ERGONOMICS IN LAPAROSCOPIC SURGERY

By
Dr Hemant Bhansali
MS, FCPS, FICS, FACG, PhD (Lap. Surgery), LLB

TABLE OF CONTENTS

1. INTRODUCTION
1.1 Rationale
1.2Applications

2. LITERATURE REVIEW
2.1 Work Related Injuries
2.2 Psychophysics in Laparoscopic Surgery
2.3 Ergonomics Problematic Areas in Laparoscopic Surgery
2.3 .1. Surgical Team
a Surgeon
Posture of Shoulder, Elbow/arm, Gaze, Movements of
arm, Grasping, Suturing, Pointing and Speed
b Assistant
Position and Posture, Gaze pattern
c Cameraman
2.3.2 Instruments
Handle ergonomics, Jaws/Length
2.3.3 Operation Theatre Ergonomics
Table Height, Monitor, Instrument Set-up
2.4 Muscle Fatigue and Score
2.4.1 Fatigue and RULA
2.4.2 Stress Index
2.4.3 Fatigue and Endurance
2.5 Summary

1
 3. EXPERIMENTAL METHODS AND UNIFIED ERGONOMICS SCORE
3.1 Overview
3.2. Work Factors
3.2.a Postural Code
3.2.b Bio-Mechanical Index
3.2 c Stress Index
3.2.d Eye Stress Score
3.2.e Combined Index
3.3 Variables for Score
3.4 Score Testing and Evaluation
3.5 Analysis
3.6 Biomechanics
4. RESULTS
Relationship between Subject, Posture and Muscle Strength
Relation between Strength,Torque,Fatigue and Endurance
5 DISCUSSION
Summary of Study
Effects of Posture on MSD
Relation between Strength and MSD
Relation between Contributing Factors and various common
Laparoscopic Surgeries
Improvement of Technique depending upon the Score
Improvement of Suturing Technique
Limitations of the Study
Conclusions
6 REFERENCES

LIST OF FIGURES

LIST OF TABLES

2
 1. INTRODUCTION

10.1 RATIONALE
Ergonomics is the ‘‘science relating man and his work, embodying the anatomic
physiologic, psychological, and mechanical principles affecting the efficient
use of human energy’’ (1) Laparoscopic surgery may be kinder to the patient,
but it is more demanding on the surgeon. Fixed trocar positions often
require the surgeon to work with instruments at awkward angles to their
body (1).

Little research has been done to investigate the kinematics motion analysis and
kinetics (muscle work, muscle fatigue, comfort) of surgeons during laparoscopic
surgery. The surgeon operates at a disadvantage during laparoscopic surgery
because all instrument traffic is through ports anchored within the abdominal
wall. Aside from these intrinsic limitations of laparoscopic surgery, there are other
important performance-shaping factors. Highly developed motor skills are
required of the surgeon. Changing instruments and repositioning within the
abdomen are cumbersome and time consuming because of the need to introduce
the instrument through the trocar. Foot switches, which are necessary for

3
additional instrument functions such as electro coagulation or suctioning and
irrigation, at times, demand that the surgeon be able to perform these precise
surgical maneuvers while standing on one leg(2). The awkward stance acquired,
the surgeon has to sustain for long periods, often with both arms abducted, and
the design of the handle of the endoscopic instruments used to execute the steps
of the laparoscopic operation will produce much discomfort.
Discomfort is the most conspicuous effect of localized fatigue. Measurement of
discomfort draws on the field of psychophysics. Psychophysics is defined by
Gescheider (1997)(12) as the scientific study of the relationship between stimuli
and sensation - in other words, it is the study of how the body perceives outside
influences that act upon it. Each individual may have differing perceptions of
external stimuli that act on the body at any given time. For example, some may
only be willing to comfortably lift a small fraction of their physical maximum.
Others, however, may be willing to lift a significantly greater fraction of their
physical maximum, while still fulfilling the self-defined criterion of ‘comfort’.
Individuals that do not accurately perceive a safe physical capacity may be at a
higher risk of overestimating physical limits and consequently an increased risk of
injury. Snook (1978),(15) in his classic article 'The Design of Manual Handling
Tasks’, suggested that the individual worker is the only one who can best sense
various strains on the body which are associated with manual handling tasks. He
also suggested that only the worker or operator could integrate these individual
sensory inputs into one meaningful ‘whole body’ response.
A combination of factors contributes to laparoscopic surgeons fatigue and chronic
MSD (Musculo-skeletal Disorders) and injuries. The lengths of the instruments,
degree of precision, postural requirements become the contributing factors. It is

4
known that musculoskeletal disorders are generally caused from over-exertion in
performing MMH (Manual Handling) tasks (Gallagher, 1988) (13) and poor
working postures (Putz-Anderson, 1988). Therefore, an ergonomic evaluation of
postural stress as well as biomechanical stress is important to improve working
methods on the basis of identifying and eliminating harmful working postures.(2)
Work techniques and skill level are sometimes predominant factors influencing
musculo-skeletal disorders. However, sometimes-individual anatomy, work style,
posture, and correct technique also are influencing factors. Discomfort can be
further quantified with established pain or effort scales such as that described by
Borg (1982, 1990)

In order to minimize the risk of injuries resulting from two handed laparoscopic
surgeries or with the odd posture and angles of upper arm holding the
instruments, guidelines have to be established to set limits regarding the amount
of shoulder elevation or abduction movements of the arm during the surgery. The
guidelines, such as the NIOSH Work Practices Guide for Manual Lifting (WPG), are
partially reliant on subjective data that has been gathered from various research
findings (Waters, et al., 1993). The bulk of the NIOSH-reviewed studies (Bernard
and Fine, 1997, Ex. 26-1) (14) do not provide sufficient evidence for the link
of postural factors with CTS. However, de Krom et al. (1990, Ex. 26-102) found
associations between awkward (flexed and extended) wrist postures and Carpel
Tunnel Syndromes (CTS)and the strength of association increased with hours of
exposure.

