Presentation
HE18 - Robotic Surgery: Ergonomics in a New Sociotechnical Environment.
SessionPoster Session 2
DescriptionRobotic surgery is increasing on a global scale. New surgical robots, with distinct surgeon-machine and patient-machine interfaces, are also diversifying the operating room environment. Hospitals and nations are increasingly using several robot types. Though evidence shows improved technical performance and clinical outcomes, the ergonomic and human factors impact requires further elucidation. Musculoskeletal discomfort among robotic surgeons is common (41-56% reported), affecting the neck, lower back, fingers, eyes, and can affect daily activity. In addition, the surgeon is situated remote from the bedside team, adding complexity to communication, situational awareness, and other non-technical skills.
There is limited guidance on these areas of robotic surgery. As a robotic surgeon working in a multi-robot hospital, ergonomic understanding is key for optimum team performance and longevity. This applies to surgical robotics in general, to specific robot types, and also has relevance for training future robotic surgeons and teams. This presentation reviews the relevant literature as the initial step to developing evidence-based guidance for practice and training.
Ergonomics in robotic surgery has been measured through subjective validated instruments and real-time physiological metrics, with some triangulation. As laparoscopic surgery is the conventional and globally more prevalent form of minimally invasive surgery, much of the evidence uses this as the comparator.
Surface electromyography (EMG) generally shows increased forearm activity and reduced shoulder activity, with reduced right arm abduction and anteversion, in robotic surgery compared to laparoscopic surgery. Trapezius activity was increased, with mixed results on extensor digitorum activity. ECG monitoring showed a lower heart rate in robotic surgery (by 9 beats per minute). This triangulated with subjective surgeon reports of less perceived physical activity, lower physical effort and workload (NASA-TLX), but no differences in fatigue between the approaches. Electroencephalography (EEG) identified distinct patterns of coherence, with robotic surgery showing increased inter-hemispheric coherence. There was also a neurophysiological signature of error, which requires further investigation.
Surgeon-specific ergonomic factors related primarily to experience, case volume, and specialty. Whilst young surgeons reported lower physical demand in robotic surgery, experienced surgeons showed less physical ergonomic improvement. This correlates with the diminished differences in EMG activity with increasing experience. Expertise also favoured ergonomic console hand controller position, even if it resulted in visual perception mismatch (VPM; the difference between internal instrument and external surgeon hand positions). Relationship with robotic case volume showed mixed results, with decreased and increased physical symptoms reported. There was also some individual variation in postural habits.
Robotic-specific signals have started to emerge from the data as several robot types are now in clinical service. On the da Vinci robot, which has a closed console, surgeons showed medium risk on Rapid Upper Limb Assessment (RULA) and Rapid Entire Body Assessment (REBA), with action recommended to improve ergonomics. Joint angle at the neck was potentially harmful for all users, and trunk angles varied but was inadequate in some. Furthermore, for surgeons at the extremes of height distribution, optimal arm-rest height was outside adjustment range of console. In contrast, the open-console Versius robot showed lower injury risk score (REBA), lower mental demand (NASA-TLX), and no detriment in communication (Oxford NOTECHS) compared to laparoscopic surgery. This correlated with a study on Versius simulator tasks, with wearable devices showing improved posture and less localised muscle fatigue. A Versius checklist is also used at the critical step as the primary surgeon transitions from bedside to console.
There were some operation-specific findings. Urologists reported more physical symptoms. In colorectal surgery, suboptimal ergonomic position occurred at certain steps, such as dissection at the periphery of the operating field, left-hand use, dissecting the main mesenteric blood vessels, multi-quadrant surgery, and use of the robotic stapler. In an incisional hernia training model, robotic suturing to primarily closure the defect showed less upper limb disturbance and lower mental demand compared to laparoscopic surgery.
Some of the adverse factors were modifiable, which could therefore be incorporated into an ergonomic training programme. Surgeons that felt confident managing ergonomic settings also acknowledged these adjustments to be helpful, and reported fewer physical symptoms. Only a minority (16%) reported having ergonomic training prior to performing robotic surgery. Surgeons that participated in ergonomic training changed their practice, noticed a decrease in strain, and felt it should be a standard part of training. Specific instruction on ergonomic settings and clutch usage improved performance in clutch-oriented simulation exercises and RULA ergonomic score.
The ergonomic concept of workplace design applies in robot surgery in the longer-term. Surgeon feedback to modify system components such as microphone, pedal design and finger clutches have been reported. Previously this may have taken several years, but domestically developed robots may facilitate industry-clinical interaction, responsiveness to feedback, and a faster innovation cycle.
The bedside assistant is a key member of the robotic surgical team. Collisions with the robotic arms can cause inadvertent movement of the assistant instrument, particularly during certain steps, which have been identified. Another technical factor is port placement, which can optimise robotic arm ergonomics and robot manufacturers provide guidance on this.
Human factors also incorporates non-technical skills. High non-technical performance in robotic surgery correlated with team efficiency, improved self-perceived performance, fewer surgical flow disruptions, and fewer near-miss events. That non-technical skills did not correlate with surgeon experience level implies a need to explicitly cover this in robotic training programmes. Standardised phraseology and readback have been described in robotic surgery.
