Colon Rectal Surg. 2019 Nov; 32(6): 424–434. Published online 2019 Aug 22. doi: 10.1055/s-0039-1693026
PMCID: PMC6824896PMID: 31686994
Surgeon Health
Guest Editor: Jennifer S. Davids, MD, FACS, FASCRS
Ergonomics and Musculoskeletal Health of the Surgeon

Andrew T. Schlussel, DO, FACS, FASCRS1 and Justin A. Maykel, MD, FACS, FASCRS2
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Abstract
Surgeons face hazardous working conditions due to ergonomic deficiencies found throughout the operating room. More than 80% of surgeons have succumbed to a work-related injury or illness as a consequence of sustaining awkward or static positions throughout lengthy operations over a career. While the focus of the procedure is directed to the patient, there is little concurrent regard for proper posture or spinal stability. Even when symptoms of discomfort are experienced, they are often ignored. This results in decreased production and may ultimately threaten surgical careers. Surgeons are often unaware of recommendations or guidelines designed to improve their comfort while operating. Furthermore, there is a significant lack of any formal ergonomic education, especially for minimally invasive procedures. Several modifiable risk factors can be adjusted in the operating room to provide a safer working environment. In addition, strengthening, stability, and exercise programs directed by a trained therapist may be employed to improve the surgeon’s musculoskeletal health.

Keywords: ergonomics, occupational injury, surgeon health
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Case Example by Justin Maykel, MD
Earlier in my career, I never considered the impact surgery would have on my own musculoskeletal (MSK) health. As I progressed into my late thirties, I started to experience back and hip pain so severe that I could barely walk after long days in the operating room. I started wearing a back brace while operating. I began taking naproxen on a regular basis. I never told anyone out of fear of stigma. I wanted to keep building my practice and not slow down. At first, I assumed it would just get better. Eventually, as my symptoms progressed, I tried everything—stretching, braces, massage therapy, acupuncture, physical therapy, chiropractor, steroid injections.

A magnetic resonance imaging (MRI) revealed torn cartilage around my hip. This resulted from years of repetitive, positional trauma working in the operating room without regard for proper ergonomics. It required surgery and an associated 6-week recovery, during which I was sidelined out of work.

I was shocked to learn that nearly all of my colleagues had chronic MSK conditions related to the physical demands of our job. Surgeons are like professional athletes, who require conditioning to keep them performing at the top of their game. We need to improve our working environment and maintain our physical health to make sure that we can perform optimally and maintain career longevity. Step 1 is to recognize the reality of the situation. Step 2 is to do something about it, and therefore we welcome you to keep reading.

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Introduction
At the conclusion of medical school, young physicians embark upon their professional journey with the acceptance of the Hippocratic Oath, affirming they will do no harm. As admirable as this pledge may be, surgeons rarely consider the personal harm that may ensue from years of operating in hazardous conditions. A recent report from the American College of Surgeons’ Surgery News Bulletin has addressed the mounting health concerns of surgeons, declaring “This has to change, for how can we provide excellent care to the patient if we cannot maintain our own health and safety.” 1

Surgeons are conditioned and trained in a high-paced, productivity-driven environment, where the thoughts or complaints related to stress and fatigue are often discouraged or simply ignored. Medical students and residents are generally young, flexible, and limber. Their senior surgeons would be unlikely to admit or address any personal weakness or limitations to their trainees. This flawed relationship represents a critical barrier to open dialog and progress. The consequences are severe and relate to both physical and mental health. 2

Despite all the advances in medical technology, operating rooms are still not designed ergonomically nor with the surgeon’s health in mind. Operating tables have limited mobility, floor surfaces are hard, and monitors are positioned incorrectly. Furthermore, the complexity and duration of operations have evolved, often related to the epidemic of morbid obesity in our population. The surgeon stands and operates in awkward positions for multiple hours. As a consequence, reports have demonstrated that 50 to 85% of practicing surgeons worldwide experience regular MSK discomfort in the neck, shoulders, and back. Endoscopic procedures are another risk factor for the incidence of hand and finger injuries (42%), as well as neck pain (11%). These symptoms may all lead to chronic disorders over time. 3 4 5 6 7 8 9 10