5
Fatigue during Laparoscopic Surgery is defined as subjective and objective
changes that occur in the areas of body because of sustained or repeated exertion
of that part or muscle of the body. This subjective data is obtained by using
psychophysical methods to determine endurance of the muscle. One reason for
the frequent use of the psychophysical approach in the last few decades is the
relative ease of obtaining data through this method. Alternate methods for
establishing limits or guidelines, such as the biomechanical and physiological
approaches, can take much longer and be more costly to perform. For many
researchers and practitioners, the psychophysical method has become the
method of choice when a quick evaluation of workload is needed. In laparoscopic
surgery, the type of surgery, the extent of the time required for execution
requires surgeon to assume atypical or unnatural positions. As a result, he suffers
from muscle fatigue, discomfort and Repetitive Stress Syndrome (RSS)
When employing the psychophysical methodology, two main approaches are
typically used: 1) self-reporting of the effort levels exerted to resist an external
force or torque: 2) the method of adjustment, in which a technique is adjusted by
surgeon until it is perceived to be a comfortable. In order to use such subjective
data, one must assume that an individual can accurately identify the physical
stresses to which his or her body is subjected during a given surgery. In addition,
it must be assumed that the use of such data when compiled as guidelines or a
Combined Stress Score will lead to a safer and stress free laparoscopic surgeries

There were two main goals in this study. The first was to determine the
correspondence between biomechanical force on upper arm and shoulder and
subjective ratings of joint loads, as well as subjectively determined maximal loads.

6
A unified stress or postural score tells the strain on the body. Joint loads and
moments were determined using standard kinetic analysis of multiple joints
(specifically the shoulder, elbow and low back). Maximally acceptable angles of
joints were determined by using the psychophysical method of adjustment
(Gescheider, 1997), whereby each subject adjusted the angle of flexion and
abduction, until the surgery fits a comfort criterion set through verbal
instructions. Subjective ratings of exertion were obtained by prompting the
subject for a perceived level of exertion while a load was statically supported in a
specific posture. These ratings reflected the subject’s perception of the exertion
that was put forth for each task. The postures in which the subject posed were
selected to isolate specific joints (elbow, shoulder and low back). Subjective
ratings at each of these joints were later compared to a baseline posture so that
any rating trends could be examined.
The second goal was to identify whether any particular joint (i.e. twisted trunk,
shoulder, and elbow) is the limiting factor when a surgeon does laparoscopic
intracorporeal suturing. In other words, the goal was to find whether there is a
'weak link' of the body.

10.2 METHOD and ANALYSIS

10.2. Work Factors

10.2.a Postural Score
10.2.b Bio-Mechanical Index
10.2 c Stress Index
10.2.d Eye Stress Score
10.2.e Combined Index

7
A Postural code was developed through the combined study of OWAS or Ovako
Working Posture Analysis System, RULA or The Rapid Upper Limb Assessment,
REBA or Rapid Entire Body Assessment and Moore-Garg Strain Index
The following diagram represents the methodology to come to a unified score
which we coin as BJ Score.

8
POSTURAL SCORE EVALUATION MODEL

Upper Arm (Shoulder)

In laparoscopic surgery, the use of legs is limited as surgeons will always be

standing and therefore, in evaluating the score, we have emphasised the use of
arms. During laparoscopic surgery, legs are always in fixed position and with
simultaneous use of two hands, the left-hand crosses the midline often whereas,
the right-hand is always in a working posture. The postural score for arm was
calculated as given below.

Upper Arm Score

Both arms below Shoulder 1

One arm above or Below 2

shoulder
Both the arms above shoulder 3
Add +1 for each if the arm Max. 5
abduct

Lower Arm (Elbows) Score

Score L R

9
Flexion 60-100 1 If Crosses midline, Add
(If 0 to +10 cm of OR table) 1
Flexion 0-60 or >100
(If 0 to -10 or >+10 cm 2
Max. 3 for each elbow and if
crossing the midline , maximum is 4 at any given time

Hand/wrist Posture Score

Hand/Wrist (flexion- Pronation/

extension)(in degrees) Ulnar/Radial Supination
deviation
+1
Neutral (-5 - +5) 1 15-15
Add 1
Moderate Flexion (-15-+15) 2 <15- >15
Add 2
Severe Flexion (<-15;>+15 ) 3

Max. 6 for each hand

Total 12

TABLE A-Arm Score

Upper Arm+Lower Arm+ Wrist =Table A Score

Upper Lower Wrist Total
Arm Arm score
1 2Ulnar 3
Flexion Deviation Pronation/
Supination