This focused coverage of the robotic surgical literature identifies important themes than should be incorporated into surgical robotic human factors training. As well as general principles, there are elements specific to surgeon, robot type, and surgical speciality, as well as the bedside assistant.
There is limited guidance on these areas of robotic surgery. As a robotic surgeon working in a multi-robot hospital, ergonomic understanding is key for optimum team performance and longevity. This applies to surgical robotics in general, to specific robot types, and also has relevance for training future robotic surgeons and teams. This presentation reviews the relevant literature as the initial step to developing evidence-based guidance for practice and training.
Ergonomics in robotic surgery has been measured through subjective validated instruments and real-time physiological metrics, with some triangulation. As laparoscopic surgery is the conventional and globally more prevalent form of minimally invasive surgery, much of the evidence uses this as the comparator.
Surface electromyography (EMG) generally shows increased forearm activity and reduced shoulder activity, with reduced right arm abduction and anteversion, in robotic surgery compared to laparoscopic surgery. Trapezius activity was increased, with mixed results on extensor digitorum activity. ECG monitoring showed a lower heart rate in robotic surgery (by 9 beats per minute). This triangulated with subjective surgeon reports of less perceived physical activity, lower physical effort and workload (NASA-TLX), but no differences in fatigue between the approaches. Electroencephalography (EEG) identified distinct patterns of coherence, with robotic surgery showing increased inter-hemispheric coherence. There was also a neurophysiological signature of error, which requires further investigation.
Surgeon-specific ergonomic factors related primarily to experience, case volume, and specialty. Whilst young surgeons reported lower physical demand in robotic surgery, experienced surgeons showed less physical ergonomic improvement. This correlates with the diminished differences in EMG activity with increasing experience. Expertise also favoured ergonomic console hand controller position, even if it resulted in visual perception mismatch (VPM; the difference between internal instrument and external surgeon hand positions). Relationship with robotic case volume showed mixed results, with decreased and increased physical symptoms reported. There was also some individual variation in postural habits.
Robotic-specific signals have started to emerge from the data as several robot types are now in clinical service. On the da Vinci robot, which has a closed console, surgeons showed medium risk on Rapid Upper Limb Assessment (RULA) and Rapid Entire Body Assessment (REBA), with action recommended to improve ergonomics. Joint angle at the neck was potentially harmful for all users, and trunk angles varied but was inadequate in some. Furthermore, for surgeons at the extremes of height distribution, optimal arm-rest height was outside adjustment range of console. In contrast, the open-console Versius robot showed lower injury risk score (REBA), lower mental demand (NASA-TLX), and no detriment in communication (Oxford NOTECHS) compared to laparoscopic surgery. This correlated with a study on Versius simulator tasks, with wearable devices showing improved posture and less localised muscle fatigue. A Versius checklist is also used at the critical step as the primary surgeon transitions from bedside to console.
There were some operation-specific findings. Urologists reported more physical symptoms. In colorectal surgery, suboptimal ergonomic position occurred at certain steps, such as dissection at the periphery of the operating field, left-hand use, dissecting the main mesenteric blood vessels, multi-quadrant surgery, and use of the robotic stapler. In an incisional hernia training model, robotic suturing to primarily closure the defect showed less upper limb disturbance and lower mental demand compared to laparoscopic surgery.
Some of the adverse factors were modifiable, which could therefore be incorporated into an ergonomic training programme. Surgeons that felt confident managing ergonomic settings also acknowledged these adjustments to be helpful, and reported fewer physical symptoms. Only a minority (16%) reported having ergonomic training prior to performing robotic surgery. Surgeons that participated in ergonomic training changed their practice, noticed a decrease in strain, and felt it should be a standard part of training. Specific instruction on ergonomic settings and clutch usage improved performance in clutch-oriented simulation exercises and RULA ergonomic score.
The ergonomic concept of workplace design applies in robot surgery in the longer-term. Surgeon feedback to modify system components such as microphone, pedal design and finger clutches have been reported. Previously this may have taken several years, but domestically developed robots may facilitate industry-clinical interaction, responsiveness to feedback, and a faster innovation cycle.
The bedside assistant is a key member of the robotic surgical team. Collisions with the robotic arms can cause inadvertent movement of the assistant instrument, particularly during certain steps, which have been identified. Another technical factor is port placement, which can optimise robotic arm ergonomics and robot manufacturers provide guidance on this.
Human factors also incorporates non-technical skills. High non-technical performance in robotic surgery correlated with team efficiency, improved self-perceived performance, fewer surgical flow disruptions, and fewer near-miss events. That non-technical skills did not correlate with surgeon experience level implies a need to explicitly cover this in robotic training programmes. Standardised phraseology and readback have been described in robotic surgery.
This focused coverage of the robotic surgical literature identifies important themes than should be incorporated into surgical robotic human factors training. As well as general principles, there are elements specific to surgeon, robot type, and surgical speciality, as well as the bedside assistant.
Authors
Event Type
Poster Presentation
TimeTuesday, April 14:45pm - 6:15pm EDT
LocationFrontenac Foyer