Those at a greater risk of injury include surgeons with a history of preexisting neuromuscular disorders such as carpal tunnel syndrome, tendonitis, and arthritis. 11 12 In addition, case volume, duration, and disproportionate hand size to instrumentation are associated with a greater rate of neurapraxia. 13 14 15 Maintaining a static position for an extended period of time, especially when operating in the extremes of quadrants of the abdominopelvic cavity, increases the physical workload endured by the MSK system. Davis et al have reported that more than 40% of surgeons experienced one or more injuries in the workplace. These injuries affect operative performance in half of these surgeons, whereas 20 to 30% missed work or reduced the number of operations performed as a direct result of their injury. Sadly, only 20% of surgeons officially reported their injury. 16 As a result, the cost for medical treatment of occupational related injuries have exceeded 100 billion dollars annually, a significant economic burden on society. 17 18

It is critical that our profession focuses not only on the patient but also on improving the physical and mental well-being of the provider. Surgeons are not invincible and should be encouraged to reveal their limitations and recognize the potential risks related to performing surgery. Failing to embrace these issues will affect a surgeon’s ability to function, resulting in diminished career satisfaction, fatigue, and burnout. 8 19 Unfortunately, many surgeons never receive a formal education or are even aware that guidelines exist to help prevent these prevalent occupational injuries. 9 20 21 Even more disappointing, when properly trained and educated, only 60% of surgeons actually incorporate appropriate ergonomic designs in their surgical practices. 21

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Human Factors and Ergonomics
To master surgeon safety in the operating room, one must understand the science of ergonomics. The word ergonomics stems from the Greek words “ergon,” meaning work, and “nomos,” meaning natural laws or arrangements. It is the study of people at work and how the working environment is designed to suit the worker. 22 Ergonomics relates to the interaction between person and machine, and the subsequent interaction the machine plays on the person, with the goal of optimizing how technology is used. 11 23 24 Combined as a complete system, the principles of ergonomics use anatomy, physiology, psychology, and engineering to create a favorable environment that mitigates MSK complaints and optimizes performance and efficiency. 24

The conditions that surgeons withstand have been compared with those of certain industrial workers. 25 Unfortunately, little basic science research has been implemented to address and evaluate the ergonomics in the operating room. 15 26 Integrating the field of ergonomics into medicine, especially surgery, can be challenging as multiple factors cannot be manipulated. These include the patient’s body habitus or the necessity to remain within the constraints of a sterile surgical field.

The discipline of ergonomics has evolved significantly since its inception in the early 1900s. 27 28 Research has been performed and employed in large industrial companies, the military, and sports training to maximize performance while reducing errors and injury. 11 More recently, focus has been drawn to the medical environment. Methods to mobilize and care for patients in intensive care units, gastrointestinal endoscopy suites, and medical-surgical wards have been implemented to specifically minimize back injuries. 29 As the incidence of cervicobrachial injuries rose in the dental profession, this encouraged the redesign of equipment and techniques to mitigate further health risks to the provider. 30 31 Similar responses are more complex in the field of surgery. The wide variety of operative techniques, disease locations, and patient position all alter the operating room environment. These factors contribute to how the operative field is visualized, the way surgical instruments are manipulated, and, ultimately, surgeon stance and posture. 11 26 These variables span open, laparoscopic, and robotic approaches.

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Body Positioning
“Posture” is defined as the spatial arrangements of body parts as they align to perform a task. This is an interface between segmental joints of the body and muscles crossing these joints to protect the body’s support structures and prevent damage in any position. These factors are influenced by the task, environment, working tools, and biologic characteristics of the worker. 32 A healthy, stable posture occurs when one is standing upright without a rounded back. The spine should remain straight to maintain the natural lordotic and kyphotic curves of the vertebrae. The elbows should be facing outward, the shoulder blades brought down and inward, while tucking in the core and buttocks. Focus on a line of gravity transecting all the spinal curves, and this will provide a stable structure and base of support ( Fig. 1 ). The best means of preventing work-related injuries are understanding and recognizing how a stable posture feels and understanding the downsides of a faulty posture that will lead to MSK injuries. 33 34 This understanding is not innate and requires coaching and training to develop muscle memory.

Fig. 1
Optimal ergonomic position.
One must not underestimate the physical exertion and mechanical load
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