Bethany R. Lowndes

Intraoperative “Micro Breaks” With Targeted Stretching Enhance Surgeon Physical Function and Mental Focus: A Multicenter Cohort Study

Objective: The aim of this study was to investigate the effect of intraoperative targeted stretching micro breaks (TSMBs) on the experienced pain and fatigue, physical functions, and mental focus of surgeons. Background: Surgeons are routinely subject to mental and physical stresses through the course of their work in the operating room. One of the factors most contributory to the shortening of a surgeons career is work-related pain and its effects on patient safety and personal relationships. Methods: Surgeons and operating room staff from 4 medical centers rated pain/fatigue, physical, and mental performance using validated scales during 2 operative days: 1 day without implementing TSMB, the other including standardized (1.5 to 2 minutes) guided TSMB at appropriate 20 to 40-minute intervals throughout each case. Case type and duration were recorded as were surgeon pain data before and after each procedure and at the end of the surgical day. Individual body part pre/postdiscomfort difference was modeled, controlling for clinical center. Random coefficient mixed models accounted for surgeon variability. Results: Sixty-six participants (69% men, 31% women; mean 47 years) completed 193 “non-TSMB” and 148 “TSMB” procedures. Forty-seven percent of surgeons were concerned that musculoskeletal pain may shorten their career. TSMB improved surgeon postprocedure pain scores in the neck, lower back, shoulders, upper back, wrists/hands, knees, and ankles. Operative duration did not differ (P> 0.05). Improved pain scores with TSMB were statistically equivalent (P > 0.05) for laparoscopic and open procedures. Surgeons perceived improvements in physical performance (57%) and mental focus (38%); 87% of respondents planned to continue TSMB. Conclusions: Many surgeons are concerned about career-ending or limiting musculoskeletal pain. Intraoperative TSMB may represent a practical, effective means to reduce surgeon pain, enhance performance, and increase mental focus without extending operative time.

The impact of intraoperative microbreaks with exercises on surgeons: A multi-center cohort study

Recent literature has demonstrated ergonomic risk to surgeons in the operating room. One method used in other industries to mitigate these ergonomic risks is the incorporation of microbreaks. Thus, intraoperative microbreaks with exercises in a non-crossover design were studied. Fifty-six attending surgeons from 4 Medical Centers volunteered first in a day of their regular surgeries and then second day where there were microbreaks with exercises that could be performed in the sterile field, answering questions after each case, without significantly increasing the duration of their surgeries. Surgeons self-reported improvement or no change in their mental focus (88%) and physical performance (100%) for the surgical day incorporating microbreaks with exercises. Discomfort in the shoulders was significantly reduced while distractions and flow impact was minimal. Eighty-seven percent of the surgeons wanted to incorporate the microbreaks with exercises into their OR routine. Intraoperative microbreaks with exercises may be a way to mitigate work-related musculoskeletal fatigue, pain and injury.

Validation of Inertial Measurement Units for Upper Body Kinematics

The purpose of this study was to validate a commercially available inertial measurement unit (IMU) system against a standard lab-based motion capture system for the measurement of shoulder elevation, elbow flexion, trunk flexion/extension, and neck flexion/extension kinematics. The validation analyses were applied to 6 surgical faculty members performing a standard, simulated surgical training task that mimics minimally invasive surgery. Three-dimensional joint kinematics were simultaneously recorded by an optical motion capture system and an IMU system with 6 sensors placed on the head, chest, and bilateral upper and lower arms. The sensor-to-segment axes alignment was accomplished manually. The IMU neck and trunk IMU flexion/extension angles were accurate to within 2.9 ± 0.9 degrees and 1.6 ± 1.1°, respectively. The IMU shoulder elevation measure was accurate to within 6.8 ± 2.7° and the elbow flexion measure was accurate to within 8.2 ± 2.8°. In the Bland-Altman analyses, there were no significant systematic errors present; however, there was a significant inversely proportional error across all joints. As the gold standard measurement increased, the IMU underestimated the magnitude of the joint angle. This study reports acceptable accuracy of a commercially available IMU system; however, results should be interpreted as protocol specific.

