surgeons hold awkward postures and static positions for prolonged periods while operating. [1] 60-90% of surgeons report experiencing pain and discomfort during or after performing surgery. [2-8] Over time, these poor ergonomic work conditions can lead to musculoskeletal fatigue, work-related injury, and musculoskeletal disorders among surgeons. [4-6] Musculoskeletal disorders and physical pain drive, burnout, and early retirement. [7-12] The current protocol describes two ergonomic interventions for mitigating musculoskeletal pain in surgery: 1) providing preventive education on ergonomic principles,[5] 2) incorporating intraoperative microbreaks with stretching exercises (1.5 minibreaks every 30-120 min) to be performed during surgery,13-14 and 3) self-treatment exercises to be practiced before and after surgery. [5] These interventions have been found to be beneficial for reducing fatigue, discomfort, and pain in surgeons with minimal disruption to flow. [5, 13-15]


Organizational Culture and Values

Providing ergonomic educations communicates to residents that the department cares about protecting their physical health and well-being.
Workload & Job Demands

Providing ergonomic interventions for surgical teams may help mitigate the musculoskeletal pain, discomfort, fatigue, and injury that many surgical residents and surgeons experience as a consequence of the physical demands of performing surgery.

HOW?                                                                                                                                                   

We describe three ergonomic interventions in the current protocol:                                                                                                                                                                                                 

Ergonomic intervention #1: Education about ergonomic principles [5,16]

Step 1: Identify an individual to serve as an ergonomic champion to plan and deliver the program.

Consider:

  1. Ideally, the ergonomic champion should have experience in musculoskeletal disorders (e.g., physical therapist, orthopedist).
  2. Moreover, the ergonomic champion should have interest in understanding and working with surgeons.
  3. Alternatively, you may invite our coaches to speak at your Grand Rounds:
    1. Susan Hallbeck, PhD, the Robert D. and Patricia E. Kern Scientific Director for Health Care Systems Engineering.
    2. Dr. Geeta Lal, MD, Associate Professor of Surgery at University of Iowa. 

Step 2: Provide the ergonomic champion with training materials [16,17]

  1. Ergonomic principles and guidelines
    1. Position of monitor [16-20] (Figure 1): In the horizontal plane, the monitor should be straight in front of each person and aligned with the forearm-instrument motor axis to avoid axial rotation of the spine. In the sagittal plane, the monitor should be positioned with the center of the screen 10-20 degrees below eye level (i.e., the top of the screen at eye level). This position mimics the neutral orientation of the human eye in its orbit, which is at an inclination of 15 degrees, and avoids awkward neck extension and flexion.
    2. Height of the operating table [19,21] (Figure 2): The table should be adjusted for tallest surgeon with shorter surgeons on steps. This may disadvantage shorter surgeons, as steps are only available in fixed heights. For open surgery, the angle of the elbow joint should be between 90 and 120 degrees. Laparoscopic instrument handles should be close to surgeons’ elbow level (64-77 cm above floor).
    3. Use and position of foot pedal [19,22]: Pedals should be near the foot and aligned in the same direction as the instruments (toward target quadrant and principal monitor). If the surgeon is on a step, the pedal must be at the same level.
    4. Port placement [19] (Figure 3): The ideal manipulation angle is between 45 and 75 degrees with equal azimuth angles. The target organ should be 15-20 cm from the optical trocar. The two remaining trocars are placed in the same 15-20 cm arc at 5-7cm on either side of the optical trocars.
    5. Footrests [23]: Prop alternating feet on foot stools to decrease the effects of static posture.
    6. Sit/stand stools for micro-breaks [23]: Sit when the case allows. Alternating sitting and standing increases blood flow as well as the number of muscles used (and therefore the distribution of load on different parts of the body). Stools should be placed at a height that allows the surgeons to look straight ahead during sit/stand breaks to provide relief to neck and shoulders.
    7. Lead aprons [23]: Two-piece aprons are more ergonomic. Minimize time wearing lead. Consider use of a portable lead shield instead of an apron.
    8. Anti-fatigue mats and footwear [23]: Antifatigue mats are designed (with holes on the top or a foam bottom) to cause a slight postural sway that induces minor activation of the leg muscles, improving blood flow and reducing blood pooling. Anti-slip and other regular soft mats do not necessarily have anti-fatigue properties. Avoid mats with thick cushioning because they may induce too much instability and increase muscle demand. Choose a mat with tapered sides that do not slide and that have a top anti-skid coating to reduce the possibility of tripping or slipping. Institutions may limit purchases to particular mats or materials for infectious control reasons.
    9. Positioning [23]: During lifting and moving, position yourself as close to the patient as possible. Face the work area when performing tasks. Avoid reaching behind your shoulders. Avoid working with neck flexed more than 30 degree or rotated for more than 1 minute.
    10. Extra-working physical activity is protective. [5]


