Feasibility of implementing a virtual reality program as an adjuvant tool for peri-operative pain control; Results of a randomized controlled trial in minimally invasive foregut surgery.

BACKGROUND: Post-operative pain control and narcotic over-utilization are challenging issues for surgeons in all fields. While virtual reality (VR) has been increasingly applied in various fields, its feasibility and efficacy in the peri-operative period has not been evaluated. The aim of this study was to examine the experience of an integrated VR protocol in the perioperative setting. METHODS: Patients undergoing minimally invasive foregut surgery at a single institution were randomized to receive a series of VR meditation/mindfulness sessions (VR) or to standard care after surgery (non-VR). Post-operative pain levels, narcotic utilization and patient satisfaction were tracked. RESULTS: Fifty-two patients were enrolled with 26 in each arm. Post-operative pain scores, total narcotic utilization, and overall satisfaction scores were not significantly different between the two groups. For patients in the VR arm, sessions were able to be incorporated into the perioperative routine with little disruption. Most (73.9 %) were able complete all six VR sessions and reported low pain, anxiety, and nausea scores while using the device. A high proportion responded that they would use VR again (76.2 %) or would like a VR program designed for pain (62.0 %). There were no complications from device usage. CONCLUSION: VR is a safe and simple intervention that is associated with high patient satisfaction and is feasible to implement in the perioperative setting. While the current study is underpowered to detect difference in narcotic utilization, this device holds promise as an adjuvant tool in multimodal pain and anxiety control in the peri-operative period.

Operative performance outcomes of a simulator-based robotic surgical skills curriculum.

BACKGROUND: Robotic technology has become increasingly prevalent throughout modern surgical practice as surgical training programs are determining how to best include this robotic training in their curricula. In this study, we sought to measure changes in performance and workload metrics in the live operative setting following completion of a novel simulator-based robotic skills curriculum. METHODS: 31 surgical residents naïve to robotic platforms were recruited. They first participated in a live robotic case and had a baseline assessment using RO-SCORE, a robotic modification of the O-SCORE tool, and self-assessed their workload using the NASA Task Load Index (NTLX). Subjects then completed the curriculum, created by an expert panel, on a da Vinci Skills Simulator to pre-set proficiency goals. Subjects were encouraged to train on their own time and could complete the curriculum in one or more sittings, in a 1-month time period. Subjects were then assessed after another live case. Data were analyzed using paired Student's t test. RESULTS: Completion of the curriculum was associated with significant RO-SCORE improvements in operative performance across all domains including Camera Control (pre-curriculum mean: 1.9; post-curriculum mean: 4.8; p < 0.001), Needle Control (pre-curriculum mean: 1.7; post-curriculum mean: 4.4; p < 0.001), Tissue Handling (pre-curriculum mean: 2.0; post-curriculum mean: 4.4; p < 0.001). There were significant reductions in all NTLX workload domains including Physical Demand (pre-curriculum mean: 5.2; post-curriculum mean: 2.1; p < 0.001), and Frustration (pre-curriculum mean: 6.4; post-curriculum mean: 1.42; p < 0.001). CONCLUSIONS: We describe a feasible robotic simulation curriculum that requires a reasonable amount of time and is self-directed. Significant improvements were seen across all performance metrics and subjective operator workload. Importantly, this is translated to the clinical environment. These types of curricula will be necessary for improving the skills and confidence of trainees and attending surgeons as robotic technology becomes more pervasive.

Combination of Surgical Technique and Bioresorbable Mesh Reinforcement of the Crural Repair Leads to Low Early Hernia Recurrence Rates with Laparoscopic Paraesophageal Hernia Repair.

