Primum Non Nocere: To Our Body! Surgical Ergonomics for Vascular and Endovascular Surgeons

Technological advancements in vascular and endovascular surgery result in treating more complex procedures; however, these time-consuming procedures take a physical toll on the vascular surgeon. Davila VJ etal. did a survey on vascular surgeons and reported that pain was present in 74.7% of surgeons before beginning an operation, in 92.3% during an operation, and in 96.8% at completion, thereby highlighting the strong correlation between self-reported workplace burnout and an increased severity of work-related pain.[1] Wohlauer etal. did a survey on practicing vascular surgeons that showed 36.9% had sought medical care for work-related pain, 8.3% took time away from the operating room, 26.2% reported pain severe enough to interfere with sleep, and 10% required surgery or other significant medical procedures for work-related musculoskeletal pain. This survey reported that 26% ended their careers owing to physical disabilities from work-related pain, and 52.7% mentioned that physical discomfort affected the longevity of their careers.[2] This increased work-related musculoskeletal pain can affect the cognitive attention resources for the surgeon,[3] affect the surgical decision-making,[4] and potentially impact the surgical outcome.[5] In 1915, GiIbreth made an analysis of hospital efficiency and emphasized that the work simplification is essential for the operating person to achieve maximum efficiency.[6] In 1944, McCarty, suggested that motion simplification reduces the surgical fatigue and gives the desired result in the simplest way.[7] In 2017, Gibbon, at the American College of Surgeons 102nd Annual Clinical Congress, in his lecture "The Elite Athlete, the Master Surgeon," described surgery as a high-performance sports which needs grit, growing mindset, and deliberate practice.[8] It has been more than 100 years since these scientific papers have emphasized the importance of surgical ergonomics; however, unfortunately, it is still underestimated and underemphasized. All of the above-mentioned literature suggests that our bodies undergo tremendous physical stress and we need to concentrate on healthy work ergonomics, i.e., do no harm to ourselves to improve our patient care. Being surgeons, we are very often proudly stoic, do not seek help, and suffer in silence due to poor surgical ergonomics. However, it is the need of the hour to take concrete steps in making surgical ergonomics a part of our daily routine. As surgical mentors, we teach our students Vascular and Endovascular Surgical skills, and hence, it is also our responsibility to imbibe surgical ergonomics dos and don'ts during their training period. Appropriate posture, proper use of loupes, appropriate placement of equipment, and exercise help to mitigate physical pain, prevent injuries, prolong career longevity, and the surgical outcome. The key points related to surgical ergonomics for vascular and endovascular surgeons are:[9] OPERATING TABLE Open surgery: The height should be at elbow level in such a way that the elbow is at 90°, hands are close to the elbow, shoulders, and upper arms are relaxed [Figure 1]. Figure 1: Operating table-dos and don'tEndovascular procedure: In the angio suite/cath lab, adjust the table height to maintain the elbow joint in the neutral position and thereby preventing the operator from bending forward. b. Table height to be adjusted for the tallest surgeon and others to use step/stool. Consider using OR grade anti-fatigue mats or soft insoles, especially when the operator needs to stand on hard floors for long periods. MONITOR Especially for endovascular or hybrid procedures, the monitor screen is to be placed in front of the operator, just below the eye level, at a downward viewing angle of 10°–15° to decrease neck strain [Figure 2]. Ceiling-mounted flexible C-arms, monitors, and large screen high-definition monitors help ergonomic multimodal visualization, reducing strain on the eyes and cervical spine.Figure 2: Monitor positionPOSTURE: SPINE, HANDS, GLOVES, LOUPES, LEAD APRONS Posture & Spine In neutral spine position, the cervical, thoracic, and lumbar curves align properly, and thereby decrease the strain on intervertebral discs and muscles. Avoid excessive neck rotation and do not tilt more than 15°, especially while operating in deep cavities or doing endovascular procedures. Avoid putting more weight on one leg or other and occasionally keep shifting weight from one foot to another, especially during long-standing procedures. Hands Hands are to be kept in such a way that the position of the elbow is between 90° and 120° and the wrist is in a near neutral posture (work in box pattern) [Figure 3].Figure 3: Hands-work in boxGloves As surgeons, we ought to know the right instruments for the procedure. Similarly, we need to know our correct glove size because ill-fitting gloves will cause discomfort while operating, lead to clumsy hand movements, and, eventually, early fatigue. Anatomically correct and ergonomically appropriate double gloves with proper grip help improve the surgical efficiency of the operator. Loupes Loupes aid in increasing the visual acquity and thereby improve the surgical outcome. However, the weight of loupes can cause strain on the cervical spine. It is recommended to use loupes that are light weighted, have sufficient depth of the surgical field, stress-free parallel viewing with modified declination angle to minimize forward neck bending. Clean the loupes regularly to ensure superior visual acuity. Lead Aprons Especially for Endovascular and Hybrid Angio suite procedures light weight lead aprons are recommended. These ergonomically designed aprons limit weight on the back and shoulders, have specially designed lumbar support that significantly reduces discomfort and muscle fatigue. POSITION OF PATIENT, INSTRUMENTS, AND LIGHT Depending on the type of surgery, the patient's arms to be tucked in or out and the torso is to be placed in such a way that the surgeon's neutral spine posture is maintained. Avoid excess forward bending or trunk twisting to gain operative field accessibility. The instruments should be chosen to assist neutral postures, minimize wrist flexion and rotation, and ulnar deviation. Choose the appropriate instrument and hold it using a power grip to minimize finger fatigue. The foot pedal should be placed in such a way that there is minimal ankle dorsiflexion, and position the pedals to be within reach without having to balance on the opposite foot. The overhead lights should have high illuminance and two or more OR lights to be adjusted at different angles between the surgeon and assistant. If the operator is using light-fitted loupes then avoid creating shadows from the light source and use light-weighted loupes. PRE AND POST CASE STRETCHING EXERCISES Avoid prolonged static postures, and whenever possible, take minibreaks to do stretching exercises. Neck and shoulder stretching exercises followed by lumbrical stretching and passive wrist extension are recommended [Figures 4 and 5].Figure 4: Pre and post case stretching exercisesFigure 5: Pre and post case stretching exercisesAll athletes have coaches that pay attention to the needs and demands of their trainee's bodies to promote consistency and longevity so that the athletes excel in their sports. In a similar way, as mentors surgical mentors, we need to have a structured training program for surgeons emphasizing the importance of surgical ergonomics inside and outside the operation theater, appropriate optimization of materials inside the theaters and promoting regular stretches/physical exercises for surgeons so that both surgeon and patient health is benefitted and eventually better long-lasting surgical outcome. Acknowledgment for operative ergonomics illustrations Dr. Rapaka Rohit Reddy, Vascular and Endovascular Senior Registrar, Care Hospital, Hyderabad.