Laparoscopy: Patients Benefit, But Do Surgeons Suffer?
Posted Dec 02 2010 12:00am
When compared with open surgical techniques, the benefits of minimally invasive surgery have been well documented in medical literature, including increased safety, quicker recovery, shorter hospital stays, and cosmetic advantages. Nonetheless, surgeons who perform a majority of their cases laparoscopically appear to encounter physical stress and mental strain beyond what they experience when performing open surgery. New survey findings suggest that surgeon burden may be greater than previously assumed.
“Surgeon injuries appear to be a significant problem that not only affects surgeons but also all stakeholders in the delivery of healthcare, particularly surgical care,” says Adrian E. Park, MD. “Any type of surgery, particularly minimally invasive surgery, takes a physical and mental toll on surgeons. They continuously adapt to ensure the best outcome for patients, often dipping hugely into their own health reserve. We’re not going to serve our patients, the public, or the healthcare system well if we have prematurely shortened careers because of the physical tolls and cognitive ravages of what we do.”
Scant literature is available on the extent to which strain during laparoscopy affects surgeons’ bodies when compared with open surgery. In a study in the March 2010 Journal of the American College of Surgeons, Dr. Park and colleagues published a study that sought to confirm the prevalence of minimally invasive surgery-related operator symptoms and discomforts within a broad population of laparoscopic surgeons. Since previous surveys, the adoption rate of minimally invasive procedures has steadily grown, and more surgeons are now performing these surgeries than ever before. According to findings from the study, a fairly astounding number of injuries or symptoms were related to occupation among surgeons. Nearly 87% of surgeons completing the survey reported experiencing physical discomfort or symptoms attributed to performing minimally invasive surgery. This figure extends far beyond previous estimated rates of discomfort and symptoms, which ranged between 20% and 30%.
Causes of Physical & Mental Strain
In both open and minimally invasive surgery, surgeons must maintain static posture for long periods of time. “Surgeons are generally flexing their necks and shifting their weight, which can adversely affect the low back,” says Dr. Park. “However, minimally invasive surgery can be much more strenuous. Open surgery allows surgeons over 20° of freedom because instruments can be oriented using finger, wrist, elbow, and shoulder joints. In minimally invasive surgery, surgeons only have 4° to 6° of freedom due to a small portal of entry and a trocar fixed in space. Consequently, surgeons must contort their bodies to make up for limited movementoften holding unnatural positions for extended periods of time. This puts tremendous strain on joints and muscle groups.”
Additionally, a surgeon’s visual and motor axes are affected in minimally invasive surgery. In open surgery, the hands and visual axis are directly connected with the target anatomy, and surgeons work in three dimensions. In minimally invasive surgery, surgeons look at the target anatomy using a two-dimensional image on a video screen, which is usually raised up and quite separate from the patient. “Our visual axis looking at the target anatomy is very different from our motor axis,” says Dr. Park. “This expends more mental energy and requires more adaptations. In the analysis, the investigators found that discomfort ranged from eye strain to problems in the surgeon’s dominant hand to neck, back, and leg pain.
The strongest predictor of symptoms in the study by Dr. Park and colleagues was high case volume, with an exception of eye and back symptoms. Surprisingly, symptoms were only slightly related to age, height, or practice length. The study also specifically isolated the times at which symptoms were bothersome.
More Research Required
Increased, coordinated, and focused research efforts are still needed to evaluate the effects of laparoscopic surgery on surgeons, especially as laparoscopic procedures become more prevalent. “Recommendations can’t come in a vacuum; they have to be informed by concrete science and credible knowledge,” Dr. Park says. “The basic knowledge and understanding has to be further established so that meaningful and impactful recommendations can be made.
Furthermore, hospitals, policy makers, and industry are encouraged to better recognize surgeon health and wellbeing. While the armamentarium of advanced medical devices continues to grow, little attention is paid to surgeon-patient and surgeon-technology interfaces. “Focus is always on the tip of the spearwhere it will affect and interact with the patient,” explains Dr. Park. “More focus should be directed at the other end of the spear, where it’s being manipulated.”
Dr. Adrian E. Park is Chief of General Surgery, Professor of Surgery and Vice Chair, Department of Surgery University of Maryland Medical Center