INTRODUCTION: Laparoscopic paraesophageal hernia (PEH) is associated with a low morbidity and mortality but an objective hernia recurrence rate in excess of 50% at 5 years. Biologic mesh has not been shown to reduce hernia recurrence rates. Recently, a new bioresorbable mesh made with poly-4-hydroxybutyrate with a Sepra-Technology coating on one side (Phasix-ST mesh) has become available. The aim of this study was to evaluate the feasibility, safety, and short-term efficacy of Phasix-ST mesh for reinforcement of the primary crural closure in patients undergoing elective, laparoscopic PEH repair. METHODS: A prospective database was initiated and maintained for all patients undergoing PEH repair with the use of Phasix-ST mesh. We retrospectively reviewed the records of consecutive patients who had an elective, first-time laparoscopic PEH repair with Phasix-ST mesh and who completed their 1-year objective follow-up study. Patients having a reoperation, non-laparoscopic repair, or who failed to comply with the objective follow-up were excluded. RESULTS: To achieve the desired 50 patients with 1-year objective follow-up, we reviewed the records of 90 consecutive PEH patients. In the final cohort of 50 patients, there were 32 females (64%) and 18 males. The median age of the patients at surgery was 67 years (range 44-84). The operation was PEH repair with fundoplication alone in 29 patients (58%) and PEH repair with Collis gastroplasty and fundoplication in 21 patients (42%). Phasix-ST mesh was used for crural reinforcement in all patients, and there were no intraoperative issues with the mesh or any difficulty placing or fixating the mesh at the hiatus. A diaphragm relaxing incision was performed in 2 patients (4%). The mean length of hospital stay was 2.8 days, and there was no major morbidity or mortality. On the 1-year objective follow-up study (median 12 months) a recurrent hernia was found in 4 patients (8%). No patient that had a Collis gastroplasty or a relaxing incision had a recurrent hernia. No patient had a reoperation. No patient had a mesh infection or mesh erosion. CONCLUSIONS: Phasix-ST mesh reinforcement of the crural closure during laparoscopic primary, elective PEH repair was associated with no adverse mesh-related events such as infection or erosion. Phasix-ST crural reinforcement in combination with tension-reduction techniques when necessary resulted in a very low (8%) objective hernia recurrence rate at a median follow-up of 1 year. These results demonstrate the safety of Phasix-ST mesh for use at the hiatus for crural reinforcement. This safety, along with the encouraging short-term efficacy for reducing hernia recurrence, should encourage further studies using the combination of resorbable biosynthetic mesh crural reinforcement and tension-reducing techniques during repair of paraesophageal hernias.

Effect of Patient Body Mass Index on Laparoscopic Surgical Ergonomics.

BACKGROUND: Minimally invasive surgery may introduce new ergonomic challenges for surgeons. Increased patient body mass index (BMI) may further add to this ergonomic stress. OBJECTIVES: The objective of this study was to quantify the ergonomic impact of patient BMI on surgeons during laparoscopic surgery. SETTING: University Hospital, USA. METHODS: This prospective cohort study analyzed five minimally invasive surgeons during 24 laparoscopic procedures. Each subject's muscle stress was assessed by recording surface electromyography (EMG) data from eight upper body muscle groups during laparoscopic procedures. EMG data was normalized against the maximal voluntary contraction (MVC) of each muscle measured before the start of surgery to create a percentage of the MVC value (%MVC). Subject workload was assessed through the NASA Task Load Index (NTLX). Statistical analysis was used to determine significance between surgeons operating on patients with or without obesity for %MVC and NTLX scores. RESULTS: There was no significant difference (p > 0.05) in both the average muscle activation of all eight muscle groups and NTLX scores during laparoscopic surgery in surgeons operating on patients with BMI > = 30 compared with patients with a BMI < 30. CONCLUSIONS: We detected no differences in ergonomic stress or workload for surgeons operating on patients with or without obesity. For surgeons, the laparoscopic approach may offer an additional advantage over open surgery in patients with obesity. This advantage may be due to an "equalizing effect" of laparoscopy-that surgical ergonomics are less affected by the BMI of the patient when using laparoscopic tools.

Surgical Management for Gastroparesis.

