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Special Article |

Surgery and Ergonomics FREE

Ramon Berguer, MD
[+] Author Affiliations

From the Department of Surgery, University of California[[ndash]]Davis, Sacramento, and the Surgical Service, VA Northern California Health Care System, Martinez.


Arch Surg. 1999;134(9):1011-1016. doi:10.1001/archsurg.134.9.1011.
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Published online

This article will provide the reader with an overview of ergonomic issues relevant to the operating room environment. Minimally invasive surgical technologies have increased the therapeutic value of surgical procedures by allowing operations to be performed with less trauma to the patient. At the same time, the surgical team—and particularly the surgeon—have been further removed from direct interaction with the patient's tissues. A scientific and ergonomic approach to the analysis of the operating room environment and the performance and workload characteristics of members of the modern surgical team can provide a rational basis for maximizing the efficiency and safety of our increasingly technology-dependent surgical procedures.

Although surgeons have undoubtedly had a long-standing interest in the design and efficiency of their tools, Frank Gilbreth, a pioneer in the field of time and motion study, noted in 1916 that " . . . surgeons could learn more about motion study, time study, waste elimination, and scientific management from the industries than the industries could learn from the hospitals."1 Gilbreth observed that surgical practices and instrumentation varied greatly throughout the country, leading to inefficiency and the lack of a "best" approach to each treatment modality. This mindset reflected the growing interest in the method of scientific management in industry2 during the early part of this century. Despite some early efforts at objectively studying surgical operations,3,4 objective work analysis was not widely applied to surgical procedures.5 Indeed, only 20 years ago Dudley6 noted that " . . . looked at from the ergonomic point of view most major operations are, at first sight, a mess."

This state of affairs is curious, for there are, in effect, many mental and physical similarities between a surgeon's work and skilled industrial and military jobs. Surgery requires a high level of intellectual preparation, an efficient and controlled workspace, fine motor skills, physical endurance, problem-solving skills, and emergency response skills. Moreover, surgical care is expensive and the costs of errors or delays in surgical treatment are substantial in both economic and human terms. Ergonomic methods would thus seem well-suited to the analysis of surgeons' work. That this has not occurred is probably the result of many interrelated factors, some unique to the field of surgery.

Surgeons train in an environment that discourages complaints about stress and fatigue. The inherent drama of surgical work, coupled with surgeons' historically high social standing, is likely to have encouraged them to see themselves as elite craftsmen and to be reluctant to have their unique work habits analyzed or criticized by others. The relatively low technological demands of surgical operations (with the exception of cardiac and orthopedic subspecialties) until the recent advent of video endoscopic surgery (VES) may also have been a contributing factor to this lack of interest in medical ergonomics. Perhaps most importantly, under a fee-based and physician-driven health care compensation system, surgeons and administrators may well have thought of work analysis as an unnecessary annoyance that could be financially counterproductive. In today's highly competitive and cost-conscious health care system, it is likely that our technical progress toward the full potential of less-invasive surgical techniques will be substantially moderated by cost and human performance issues.

Ergonomics as a science is relatively new. This field, also called "human factors," has to do with designing machines and tools that optimize the performance of the user.7 The first modern ergonomic studies were Frederick W. Taylor's time study2 and Frank B. and Lillian M. Gilbreth's motion study.8 Between 1900 and 1940 there was a growing interest in scientific management, but the availability of cheap labor and the scarcity of funds limited research into this area. World War II created a new interest in the measurement of operator performance in skilled military jobs, providing the impetus for the development of the field of "engineering psychology."9 As the demands of work-related machinery increasingly exceeded the intuitive human ability to cope with them during the next 3 decades, the field of ergonomics developed into a science of its own. Ergonomic analyses are widely applied today in industry,10 the military,11 and sports training12 to help people achieve optimum performance with a low risk of error and injury.

In the field of medicine, there has been an increased awareness of the importance of ergonomics13 and the applications of systems analysis.14 Ergonomic problems have been investigated in relation to intensive care units,15 gastrointestinal endoscopy,16 back injuries in health care workers,17,18 and job difficulty in medical-surgical staff nurses.19 Anesthesiologists, perhaps more than any other medical specialty, have addressed the important information display and equipment design factors that affect their work.2022 In a related specialty, the higher incidence of occupational cervicobrachial disorders among dentists23 has prompted improved designs of the dental operatory.24 Despite the increasing attention to ergonomics in health care, it is sobering to read a recent report by the Food and Drug Administration that estimates that poor design of medical instruments may account for half of the 1.3 million unintentional patient injuries in US hospitals each year.25

Visualization

Under open conditions surgeons can view their work directly. The main visual ergonomic considerations are the adequacy of the exposure of the operating field to direct viewing and the quality and intensity of lighting on the field. Exposure is greatly aided by proper positioning of the patient and the application of mechanical retractors to the wound and internal tissues. Retractors with various shapes have long been in use but there has been little formal evaluation of their performance.26 For example, a comparative study of different retractor handles27 concluded that a hand-held abdominal retractor handle with a vertical "T" handle configuration was preferred by almost all users, yet this information has had no effect on retractor design. Although there are numerous self-retaining retractor designs available today, there are no objective data to support the choice of one design over another. The proper lighting of the surgical field has been the subject of several reviews,28,29 and detailed recommendations for optimum lighting during open surgery have been published.30 However, uncertainties still remain regarding the optimum size, location, and number of surgical lights and the most efficient type of controls.

