Getting started-and-ergonomics-BY Prod/Dr Ahmed Ragab Ali

By
Ahmed Ragab Ali
Assistant Prof of urology, Zagazig university, EGYPT
Getting started and ergonomics of laparoscopy

Goal
 The goal is to produce a surgeon who is highly competent
and confident in performing laparoscopic procedures; and
thereby avoiding the risks of complications.
 Because of the steep learning curve that is unique to
laparoscopy, hands-on training on a box or virtual
simulator is the recommended way to start learning
laparoscopic skills.

Learning Points
 What is laparoscopy and its history ?
 To understand why there is a need to learn laparoscopy?
 How do you start?
 What are the obstacles in starting and how can they be overcome?
 To understand the basics of OR set up.
 Understanding role of ergonomics in laparoscopy.

 Both H. Kalk from Germany and Kurt Semm, a German
gynecologist, share the title “Father of Modern Laparoscopy”
 They developed many laparoscopic operative techniques and
instruments including intracorporeal suturing techniques, a
controlled insufflation apparatus, and safe endocautery devices.

Reasons for slow growth
 Steep learning curve.
 2D vision.
 Loss of tactile sensations.
 Fewer urological procedures requiring laparoscopy as compared
to general surgeons.
 High level of difficulty as compared to gynecological or general
surgical procedure.

Principle differences between laparoscopic and open
surgery FOR THE PATIENT
1- Post operative pain related to size of incision
Small incisions =less pain
2- Small incisions less scarring better cosmesis.
3- Avoidance of trauma to the abdominal wall by long incision decrease
incidence of infection and cross infection
4- Less Handling of intestines results in little or no disturbance of normal
function.
5- Allows early return to more strenuous activities: driving, lifting, sport etc.

Principle differences between laparoscopic and open
surgery For the Surgeon
 Magnified view often better than obtained via an incision allows precise
dissection.
 Altered tactile response
 Recently 3D vision with better light .
 Usually (but not always) longer operating time
 Sometimes Need to develop entirely different operating technique
 Work well in a narrow field without the need of retractors.
 Decrease incidence of cross infection (needle stick)

Principle Differences between laparoscopic and open
surgery FORTHEHOSPITAL
 Initial capital costs to establish laparoscopic surgery is
compensated by shortening of hospital stay e.g. reduced from 5 to
1 day in some surgeries, thus reduced overall costs
 Reduce incidence of infection and cross infection
 Propaganda for the hospital

surgery For the community
 Rapid return to the activity and to the work.
 Less cost in broadline.
surgery For theTeam
 Video imaging allows surgical assistants, anesthesiologists, to
actively participate in the procedure in their respective roles.
 Decrease incidence of cross infection (needle stick)

IMPORTANT RULES
 Safety comes first……….!!!
 Looking through a hole
 Magnified field
 Highly technical subspecialty.
 Valid indication in the absence of contraindication and
caution with every possible step to avoid complication leads
to successful laparoscopy.

TWO YEARS BEFROE
 Prepare yourself by knowledge, skills and competence in open surgery.
 Develop eyes-hands-foot coordination by being a goodWii player.
 Always attend courses, workshops, use pelvitrainer exercises, use virtual
reality simulators, and watch video films.

 Stick to a competent laparoscopic surgeon to observe then
perform under supervision, perform alone then train others.
 Prepare an experienced anesthesiologist.
 Prepare a well-equipment OR for laparoscopy.
 Build up a team for laparoscopic surgery.

THE WEEK BEFORE
 The indications.
 The contraindication.
 The counseling.
 Realistic expectations.
 Patient awareness.
 Timing
 Treat any risk before like chest infection or urinery .

 Discuss the operation, instruments
 Dedicated nursing staff in theatre
 Post-operative care plan
 Cost
 Length of stay – Short vs Long stay
 What will the health funds pay for?

THE DAY BEFORE (DAY -1)
 Consent and documentation.
 Inform an experienced anesthesiologist to meet with him before .
 Tell the patient to have full fasting for 8 hours.
 Patient should clean , shave .
 If expecting adhesion, bowel preparation is done.
 Ask ass to mark the side of surgery
 Sleep well !!!!!!.