Gastroparesis is a debilitating chronic condition of indeterminate cause. Although conservative management is the mainstay of treatment, a significant percentage of patients will need interventions. Interventions range from supportive measures, such as feeding tubes, to more radical surgeries, including endoscopic pyloromyotomy (per oral pyloromyotomy), laparoscopic pyloroplasty, laparoscopic gastric stimulator placement, and even subtotal or total gastrectomy. The authors present some current treatment algorithms focused on the treatment side of the spectrum along with outcomes data to support the various approaches.

Long-term outcomes following POEM for non-achalasia motility disorders of the esophagus.

BACKGROUND: Optimal treatment for symptomatic patients with non-achalasia motility disorders (NAD) such as diffuse esophageal spasm, esophagogastric junction outlet obstruction, and hypercontractile disorder is not well established. POEM has been offered to these patients since it is a less invasive and less morbid procedure but long-term outcomes remain undetermined. The aim of this study was to assess long-term outcomes of POEM for patients with NAD. METHODS: Records of 40 consecutive patients undergoing POEM for NAD from May 2011 to January 2016 at a single center were retrospectively reviewed. Preoperative and 6-month postoperative symptom scores, high-resolution manometry, pH testing, and timed barium swallow (TBS) data were collected. Patients were contacted by phone to obtain long-term symptom assessment. Symptoms were assessed using a standardized symptom questionnaire with scores for symptoms graded according to frequency and the Eckardt score. RESULTS: Ten percent had minor complications with no postoperative sequelae. 90% of patients had significant improvement in their mean Eckardt scores (5.02 vs. 1.12, p < 0.001) at early follow-up. Improvements in chest pain (1.02-0.36, p = 0.001) and dysphagia (2.20 vs. 0.40, p = 0.001) were seen. Significant improvements in manometric pressures and esophageal emptying on TBS were observed across groups. 38% (10/26) of patients had a postoperative pH score > 14.72. Long-term (median 48 months) symptom scores were obtained from 29 (72.5%) patients. 82% of patients (24/29) had sustained symptom improvement. A small increase in the dysphagia scores was reported in the long-term follow-up compared to the immediate postoperative period (0.36-0.89, p = 0.046). CONCLUSIONS: Chest pain and dysphagia are effectively palliated with POEM in patients with non-achalasia disorders of the esophagus. Significant improvements are durable in long-term follow-up. Despite earlier reports by our group suggesting possible inferior outcomes from POEM for this difficult group of patients, this study is far more encouraging. POEM should be considered in the treatment of patients with non-achalasia disorders of the esophagus.

Ergonomic analysis of laparoscopic and robotic surgical task performance at various experience levels.

INTRODUCTION: Traditional laparoscopic surgery (TLS) has increasingly been associated with physical muscle strain for the operating surgeon. Robot-assisted laparoscopic surgery (RALS) may offer improved ergonomics. Ergonomics for the surgeon on these two platforms can be compared using surface electromyography (sEMG) to measure muscle activation, and the National Aeronautics and Space Administration Task Load Index (NTLX) survey to assess workload subjectively. METHODS: Subjects were recruited and divided into groups according to level of expertise in traditional laparoscopic (TLS) and robot-assisted laparoscopic surgery (RALS): novice, traditional laparoscopic surgeons (TL surgeons), robot-assisted laparoscopic surgeons (RAL surgeons). Each subject performed three fundamentals of laparoscopic surgery (FLS) tasks in randomized order while sEMG data were obtained from bilateral biceps, triceps, deltoid, and trapezius muscles. After completing all tasks, subjects completed the NTLX survey. sEMG data normalized to the maximum voluntary contraction of each muscle (MVC%), and NTLX data were compared with unpaired t tests and considered significant with a p ≤ 0.05. RESULTS: Muscle activation was higher during TLS compared to RALS in most muscle groups for novices except for the trapezius muscles. Muscle activation scores were also higher for TLS among the groups with more experience, but the differences were less significant. NTLX scores were higher for the TLS platform compared to the RALS platform for novices. DISCUSSION: TLS is associated with higher muscle activation in all muscle groups except for trapezius muscles, suggesting greater strain on the surgeon. Increased trapezius muscle activation on RALS has previously been documented and is likely due to the position of the eye piece. The differences seen in muscle activation diminish with increasing levels of expertise. Experience likely mitigates the ergonomic disadvantage of TLS. NTLX survey data suggest there are subjective benefits to RALS, namely in the perception of temporal demand. Further research to correlate NTLX data and sEMG measurements, and to investigate whether these metrics affect patient outcomes is warranted.