Video endoscopic surgery has introduced the greatest challenge yet to the surgeon's natural view of the operating field. Using current technology, the surgeon views a relatively low-resolution monocular video image of the operating field, which is often degraded by variable lighting inside the body cavities and by the movement of the camera-holding assistant. Under these visual conditions, surgeons require significantly longer times to complete manipulative tasks when compared with direct binocular or direct monocular vision.31 The lack of depth perception with monocular video systems has been thought to be a significant performance limitation. However, several comparative performance studies of standard monocular and 3-dimensional (3-D) binocular VES systems3235 have demonstrated improvement in surgeons' performance using 3-D systems only during complex positioning tasks in a laboratory setting.32,36 Indeed, a recent randomized clinical study reported no difference in performance or adverse visual symptoms using 2-dimensional or 3-D imaging systems during laparoscopic cholecystectomy.37 The lack of significant clinical performance enhancement with 3-D VES may be due to a number of factors such as the small distance between the binocular endoscopic channels, the low resolution of current video systems, slow frame refresh rates, and subjects' complaints of eye fatigue and headaches during use of the 3-D systems.35,37 Others investigators suggest that factors such as background contrast and illumination are equally important 3-D visual cues for the surgeon.38 The objective performance data regarding the efficacy of 3-D imaging systems is an excellent example of the kind of practical answers one can obtain through ergonomic evaluations of new technology. High technology is not always the answer to human interface problems. For example, in a blinded comparison of several VES camera systems, operating room personnel subjectively preferred digitized video systems but saw no advantage in image quality with the use of 3-chip vs single-chip camera systems.39

One basic ergonomic consideration—the correct position of the video display relative to the user's eyes—is almost routinely ignored in VES. Video monitors are commonly placed on top of equipment carts or wherever there is space in the operating room, with the consequence that the image lies at or above the average surgeon's eye level and often to the surgeon's side. Studies of office video terminal display (VDT) users demonstrate that the preferred viewing angle for VDTs is between 10° to 25° below the line of sight.40 Excessive height of VDTs has been linked to symptoms of neck and back pain in office workers,41 which may explain why a small but significant number of laparoscopic surgeons complain of frequent neck stiffness and pain.42 Indeed, Hanna et al43 have reported an increase in knot-tying performance when surgeons view a monitor placed at hand level instead of at eye level. One approach to improving monitor position has been to install VDTs on ceiling-mounted booms44 that can be positioned as desired around the operating table. While this approach can facilitate the proper alignment of the surgeon and assistants with the image of the surgical field, the cost of installation remains high and many booms cannot be positioned below eye level. Other innovative approaches to solving the problem of VES display position have included projecting the video image onto a 13-in sterile screen placed in front and slightly below the surgeon within the surgical field (ViewSite display system; Karl Storz Endoscopy, Culver City, Calif) and incorporating the image into a head-mounted display system worn by the surgeon.45 Clinical and ergonomic studies to assess the effect of these display systems are in progress. Other ergonomic problems with visualization still remain, such as the natural control of the direction of view during VES. Preliminary studies using a voice-controlled robotic assistant suggest this device can facilitate the surgeon's visualization of the field,46 although savings in actual operating time have not been documented.47 Achieving adequate visualization in a cost-effective and user-friendly manner will remain a major challenge.

Manipulation

Standard open surgical instruments surgery such as forceps, clamps, and scissors evolved rapidly into standardized designs that accommodated ease and universality of use, mass production, and rapid sterilization.48 While surgeons have championed the skilled and efficient use of these instruments, there have been relatively little published experimental data describing the biomechanics of open surgical instrument use. Patkin26 described the power grip and the precision grip used by surgeons. Dudley6 briefly described the mechanics of passing instruments from the scrub nurse to the surgeon. Tendick and Stark49 reported a theoretical analysis of surgeons' grasp. Seki50 published a detailed classification of needle holder grips and an analysis of suturing movements. A recent study reported that surgeons' dexterity was not adversely affected by the use of double gloves.51

Video endoscopic surgery brought to the forefront new and significant ergonomic problems related to the surgical manipulation of tissues. Instruments for VES generally incorporate a pistol or axial grip handle, a 5- to 12-mm-diameter circular shaft that houses the actuating mechanism, and a rotating double-action tip for tissue manipulation. The fulcrum point created by the trocars inserted in the body wall limits the internal movement of the instrument tip to 4 degrees of freedom.52 The internal mechanical design of VES instruments results in substantially diminished tactile feedback53 and an unfavorable force transmission ratio from handle to tip.54 Laparoscopic instruments have also been shown to have a nonlinear relationship between input and output forces, which further degrades the surgeon's ability to delicately sense tissue characteristics.55 All told, VES instruments have been shown to require 4 to 6 times more force than open surgery instruments to complete the same task.56,57 With these less-effective instruments, it is not surprising that surgeons report increased fatigue following VES.42 Indeed, a recent questionnaire by the Society of American Gastrointestinal Endoscopic Surgeons revealed that 8% to 12% of 149 responding surgeons reported frequent pain or numbness in the arms, wrists, or hands following laparoscopic surgery. There have also been reports of thenar neuropathies from the awkward thumb ring in pistol-grip laparoscopic instruments5861 and of pectoralis tendonitis from prolonged use of a bowel clamp.62 Some alternative laparoscopic instrument handle configurations have been proposed63 but ergonomic data to support their use are still lacking. Although the axial design handle is generally preferred for suturing, there is no objective evidence that this handle design is superior to the pistol configuration.57 To address some of these problems, some authors have developed guidelines for skills training similar to those used in microsurgery.64,65 Other investigators have studied the optimal port locations for endoscopic intracorporeal knotting66 as well as the best visual angles for the laparoscopic camera67 based on ergonomic performance studies in an inanimate trainer.

