I was recently asked to complete a survey into the “pain of laparoscopic surgery”. The authors were interested in the pain experienced by surgeons who perform laparoscopic surgery. This started me thinking about a subject that I have often discussed with trainee surgeons under my care; that is the ergonomics of laparoscopic surgery. For those who are unfamiliar with this type of surgery, it involves standing essentially on one leg (the other being used to activate energy sources for cutting and coagulation) and then using long instruments with the fulcrum set close to the patient such that large movements are required to elicit smaller movements within the patient in a setting where the movements are all in reverse and then viewed on a two dimensional monitor. This is not a natural human task and requires training. Like many repetitive behaviours in life there are some who are naturally gifted but everybody requires practice to become competent at the tasks required. I see many aspiring surgeons (and some surgeons) who manage to contort themselves into highly uncomfortable positions while performing this type of surgery. Historically and since most surgeons tend to be right handed the initial trocar is placed with the right hand such that the surgeon stands on the left side of the patient. If the surgeon then remains standing on the left side of the patient, the right hand, which many use as the dominant hand, needs to be elevated at the elbow to clear the operating table and maintain full access of movement. Unfortunately it is not possible to operate for long periods of time with the elbows extended out from the body. It is also exceedingly difficult to concentrate for extended periods when the shoulders are not square on to the monitor and the head is in a relaxed natural position. These positions lead to a significant loss of stability and precision resulting in fatigue, pain and tremor. This clearly has the potential to increase the risk of inadvertent damage at the target operative site. In many endeavours involving fine repetitive movements, core stability with the elbows kept close to the body and with the elbows bent allowing small movements at the wrists, results in the optimal outcome. Try writing with your elbows straight or elevated and you soon grasp the concept.
I believe ergonomics and core stability are critical and under-researched facets of successful laparoscopic surgery. In my experience the more gifted surgeons have tended to be fitter and look more comfortable when operating. Conversely those surgeons who require contorting their body to unusual positions resulting in pain for themselves as they operate are unlikely to be able to operate with a high level of focus and accuracy for extended periods of time. It would not be surprising if the outcomes of surgery differ between the two.
Your mother and your gym coach were almost certainly correct. Stand up straight with your shoulders back, work on your core muscles and keep your elbows by your side if you wish to be a good laparoscopic surgeon.
There is however, hope in the future for those incapable of contemplating the ergonomics of laparoscopic surgery. The coming robot revolution will mean that irrespective of the degree of your core fitness or ergonomic impediments, the robot will be able to cope with the situation. For the moment, my belief is that your surgeon should look relaxed at the time of surgery.