Advanced Endoluminal Technologies for Barrett's Esophagus: Focus on Optical Coherence Tomography and Confocal Laser Endomicroscopy.

Barrett's esophagus (BE) may progress to dysplasia and adenocarcinoma. The value of Barrett's surveillance with random biopsies is being questioned, but new technologies may enhance detection of progression within BE and guide endoscopic resection and ablation techniques. This review will focus on optical coherence tomography and endomicroscopy for patients with BE.

Comparison of precision and speed in laparoscopic and robot-assisted surgical task performance.

BACKGROUND: Robotic platforms have the potential advantage of providing additional dexterity and precision to surgeons while performing complex laparoscopic tasks, especially for those in training. Few quantitative evaluations of surgical task performance comparing laparoscopic and robotic platforms among surgeons of varying experience levels have been done. We compared measures of quality and efficiency of Fundamentals of Laparoscopic Surgery task performance on these platforms in novices and experienced laparoscopic and robotic surgeons. METHODS: Fourteen novices, 12 expert laparoscopic surgeons (>100 laparoscopic procedures performed, no robotics experience), and five expert robotic surgeons (>25 robotic procedures performed) performed three Fundamentals of Laparoscopic Surgery tasks on both laparoscopic and robotic platforms: peg transfer (PT), pattern cutting (PC), and intracorporeal suturing. All tasks were repeated three times by each subject on each platform in a randomized order. Mean completion times and mean errors per trial (EPT) were calculated for each task on both platforms. Results were compared using Student's t-test (P < 0.05 considered statistically significant). RESULTS: Among novices, greater errors were noted during laparoscopic PC (Lap 2.21 versus Robot 0.88 EPT, P < 0.001). Among expert laparoscopists, greater errors were noted during laparoscopic PT compared with robotic (PT: Lap 0.14 versus Robot 0.00 EPT, P = 0.04). Among expert robotic surgeons, greater errors were noted during laparoscopic PC compared with robotic (Lap 0.80 versus Robot 0.13 EPT, P = 0.02). Among expert laparoscopists, task performance was slower on the robotic platform compared with laparoscopy. In comparisons of expert laparoscopists performing tasks on the laparoscopic platform and expert robotic surgeons performing tasks on the robotic platform, expert robotic surgeons demonstrated fewer errors during the PC task (P = 0.009). CONCLUSIONS: Robotic assistance provided a reduction in errors at all experience levels for some laparoscopic tasks, but no benefit in the speed of task performance. Robotic assistance may provide some benefit in precision of surgical task performance.

Which causes more ergonomic stress: Laparoscopic or open surgery?