There has been increasing interest in developing telerobotic manipulators for VES applications.49,68 Such sophisticated robotic instruments can give surgeons increased freedom of movement of the instrument tip, coupled with force feedback and binocular vision. These systems have been shown to be very effective for performing delicate surgical manipulations in animal models.69,70 Published clinical case reports involving the use of robotic assistants during surgery suggest they can also be very useful and more precise than human assistants in some instances.71,72 Sensors are under development that can transmit tactile information to the surgeon's hand through tactile "displays."73 Computerized instrument systems74,75 have been designed in an attempt to increase the surgeon's efficiency during laparoscopic surgery by automatically coordinating different tasks such as suction, irrigation, insufflation, and coagulation. Proof is still lacking that these relatively expensive and complex systems increase efficiency. However, one recent study did demonstrate a 20% increase in the speed of gynecological operations with the use of a more compact computer-controlled multifunction instrument.76 The ultimate role that "intelligent" robotic instruments will play in modern surgery will depend on the balance between any ergonomic improvements in surgical performance and the cost of the systems.77

Posture

Performing open surgical procedures has almost always required standing, awkward body positions, and the occasional need to exert substantial forces on tissues. In industrial ergonomics it is well recognized that static as well as dynamic postural stress can lead to fatigue and disability.78,79 Indeed, dentists have a high rate of subjective musculoskeletal complaints and disability claims related to cervicobrachial disorders23 that are presumably due to the nature of their working posture. There is little quantitative information about the musculoskeletal loads experienced by surgeons. Kant et al80 studied the posture of physicians and nurses during surgery and found that surgeons and scrub nurses experience substantial stress to the musculoskeletal system owing to their frequent and prolonged static head-bent and back-bent postures. Radermacher et al81 also reported that during laparoscopic and orthopedic surgery more than 70% of intraoperative work postures are substantially static. Mirbod et al82 recently surveyed musculoskeletal complaints among orthopedic and general surgeons and found a substantial prevalence of complaints of pain in the shoulders (32%) and neck (39%) among orthopedic surgeons. In the same study, general surgeons reported similar symptoms, with a prevalence of 18% and 21%, as compared with pharmacists at 15% and 18%, respectively. Sitting is more restful during extended periods of suturing and also provides a more stable posture for controlling instruments during microsurgery.83 Indeed, a sitting posture has long been recognized to be a preferred position for light manipulative work84 and suggestions have been made to allow surgeons to adopt a sitting position during at least part of an operation.85,86 In the United States, however, sitting during major torso or extremity surgery remains uncommon.

Video endoscopic surgery has altered the way surgeons interact with the surgical field, and in doing so has changed surgeons' posture. During transurethral resection of the prostate, the use of a video monitor significantly decreases the physical load on the shoulder musculature by allowing the urologist to view the endoscopic image while sitting upright.87 Surgeons' axial skeletal posture is also more upright during laparoscopic surgery as compared with open surgery.88 This upright posture during VES, however, seems to be accompanied by substantially less body movement and weight shifting than during open surgery.88 This situation could account for increased static postural fatigue during laparoscopic surgery. As is the case with the positioning of the VES monitor, some basic ergonomic rules that affect surgeons' posture, such as lowering the height of the operating room table to accommodate the increased length of VES instruments, are often ignored.86

Mental and Physical Workload

As new technology has entered the workplace, there have been increasing psychological demands placed on workers in many fields. Advances in psychology and neurobiology have put forth new concepts of mental workload and stress that have seen widespread application toward critical task analysis in industry89 and the military.11 Levey et al90 were the first to directly measure the energy expenditure of operating room personnel. He found that while activities such as hand scrubbing and the performance of amputations required the greatest oxygen consumption, the average energy expenditure of surgeons in the operating room was not much above sedentary levels. Oxygen consumption measurements, however, are at best only an indirect measure of physical effort and do not accurately reflect cognitive workload. For example, Becker et al91 reported heart rates in 10 surgeons to be higher than commensurate for the measured oxygen consumption. Chavez-Lara et al92 reported significantly increased urinary epinephrine and norepinephrine excretion in surgeons before and during surgery. Foster et al,93 Payne and Rick,94 and Goldman et al95 also reported significantly elevated heart rates in surgeons during operations. Czyzewska et al96 analyzed heart rate variability patterns and correlated decreased heart rate variability during the operation proper with an increased mental workload experienced by the surgeon. Thus, the evidence to date suggests that surgeons experience significant cardiovascular stress during operations and that the magnitude of this stress exceeds the level of aerobic physical work performed. Contemporary behavioral psychology would attribute this differential effect to an increase in mental workload required by surgeons to perform surgery.

