Laparoscopic Device: A Double-edged Sword for Surgeons?
Laparoscopic minimally invasive surgeries (MIS) outweigh open surgeries in many aspects such as the less workload, the less surgical smoke produced [1], the less intraoperative tissue ischemia, the better postoperative quality of life for the patients, and even the less exposure to the COVID 19 virus [2].
To utilize the benefits of MIS, laparoscopic surgical instruments are in great demand. The common design of such instruments (i.e. endoscopic staplers, bipolar radiofrequency laparoscopic vessel sealer, laparoscopic ultrasonic scalpel et, al.)is a slim and long shaft connecting the distal functional part and proximal operational part. The R&D of such instruments diverged in advancing and improving clinical functionality. And the rare concern was taken into the experiences and even the health of the operators. The question left to be answered for the surgeons is:
Is your device secretly consuming your health while treating the patient?
A recent survey involved 373 surgeons in Denmark revealed a closer look at multisite musculoskeletal pain relating to the modality of the surgeries. In comparison with open surgeries and robotic-assisted surgeries, conventional laparoscopic surgeries were regarded as the most painful surgery modality (65%)[3]. A similar conclusion was made by the previous work of Timothy and co. 55% of the surgeons worldwide who participated in the research had linked their discomfort and symptoms to laparoscopic surgery (n=1215, p<0.0001)[4]. Moreover, the lack of direct 3D visual input of laparoscopic MIS requests greater mental concentration than open surgery [5]. This mental stress deepens the physical discomfort during the operation.
An interesting study monitoring differences in work postures between open surgeries and laparoscopic surgeries found that surgeons performing laparoscopic surgery would fit in the much safer neck, torso, and shoulder angles yet with a smaller range of motion[6]. The relative static postures and limited range of motion would give rise to muscular strains around the neck and waist joints along with the procedure. These findings are in line with many other studies. The neck and lower back regions were believed to be the most prevalent painful sites relating to laparoscopic operations. This is due to a rather time for standing and monitoring the video screen [3][6][7]. Following those, shoulder pain and aching wrist would be the most concerning problem to the surgeons.
Although only 21% of the aforementioned discomfort/illness was considered to be related to the use of laparoscopic surgical instruments [3], there are many key points worth discussing:
The simplified model of force analysis while holding the instruments is to consider the weight of instrument and the muscular force as two weight balance around the lever point: the shoulder. The force arm between muscle and shoulder joint is relatively smaller between the distal instrument and shoulder joint. Therefore even small distal weight would give rise to much greater muscular tention.The desired weight of the tool for precisional control is suggested to be below 0.4kg [8].
To perform a laparoscopic surgery require complex wrist motions while gripping the handle of the instrument. The natrual angle while gripping a handle was found to be around 67 to 70 degrees in the study of Young et al [9].Therefore, the handlebar shall be tilted around 10-20 dgrees away from the classical straight handle design.
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As the procedure prolonging, the amounted muscular tention would inevitably reduce the mental focus of gripping or holding the device. The blood may contaminate either the handle or the gloves of the surgeons and hence reduce the friction between hand pals and the device handle. Extra anti-slippery design shall be facilitated to prevent such scenario.
To best accommodate the clinical needs of the surgeons, we had merged the above mentioned features in our brand new powered endoscopic linear stapler LUNAR U. The overall weight of the device is merely 780g and is 20% lighter than previous version of LUNAR. The true ergonomic design of handpiece allows optimal fit to the palms of the surgeons.In the meantime, tilting angle of the hand bar would allow allow maximal rotational and axial force transmission.
Conclusively,laparoscopic devices benefits the patients yet damaging the health of the operators either mentally or physically. The long period of operating time would cause severe painfulness for the surgeons along with their carreer life. Currently, limited attentions to these issues are drawed by manufacturers or even the surgeon group themselves. Will there be a perfect solution to this in the future? From the viewpoints of the writer, an exoskeleton unit might be a great solution to solve this problem in a short term. Long-term speaking, a real AI driven surgical robot would solve this issue once and for all.
[1] H. Kameyama et al., “Comparison of surgical smoke between open surgery and laparoscopic surgery for colorectal disease in the COVID-19 era,” Surg. Endosc., vol. 36, no. 2, pp. 1243–1250, 2022.
[2] C. Hadjittofi et al., “Laparoscopic vs open surgery during the COVID-19 pandemic: What are the risks?,” Ann. R. Coll. Surg. Engl., vol. 103, no. 5, pp. 354–359, 2021.
[3] T. Dalager, K. S?gaard, E. Boyle, P. T. Jensen, and O. Mogensen, “Surgery Is Physically Demanding and Associated With Multisite Musculoskeletal Pain: A Cross-Sectional Study,” J. Surg. Res., vol. 240, pp. 30–39, Aug. 2019.
[4] T. A. Plerhoples, T. Hernandez-Boussard, and S. M. Wren, “The aching surgeon: A survey of physical discomfort and symptoms following open, laparoscopic, and robotic surgery,” J. Robot. Surg., vol. 6, no. 1, pp. 65–72, Mar. 2012.
[5] R. Berguer, W. D. Smith, and Y. H. Chung, “Performing laparoscopic surgery is significantly more stressful for the surgeon than open surgery,” Surg. Endosc., vol. 15, no. 10, pp. 1204–1207, 2001.
[6] L. Yang, T. Wang, T. K. Weidner, J. A. Madura, M. M. Morrow, and M. S. Hallbeck, “Intraoperative musculoskeletal discomfort and risk for surgeons during open and laparoscopic surgery,” Surg. Endosc., vol. 35, no. 11, pp. 6335–6343, 2021.
[7] A. Soueid, D. Oudit, S. Thiagarajah, and G. Laitung, “The pain of surgery: Pain experienced by surgeons while operating,” Int. J. Surg., vol. 8, no. 2, pp. 118–120, 2010.
[8] “Hand Tool Ergonomics - Tool Design.” [Online]. Available: https://www.ccohs.ca/oshanswers/ergonomics/handtools/tooldesign.html.
[9] J. G. Young, J. H. Lin, C. C. Chang, and R. W. McGorry, “The natural angle between the hand and handle and the effect of handle orientation on wrist radial/ulnar deviation during maximal push exertions,” Ergonomics, vol. 56, no. 4, pp. 682–691, 2013.