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1 1 1 1
2 2 1
3 3 2
4
2 1 1 1 1
2 2 2
3 3
4
3 1 1 1 1
2 2 2
3 3
4
4 1 1 1 1
2 2 2
3 3
4
5 1 1 1 1
2 2 2
3 3
4

Table A or First Digit= Total is Upper arm Lower arm + wrist score = 21 (maximum
Score)

Trunk
Erect 1

Bend forwards or 2
Backwards
Inclined sideways or 3
Twisted
Inclined +Twist or 4
Inclined+
Forward/Backward Bend
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Maximum Score =4

Neck

Neutral 1 0-20

Moderate 2 20-50
Flexion/Extension
Severe Flexion/Extension 3 > 50

Mild Lateral Add 1 30-45

bending/Twisting
Severe Lateral Add 1 > 45
bending/Twisting

Maximum allowable score =4

Legs

Seated on proper seat 1

Standing Neutral or Well 1

Balanced
Standing on one foot with 2
one strained leg
Standing with one folded 3
knee
Standing with both folded 4
knees

Maximum Total score =4

Table B = second digit= score = Trunk+ Neck + Legs score

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Total maximum score=12

Synchronization /Simultaneous use /Coupling Score

Since laparoscopic surgery is always considered as two handed surgery wherein
the dominant hand(Right) is in working action of dissection, cutting, clipping,
pushing, pulling etc and the other hand (left) is considered in a supportive role of
grasping and retraction, counter pressure, grasping and holding etc. However, for
the perfect execution of the task both hand should move in a synchronous
manner.

Synchronization Score is

Good 0
Fair 1
Poor 2
Unacceptable 3

Therfore, Total Postural Score is

U. Extremity
U.Arm
L. Arm Posture Score
Wrist
+

Neck L.Extremity

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Trunk
Legs

Total Maximum allowable Postural is 21+12+3 = 36

(B) BIOSTRESS EVALUATION MODEL

This will have two important factors. The first and important is Anthropometric
data and the second factor is related to weight load. Since laparoscopic surgeon is
not required to lift heavy weight, the second factor can be ignored.
Sex Factor/Muscle Power
In muscle strength, Women are only 68-71 percent of the cross sectional area of
that of men, the correction factor is required for the score. It is calculated as 0.5
as the exactness of 0.6 or 0.7 would have made calculations difficult and as such
also, the accuracy is really not required.

Add for
Male 0

Female 0.5

Age/Muscle power factor

Medical profession is the only one where there is no retirement age. Surgeons of
even 70 years also perform alongside of surgeons with the age of 30 years. The
enthusiasm of learning new techniques and their application is seen even at the
age of 70 years and the biggest example is Laparoscopic surgeries where surgeons
at all ages have strived to learn basic as well as advanced courses. However, it is

14
shown that Muscle strength appears to be relatively well maintained up through
50 years of age. A 15% loss in muscle strength per decade occurs between the
ages of 50 and 70 years of age. The decline in muscle strength with aging can be
attributed to the loss of muscle mass (From 24-50 years of age, 10% of the total
muscle cross-sectional area is lost. Thereafter, muscle atrophy is accelerated so
that between 50 and 80 years of age, an additional 30% of total muscle cross-
sectional area is lost.

AGE SCORE

< 50 years 0

50-60 years +1.5

60-70 years +3
>70 years +4.5

(Since muscle use is taken in strain index and since the force or heavy weight
lifting is not involved in laparoscopic or general surgery, their consideration as in
RULA or REBA score is not taken into account)

Eye Strain Score

Continuous and intense watching of the monitor screen causes severe eye strain.
Though the eye strain is dependent upon the flicker rate of the screen, for a
normal CRT monitor. For each symptom add 1

15
Excessive Blurry or teary Blurry 1
Inability to visualise the screen 1
properly
Increased demand for glasses or 1
Reversal of Image
Headaches 1
Mental Fatigue,Irritable,Exhaution 1
Maximum Total score = 5

Previous Disease Factor

Factors specific to the individual can also affect the development
and/or manifestation of pathology. These include, for example, preexisting
injuries or illnesses (such as diabetes, degenerative joint disease, or rheumatoid
joint disease); individual susceptibility to injury or tissue damage (related to
anthropometric characteristics, physical conditioning, age, or genetics); and a
vocational activities or hobbies. These can interact in a complex fashion, such that
work acts either as a causative, contributing, or accelerating factor in the
development and/or manifestation of disease (Putz-Anderson, Doyle, and Hales,
1992, Ex. 26-419; Rempel, Harrison, and Barnhart, 1992, Ex. 26-520). Important
considerations pertain to interactions between co-existing MSDs. For example,
once an MSD is established, subsequent physical compensatory changes
can further predispose an individual to the development of additional MSDs.
When injury causes an altered posture, decreased range of motion, or weakness
or ability to respond to tactile feedback to one joint or region, there is often
increased risk of injury to another joint or region due to compensatory, increased

16
loading. One example is the loss of tactile feedback from CTS, leading to
greater hand force output that in turn contributes to the development of
tendonitis or epicondylitis.