Most surgeons admit experiencing higher levels of frustration and tension during complex VES procedures, although there are no objective data to confirm this observation. Cuschieri97 described a 4-hour performance "wall" that surgeons encounter during long VES procedures. During training for advanced laparoscopic procedures, most surgeons report exhaustion at the end of a 5- to 6-hour training session, despite optimized instrument and equipment conditions.98 Interestingly, no such sharp performance barrier has been described during open surgery. Although operating times for simple VES procedures approximate those for open surgery, the cost of this performance during VES may be a higher level of adaptive mental stress by the surgeon.

The Operating Room Environment

The efficient design and setup of the operating room has long been a subject of interest to surgeons, architects, and engineers. The optimum design characteristics of an operating room have been widely discussed99,100 and standards for operating room construction have been published by the American College of Surgeons' Committee on the Operating Room Environment30 and the American Institute of Architects' Committee on Architecture for Health.101 While there is general agreement about the proper size of modern operating rooms,30 some authors29 have expressed concern about the potential hazard to personnel and equipment from the many cables and tubes present in the operating room. Several solutions have been proposed to reduce equipment crowding and lines crossing the floor in the operating room.102 Among the most popular are ceiling-mounted movable arms or tracks that can conveniently position equipment near the patient, thus freeing the floor space around the operating table. Increasingly, the usefulness of these and other design concepts will be able to be tested in advance through the use of virtual reality design tools.103,104

Video endoscopic surgery requires an increase in the amount of equipment in the operating room and poses a new challenge to optimizing the use of operating room space.105 Alarcon and Berguer106 reported that the percentage of total floor space occupied by persons, furniture, and equipment during laparoscopic operations is increased by 10% over open operations. Nonproductive activities can occupy up to 25% of the surgeon's time during VES.107 Simple aids such as an autoclavable multicompartment sheath can help to organize instruments on the field and a foot pedal template can keep different pedals correctly positioned for the surgeon.108 Every surgeon and nurse knows that a well-rehearsed operating room team is advantageous in reducing operating time and perhaps even conversion rates during VES.109 The effects of environmental conditions such as temperature and humidity on the performance of the surgical team are largely unstudied. Excessive noise levels in the operating room may cause distractions and make it difficult for the anesthesiologist to hear alarms and physiologic breath sounds.110 While there are several collaborative projects addressing the overall design of the operating room of the future,105,111 the lack of comprehensive task-analysis and time-motion data related to surgical operations continues to hamper the development of objective solutions to the problem of optimum operating room design.

More than a quarter-century ago, Laufman99 lamented that "only a few surgeons have made the surgical environment their main research interest." Future efforts to create a more user-friendly operating room environment will require the rethinking of traditional concepts of architecture, asepsis, and staffing. A greater involvement by surgeons and the other members of the operating team in this process can help assure the goals of increased efficiency and flexibility while maintaining patient and staff safety.

Corresponding author: Ramon Berguer, MD, 150 Muir Rd (112), Martinez, CA 94553 (e-mail: berguer.ramon@martinez.va.gov).

