Ergonomics, making the OR a comfortable place. The authors have no disclosures. Work-related musculoskeletal disorders, or WMSDs, are prevalent among surgeons, including those that perform gynecologic and minimally invasive surgery. WMSDs are repetitive strain injuries that can damage surgeons' muscles, nerves, and or joints, and commonly affect the neck, back, wrists, and hands. In addition to chronic pain, these injuries can lead to decreased job satisfaction and productivity. Risk of WMSDs with vaginal surgery is 54 to 87 percent, conventional laparoscopy, 73 to 100 percent, and robotic surgery, 23 to 80 percent. The objectives of this video are to highlight strategies to improve operating room ergonomics, which will result in increased surgeon comfort during minimally invasive surgery and decreased risk of musculoskeletal injury. This video will discuss general ergonomic principles and demonstrate ergonomic techniques in conventional laparoscopic, vaginal, and robotic surgery. Surgery is analogous to athletics in that it can be physically and mentally demanding. Similar to sports, baseline health, nutrition, and conditioning are important for surgical performance and to decrease the risk of injury to the surgeon. Key to maintaining proper ergonomics is decreasing muscle and joint fatigue, which can lead to injury. Essential to this is increasing one's core and total body strength as well as agility. It is vital to keep muscles and joints healthy with regular stretching. Foam rolling can relieve muscle tightness and provide stress relief similar to a massage. In addition, consider preventative or protective orthotics like supportive shoes, compression stockings, and back and knee braces. There are several safe and effective exercises to improve one's core and total body strength. We believe that combination exercises that engage several muscle groups simultaneously, such as the exercises shown here, are not only more time efficient for a busy surgeon, but also more akin to movement in the OR. Regular stretching should be a part of a surgeon's health maintenance routine as it improves flexibility and decreases the risk of musculoskeletal injury. Shown on the right is the use of a foam roller, which can be used to relieve muscle tension and soreness in lieu of or as a supplement to massage therapy. Preoperatively, it is important that the surgeon set herself up for success. Part of this preoperative planning is knowing what the surgical goals are and anticipating intraoperative needs and accomplishing these without physically encumbering the OR team. The OR light should be configured to facilitate ease and comfort and to decrease strain on the person manipulating the lights. The light handle should be easy to reach with the light elbows outward facing so as not to collide with or obstruct neighboring lights when rearranging intraoperatively. If a combined laparoscopic and vaginal procedure is being performed, position one light directly above the table to provide visualization during laparoscopic entry and the other two lights more distantly near the end of the table for elimination of the pelvis during vaginal surgery. It is recommended to routinely tuck the patient's arms when performing laparoscopic surgery as outstretched arms can limit the surgeon's operative space and their ability to position themselves ergonomically. We recommend initially using the arm board to assist in padding the patient's arm prior to tucking. The patient's thumb should be facing upward and the upper extremity beside and not under the patient's body. Remove the arm board once the patient's arm is properly tucked. With the patient in lymphotomy position, align her greater trochanter to the end of the table while ensuring that her sacrum is supported. Once the patient is secured to the bed, place her in maximum Trendelenburg position even if the case will not require this. Return the table to zero degrees and reevaluate the patient's positioning to ensure that she has not slid too far cephalad. This is especially important if subsequent vaginal surgery is anticipated as an ill-positioned patient can not only potentially injure the patient but also the surgeon. Keeping in line with the principle of thoughtful anticipatory planning is the strategic placement of instruments and cords. At our institution, as a tribute to obstetrics, we create what we like to call the three-vessel cord in which the camera, light source, and insufflation tubing are bundled and secured to the drape as shown. This limits cord entanglement and further contributes to a more ergonomic and comfortable OR experience. Proper posture is fundamental in OR ergonomics. The table height should be set at the appropriate height for the tallest surgeon. The other surgeon should use a step if indicated. The surgeon's hips, back, shoulders, and neck should be in alignment. The neck should be flexed at approximately 20 degrees. Minimize truncal torsion. Avoid locking knees and distribute weight evenly. When using laparoscopic instruments, the forearm should be 90 degrees or more from the upper arm. Shoulder abduction should be maintained at 30 degrees or less. In pelvic laparoscopy, the monitor should be positioned near the patient's feet. The monitor height should be adjusted to avoid neck extension. Shoulders should be dropped and hands relaxed. Wrists and forearm should be in neutral position. Please elevate hands above shoulders. The OR tech should be in close proximity to the surgeons to facilitate comfortable passing of instruments. Place and use the step as needed throughout the procedure. The handling of laparoscopic instruments is another component of OR ergonomics. It is not recommended to hold the camera as demonstrated as this position causes extreme shoulder abduction and for wrists and arms to be uncomfortably elevated. The proper technique is to cradle the camera in the palm of your hand. Keep wrists in a neutral position and avoid prolonged wrist flexion or extension. Keep your grip loose and adjust your grasp on the laparoscopic instruments as indicated. A technique utilized at our institution is to essentially palm the handle of the laparoscopic instrument. Many of the previously discussed ergonomic techniques can be applied to vaginal surgery. Posture remains vital to surgeon comfort. Sit whenever possible with feet resting on the ground and square with hips in order to maintain proper posture and alignment. Adjust the bed height and angle of the table to accommodate the operating surgeon. Adjust the chair height of the other surgeons accordingly. Surgeons should sit in close proximity to each other to avoid strain on assistant surgeons. This includes excessive reaching to retract and truncal malalignment. If there is more than one assistant, it is important to have clear, established roles. It is also important to rotate positions and take turns retracting to decrease muscle fatigue and injury. Considering using self-retaining instruments and retractors, if appropriate, to decrease the physical demands on the surgical assistants. When retracting, favor technique over sheer strength in order to provide adequate exposure while maintaining comfort. For example, sometimes simply rotating the wrist or even substituting for another instrument provides better exposure than forcefully elevating the instrument. Lastly, ergonomic principles can also be applied to robotic surgery. Remember to keep the back and neck erect, allowing for no more than 20 degrees of neck flexion. When sitting at the console, excessive knee flexion should be avoided. Feet should rest on the ground in front of the foot pedals at an angle of 90 degrees or greater. The surgeon's forehead should rest gently on the headrest while her forearm should rest comfortably on the armrest. Remember to utilize the clutch often in order to restore proper and comfortable posture. In summary, in order to make the operating room a more comfortable place, one should maintain baseline health and fitness in order to optimally combat the mental and physical demands of surgery. The surgeon should keep in mind her surgical goals and anticipate her intraoperative needs and plan accordingly. Minimally invasive gynecologic surgery can be physically taxing on the surgeon. Understanding principles and utilizing techniques of OR ergonomics can minimize these physical demands and result in a long, healthy, and pain-free surgical career.

ergonomics

operating room

work-related musculoskeletal disorders

surgeons

chronic pain