A surgeon’s approach to ergonomic modifications in the OR
The challenges female surgeons experience with using surgical instruments that have historically been designed for use by male surgeons with taller, stronger physiques — and often larger-sized hands — have been well documented (Sutton, et al, 2014).
For example, in one study involving laparoscopic surgeons, a majority of the participants identified instrument design as a source of their physical symptoms, which included discomfort in the neck as well as the shoulder area.
In another article, the authors cited concerns regarding the negative impacts that result from the discrepancies between hand and medical device sizes (Stellon, et al, 2017). To accommodate a wider range of surgeons, they recommended that medical device manufacturers refer to anthropometric data and the population when designing devices, utilizing data of physical measurements of the human body such as hand span, height and arm reach.
Finally, another study highlighted the importance of involving surgeons in the design process, as this can help with surgeon acceptance of a new device and improve performance, and the safety of the patient and surgeon (Santos-Carreras, et al, 2011). The Centers for Disease Controls also makes recommendations on tool design (CDC, 2004). Although generally indicated for nonpowered tools, it can be relevant for surgical instruments, as well. Features of ideal tools include reducing applied forces, fitting the hand well, and positioning the body in more neutral postures during usage.
From Dr. Tsao’s perspective, hand size and grip strength is a consistent factor for a smaller surgeon. For example, instruments that use a wider hand span are difficult for her to use. Therefore, she either use two hands and positions her assistants to help, or she uses a different instrument with a pistol grip. She has changed almost all of her rongeurs from standard ones to a pistol-grip pituitary rongeurs.
Another approach she uses is to grasp an instrument in a different position, which may trigger the need for a stronger grasp strength but allows reasonable excursion of her hand span. However, resulting awkward postures should be monitored for and not maintained.
She will also often use a larger pick-up to allow for greater mechanical strength and decrease her hand fatigue. Surgeon awareness of the mechanical force exerted at the tip of the forceps is important when using potentially oversized instruments.
Since she is unable to palm instruments due to her smaller hand size, she often uses sterile rubber bands to attach her forceps and place her fingers through the loop so her hands are not trying to tie and grip the forceps. This allows her to avoid repetitively putting down and picking up the instrument while tying sutures.
To increase the friction between her gloved hand and an instrument, she wraps coban around a grip, which increases the stickiness of the handle, requiring less power to grip it.
In addition to instrument designers adjusting their approach to designing tools, surgeons can also adapt their operating environment to improve ergonomics.
One of the things she is very aware of is that, given her height, there is an advantage to focus the work she does so that it is below shoulder level. This reduces strain on the muscles around her shoulders and allows for less fatigue throughout the day.
To accomplish this she:
- Uses two risers, side by side, to provide larger platforms to work on (if she is unable to lower the table further), and always adjust the equipment in the operating room to avoid awkward postures.
- Ask a taller assistant to move the overhead surgical lights — but always in the same trajectory that he/she pre-positioned them so that no light obstruction occurs.
- Remove the elevated platforms on the operating room table that are designed to allow for placement of radiographic plates, as this decreases the height of the space she is operating in.
She also prefers to pick up her own instruments instead of waiting for an assistant to hand them to her. She modified her workspace to accommodate this approach to surgery in the following ways:
- She uses a second mayo stand and allows large instruments to be placed on and off, with handles positioned for her.She also standardizes where the instruments are on the mayo stand for muscle memory.
- She uses additional surgical pockets and places her pickups and cautery into these pockets directly across from her.She provides her assistants with additional pockets and allow them to maintain their own commonly used instruments.
Dr. Tsao is currently in practice with the Mid-Atlantic Group of Permanente Medicine in the DCSM group located in the District of Columbia and Southern Maryland. Previously she was in private practice in Arizona after relocating there from her academic practice at the University of Mississippi Medical Center in 2006. She has worked in the field of total joint arthroplasty and been involved in full time academics as a professor of Orthopedic Surgery. Her special interests included the design of total knee and hip implants, design of surgical instrumentation and the wear of materials involved in total joint replacement. She has also been involved in the international AO trauma as a faculty member and alumnus Currently she is the chair of the Women in Arthroplasty Committee for the American Association of Hip & Knee Surgeons known as AAHKS. Her special interests include innovation methods for bioengineering within orthopedics, implant and instrument design. She is an advocate for women in orthopedic surgery and enjoys teaching and mentoring women at all stages of their career. In her spare time, she continues her work as a founding member of WOGO, Women Orthopedic Global Outreach in an effort to enhance mentorship and provide role models for young women all over the world. WOGO as an Op Walk team has done multiple medical mission trips performing total knee replacements for those without access to including Nepal, Tanzania, the Democratic Republic of Congo and Cuba. She continues to practice the 4 G’s: Be giving of yourself, generous with your praise, gracious in your thanks and gentle in your feedback.
Ms. Pentico had practiced as an occupational therapist for 14 years before, and as an ergonomist for 15 years. In addition to the surgical ergonomics program, she has developed and/or managed lab/office/material handling ergonomic programs within the Duke University Health System. She also conducts ergonomic evaluations, provides departmental education and training as well as consultative services within the organization.
CDC. (2004) A guide to selecting non-powered hand tools. California Department of Industrial Relations and the National Institute for Occupational Safety and Health. https://ehs.ucsc.edu/programs/ergo/documents/ergonomic-handtool-guide.pdf
Santos-Carreras, L., Hagen, M., Gassert, R. & Bleuler, H. (2011) Survey on surgical instrument handle design: Ergonomics and acceptance. Surgical Innovation, 19(1). https://doi.org/10.1177/1553350611413611
Stellon, M., Seils, D. & Mauro, C. (2017). Assessing the importance of surgeon hand anthropometry on the design of medical devices. ASME Journal of Medical Devices, 11(4). https://doi.org/10.1115/1.4037257
Sutton, E., Irvin, M., Zeigler, C., Lee. G. & Park A. (2014). The ergonomics of women in surgery. Surgical Endoscopy, 28(4). https://doi.org/10.1007/s00464-013-3281-0