THE DAY OF SURGERY DAY (0)
 Check for the setup before patient gets in.
 Any failure counts only against you. !!!!!!!
 Be near to a conventional surgery theatre –just in case- !!!
 prophylactic antibiotic 0.5 hour with the induction anesthesia.
 Anticoagulation if surgery lasts > 30 minutes. Extended and or
pneumatic calf.

Convince yourself it is doable !!

General principles ofOR setup
 Surgeon operative field and monitor in same line
 Surgeon should be optically correct
 Insufflator :just below or along the monitor
 Light source : on same cart as monitor
 All lines secured and tangle free
 Drapes with straps and pockets to place instruments , telescope
 Two monitors (ideal) on either side of table

Laparoscopy drapes
Bag to hold
instruments
Secured
lines
Straps

Positioning of PrimarySurgeon and
Cameraperson

UrologicSurgeries for the beginner
 Varicocele
 Renal cyst
 Simple nephrectomy (nonfunction non inflamed)
 Ureteric stone

Three important pillars of laproscopic
surgery
 Ergonomics,”Hawthorne effect”
 Task Analysis
 Psycho-engineering

Ergonomics
 Greek words "ergon" meaning work and "nomos" meaning
natural laws or arrangement.
 The concept of designing the working environment to fit the
worker.

Importance
 Correct ergonomics can reduce time and fatigue.
 Pressure-related chronic pain : decreased in laparoscopic surgeons
:by the use of ergonomically designed products.
EMG and data glove data acquisition during the performance of laparoscopic tasks on simulator.

Hawthorne effect
“It has been a well-observed phenomenon that any individual
performs a skill better and with more caution whenever he has
the knowledge that he is under observation and assessment”

Ergonomical considerations for the instruments
 Level of the instrument
 Handle at the level of elbow
 Manipulation angle:
 Angle between two instruments :ideally= 600 degrees
 Azimuth angle: Angle between scope and instrument
 Ideal : 300 degrees, never <150 or >450
 Elevation angle:
 Angle between Instrument and body of the patient: Ideally =450-600

Azimuth angle
 Task efficiency better with equal azimuth angles than with unequal
azimuth angles.
 The best ergonomic layout for endoscopic surgery consists of a
manipulation angle ranging from 45° to 75° with equal azimuth angles

Summary of instrument characters
 Instruments should behave like type one lever
 Telescope should be in the middle of the working instruments
 Manipulation angle
 Elevation angle
 Distance between two ports between 5 to 7.5cm
 Azimuth angle between 15 to 45 degree

Ergonomic posture (Ideal relaxed position)
• Straight head, in axis of trunk,
without rotation. or extension of
the cervical spine.
• Shoulders in relaxed and neutral
position.
• Arms along side the body.
• Elbows bent to 70 to 90 degrees.
• Forearms in horizontal or slightly
descending axis.
• Hands pronated.
• Hands and fingers lightly grip the
handles/ hand piece.
• Gaze down view of monitor

Co-axial alignment
Eye –target- center of monitor
200 downwards- normal gaze
Resting position of eye
> 150 tilt performance deteriorates
by 20%
Stretch on neck muscles STM
fatigue
Alteration in screen height-
oculomotor muscle fatigue

Distance from the monitor
 Ideal distance : 5 x
diagonal length of monitor
 At this distance image
formation on macula of
retina was optimal.
 Maximum acuity and color
perception

Operatingroomconsiderations
Height of OT table
 0.49 x height of the surgeon.
 Laparoscopic OT table must be
able to reach up to 24 cm from ground
OT lights
 Illumination of 20 lucs
Dark light- poor visualization
Bright light – optical illusion

Task Analysis
 Stepwise description of any task
 Components
 Procedural steps
 Executional steps
 Scientific sequential arrangement of steps

Psyco- Engineering
 Know you Machine
 Know about trouble shooting
 Temperament of a surgeon

WISHINGYOU A BENEFICIAL AND
SUCCESSFUL LAPAROSOCPIC WORKSHOP

Getting started-and-ergonomics-BY Prod/Dr Ahmed Ragab Ali

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