Normal,Healthy 0
Localised diseases & 1
Disabilities like MSD, Arthritis,
Systemic diseases Like 2
Diabetes,Hypertension,Cardiac
problems

Maximum total =3

Table C score = Sex + Age score + Eye Strain+ Previous Disease Factor =
Maximum Total Score=13

C) WORKLOAD ASSESSMENT:

Calculation of Strain Index or Bio-mechanical Strain Index (Based on Moore and

Garg Strain Index)

This is a subjective rating. This rating is found by observing one or more surgeons
or medical personnel at work performing laparoscopic surgeries and thus rating is
based on the verbal description or their rating on Borg exertion scale.
A surgical procedure is divided into various tasks. For each task and for each
surgeon the risk factors are assessed by assigning them to category. For each
category, there is a rating. The strain index is a product of this rating.
Following guide is used to find the ratings.

17
 • Intensity of exertion during dissection-the force required for a single
performance of the task.
• Duration of exertion. It is the proportion of the exertion cycle. Exertion
cycle time is the average length of time associated with each exertion. The
average length of exertion divided by the cycle time multiplied by hundred
gives the duration%.
• Efforts per minute is the frequency of exertion and can be found from the
exertion cycle time (cycle time of 20 seconds is three efforts per minute).
• Speed of work is according to the observer’s perception.
• Duration per day is a total amount of surgical work done in a day.

Rating Intensity of Duration of Effort or Speed of Duration

exertion Exertion(%of Moving hand Work per Day
During Cycle) for in Hours
dissection dissection/Min of work
1 Light or Easy <10 <4 Very <2
slow
2 Somewhat 10-30 4-8 Slow 2-4
Difficult
3 Difficult 31-50 9-14 Fast 4-8
4 Extremely >50 >15 Very Fast > 8
Difficult

Multiplier Table
Rating Intensity Duration of Effort or Speed of Duration
of Exertion(%of Moving hand Work per Day in
exertion Cycle) for Hours of

18
 During dissection/Min work
dissection
1 1 0.5 0.5 1 0.25

2 3 1 1 1 0.5
3 6 1.5 1.5 1.5 0.75
4 9 2 2 2 1

The maximum score will be 64

This is because if he is working very fast may clock in for more than 8 hours to do
more work which again is possible when he finds dissection very easy to perform,
duration of exertion is least and effort of moving hand is minimum.

The stress index is calculated by adding the products of ratings with the
corresponding multiplier.
Strain index =sum of ratings x multiplier for all criteria.

Generally a surgeon may perform more than one surgery a day. The effort
required for the performance will depend upon the difficulty and skill for each
procedure. The average time required will depend upon these factors. Moreover,
he may perform certain steps assisted by his team members to perform other
designated tasks. Alternatively, he may choose to perform all the tasks by himself.
The effort and stress required will be more. This will be calculated as in the last
column of table described above by logging in total number of work hours per
day.

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UNIFIED BJ SCORE:
After analyzing and scoring of all the 3 indices, a unified ergonomic evaluation for
laparoscopic surgeons developed in this study can be used to evaluate the
workload on surgeons. The risk level decisions for surgeons and
recommendations are worked out. The total maximum score for all three criteria
like Postural Score, Biostress Evaluation and Workload will be 113

Category Score Risk Levels

1 0-25 Negligible
2 26-50 Low
3 51-75 Medium
4 76-100 High
5 >100 Very High

The higher the risk factor, the more a surgeon is likely to suffer from temporary or
permanent MSDs.

PART 2

40 surgeons and gynecologist with skill level from training to advanced level were
interviewed for basic data before surgical procedures. They were tacitly observed
for their ergonomical positions. Similarly 20 assistants were also interviewed for
their basic data and were tacitly observed for their ergonomical positions. Their
scores were drawn based on the presented GAJAB score. They were interviewed
again for their problems post surgery.
The score was converted to weighted score.

20
 A) An arbitrarily selected, dimensionless Criterion Weight (i.e. “Importance
Value”)to each Selection Criterion according to its judged worth.

Criterion Description Weight

C1 Postural 35
Score
C2 Bio-Stress 25
Score
C3 Workload 40
score

B) Mutually exclusive, discrete-step Merit Factor Levels within each Selection

Criterion was assigned. A dimensionless Merit Factor Score to each Level
according to its perceived significance was assigned. No score exceeds 1.0.

C1 Merit Factor Merit factor

Level Score
I <9 1.0
II 10-18 0.6
III 19-27 0.3
Iv 28-36 0

C2 Merit Factor Merit factor

Level Score
I <4 1.0
II 5-8 0.6
III 9 0.3

C3 Merit Factor Merit factor

Level Score
I 1-16 1.0
II 17-32 0.7
III 33-48 0.5
IV 49-64 0.2

21
 C) Score each candidate:
Candidate Score =Σ [(Criterion Weight) x (Merit Factor)]
The candidate earning the highest score has excellent ergonomical methods and
least likely to have occupation related MSDs (Musculo-skeletal Disorders).
Note that no candidate score can exceed 100 — the perfect score. The results
were tabulated on a 7 point Liekert Scale
The results were tabulated and analyzed.