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Howe  RDPeine  WJKantarinis  DASon  JS Remote palpation technology. IEEE Eng Med Biol Magazine. 1995;14318- 323
Link to Article
Schurr  MOBuess  G OREST II: ergonomic workplace and systems platform for endoscopic technologies. Endosc Surg Allied Technol. 1995;3193- 198
Melzer  ASchurr  MOKunert  WBuess  GVoges  UMeyer  JU Intelligent surgical instrument system ISIS: concept and preliminary experimental application of components and prototypes. Endosc Surg Allied Technol. 1993;1165- 170
Wallwiener  DStumpf  BBastert  GMueller  W Multifunctional instrument for operative laparoscopy: technical, experimental and clinical results in gynaecology. Endosc Surg Allied Technol. 1995;3119- 124
Visarius  HGong  JScheer  CHaralamb  SNolte  LP Man-machine interfaces in computer assisted surgery. Comput Aided Surg. 1997;2102- 107
Link to Article
Hagberg  M Electromyographic signs of shoulder muscular fatigue in two elevated arm positions. Am J Phys Med. 1981;60111- 121
Stock  SR Workplace ergonomic factors and the development of musculoskeletal disorders of the neck and upper limbs: a meta-analysis. Am J Ind Med. 1991;1987- 107
Link to Article
Kant  IJde Jong  LCvan Rijssen-Moll  MBorm  PJ A survey of static and dynamic work postures of operating room staff. Int Arch Occup Environ Health. 1992;63423- 428
Link to Article
Rademacher  KPichler  KVErbse  S  et al.  Using human factor analysis and VR simulation techniques for the optimization of the surgical worksystem. Sieburg  SWMorgan  KedsHealth Care in the Information Age Amsterdam, the Netherlands IOS Press1996;533- 541
Mirbod  SYoshida  HMiyamoto  KMiyashita  KInaba  RIwata  H Subjective complaints in orthopedists and general surgeons. Int Arch Occup Environ Health. 1995;67179- 186
Meuli-Simmen  CSzabo  Z Video plastic surgery. Szabo  ZLewis  JKerstein  MedsSurgical Technology International. 3rd ed. San Francisco, Calif Universal Medical Press1994;515- 522
Goetschel  GE A review of the development of an ergonomically balanced chair. J Manipulative Physiol Ther. 1987;1065- 69
Irving  G A standing/sitting pelvic tilt chair: new hope for back-weary surgeons? S Afr Med J. 1992;82131- 132
Bendix  TKrohn  LJessen  FAaras  A Trunk posture and trapezius muscle load while working in standing, supported-standing, and sitting positions. Spine. 1985;10433- 439
Link to Article
Luttmann  ASokeland  JLaurig  W Electromyographical study on surgeons in urology: influence of the operating technique on muscular strain. Ergonomics. 1996;39285- 297
Link to Article
Berguer  RRab  GGhaida  HAAlarcon  AChung  J A comparison of surgeons' posture during laparoscopic and open surgical procedures. Surg Endosc. 1997;11139- 142
Link to Article
Welford  AT Mental work-load as a function of demand, capacity, strategy and skill. Ergonomics. 1978;21151- 167
Link to Article
Levey  SDrucker  WRCzarnecki  N Energy expenditure of surgeons, nurses, and anesthesiologists during operative procedures. Surgery. 1959;46529- 533
Becker  WGEllis  HGoldsmith  RKaye  AM Heart rates of surgeons in theatre. Ergonomics. 1983;26803- 807
Link to Article
Chavez-Lara  BLerdo de Tejada  AQuijano Pitn  FSerrano  PA Urinary elimination of catecholamines in surgeons and in patients during open heart surgery [in Spanish]. Arch Inst Cardiol Mex. 1969;3912- 16
Foster  GEEvans  DFHardcastle  JD Heart rates of surgeons during operations and other clinical activities and their modification by oxprenolol. Lancet. 1978;11323- 1325
Link to Article
Payne  RLRick  JT Heart rate as an indicator of stress in surgeons and anaesthetists. J Psychosom Res. 1986;30411- 420
Link to Article
Goldman  LIMcDonough  MTRosemond  GP Stresses affecting surgical performance and learning, I: correlation of heart rate, electrocardiogram, and operation simultaneously recorded on videotapes. J Surg Res. 1972;1283- 86
Link to Article
Czyzewska  EKiczka  KCzarnecki  APokinko  P The surgeon's mental load during decision making at various stages of operations. Eur J Appl Physiol. 1983;51441- 446
Link to Article
Cuschieri  A Whither minimal access surgery: tribulations and expectations. Am J Surg. 1995;1699- 19
Link to Article
Lewis  JSzabo  Z Formal laparoscopic skills training: evaluation by surgical specialists in a health maintenance organization. Szabo  ZLewis  JFantini  GedsSurgical Technology International. 4th ed. San Francisco Calif Universal Medical Press1995;66- 70
Laufman  H What's wrong with our operating rooms? Am J Surg. 1971;122332- 343
Link to Article
Nora  PF OR environment: a surgeon's view. Am Operating Room Nurse J. 1976;24266- 267
Link to Article
Not Available, Guidelines for Construction and Equipment of Hospital and Medical Facilities.  Washington, DC The American Institute of Architects Press1987;
Smith  HMcIntosh  PSverisdottir  ARobertson  C Improved coordination makes for faster work: ergonomic analysis of a trauma resuscitation room. Prof Nurse. 1993;8711- 715
Fener  E Real-time, 3-D simulations: improving OR efficiencies and outcomes. Health Inform. 1993;1018- 24
Kaplan  KHunter  IDurlach  NISchodek  DLRattner  D A virtual environment for a surgical room of the future. Satava  RmMorgan  KSieburg  HBMattheus  RChristensen  JPedsInteractive Technology and the New Paradigm for Healthcare. San Diego, Calif IOS Press1995;161- 167
Kernaghan  SG Technology and the surgical suite: forest of instrumentation improves, but complicates, surgical practice. Hospitals. 1982;56101- 105
Alarcon  ABerguer  R A comparison of operating room crowding between open and laparoscopic operations. Surg Endosc. 1996;10916- 916
Link to Article
Claus  GPSjoerdsma  WJansen  AGrimbergen  CA Quantitative standardised analysis of advanced laparoscopic surgical procedures. Endosc Surg Allied Technol. 1995;3210- 213
Curtis  PBournas  NMagos  A Simple equipment to facilitate operative laparoscopic surgery (or how to avoid a spaghetti junction). Br J Obstet Gynaecol. 1995;102495- 497
Link to Article
Kenyon  TALenker  MPBax  TWSwanstrom  LL Cost and benefit of the trained laparoscopic team: a comparative study of a designated nursing team vs a nontrained team. Surg Endosc. 1997;11812- 814
Link to Article
Weinger  MB Cardiovascular reactivity among surgeons: not music to everyone's ears [letter]. JAMA. 1995;2731090- 1091
Link to Article
Jolesz  FAShtern  F The operating room of the future: report of the National Cancer Institute Workshop, "Imaging-Guided Stereotactic Tumor Diagnosis and Treatment." Invest Radiol. 1992;27326- 328
Link to Article

