Surgeons who engage in minimally invasive, laparoscopic surgery are providing great benefits to their patients, but possibly to their own detriment. That's the finding of the largest survey ever conducted of surgeons in North America who perform laparoscopic procedures. The survey, developed at the University of Maryland School of Medicine in Baltimore, found that 87 percent of laparoscopic surgeons have experienced physical symptoms or discomfort. This was especially true among those with high case volumes. Previous surveys had found only a 20-30 percent incidence of occupational injury among these surgeons. Results of the survey will appear in the March 2010 Journal of the American College of Surgeons and are now available online.
Millions of patients around the world have benefited from minimally invasive surgical techniques introduced some 20 years ago. The benefits include increased safety, quicker recovery, shorter hospital stays and cosmetic advantages compared to open surgery techniques.
Despite these successes, the impact of minimally invasive techniques on those who perform them is little-known and under-appreciated. "We face a pending epidemic of occupational injuries to surgeons and we can no longer ignore their safety and health," says the survey's principal author, Adrian E. Park, M.D., chief of general surgery at the University of Maryland Medical Center and professor of surgery and vice chair of the Department of Surgery at the University of Maryland School of Medicine.
"Sadly, it is easier for a surgeon to obtain an ergonomic assessment and direction to improve his golf swing than his posture or movement during surgery," says Dr. Park, who is also executive director of the Maryland Advanced Simulation, Training, Research, and Innovation (MASTRI) Center at the University of Maryland Medical Center. It is the first facility in the world to focus on surgical movement. "If injuries among surgeons are not addressed significantly, we're going to face a problem in the near future of a shortage of surgeons as well as shortened career longevity among surgeons who enter, or are already in, the field."
Dr. Park says surgeons who perform laparoscopic surgery face constraints that are not part of open surgery. "In laparoscopic surgery, we are very limited in our degrees of movement, but in open surgery we have a big incision, we put our hands in, we're directly connected with the target anatomy. With laparoscopic surgery, we operate by looking at a video screen, often keeping our neck and posture in an awkward position for hours," says Dr. Park. "Also, we're standing for extended periods of time with our shoulders up and our arms out, holding and maneuvering long instruments through tiny, fixed ports."
A comprehensive 23-question survey was sent to 2,000 board-certified gastrointestinal and endoscopic surgeons in North America and abroad who are members of the Society of American Gastrointestinal and Endoscopic Surgeons, a diverse group of experienced laparoscopic practitioners. The questions were grouped in four categories: demographics, physical symptoms, ergonomics and environment or equipment. Some questions required single answers, such as "Have you ever had any physical discomfort or symptoms you would attribute to your laparoscopic operating? Yes/No." Other questions allowed selection of multiple applicable answers.
Of 317 surgeons completing the survey, 272 (86.9 percent) reported experiencing physical discomfort or symptoms they attributed to performing minimally invasive surgery. The discomfort ranged from eye strain to problems in the surgeon's dominant hand, to neck, back and leg pain. A few surgeons also reported headaches, finger calluses, disc problems, shoulder muscle spasm and carpel tunnel syndrome. Age played a role in hand problems, with younger surgeons and those over 60 at highest risk, but there was no correlation between age and symptoms in other parts of the body.
Annual case volume emerged as a key predictor of physical symptoms. Case volume impact was seen in surgeons who had received postgraduate surgical fellowship training. Those surgeons averaged 249 cases a year, while the non-fellowship average was 192. Neck, hand and leg symptoms rose with increased case volume. "If surgeons had more than 150-200 cases a year, they were at a much higher risk," says Dr. Park. "However, if the surgeon did long, complex cases, they only needed half that number to increase the risk."
To minimize the problems, 84 percent said they had changed their position, while 30 percent said they changed instruments or took a break. Significantly, 40 percent of all participants said they would just ignore any such problem.
Instrument design was listed as the main source of symptoms for more than 74 percent of the surgeons, while 40 percent cited operating room table setup and display monitor location. More than half of the surgeons (58.7 percent) said they were only slightly aware or not aware at all of recommendations to reduce symptoms from researchers in the field of surgical ergonomics.
Dr. Park says the survey results provide important pieces to the puzzle, but ergonomic researchers do not know what all the issues are. As a first step toward developing solutions, he calls for a fresh, comprehensive attempt to understand the surgical workplace. "Many manufacturers and industries have been able to optimize workflow, worker safety and efficiency by characterizing their workspace, while we in surgery have done nothing. We have not seriously investigated or addressed the surgeon-patient interface and the surgeon-instrumentation interface. If you go into the cockpit of an airplane, everything is integrated. In the operating room there is very limited integration of technologies," says Dr. Park.
"The patient has always been the main focus of medicine, as caregivers and researchers grapple with disease treatment and prevention, enhanced patient safety and comfort and the extension of care to more people," says E. Albert Reece, M.D., Ph.D., M.B.A., vice president for medical affairs at the University of Maryland and dean of the University of Maryland School of Medicine. "At a time when minimally invasive, laparoscopic techniques are expanding, Dr. Park's research raises new questions that may affect patient care in the future. It is my hope that further research will provide answers, and will help stem what may indeed be an impending epidemic among surgeons."
Park AE, Lee G, Seagull FJ, Meeneghan N, Dexter D. "Patients Benefit While Surgeons Suffer: An Impending Epidemic." Journal of the American College of Surgeons 2009.10.017. Published online ahead of print, December 24, 2009.