RESULTS:

40 surgeons and gynecologist with varying skill levels were recorded. The 3
important scores were postural scores, biostress score and workload scores.
For the surgeons, the Workload scores were more than the rest and were dependent
upon the difficulty of surgery. The Biostress score was more for the surgeons with
systemic disease like diabetes and hypertension. The risk factor was dependent
upon the scores.
The raw score was converted into weighted score to give a disciplined approach
considering multiple criteria.
The data was tabulated as weighted Score for performance effectiveness and to
make the process orderly and persuasive. The process is however entirely
subjective. The results are tabulated on a 7 point Liekert Scale.
C1(35) C2(25) C3(40) Merit factor Total 7 point
Liekert
difficulty Scale
1 18 6.5 18 21+15+28 64 low
2 19 3 35 10.5+25+20 55.5 Moderate

22
3 21 8.5 21.5 10.5+7.5+28 46 Moderate
4 18 4.5 18 21+15+28 64 low
5 24 5 13 10.5+15+40 65.5 low
6 21 2 27.5 10.5+25+28 63.5 low
7 22 2.5 27.5 10.5+25+28 63.5 low
8 22 2 20.5 10.5+25+28 63.5 low
9 22 8.5 33.5 10.5+7.5+20 38 ModeHigh
10 19 4.5 9 10.5+15+40 65.5 low
11 24 5.5 48 10.5+15+20 45.5 ModeHigh
12 26 5 19 10.5+15+28 53.5 Moderate
13 28 2.5 55.5 0+25+8 33 ModeHigh
14 26 4 31.5 10.5+25+28 63.5 Low
15 29 9 30 00+7.5+28 35.5 ModeHigh
16 19 3.5 11.75 10.5+25+40 75.5 AccepLow
17 22 8 13 10.5+15+40 65.5 Low
18 27 10.5 30 10.5+7.5+28 46 Moderate
19 24 7 8 10.5+15+40 65.5 low
20 24 2 33 10.5+25+20 55.5 low
21 25 3.5 32 10.5+25+28 63.5 low
22 21 7 18 10.5+15+28 53.5 low
23 26 7.5 33.5 10.5+15+20 45.5 ModeHigh
24 18 5 15.5 10.5+15+40 65.5 low
25 23 1 31.25 0+25+28 53 Moderate
26 26 3.5 18 10.5+25+28 63.5 Low
27 25 2.5 31.25 10.5+25+28 63.5 Low
28 24 1.5 53.5 10.5+25+8 43.5 ModeHigh
29 16 2 14 21+25+40 86 AcceptLow
30 25 9 30 10.5+7.5+28 46 Moderate
31 21 6.5 36 10.5+15+20 45.5 ModeHigh
32 26 6.5 39.5 10.5+15+20 45.5 ModeHigh
33 27 8 21.5 10.5+15+28 53.5 Moderate
34 13 1 9 10.5+25+40 75.5 AcceptLow
35 22 8.5 33.5 10.5+7.5+20 38 ModeHigh
36 23 2.5 18 10.5+25+28 63.5 low
37 23 4.5 33.5 10.5+15+20 45.5 ModeHigh
38 17 2 14 21+25+40 86 AcceptLow
39 18 4.5 25 21+15+28 64 low
40 14 2 12 21+25+40 86 AcceptLow

23
 difficulty
1 21 3.5 10.5 10.5+25+40 75.5 AcceptLow
2 23 6.5 9 10.5+15+40 65.5 low
3 17 4 9 21+25+40 86 AcceptLow
4 22 4.5 10.5 10.5+15+40 65.5 Low
5 25 5 24.5 10.5+15+28 53.5 Moderate
6 27 5.5 25.5 10.5+15+28 53.5 Moderate
7 27 5.5 9 10.5+15+40 65.5 Low
8 20 2.5 9 10.5+25+40 75.5 AcceptLow
9 22 3.5 9 10.5+25+40 75.5 AcceptLow
10 28 6 25 0+15+28 43 ModeHigh
11 21 3.5 9 10.5+25+40 75.5 AcceptLow
12 27 6.5 25 10.5+15+28 53.5 Moderate
13 22 3 13 10.5+25+40 75.5 AcceptLow
14 28 3.5 25 0+25+28 53 Moderate
15 18 1.5 4 21+25+40 86 AcceptLow
16 26 2 9 10.5+25+40 75.5 AcceptLow
17 25 3.5 13 10.5+25+40 75.5 AcceptLow
18 25 2.5 4 10.5+25+40 75.5 AcceptLow
19 30 6.5 25 0+15+28 43 ModeHigh
20 29 3 25 0+25+40 65 low

Table 1
Lieker value Risk Level No. of No of
tscale Surgeo assistan
ns ts
1 >90 negligible -
2 76-90 Acceptably low 5 10
3 61-75 Low 18 4
4 46-60 Moderate 7 4
5 31-45 Moderately High 10 2
6 16-30 High -
7 0-15 Serious/Very -
High

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Table 2(5 Point Liekert Scale)
Risk level Surgeons MSD complained after surgery
Negligiable Stress
low BackAche, Tired, Digital N Numbness
moderate Supraspinatus Tendinitis, Shoulder pain, Ulnar N tingling
High Supraspinatus Tendinitis, Shoulder pain, Ulnar N and digital
tingling,Low Backache
Unacceptably
High

Symptoms No(60)
Stress/Tired Feeling 18
BackAche 27
Shoulder Pain 25
Suprasinatus Tendinitis 13
Didital N tingling 10
Ulnar N Tingling 11

Many had more than one symptoms.

DISCUSSION:

The individual reparative ability is dependent upon

• Genetic factors. This is dependent upon various anthropometric data, sex,

muscle mass, laxity of ligaments, carpal tunnel size and physiological
variables (Radwin and Lavender, NRC 1998, Ex. 26-37).