Mental and physical workloads in a competitive laparoscopic skills training environment: A pilot study

Surgical trainees undergo demanding training to achieve high surgical task proficiency. Abounding clinical and educational responsibilities mandate efficient and effective training. This research measured resident workload during laparoscopic skills training to identify excessive workload and how workload impacted task performance. Twenty-eight surgical trainees performed a standardized surgical training task and completed a workload questionnaire while observers measured physiological stress, posture risk assessment, and task performance. Participants self-reported mental demands, physical demands, temporal demands, performance, effort, and frustration. Effort (12±4) and frustration (12±5) were the highest subscales while physical demand (8±4) was the lowest. All participants were observed performing the task in at-risk postures, with 21% exhibiting risk levels requiring immediate intervention. Physical demand was associated with posture risk assessment scores (p<0.05). Mental demand was positively (R2=0.20, p<0.05) and frustration was negatively (R2=0.18, p<0.05) associated with skin conductance range. A point increase in physical demand was associated with a six second increase in performance time (β=6.0, p=0.01). These results support the fact that human factors and ergonomic tools can be used to relate surgical skills performance with workload, stress, and posture risks.

Task analysis method for procedural training curriculum development

AbstractA central venous catheter (CVC) is an important medical tool used in critical care and emergent situations. Integral to proper care in many circumstances, insertion of a CVC introduces the risk of central line-associated blood stream infections and mechanical adverse events; proper training is important for safe CVC insertion. Cognitive task analysis (CTA) methods have been successfully implemented in the medical field to improve the training of postgraduate medical trainees, but can be very time-consuming to complete and require a significant time commitment from many subject matter experts (SMEs). Many medical procedures such as CVC insertion are linear processes with well-documented procedural steps. These linear procedures may not require a traditional CTA to gather the information necessary to create a training curriculum. Accordingly, a novel, streamlined CTA method designed primarily to collect cognitive cues for linear procedures was developed to be used by medical professionals with minimal CTA training. This new CTA methodology required fewer trained personnel, fewer interview sessions, and less time commitment from SMEs than a traditional CTA. Based on this study, a streamlined CTA methodology can be used to efficiently gather cognitive information on linear medical procedures for the creation of resident training curricula and procedural skills assessments.

Laparoscopic Surgical Team Stress Measures During Randomized Controlled Trials of 4-port vs. Single Incision Cholecystecomies A Pilot Study

The Institute of Medicine lists investigations of the comparative effectiveness for minimally invasive surgical procedures as a research priority. As new minimally invasive procedures are developed, comparisons of the resulting workload contribute valuable information about the impact of the new procedures. Recent reports suggest that surgeon workload can influence patient outcomes. Measurements of stress and fatigue for the surgical team participating in a randomized NIH supported trial of single incision versus traditional laparoscopic cholecystectomy were obtained. These stress measures showed that the SURG-TLX was sensitive to the difficulty of the surgery. The SURG-TLX and a surgical difficulty score was obtained from the surgical team for 16 laparoscopic surgeries by surgical approach (8 SILC and 8 4-port) showed that for this small sample size, there were no statistically significant differences in length of surgery, degree of difficulty, nor patient considerations such as post-operative pain scores. In addition, no statistically significant differences in the individual Surg-TLX subscale scores or Surg-TLX total for the surgical team overall or for the surgeon alone by surgical platform. This is likely due to the small sample size reducing the power of the tests.

