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Article of the Week: An assessment of the physical impact of complex surgical tasks on surgeon errors and discomfort

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

An assessment of the physical impact of complex surgical tasks on surgeon errors and discomfort: a comparison between robot-assisted, laparoscopic and open approaches

Oussama Elhage*, Ben Challacombe*, Adam Shortland‡ and Prokar Dasgupta*
§*The Urology Centre, Guy’s and St Thomas’ NHS Foundation Trust, Medical Research Council (MRC) Centre for Transplantation, King’s College London, One Small Step Laboratory, and §MRC Centre for Transplantation & National Institute for Health Research (NIHR) comprehensive Biomedical Research Centre, King’s College London, King’s Health Partners, Guy’s Hospital, London, UK

 

OBJECTIVES

To evaluate, in a simulated suturing task, individual surgeons’ performance using three surgical approaches: open, laparoscopic and robot-assisted.

SUBJECTS AND METHODS

Six urological surgeons made an in vitro simulated vesico-urethral anastomosis. All surgeons performed the simulated suturing task using all three surgical approaches (open, laparoscopic and robot-assisted). The time taken to perform each task was recorded. Participants were evaluated for perceived discomfort using the self-reporting Borg scale. Errors made by surgeons were quantified by studying the video recording of the tasks. Anastomosis quality was quantified using scores for knot security, symmetry of suture, position of suture and apposition of anastomosis.

RESULTS

The time taken to complete the task by the laparoscopic approach was on average 221 s, compared with 55 s for the open approach and 116 s for the robot-assisted approach (anova, P < 0.005). The number of errors and the level of self-reported discomfort were highest for the laparoscopic approach (anova, P < 0.005). Limitations of the present study include the small sample size and variation in prior surgical experience of the participants.

CONCLUSIONS

In an in vitro model of anastomosis surgery, robot-assisted surgery combines the accuracy of open surgery while causing lesser surgeon discomfort than laparoscopy and maintaining minimal access.

Editorial: Conventional laparoscopic surgery – more pain, no gain!

Advances in surgical technology have revolutionized the way surgery is performed today. Conventional laparoscopic surgery dominated the surgical paradigm for several decades, until robot-assisted surgery created the next giant leap. In the pressent article, Elhage et al. [1] compare and correlate physical stress and surgical performances among three modes of a standardized surgical step. Their study shows the obvious physical strain and technical limitations faced while performing conventional laparoscopic surgery, subsequently leading to compromised surgical outcomes. The physical impact of conventional laparoscopic surgery has been well documented through surgeon feedback as well as ergonomic assessment [2, 3]. Various studies have reported that higher physical stress, associated with ergonomic limitations, is experienced when performing conventional laparoscopy compared to the comfort and ease of robot-assisted surgery, as highlighted in the present study. Increased workload has also been associated with performance errors, with a steep learning curve needed to achieve surgical excellence during conventional laparoscopy [4].

Currently, the use of robot-assisted surgery is on the rise, as an alternative to both open and conventional laparoscopic surgery across the developed world, despite its obvious economic limitations. Better ergonomics during robot-assisted surgery will increase the comfort of the surgeon, but the future of surgery may easily be linked to the improvements experienced by all of us in the automobile industry. Developments, from manual gear-clutch control to automatic speed control and the luxury of adaptive cruise control today, make us safe drivers with minimal physical stress. The concept of adaptive cruise control, which adjusts the speed of a vehicle in relation to its surroundings, sounds similar to the leap from manual camera control during conventional laparoscopy to console-based control during camera navigation in robot-assisted surgery. With advances in the speed and size of computers, pneumatic-based joint mechanics and mindfulness meditation on the horizon, it will not be long before surgeons will sit back and watch the marvel of the machine. Surgeons just need to learn to hold on to their seats!

Syed J. Raza*, Khurshid A. Guru† anRobert P. Huben†
*Fellow, †Endowed Professor of Urologic Oncology, Department of Urology and A.T.L.A.S (Applied Technology Laboratory for Advanced Surgery) Program, Roswell Park Cancer Institute, Buffalo, NY, USA

 

References

 

2 Plerhoples TA, Hernandez-Boussard T, Wren SM. The aching surgeon: a survey of physical discomfort and symptoms following open, laparoscopic and robotic surgery.

J Robotic Surg 2012; 6: 65–723 Hubert N, Gilles M, Desbrosses K, Meyer JP, Felblinger J, Hubert J. Ergonomic assessment of the surgeon’s physical workload during standard and robotic assisted laparoscopic procedures. Int J Med Robot 2013; 9:142–147

4 Yurko YY, Scerbo MW, Prabhu AS, Acker CE, Stefanidis D. Higher mental workload is associated with poorer laparoscopic performance as measured by the NASA-TLX tool. Simul Healthc 2010; 5: 267–271

 

Step-by-Step. Ergonomic use of the fourth arm

Ergonomic use of the fourth arm to oversew the dorsal vascular complex (DVC) during robot-assisted laparoscopic prostatectomy (RALP)

Omer Karim, Amrith Rao, Emma Marsdin, Rajesh Kavia, Arie Parnham, Hanif Motiwala and Marc Laniado
Centre for Robotics and Minimally Invasive Surgery,Wexham Park Hospital, Slough, Berkshire, UK

Objective

• To demonstrate an ergonomic fourth arm technique to oversew the dorsal vascular complex (DVC) during robot-assisted laparoscopic prostatectomy (RALP).

Patients and Methods

• Balloon of a Foley catheter inflated in the bulbar urethra.
• Fourth arm cranial traction via suture in the tip of the catheter.
• DVC oversewn under direct vision.

Results

• Oversew of DVC with minimal patient-side surgical assistance.
• About a 50% reduction in apical positive margin rate.

Conclusion

• A useful, ergonomic method of oversewing the DVC
during RALP.

Karim O, Rao A, Marsdin E, et al. Ergonomic use of the fourth arm to oversew the dorsal vascular complex (DVC) during robot-assisted laparoscopic prostatectomy (RALP). BJU Int 2013; 111: 179–180.

Read the full article
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