Figures

Tables

References

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Ehrenwerth  JEisenkraft  JB Anesthesia Equipment: Principles and Applications.  Louis, Mo Mosby–Year Book Inc1993;
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Harris  NOCrabb  LJ Ergonomics: reducing mental and physical fatigue in the dental operatory. Dent Clin North Am. 1978;22331- 345
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Putsep  E Planning of Surgical Centres.  London, England Lloyd-Luke Ltd1973;
Quebbeman  EJ Preparing the operating room. Wilmore  DWBrennan  MFHarken  AHHolcroft  JWMeakins  JLedsCare of the Surgical Patient A Publication of the Committee on Pre and Postoperative Care. New York, NY Scientific American1993;1- 13
Tendik  FJennings  RWTharp  GStark  L Sensing and manipulation problems in endoscopic surgery: experiment, analysis, and observations. Presence. 1993;266- 80
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Crosthwaite  GChung  TDunkley  PShimi  SCuschieri  A Comparison of direct vision and electronic two- and three-dimensional display systems on surgical task efficiency in endoscopic surgery. Br J Surg. 1995;82849- 851
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Durrani  AFPreminger  GM Three-dimensional video imaging for endoscopic surgery. Comput Biol Med. 1995;25237- 247
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Satava  RM 3-D vision technology applied to advanced minimally invasive surgery systems. Surg Endosc. 1993;7429- 431
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Goh  PTekant  YKrishnan  S Future developments in high-technology abdominal surgery: ultrasound, stereo imaging, robotics. Balliere's Clin Gastroenterol. 1993;7961- 987
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Hanna  GBShimi  SMCuschieri  A Randomised study of influence of two-dimensional versus three-dimensional imaging on performance of laparoscopic cholecystectomy. Lancet. 1998;351248- 251
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Tendick  FBhoyrul  SWay  LW Comparison of laparoscopic imaging systems and conditions using a knot-tying task. Comput Aided Surg. 1997;224- 33
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Berci  GWren  SStain  SPeters  JPaz-Partlow  M Individual assessment of visual perception by surgeons observing the same laparoscopic organs with various imaging systems. Surg Endosc. 1995;9967- 973
Menozzi  Mvon Buol  AKrueger  HMiege  C Direction of gaze and comfort: discovering the relation for the ergonomic optimization of visual tasks. Ophthalmic Physiol Opt. 1994;14393- 399
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Arndt  R Working posture and musculoskeletal problems of video display terminal operators: review and reappraisal. Am Ind Hyg Assoc J. 1983;44437- 446
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Berguer  RForkey  DSmith  W Ergonomic problems associated with laparoscopic surgery. Surg Endosc. 1999;13466- 468
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Hanna  GBShimi  SMCuschieri  A Task performance in endoscopic surgery is influenced by location of the image display. Ann Surg. 1998;227481- 484
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Sugita  SSugita  K Modified ceiling-mounted zoom operating microscope. Am J Ophthalmol. 1971;72972- 974
Satava  RMEllis  SR Human interface technology: an essential tool for the modern surgeon. Surg Endosc. 1994;8817- 820
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Kavoussi  LRMoore  RGAdams  JBPartin  AW Comparison of robotic versus human laparoscopic camera control [published erratum appears in J Urol.1997;158:1530]. J Urol. 1995;1542134- 2136
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Jacobs  LKShayani  VSackier  JM Determination of the learning curve of the AESOP robot. Surg Endosc. 1997;1154- 55
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Riall  CT Surgical and medical devices and their origins: surgical instrument manufacturers. J Oper Room Res Inst. 1983;333- 42
Tendick  FStark  L Analysis of the surgeon's grasp for telerobotic surgical manipulation. Images of the Twenty-First Century Proceedings of the Annual International Conference of the IEEE Engineering in Medicine and Biology Society. Chicago, Ill Institute of Electrical and Electronics Engineers1989;914- 915
Seki  S The "left-hand rule" in directional changes of the needle holder with different needle grips: suturing technique in a restricted operating space. Int Surg. 1994;79172- 175
Nelson  JBMital  A An ergonomic evaluation of dexterity and tactility with increase in examination/surgical glove thickness. Ergonomics. 1995;38723- 733
Link to Article
Tendick  FCavusogly  MC Human-machine interfaces for minimally invasive surgery. Proceedings of 19th IEEE Engineering in Medicine and Biology Society Conference Chicago, Ill IEEE1997;2771- 2776