Ergonomic intervention #2: An Intraoperative Microbreak and Exercise Intervention for Surgeons, adapted from Park et al., 2017 and Hallbeck et al 2017, [8] to be implemented during surgery

Step 1: Select a trainer and have trainer familiarize themselves with the content.

  1. The protocol provides 1.5 minute microbreaks with 70 second exercises that should be performed at appropriate 30-120 min intervals throughout each case. Each stretching exercise is designed to be completed while maintaining sterile technique. Standing and seated options are available.
    1. Neck exercises (flexion, extension, lateral rotation)
    2. Shoulder exercises (backward shoulder rolls with chest stretch)
    3. Upper back and hand (upper back and hand stretch)
    4. Foot and ankle (forefoot and heel lifts for lower extremity and ankle stretches)
  2. See script, videos, and posters for standing and seated exercises.
  3. An app may also be found at ORStretch.mayoclinic.org. Log in using your email-you will be asked to complete a survey.
  4. The Society of Surgical Ergonomics created online modules that are the source material for the SCORE module on ergonomics.

Step 2: Train all members of the operating team to implement the microbreak exercises in the OR

  1. Identify 10 minutes of protected time for various members of the OR team.
    1. Didactic curricular time for residents
    2. Grand Rounds or M&M for residents and faculty
    3. OR staff meeting for circulators and scrubs
  2. Explain the purpose of the session, teach the exercises, and provide practice time. You may use or adapt our PowerPoint slides.
  3. Consider distributing scripts or hanging these posters for standing or seated exercises in the OR. An app may also be found at ORStretch.mayoclinic.org (log in using the surgeons’ email; no password needed; you will be emailed research surveys).

Step 3: Designate an individual on the operating team (e.g., nurse) to be responsible for implementing microbreaks on the day of the surgery

  1. Identify anon-sterile individual on the operating team (e.g., circulating nurse) to be responsible for implementing microbreaks on the day of the surgery.
  2. Discuss the best timing during the procedure for the team to pause and perform the microbreak exercises.
  3. This individual will keep track of time and remind the surgeons when the microbreak exercises are to be performed.
    1. The app (ORStretch.mayoclinic.org) may be used to keep track of time. The reminder interval can be set between 30 and 120 minutes by 15 minute increments.
    2. The app has a “Snooze” button (5 minutes increments, up to 40 minutes) if the reminder falls at an inconvenient time.
  4. This individual will lead the exercises, using any of the following options:
    1. Reading the script and/or posters for standing or seated exercises.
    2. Pressing “Go” on the app. If this option is chosen, the individual should check all equipment prior to the start of the case to ensure:
      1. The app is accessible from the OR computer (i.e., internet is working, firewall does not prohibit access)
      2. The screen is visible from the sterile field (i.e., can be projected to laparoscopy monitors)
      3. The speakers are audible from the sterile field (i.e., check sound levels)
      4. The computer will not go into “sleep” mode during the operation                                                                                                                                                                   

Ergonomic intervention #3: Self-treatment exercises, to be performed before and after the surgical procedures. 

Step 1: Have trainer familiarize themselves with the exercises

  1. From Giago et al. (Figure 4): [5]
    1. These exercises are designed to be performed 5 minutes before and after the procedure.
    2. The first phase consists of nonresistance active exercises. Each should be performed for at least 10 repetitions.
      1. Neck roll
      2. Shoulder shrug
      3. Bend elbow, extend arm forward at shoulder height, bend elbow
      4. Clasp hands and extend arms in front, then above head and tilt to either side
      5. Put hands on hips and laterally rotate torso
    3. The second phase consists of static stretching. Each should be held for at least 20 seconds per muscle group
      1. Neck flexion
      2. Clasp hands behind back; pull one arm down and tilt the head in the opposite direction to stretch the ipsilateral neck
      3. Clasp hands behind back and lift up, pushing chest forward
      4. Cross one leg over the other, leaning into it, then stretch arm above head to contralateral side
      5. Stand in front of a wall and laterally rotate torso to put palms on wall
  2. From the Mayo:
    1. These were designed to be done discreetly, as some surgeons did not want to be perceived as physically struggling. They can be performed without others knowing they are exercises or stretches (e.g., in the OR lounge or in meetings).
      1. Hamstring stretch
      2. Seated trunk extension & flexion
      3. Shoulder shrugs
      4. Neck extension & flexion
      5. Seated trunk rotation
      6. Trunk rotation with hip stretch
      7. Seated lateral trunk rotation
      8. Shoulder extension with neutral tension
      9. Shoulder flexion with neutral tension
    2. A video is available.
    3. The Society of Surgical Ergonomics created online modules that are the source material for the SCORE module on ergonomics