• Acquired characteristics. This includes, physical conditioning of an

individual, previous as well as present disease status, aging and its effect.
Acquired characteristics have influence on the genetically based

25
 characteristics. The type and intensity of exercises can change muscle mass
and fibre type distribution in muscle. Similarly, the level of training, skill
and working habits will also affect the bio-mechanical stress on body
tissues.

Work techniques and skill level are sometimes predominant factors influencing
musculo-skeletal disorders. However, sometimes individual anatomy, work style,
posture and correct technique also are influencing factors. Hand problems of
people like musicians, surgeons should be looked on an individual basis because
there is no involvement of lifting of heavy weight or use of tools. (Amadio and
Russotti, 1990, Ex. 26- 925; Fry, 1986, Ex. 26-850)(16,18).In industries like meat
packing the wrist problems are extremely common and associated with particular
task that the identifying cause in a work process is identifiable.(Schottland et al.,
1991, Ex. 26- 1001)(19). However, for professionals like surgeons, the multi-
dimensional pattern of personalized risk factors, external work related risk factors
and non-work risk factors make identifying etiology almost impossible. The
external environment like age factors with chronic and sub chronic diseases may
make differentiating underlying disabling causative or exacerbating features almost
impossible.

In understanding, the etiologies of MSDs, there are problems with measurement,

quantification, recognition of particular disease affecting the outcome for the
surgeons. Research methodologies understanding the association between the
modalities are not properly defined. Following criteria represents the consensus in
the field of epidemiology. However, these are not exhaustive. Any given study
may not satisfy each criterion but, the cumulative effect of all the criteria in
understanding the risk factor of causes of MSDs.

26
• The study requires larger association with operative team. The larger the
association, the less likely is an interpretation having undetected bias.
Knowledge of a known or understandable proposed mechanism aids
determination of cause.

• Consistency with other research. Similar results from independent studies,

especially with different measurement techniques, strengthen a causality
hypothesis.

• Proposed suggestion and response relationship should be properly recorded.

• Specificity of association which refers to the degree to which a particular

disease or discomfort is always associated with a particular risk factor.

Much work is done by authors like R. Berguer and others, in measuring the
postural angles and positions, and suggesting corrections for surgeons and
industry as well to have good ergonomics for procedural positions and
instrumentations. Few other authors have taken the MMG recordings and
combined with surface EMG signals to study the effects of localized fatigue
in the muscle. Electronyographic (EMG) signals have been collected from the
thenar compartment (TH), flexor digitorum superficialis(FDS), and deltoid (DEL)
muscles of the surgeons while performing laparoscopic surgeries. Moreover, the
fixed position of the abdominal wall trocars may require surgeons to move their
upper extremities into awkward positions to manipulate tissues at different angles
inside the body cavity. As the instrument pivots about the abdominal wall trocar,
the surgeon is forced to abduct the arm and flex, ulnar deviate, and supinate the
wrist in order to actuate the handle. These difficult “reaching” maneuvers,
combined with the mechanical inefficiency inherent in the instrument’s design

27
[20], can lead to significant upper extremity muscular effort and strain even among
experienced laparoscopic surgeons.

As much as possible, the risk factor classification analysed here, uses the
definitions and concepts defined by NIOSH in the publication,
Bernard and Fine, 1997, Ex. 26-1), (14) modified to suit surgeons during
laparoscopic surgery. There are two identifiable risk factors: basic risk
factors and modifiers. The basic risk factors discussed are agreeable by
most researchers or causing MSDs. The modifiers are characterized by
specific exposure to a risk factor that may affect the level or type of strain
produced within tissues.

The basic risk factors identifiable for laparoscopic surgery are

• Force

• Awkward postures

• Static postures

• Repetition

• Dynamic factors

The above classification was modified by Kourinka and Forcier (1995, Ex. 26-432)
(21) who linked force, repetition, and duration as components of' 'Musculoskeletal
Load'. It is therefore appropriate that even in laparoscopic surgery; these three
factors make a surgeon wary of doing the surgery producing unsatisfactory results.

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Basic Risk Factors

In Laparoscopic surgery, operating is a primary static task without involving a

heavy load lifting or much movement. Therefore, for a surgeon, the posture merits
the closest risk attention than the dynamic stress factors like range of motion,
speed of working. Total duration of working which is seen in dynamic work
pattern may also contribute to some extent. In defining the score, therefore much
weightage is given to Postural score of upper arm than the trunk. The legs and
trunk are generally kept in a static posture. Repetition as described by
Kourinka(21) will be either a very difficult surgery or multiple surgeries in a given
time of the day. The mechanisms of tissue injury attributable to these factors are as
follows.

A. Force.

Force is the mechanical effort required to carry out a movement or to prevent a

movement in any direction. Force may be exerted against a tissue, to stabilize
body segment or against tool. It may be with or against gravity. Force does not
mean motion. When the load is lifted against gravity the act of lifting as well as
static act of holding in the position, both will require force. There are two types of
forces exerted for particular task, a muscle force and the output force.

a Muscle force. It is the actual mechanical effort exerted by contraction of

muscle fibres. The total strength will depend upon, the length of the muscle during
contraction, the cross-sectional area of the muscles, the various secondary muscles
acting with the main muscles and fatigue .Various authors have tried to categorize
muscle force by measuring the muscle activity by means of
Electromyographic(EMG) and maximum voluntary contraction(MVC) studies. The
other factors which also contribute are shear force, friction, irritation induced by
lateral forces on tendons and tendons sheaths and finally the strain of the tendons

29
at the insertion point on the bones. Hence, the estimation of muscle force from the
task done is difficult to measure. The other factors controlling muscle force are the
type of muscle grip on various instrument handles, the coefficient of friction of
holding a handle, the angle of the handle and whether the instrument is axial or not
and awkward postures acquired for a grip.