Sukthankar  SMReddy  NP Force feedback issues in minimally invasive surgery. Satava  RMMorgan  KSieburg  HBMattheus  RChristensen  JPedsInteractive Technology and the New Paradigm for Healthcare. San Diego, Calif IOS Press1995;375- 379
Gerber  S A comparative study of forces involved with manipulatin of standard and laparoscopic surgical instruments. Biomedical Engineering Program Sacramento California State University1998;75
Payandeh  S Force propagation in laparoscopic tools and trainers. Proceedings of 19th IEEE Engineering in Medicine and Biology Society Conference Chicago, Ill Institute of Electrical and Electronics Engineers1997;957- 960
Forkey  DSmith  WBerguer  R A comparison of thumb and forearm muscle effort required for laparoscopic and open sugery using an ergonomic measurement station. Proceedings of 19th IEEE Engineering in Medicine and Biology Society Conference Chicago, Ill1997;1705- 1708
Berguer  R Surgical technology and the ergonomics of laparoscopic instruments. Surg Endosc. 1998;12458- 462
Link to Article
Neuhaus  SJWatson  DI Laparoscopic surgeons' thumb: is it a training phenomenon? Minim Invasive Ther Allied Technol. 1997;631- 32
Link to Article
Majeed  AWJacob  GReed  MWJohnson  AG Laparoscopist's thumb: an occupational hazard [letter]. Arch Surg. 1993;128357
Link to Article
Kano  NYamakawa  TKasugai  H Laparoscopic surgeon's thumb [letter]. Arch Surg. 1993;1281172
Link to Article
Horgan  LFO'Riordan  DCDoctor  N Neuropraxia following laparoscopic procedures: an occupational injury. Minim Invasive Ther Allied Technol. 1997;633- 35
Link to Article
Sackier  JMBerci  G A laparoscopic hazard for the surgeon [letter]. Br J Surg. 1992;79713
Link to Article
Mueller  LP Laparoscopic instrument grips: an ergonomic approach [letter]. Surg Endosc. 1993;7465- 466
Link to Article
Szabo  ZBiggerstaff  E Laparoscopic mircrosurgery: tubotubal anastomosis. Szabo  ZKerstein  MLewis  JedsSurgical Technology International. 3rd ed. San Francisco, Calif Universal Medical Press1994;333- 341
Rosser  JCRosser  LESavalgi  RS Skill acquisition and assessment for laparoscopic surgery. Arch Surg. 1997;132200- 204
Link to Article
Hanna  GBShimi  SCuschieri  A Optimal port locations for endoscopic intracorporeal knotting. Surg Endosc. 1997;11397- 401
Link to Article
Hanna  GBShimi  SCuschieri  A Influence of direction of view, target-to-endoscope distance and manipulation angle on endoscopic knot tying. Br J Surg. 1997;841460- 1464
Link to Article
Satava  RM Surgery 2001: a technologic framework for the future. Surg Endosc. 1993;7111- 113
Link to Article
Bowersox  JCShah  AJensen  JHill  JCordts  PRGreen  PS Vascular applications of telepresence surgery: initial feasibility studies in swine. J Vasc Surg. 1996;23281- 287
Link to Article
Allen  DBowersox  JJones  GG Telesurgery, telepresence, telementoring, telerobotics. Telemed Today. 1997;518- 25
Partin  AWAdams  JBMoore  RGKavoussi  LR Complete robot-assisted laparoscopic urologic surgery: a preliminary report. J Am Coll Surg. 1995;181552- 557
Masri  BAMcGraw  RWBeauchamp  CP Robotrac in total knee arthroplasty: the silent assistant. Am J Knee Surg. 1995;820- 23
Howe  RDPeine  WJKantarinis  DASon  JS Remote palpation technology. IEEE Eng Med Biol Magazine. 1995;14318- 323
Link to Article
Schurr  MOBuess  G OREST II: ergonomic workplace and systems platform for endoscopic technologies. Endosc Surg Allied Technol. 1995;3193- 198
Melzer  ASchurr  MOKunert  WBuess  GVoges  UMeyer  JU Intelligent surgical instrument system ISIS: concept and preliminary experimental application of components and prototypes. Endosc Surg Allied Technol. 1993;1165- 170
Wallwiener  DStumpf  BBastert  GMueller  W Multifunctional instrument for operative laparoscopy: technical, experimental and clinical results in gynaecology. Endosc Surg Allied Technol. 1995;3119- 124
Visarius  HGong  JScheer  CHaralamb  SNolte  LP Man-machine interfaces in computer assisted surgery. Comput Aided Surg. 1997;2102- 107
Link to Article
Hagberg  M Electromyographic signs of shoulder muscular fatigue in two elevated arm positions. Am J Phys Med. 1981;60111- 121
Stock  SR Workplace ergonomic factors and the development of musculoskeletal disorders of the neck and upper limbs: a meta-analysis. Am J Ind Med. 1991;1987- 107
Link to Article
Kant  IJde Jong  LCvan Rijssen-Moll  MBorm  PJ A survey of static and dynamic work postures of operating room staff. Int Arch Occup Environ Health. 1992;63423- 428
Link to Article
Rademacher  KPichler  KVErbse  S  et al.  Using human factor analysis and VR simulation techniques for the optimization of the surgical worksystem. Sieburg  SWMorgan  KedsHealth Care in the Information Age Amsterdam, the Netherlands IOS Press1996;533- 541
Mirbod  SYoshida  HMiyamoto  KMiyashita  KInaba  RIwata  H Subjective complaints in orthopedists and general surgeons. Int Arch Occup Environ Health. 1995;67179- 186