Step 2: Provide training to surgeons

  1. Identify 1 hour of protected time for surgeons.
    1. Didactic curricular time for residents
    2. Grand Rounds or M&M for residents and faculty
  2. Deliver the content. Provide practice time for exercises. You may use or adapt our PowerPoint slides.
  3. Consider distributing handouts:
    1. From Giago et al.
    2. From the Mayo.
  4. At Northwestern, Dr. Rho, the ergonomic champion provided postural assessments for interested faculty and staff after her session. 



                                                (Figure 1)                                         (Figure 2)                                               (Figure 3)

              

            (Figure 4)


                                                                                                                                                                                                                                                                                            

    Additional Resources                                                                                                                                        

           

    Helpful Resources for Implementation                                                                                                 

                                                                                                                                                                                                                       


    Mayo Clinic                                                                                                                                                                                                 

    Coach: Juliane Bingener-Casey, MD, Professor of Surgery                                                                                                                                                                                                          Contact: bingenercasey.juliane@mayo.edu                                                                                                                                                                                                                                Coach: Susan Hallbeck, PhD, PE, CPE, Professor, Health Care Systems Engineering                                                                                                                                                             Contact: hallbeck.susan@mayo.edu                 

                                                                                                                                                                                                                   

    University of Iowa                                                                                                                                                                                                                                                                             

    Coach: Geeta Lal, MD, Associate Professor of Surgery                                                                                                                                                                                                                      Contact: geeta-lal-2@uiowa.edu                                                                                                                                                                                                                                                        


    Collaboration Networking/Implementations in Process                                                                                                                                                                                                                       

                  

    Northwestern University                                                                                                                                                                                                                        

    Coach: Monica Rho, MD, Chief of Musculoskeletal Medicine at Shirley Ryan AbilityLab, Associate Professor, Department of Physical Medicine & Rehabilitation              Contact: mrho@sralab.org