Mini Breaks, Many Benefits: Development and Pilot Testing of an Intraoperative Microbreak Stretch Web-Application for Surgeons

Periodic intraoperative microbreaks with calesthenic exercises performed within the sterile field improved self-reported mental focus (38%) and physical performance (57%) for 56 surgeons. Therefore, targeted stretching exercises and a web-application (web-app) leading the stretches with a reminder system were developed and piloted using user-centered design principles. A focus group with 10 users was conducted to refine the developed app. Seven surgeons (4 females) at a quaternary medical institute piloted the periodic stretching web-app in their operating rooms. At the end of each surgical day, the surgeons completed a short survey about the intraoperative stretching exercises web-app impact on their physical performance, mental focus and workflow disruption. Non-Routine Events were captured during the procedures. Twelve surgical days were followed with a median of 6 microbreaks/day/surgeon. Results showed that better physical performance and lower fatigue were reported (91.7%) across the surgical days, also better mental focus was reported (83.3%) across the surgical days, and less pain/discomfort was reported (100%) across the surgical days, with others reporting no change. The web-app leading sterile field microbreak stretches helped reduce physical pain, discomfort/pain, fatigue, and improve mental focus with minimal disruption for a small sample. The web-app is a promising tool for improving surgeon mental focus and physical performance and potentially musculoskeletal health.

Surgeons’ Perspectives on User-Designed Prototypes of Microsurgery Armrests

Microsurgery is considered one of the most demanding surgical techniques. In a recent American Society of Reconstructive Microsurgeons survey, respondents reported that about half their procedures lasted 8 hours or longer and 8% had tremor during their surgery. Thus, the aim of this study was to define user centered design requirements for a microsurgery armrest, create low-fidelity armrest design concepts and evaluate microsurgeons’ perspectives on the advantages/disadvantages of five potential design concepts. Direct and videotaped observations of microsurgery, user brainstorming during a co-creation workshop and semi-structured interviews were used. The resulting five microsurgery armrest concepts were presented pictorially through semi-structured interviews, where microsurgeons defined armrest design requirements as: a) an armrest that allows the surgeons to be as close as possible to the patient; b) adjustable to accommodate different procedures sites and surgeon preferences; c) rigid enough to support arms; d) is not difficult to set up; nor e) large or bulky; and f) complies with operative sterility rules. This study illustrated how involving the users (microsurgeons) early in the design process provides useful perspectives on design requirements and implementation barrier for a cost-effective ergonomic microsurgery armrest to foster sound ergonomic surgical practice and reduce musculoskeletal health risk factors during microsurgery.

Surgical team workload comparison for 4-port and single-port laparoscopic cholecystectomy procedures

Advanced minimally invasive procedures may cause postural constraints and increased workload and stress for providers. This study compared workload and stress across surgical team roles for 48 laparoscopic cholecystectomies (4-port vs single-port) using a task load index (NASA-TLX), a procedural difficulty question, and salivary stress hormones. Statistical analyses were performed based on the presence intra-cluster correlation within team roles, at α=0.05. The single-port technique resulted in an 89% increase in physical workload for the surgeon and 63% increase for the assistant (both p<0.05). The surgeon had significantly higher salivary stress hormones during single-port surgeries. The degree of procedural difficulty was positively correlated between the surgeon and most roles: resident (r=0.67), assistant (r=0.81), and technician (r=0.81). There was a statistically significant positive correlation between the surgeon and assistant for all selfreported workload measures (p<0.05). The single-port technique requires further improvement to balance surgical team workload for optimal patient safety and satisfaction.

A Preliminary Comparison of Three Tourniquet Instructions for Just-in-Time Guidance of a Simulated Tourniquet Application

The American College of Surgeons (ACS) and the Department of Homeland Security (DHS) encourage the use of tourniquets as part of the “Stop the Bleed” campaign. Both have provided instructions for layperson tourniquet application in order to save the life of a hemorrhaging trauma victim. This study sought to compare the impact of using ACS and DHS instructions with manufacturer-provided instructions for the completion of simulated tourniquet application steps. Thirty surgical trainees completed a simulated tourniquet application with one of the three instruction sets. Their completion time and success for each step were measured. Participants that received ACS instructions failed the fewest number of steps (p < 0.01) and completed the task faster (Mean (SD) = 70 (33) seconds) compared to those with the manufacturer-provided instructions (p < 0.01). Tourniquet instruction sets need to be refined in order to optimize the success rate of just-in-time guidance for tourniquet application.