The ergonomic impact of patient body mass index on surgeon posture during simulated laparoscopy
Introduction
Over the past thirty years Laparoscopic Surgery (LS) has revolutionised patient care and has quickly become the default interventional procedure within a myriad of surgical specialties (Giannotti et al., 2015; Gill et al., 2010; Nguyen et al., 2001; NICE, 2010). The transition from open surgery has been supported by shorter recovery periods, less postoperative pain and lower risk of operative complications for the patient (Agha and Muir, 2003; Buia et al., 2015).
Despite the clear advantages of LS for the patient, the shift away from open surgery seems to have had a negative impact on surgeon health; specifically, an increased prevalence of musculoskeletal disorders (MSDs) (Alleblas et al., 2017; Nguyen et al., 2001). Laparoscopic surgery, as compared to open surgery, has been associated with a significantly greater risk of MSDs in the neck, thorax and shoulders (Stucky et al., 2018), with MSD complaints reported in 88% of 244 surgeons (Franasiak et al., 2012). The most likely cause of increased rates of MSDs has been attributed to the increase in non-neutral postures adopted by surgeons during LS (Epstein et al., 2017).
The emergence and impact of patients with obesity (BMI ≥ 30 kg/m2) has been linked with further deterioration of surgeon posture during LS (Moss et al., 2019). Obesity classification can be subdivided into three categories: Class 1, 30 kg/m2 < BMI ≤35 kg/m2, Class 2, 35 kg/m2 < BMI ≤40 kg/m2 and Class 3, BMI >40 kg/m2 often termed as ‘severe’ (NICE, 2010). Obesity incidence in the UK has doubled in the past two decades with 29% of the adult population now obese (Class 1 and Class 2) and 4% severely obese (Class 3) (Baker, 2019). A similar trend has been observed worldwide (Blüher, 2019).
Laparoscopic surgery is recognised as the optimal interventional technique for many intra-abdominal pathologies. While literature suggests that Class 1–2 obesity has a minimal impact on surgeon posture during LS (Liang et al., 2019; Moss et al., 2019), there is mounting evidence that indicates patients with Class 3 obesity have a negative impact on surgeon posture, exacerbating non-neutral postures in the problem areas previously identified (AlSabah et al., 2019; Hignett et al., 2017; Sers et al., 2021). The rising prevalence of high BMI patients and their associated negative effect on surgeon posture highlights the need for objective analysis to quantify and assess these impacts. The primary aim of this study was to objectively quantify the impact of different levels of patient BMI on surgeon posture. The authors hypothesized that increased patient BMI would degrade the quality of surgeon posture.
Section snippets
Participants and ethics
This study was conducted at the Sports Technology Institute at Loughborough University from November 2018 to June 2019. Ethical clearance for this study was obtained from the Loughborough University Ethics Approvals Sub-Committee and all participants provided voluntary informed consent before testing commenced. Study participants included six laparoscopic surgeons (5 male, 1 female) with a minimum of 4+ years of LS experience (at least > 50 laparoscopic procedures a year). The heights and body
Postural assessment results
There was a significant effect of BMI level on total LUBA score (p < 0.001) (Table 2). Pairwise comparisons showed BMI 20 kg/m2 – 50 kg/m2 (p = 0.001) and 30 kg/m2 – 50 kg/m2 (p = 0.002) to be significantly different, with 50 kg/m2 inducing significantly larger total LUBA scores in both cases. These results confirmed the hypotheses that significant degradation in posture can be observed when surgeons are subjected to larger BMI models. In all BMI levels, the major contributor to total LUBA
Discussion
The purpose of this study was to objectively quantify the effect of different levels of patientBMI on the posture of experienced laparoscopic surgeons. The upper body posture of surgeons was assessed by classifying motion capture data using the LUBA ergonomic framework. This study contributes to the growing literature concerning the impact of patient BMI on surgeons performing laparoscopy (Franasiak et al., 2012; Hignett et al., 2017; Liang et al., 2019; Moss et al., 2019; Sers et al., 2021).
Conclusion
Conducting LS on simulated high patient BMI models signficantly increased the severity of non-neutral postures compared to LS on normal BMI models. The increase in severe non-neutral postures and the average time spent maintaining them during high BMI models is more physically demanding and aggravates the musculoskeletal workload of the surgeon, which ultimately increases their risk of MSDs. Strict management of workloads, including exposure to patients with high BMIs may be necessary to reduce
Declaration of competing interest
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: This work has been partially supported by the LU-HEFCE Catalyst grant, the LU-EESE start-up grant, and by the Research Studentship awarded to R. Sers by the Doctoral College of Loughborough University, UK. Ryan Sers, Steph Forrester, Stephen Ward and Massimiliano Zecca have no conflicts of interest or financial ties to disclose. Esther Moss performs da’Vinci
Acknowledgement
The authors would like to thank the surgeons who participated in this study.
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