    References                                                                                                           

    1. Berguer R. Surgery and ergonomics. Archives of surgery. 1999 Sep 1;134(9):1011-6.
    2. Sari V, Nieboer TE, Vierhout ME, Stegeman DF, Kluivers KB. The operation room as a hostile environment for surgeons: physical complaints during and after laparoscopy. Minimally Invasive Therapy & Allied Technologies. 2010 Apr 1;19(2):105-9.
    3. Plerhoples TA, Hernandez-Boussard T, Wren SM. The aching surgeon: a survey of physical discomfort and symptoms following open, laparoscopic, and robotic surgery. Journal of robotic surgery. 2012 Mar 1;6(1):65-72.
    4. Park A, Lee G, Seagull FJ, Meenaghan N, Dexter D. Patients benefit while surgeons suffer: an impending epidemic. Journal of the American College of Surgeons. 2010 Mar 1;210(3):306-13.
    5. Giagio S, Volpe G, Pillastrini P, Gasparre G, Frizziero A, Squizzato F. A Preventive Program for Work-related Musculoskeletal Disorders Among Surgeons: Outcomes of a Randomized Controlled Clinical Trial. Annals of surgery. 2019 Dec 1;270(6):969-75.
    6. Szeto GP, Ho P, Ting AC, Poon JT, Cheng SW, Tsang RC. Work-related musculoskeletal symptoms in surgeons. Journal of occupational rehabilitation. 2009 Jun 1;19(2):175-84.
    7. Cimbak, N, Stolarski A, Moseley J, O’Neal P, Whang E, KristoG. (2019) Burnout Leads to Premature Surgeon Retirement: A Nationwide Survey. Journal of Surgery and Research 2: 159-169.
    8. Coleman DM, Money SR, Meltzer AJ, Wohlauer M, Drudi LM, Freischlag JA, Hallbeck MS, Halloran B, Huber TS, Shanafelt T, Sheahan M; SVSWellness Task Force. Vascular Surgeon Wellness and Burnout: A Report from the SVS Wellness Task Force. Journal of Vascular Surgery. 2020 Nov 25:S0741-5214(20)32466-6. doi: 10.1016/j.jvs.2020.10.065.
    9. Davila VJ, Meltzer AJ, Hallbeck MS, Stone WM, Money SR.(2019). Physical Discomfort, Professional Satisfaction, and Burnout in Vascular Surgeons. Journal of Vascular Surgery, 70(3), 913-920.
    10. Wohlauer M, Coleman DM, Sheahan M, Meltzer AJ, Halloran B, Hallbeck MS, Money S. (2019). SS12. I Feel Your Pain —a Day in the Life of a Vascular Surgeon: Results of a National Survey. Journal of Vascular Surgery, 69(6), e189.
    11. Wohlauer M, Coleman DM, Sheahan MG, Meltzer AJ, Halloran B, Hallbeck S, Money SR; SVS Wellness Task Force. (2020) Physical pain and musculoskeletal discomfort in vascular surgeons. Journal of Vascular Surgery: S0741-5214(20)31893-0. doi:10.1016/j.jvs.2020.07.097. 6.
    12. Wells AC, Kjellman M, Harper SJF, Forsman M, Hallbeck MS. (2019). Operating Hurts: A Study of EAES Surgeons. Surgical Endoscopy, 33, 933–940.7.
    13. Hallbeck MS, Lowndes BR, Bingener J, AbdelrahmanAM, Yu D, Bartley A, Park AE. The impact of intraoperative microbreaks with exercises on surgeons: a multi-center cohort study. Applied ergonomics. 2017 Apr 1;60:334-41.
    14. Park AE, Zahiri HR, Hallbeck MS, Augenstein V, Sutton E, Yu D, Lowndes BR, Bingener J. Intraoperative “micro breaks” with targeted stretching enhance surgeon physical function and mental focus. Annals of surgery. 2017 Feb 1;265(2):340-6.
    15. Abdelall ES, Lowndes BR, Abdelrahman AM, Hawthorne HJ, Hallbeck MS. Mini Breaks, Many Benefits: Development and Pilot Testing of an Intraoperative Microbreak Stretch Web-Application for Surgeons. Proceedings of the Human Factors and Ergonomics Society Annual Meeting. 2018;62(1):1042-1046. doi:10.1177/15419312186212408.
    16. Ronstrom C, Hallbeck S, Lowndes B, Chrouser K. Surgical Ergonomics. In: Surgeons as Educators [Internet]. Gewerbestrasse11, 6330 Cham, Switzerland: Springer International Publishing; 2018. p. 387–417. Available from: https://doi.org/10.1007/978-3-319-64728-99.
    17. Mayo Foundation for Medical Education and Research (2022). Surgical ergonomics [Online Course]. Learning Solutions Center. https://mccmscontent.mayo.edu/LSC/SErgo/index.html#/.
    18. Van Det MJ, Meijerink WJ, Hoff C, Totte ER, Pierie JP. Optimal ergonomics for laparoscopic surgery in minimally invasive surgery suites: a review and guidelines. Surgical endoscopy. 2009 Jun 1;23(6):1279-85.10.
    19. Yeola ME, Gode D, Bora AK. Ergonomics in laparoscopy. Int J Recent Surg Med Sci 2017;3(2):102-108.11.
    20. Albayrak A. Ergonomics in the operating room: Transition from open to image-based surgery.12.
    21. Berquer R, Smith WD, Davis S. An ergonomic study of the optimum operating table height for laparoscopic surgery. Surgical Endoscopy and Other Interventional Techniques. 2002 Mar 1;16(3):416-13.
    22. Van Veelen MA, Snijders CJ, Van Leeuwen E, Goossens RH, Kazemier G. Improvement of foot pedals used during surgery based on new ergonomic guidelines. Surgical Endoscopy And Other Interventional Techniques. 2003 Jul 1;17(7):1086-91.14.
    23. Hughes NL, Nelson A, Matz MW, Lloyd J. AORN Ergonomic Tool 4: Solutions for prolonged standing in perioperative settings. AORN journal. 2011 Jun 1;93(6):767-74.
    24. Hemmati P, Nguyen TC, Dearani JA. Ergonomics for Surgeons by Surgeons—Posture, Loupes, and Exercise. JAMA Surg. 2022;157(9):751–752. doi:10.1001/jamasurg.2022.0676.