Fatigue affects muscle fibres pattern within a single muscle and even the
substitution patterns of alternative muscles. The primary as well as secondary
muscles are vulnerable to injury due to fatigue. Muscle fatigue is a major
contributor of the disorders of upper extremity. Fatigue increases and work
capacity decreases as a result of increased strain due to increased duration
of exertion. This can be assessed by the following formula:
% Maximal Force = required force X surgeons maximal force
Two types of fatigue are described in the occupational setting: whole-body fatigue
and localized fatigue. The former affects many tissues while the latter occurs only
in affected ones.
b Output Force. The force exerted by body Parts to move or hold the
instrument is a function of muscle force. Posture, strongly affects this
relationship. In laparoscopy for example during dissection, the lever arm which is
a distance from force application point to fulcrum for most muscles is generally
much smaller than that of the external load This means that muscle forces are
usually several times greater than the external load. Deviation from the natural
posture can reduce the amount of muscle force translated into output force. Any
substantial muscle activity is always associated with little net output force. Skilled
and precise muscle activities involve co-contraction of antagonist muscle groups
for graded movements, joint stabilization or holding forces. These contractile
forces act on joint components additively. Therefore, the finger force required to

30
control and grasp laparoscopic instrument may substantially underestimate the
potential damage to the tendons, joints and nerves.

The force was seen in our analysis as workload scores. It is not possible to measure
on a routine basis in OR by any objective methods to measure the force used in the
surgery and obviously have to be observed. The force was divided in our score
pattern into intensity, duration of intensity, speed of work and the total time taken.
When the surgeon found a difficult operation, it pushed the score up. Repetitive
movement for the same intensity was similarly stressful.teh score is so devised that
it automatically makes correction for the skill of the surgeon and trainee having
difficulty in surgery had higher scores so also skilled surgeon doing not so regular
surgeries like fundoplication and splenectomy.

B. Awkward Postures.

The definition of posture means the angle between two adjacent body segments.
For each joint, a neutral posture can be determined. It is also the position allowing
the development of the greatest force very easily. A non-neutral posture is a
stressful awkward posture. A non-neutral postures often cause tissue damage not
necessarily to a biomechanical sub-optimal joint angle. For example, abduction of
upper arm through 90 degrees may put Deltoid in a neutral posture but will expose
brachial plexus to compression from other muscles and anatomical posture. This
posture also cause supraspinatus muscle tendon to get entrapped between the
acromion process and the head of the humerus.

Hence,Kourinka and Forcier (1995, Ex. 26-432) classified the term ``awkward
postures'' into

31
• Extreme posture.
• Non-extreme Posture

Extreme posters by NIOSH definition is the joint position close to the end of a
range of motion. It requires more support and stabilization either by increased
muscle force or passive tissue. This is fortunately rare for laparoscopic surgery.

Non-extreme posture exposes the joint to loading from gravitational forces causing
increased force from muscle or load on other tissues.Non-extreme posters often
change the musculo-skeletal tolerance.(21)The non extreme posture is generally
seen when surgeon is standing on one leg firmly footed and the other leg may be
trying to control foot pedal of ESU or harmonic scalpel. Neck pain and stiffness are
frequent complaints after laparoscopic operations. The Society of American
Gastrointestinal Endoscopic Surgeons (SAGES) Task Force on Ergonomics (24)
reported an 8% to 12% incidence of pain in the neck and upper extremities and a
9% to 18% incidence of stiffness in these areas among 149 surgeons responding to
a questionnaire of body part discomfort after laparoscopic operations

In the scoring pattern exhibited, postural scores were highest causing shoulder pain
and supraspinatus Bursitis when the arms were taken in extreme position or the
trunk was twisted during the performance of the surgery. The postural score was
higher in assistants whereas workload score was on higher side among surgeons
with 25.55 points on an average than assistants’ with14.57 points. Whereas,
postural points were higher among assistants 24.05 than principal surgeon with 22
points. Overall, 87.9% of surgeons were having bad ergonomical postures to give
them MSD whereas, 50% of the assistant showed bad postures.

