Denny Yu

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.

Quantitative posture analysis of 2D, 3D, and optical microscope visualization methods for microsurgery tasks.

The purpose of this paper is to present a quantitative posture analysis of microsurgery tasks performed with different visualization methods. Microsurgery is traditionally performed using a binocular microscope; however surgeons are constrained by the optical eyepieces and are forced to assume joint angles that deviate away from neutral postures. This may be especially problematic for the neck and can increase surgeon discomfort and fatigue. Alternative visualization methods may improve surgeon posture by eliminating the constraints imposed by the microscope. This study examines both 2D and 3D heads-up displays as possible alternatives. Six subjects performed microsurgical tasks with each visualization methods for four hours. Quantitative posture analysis was done using Maxtraq software that tracks reflective markers on the subjects. The initial analysis of neck, upper arm, and elbow angles found significant differences between each display. A biomechanical analysis found that the differences in angles can result in loads on the neck joint that are twice as high in the microscope than the headsup displays. Although the alternative displays can result in better postures, improvements the display technology is needed to improve microsurgical task performance.

Effect of alternative video displays on postures, perceived effort, and performance during microsurgery skill tasks

Physical work demands and posture constraint from operating microscopes may adversely affect microsurgeon health and performance. Alternative video displays were developed to reduce posture constraints. Their effects on postures, perceived efforts, and performance were compared with the microscope. Sixteen participants performed microsurgery skill tasks using both stereo and non-stereoscopic microscopes and video displays. Results showed that neck angles were 9-13° more neutral and shoulder flexion were 9-10° more elevated on the video display than the microscope. Time observed in neck extension was higher (30% vs. 17%) and neck movements were 3x more frequent on the video display than microscopes. Ratings of perceived efforts did not differ among displays, but usability ratings were better on the microscope than the video display. Performance times on the video displays were 66-110% slower than microscopes. Although postures improved, further research is needed to improve task performance on video displays.

Identification of technique variations among microvascular surgeons and cases using hierarchical task analysis

A hierarchical taxonomy was developed for identifying differences among microvascular surgeons and cases and for investigating the impact of those differences on case outcome. Hierarchical task analysis was performed on eight microvascular anastomosis cases. The analysis was simplified by redefining subtasks and elements to only describe actions and adding attributes to describe the work object, method, tool, material, conditions and ergonomics factors. The resulting taxonomy was applied to 64 cases. Differences were found among cases for the frequency and duration of subtask, elements, attributes and element sequences. Observed variations were used to formulate hypotheses about the relationship between different methods and outcomes that can be tested in future studies. The taxonomy provides a framework for comparing alternative methods, determining the best methods for given conditions and for surgical training and retraining. Practitioner Summary: A hierarchical taxonomy, created from a hierarchical task analysis and work attributes, was applied to describe technique variations among microsurgery cases. Variations in time, frequency and sequence were used to form hypotheses on best methods for standardising procedures.

Assessing Posture in Surgery: Video Sampling of Microsurgery

Prolonged static work postures and posture constraints imposed by surgical equipment may increase the risk of musculoskeletal pain and discomfort in surgeons. Four surgeons were video recorded performing live microsurgery and a work sampling methodology was used to quantify their upper body postures, investigating the proportion of static and dynamic postures, and compare surgeon postures to the postures found in laboratory studies. Surgeons were found assuming flexed postures in their neck, shoulder, elbow, and back. Most of the procedure consists of static postures where movement greater than 10 degrees per second was not frequently detected in our sampling. Of the four surgeons, one surgeon was found on average to have lower neck flexion than the other three. Further investigation showed the surgeon looking through the microscope at a distance to assume a more upright neutral posture. Identifying surgeon work postures is a key step to understanding how to reduce musculoskeletal pain and discomfort.

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 of microsurgery and biomechanical modeling of surgeons to assess static-workloads

Physical discomfort has been frequently reported in surgery, and previous studies have focused on surgeon postures and posture movements. The aim of this study is to develop a methodology and collect pilot data that can be used to test the hypothesis that static work requirements during microsurgery exceed published endurance capabilities and are a source of surgeon fatigue. Eight microsurgery surgeons were analyzed for this study. An event-based time study was performed for the entire duration of the microsurgery. Posture was quantified using ten frames randomly sampled from two surgeons using 3D Static Strength Prediction Program, and outputs were used to calculate endurance limits and maximal acceptable effort. Results found that 83% of microsurgery is performed with the microscope. Posture adjustments were highest during rest (5.5 adjustments per minute) and lowest during microscope task (0.3 adjustments per minute). Back and shoulder postures deviated further from neutral during microscope task than rest. The % MVC in the shoulders and torso have endurance times of 5-57 minutes and exceeded maximum acceptable efforts. Results suggest that the operating microscope constrains surgeon posture and restricts posture adjustments. Microsurgery is predominantly microscope tasks, and endurance capabilities are a concern for surgeon fatigue. Application of current tools to surgery are limited due to the low-force and non-cyclical nature of surgical work; however, these findings can be used to design future studies testing larger surgeon populations and workplace improvements.

Alternative 2D and 3D Visualization Methods for Microsurgery Posture, Performance, and Discomfort Analysis

The use of minimally invasive surgeries, like laparoscopy and microsurgery, is increasing due to its benefits to the patient; however, the equipment necessary for the surgeries imposes postural constraints on the surgeons and increases their risk for discomfort and injuries. In microsurgery, the microscope limits surgeon movement and the long length of the surgeries exposes surgeons to prolonged sustained postures. Stereoscopic displays may reduce these constraints and maintain surgeon performance. Six subjects with no surgical experience performed microsurgical skills tests using three visualization methods: 2D visualization, 3D visualization, and the traditional microscope. Task performance was measured through video analysis and subjective data was gathered on discomfort, posture, and equipment usability. Tasks performed on the microscopes had the highest performance efficiency and the least errors. The 3D visualization method had the lowest performance efficiency. However, subjects experienced higher back and neck discomfort using the microscopes. The 3D visualization method was ranked poorly in all usability factors and subjects particularly reported problems with focusing the depth of view. Although 3D visualization methods can provide stereoscopic information to aid in task performance and decrease postural constraints on the surgeon, hardware improvements are necessary before this technology can be easily accessible in healthcare.

Development of a Hierarchical Taxonomy for Standardization of Microvascular Surgery

Although widely practiced in the medical field, the current “see one, do one, teach one” surgical training model introduces a wide variety of variation between surgeons. Without a standardized procedure, causes of medical errors and relationships between surgery and outcomes are hard to identify. The proposed study will utilize work method techniques to develop a hierarchical taxonomy of essential tasks which will help identify and measure the effects of surgical techniques on patient outcomes. Video data of microvascular anastomosis was recorded and task decomposition analysis was completed for two full procedures. The resulting analysis was used to create a hierarchical taxonomy describing the surgery in the varying granularity levels of job, task, subtask, element, and motion. The taxonomy can be effective in identifying technique and tools variations at different levels. Future work includes linking the surgery variables to outcome measures and creating protocols for training and evaluating students in surgery.