Meuli-Simmen  CSzabo  Z Video plastic surgery. Szabo  ZLewis  JKerstein  MedsSurgical Technology International. 3rd ed. San Francisco, Calif Universal Medical Press1994;515- 522
Goetschel  GE A review of the development of an ergonomically balanced chair. J Manipulative Physiol Ther. 1987;1065- 69
Irving  G A standing/sitting pelvic tilt chair: new hope for back-weary surgeons? S Afr Med J. 1992;82131- 132
Bendix  TKrohn  LJessen  FAaras  A Trunk posture and trapezius muscle load while working in standing, supported-standing, and sitting positions. Spine. 1985;10433- 439
Link to Article
Luttmann  ASokeland  JLaurig  W Electromyographical study on surgeons in urology: influence of the operating technique on muscular strain. Ergonomics. 1996;39285- 297
Link to Article
Berguer  RRab  GGhaida  HAAlarcon  AChung  J A comparison of surgeons' posture during laparoscopic and open surgical procedures. Surg Endosc. 1997;11139- 142
Link to Article
Welford  AT Mental work-load as a function of demand, capacity, strategy and skill. Ergonomics. 1978;21151- 167
Link to Article
Levey  SDrucker  WRCzarnecki  N Energy expenditure of surgeons, nurses, and anesthesiologists during operative procedures. Surgery. 1959;46529- 533
Becker  WGEllis  HGoldsmith  RKaye  AM Heart rates of surgeons in theatre. Ergonomics. 1983;26803- 807
Link to Article
Chavez-Lara  BLerdo de Tejada  AQuijano Pitn  FSerrano  PA Urinary elimination of catecholamines in surgeons and in patients during open heart surgery [in Spanish]. Arch Inst Cardiol Mex. 1969;3912- 16
Foster  GEEvans  DFHardcastle  JD Heart rates of surgeons during operations and other clinical activities and their modification by oxprenolol. Lancet. 1978;11323- 1325
Link to Article
Payne  RLRick  JT Heart rate as an indicator of stress in surgeons and anaesthetists. J Psychosom Res. 1986;30411- 420
Link to Article
Goldman  LIMcDonough  MTRosemond  GP Stresses affecting surgical performance and learning, I: correlation of heart rate, electrocardiogram, and operation simultaneously recorded on videotapes. J Surg Res. 1972;1283- 86
Link to Article
Czyzewska  EKiczka  KCzarnecki  APokinko  P The surgeon's mental load during decision making at various stages of operations. Eur J Appl Physiol. 1983;51441- 446
Link to Article
Cuschieri  A Whither minimal access surgery: tribulations and expectations. Am J Surg. 1995;1699- 19
Link to Article
Lewis  JSzabo  Z Formal laparoscopic skills training: evaluation by surgical specialists in a health maintenance organization. Szabo  ZLewis  JFantini  GedsSurgical Technology International. 4th ed. San Francisco Calif Universal Medical Press1995;66- 70
Laufman  H What's wrong with our operating rooms? Am J Surg. 1971;122332- 343
Link to Article
Nora  PF OR environment: a surgeon's view. Am Operating Room Nurse J. 1976;24266- 267
Link to Article
Not Available, Guidelines for Construction and Equipment of Hospital and Medical Facilities.  Washington, DC The American Institute of Architects Press1987;
Smith  HMcIntosh  PSverisdottir  ARobertson  C Improved coordination makes for faster work: ergonomic analysis of a trauma resuscitation room. Prof Nurse. 1993;8711- 715
Fener  E Real-time, 3-D simulations: improving OR efficiencies and outcomes. Health Inform. 1993;1018- 24
Kaplan  KHunter  IDurlach  NISchodek  DLRattner  D A virtual environment for a surgical room of the future. Satava  RmMorgan  KSieburg  HBMattheus  RChristensen  JPedsInteractive Technology and the New Paradigm for Healthcare. San Diego, Calif IOS Press1995;161- 167
Kernaghan  SG Technology and the surgical suite: forest of instrumentation improves, but complicates, surgical practice. Hospitals. 1982;56101- 105
Alarcon  ABerguer  R A comparison of operating room crowding between open and laparoscopic operations. Surg Endosc. 1996;10916- 916
Link to Article
Claus  GPSjoerdsma  WJansen  AGrimbergen  CA Quantitative standardised analysis of advanced laparoscopic surgical procedures. Endosc Surg Allied Technol. 1995;3210- 213
Curtis  PBournas  NMagos  A Simple equipment to facilitate operative laparoscopic surgery (or how to avoid a spaghetti junction). Br J Obstet Gynaecol. 1995;102495- 497
Link to Article
Kenyon  TALenker  MPBax  TWSwanstrom  LL Cost and benefit of the trained laparoscopic team: a comparative study of a designated nursing team vs a nontrained team. Surg Endosc. 1997;11812- 814
Link to Article
Weinger  MB Cardiovascular reactivity among surgeons: not music to everyone's ears [letter]. JAMA. 1995;2731090- 1091
Link to Article
Jolesz  FAShtern  F The operating room of the future: report of the National Cancer Institute Workshop, "Imaging-Guided Stereotactic Tumor Diagnosis and Treatment." Invest Radiol. 1992;27326- 328
Link to Article

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