C. Static Postures

32
It is the posture which is kept in such a way so as to resist the force of gravity or to
stabilize and start work. It is typical when the surgeon is ready for surgery and has
to wait for the anesthesia and preparartion-drapping of the patient. This posture is
more stressful to the musculo-skeletal system. This posture often requires iso-
metric muscle force which is exertion without accompanying movement. Even if
there is some movement of a joint, the joint does not return to a neutral position
and continued muscle force is required. Static contraction of the muscle will
reduce the blood supply through it by almost 90%. The resultant reduction in
oxygen and food supply and accumulation of based products will result in onset of
fatigue. The increased intramuscular pressure exerted on neural tissue may result in
chronic decrement in nerve function (22). The static posture is highlighted in BJ
score as a score assigned to legs and trunk. The movement of the trunk is as seen
by twisting movement by the surgeons with legs firmly fixed on the ground to pick
up instruments. Static back postures also have been implicated to increase
surgeons’ back pain (24). Kant et al(25)demonstrated that static body postures
were frequently displayed by surgeons and scrub nurses during open surgery, with
up to 54% of the time spent in a forward, bent-head stance and 27% of the time
spent in a back twisted and bent stance. Rademacher et al(26)concluded that 70%
of intraoperative work postures during laparoscopic procedures were substantially
static. All the 40 surgeons and assistants scored more than 50% of points during
the surgery leading to the complaints of backache following surgery. The problem
of static posture was more seen when the surgeon was required to do more
advanced laparoscopic surgery complaining of digital nerve numbness.

D. Repetition

Repetition of the same movement will exacerbate the basic risk factors of force and
posture. High repetition of the actions will have tissue damage. For example,

33
increased friction-induced irritation of finger flexor and extensor tendons in their
sheaths can result in tendinitis and lead to increased pressure in the carpal canal. A
moderate repetition however is always beneficial as it causes increasing the muscle
strength and flexibility with increase in blood flow of the muscles relieving the
stress. This is typically seen during dissection of a very difficult or fibrotic or
highly inflamed tissue. In our table in module 3, when the effort by moving hand is
more than 9 times per minute, the surgery become difficult.

E. Dynamic Factors

Movement of a body segment consists of linear motion and rotational motion

around a joint. The increased velocity and acceleration are surrogates for increased
postural risk factors.(Marras and Granata (1995 )(23) . Brief movement cycles
otherwise moderate task. Even if a task is performed for short time, the
acceleration of movement may pose a risk which is not predicted by the muscle
forces or joint angles. With limited movement of freedom during surgery and
without any propioceptor feed back, laparoscopic surgery involves both these
factors during dissection, cutting the tissue or clipping and knotting. Laparoscopic
suturing involves rotational movements at various joints. The speed of doing the
procedure was found in our calculation to have more stress.

F. Compression.
Compression of the tissue can be due to external or internal pressure on the tissue.
External compression: This is always due to blunt or moderately sharp edge of the
instrument handles or even, the edge of the operation table. This causes
concentration of force on a small area of the body resulting in a localized pressure.
This pressure can compress nerves, blood vessels and other soft tissues resulting in
a tissue specific damage. For example, poorly shaped ring handles of the
laparoscopic instrument can cause compression of digital nerve of the thumb or

34
middle finger. Callus formation is seen on radial aspect of middle finger.The
injury is almost often on the outside area of the thumb. Compression MSDs are
also identified in the forearm seen as carpel tunnel syndrome, elbow as ulnar nerve
compression and shoulder seen as supraspinatous bursitis.

Internal compression: When the high Force is exerted on the tissue especially
with the awkward posture, static posture or high repetition of the movement, the
pressure on the nerve, blood vessels and other soft tissues increases causing
damage. When the upper arm is strongly abducted or extended along with
awkward posture of of the neck, the brachial plexus gets compressed under the
scalene muscle causing its damage. Forceful contraction of the muscle also cause
increase in intramuscular pressure with compression of blood vessels traversing the
muscles. Even the pressure due to inflammation of synovial sheath of the tendon
wil also increase the pressure and cause more damage to the nerves. This is seen in
carpal tunnel with increase in pressure causing damage to median nerve.
G. Vibration: There are two types of vibrations. A) Segmental vibrations
and B) whole body vibration
Segmental vibration is the vibration transmitted through the hands. This is often
seen using a small rotor machine as seen during surgery for fibroids when
morcellators are used This causes damage to small unmyelinated nerve fibres
causing vibration induced white fingers and vibration neuropathy. Of course, this
also depends upon the total time vibrating force is used
Whole body vibration is always transmitted through the lower extremity and back.
In endoscopic surgery, the role is uncertain..

Modifying Factors

35
These factors modify the relationship between the force and MSDs.
a Intensity or Magnitude. This is the measure of the strength of each risk
factor. It determines how much force, how awkward is the posture, and how much
is the pressure due to compression, how much vibration is used
b Duration. It is the measure of time factor. This determines how long the
risk factor was experienced. This is a task specific modality i.e. the more
frequently a task is performed; the greater is duration of exposure to risk factor.
c Recovery time.

Recovery time and recovery capacity determine the repair capacity of the body.
Excessive metabolic load and inadequate rest schedules deprive the body of
recovery time to accomplish repair on strained tissues. The recovery time and
pattern of exposure depends upon

• The total time of pauses or rest every few minutes.

• The total amount of continuous surgical work in a day.

SUMMARY:

The GAJAB score is a ready reckoner to understand the ergonomical shortcomings

during laparoscopic surgery. It helps in not only understanding which movements
or part of the procedure is likely to give stress on Musculo-skeleton but also helps
in avoiding stress giving factors. The The most salient features of this scoring
system is the Bio-stress factors that is patients age, their physical ability and
muscular strength being taken in to calculate the score. It cleverly differentiates
the problems of assistants from surgeons. In scoring pattern, the workload score of
surgeons is extrapolated whereas, for assistant, the postural score may be important
but not the operative score, which is highlighted.

36
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