BACKGROUND: There is increasing awareness of potential ergonomic challenges experienced by the laparoscopic surgeon. The purpose of this study is to quantify and compare the ergonomic stress experienced by a surgeon while performing open versus laparoscopic portions of a procedure. We hypothesize that a surgeon will experience greater ergonomic stress when performing laparoscopic surgery. METHODS: We designed a study to measure upper-body muscle activation during the laparoscopic and open portions of sigmoid colectomies in a single surgeon. A sample of five cases was recorded over a two-month time span. Each case contained significant portions of laparoscopic and open surgery. We obtained whole-case electromyography (EMG) tracings from bilateral biceps, triceps, deltoid, and trapezius muscles. After normalization to a maximum voltage of contraction (%MVC), these EMG tracings were used to calculate average muscle activation during the open and laparoscopic segments of each procedure. Paired Student's t test was used to compare the average muscle activation between the two groups (*p < 0.05 considered statistically significant). RESULTS: Significant reductions in mean muscle activation in laparoscopic compared to open procedures were noted for the left triceps (4.07 ± 0.44% open vs. 2.65 ± 0.54% lap, 35% reduction), left deltoid (2.43 ± 0.45% open vs. 1.32 ± 0.16% lap, 46% reduction), left trapezius (9.93 ± 0.1.95% open vs. 4.61 ± 0.67% lap, 54% reduction), right triceps (2.94 ± 0.62% open vs. 1.85 ± 0.28% lap, 37% reduction), and right trapezius (10.20 ± 2.12% open vs. 4.69 ± 1.18% lap, 54% reduction). CONCLUSIONS: Contrary to our hypothesis, the laparoscopic approach provided ergonomic benefit in several upper-body muscle groups compared to the open approach. This may be due to the greater reach of laparoscopic instruments and camera in the lower abdomen/pelvis. Patient body habitus may also have less of an effect in the laparoscopic compared to open approach. Future studies with multiple subjects and different types of procedures are planned to further investigate these findings.

Transfer and priming of surgical skills across minimally invasive surgical platforms.

BACKGROUND: Robot-assisted laparoscopic surgery (RALS) uses 3-dimensional visualization and wristed instruments that provide more degrees of freedom than rigid traditional laparoscopic (TLS) instrumentation. These features have been touted to improve accuracy and efficiency during surgical task performance. Little is known, however, about the transferability of skills between the two platforms or whether task performance on one platform primes surgeons for task performance on the other. METHODS: Twenty-six subjects naïve to RALS were recruited to perform three Fundamentals of Laparoscopic Surgery tasks on both TLS and RALS platforms: peg transfer, pattern cutting (PC), and intracorporeal suturing. All tasks were performed within Fundamentals of Laparoscopic Surgery testing parameters and repeated three times by each subject on each platform. Platform and task order were randomized. Errors in task performance were defined as drops in the peg transfer task, faults 5 mm or more from the defined pattern during PC, and faults greater than 1 mm in suture placement from the defined points in intracorporeal suturing. Mean completion times and mean errors per trial (EPT) were calculated for each task on both platforms. Results were compared between those who performed TLS first (LF) and those who performed RALS first (RF) using unpaired Student's t-test (P < 0.05 considered statistically significant). RESULTS: No statistically significant differences in task completion time were noted between the LF and RF groups. RF subjects had fewer errors during robotic PC than LF subjects (1.02 EPT versus 1.86 EPT, respectively; P = 0.02). No other differences in task quality were noted. CONCLUSIONS: In surgeon's naïve to RALS, there is no evidence that skills acquired on RALS or TLS platforms are transferable to the other platform or that performing tasks on one platform primes a subject for task performance on the other. Performing TLS PC may have had a negative impact on subsequent RALS PC performance. These findings suggest that distinct programs for skills acquisition are necessary for both the TLS and RALS platforms.

Ergonomic analysis of primary and assistant surgical roles.

BACKGROUND: Laparoscopic surgery is associated with a high degree of ergonomic stress. However, the stress associated with surgical assisting is not known. In this study, we compare the ergonomic stress associated with primary and assistant surgical roles during laparoscopic surgery. We hypothesize that higher ergonomic stress will be detected in the primary operating surgeon when compared with the surgical assistant. METHODS: One right-hand dominant attending surgeon performed 698 min of laparoscopic surgery over 13 procedures (222 min primary and 476 min assisting), whereas electromyography data were collected from bilateral biceps, triceps, deltoids, and trapezius muscles. Data were analyzed in 1-min segments. Average muscle activation as quantified by maximal voluntary contraction (%MVC) was calculated for each muscle group during primary surgery and assisting. We compared mean %MVC values with unpaired t-tests. RESULTS: Activation of right (R) biceps and triceps muscle groups is significantly elevated while operating when compared with assisting (R biceps primary: 5.47 ± 0.21 %MVC, assistant: 3.93 ± 0.11, P < 0.001; R triceps primary: 6.53 ± 0.33 %MVC, assistant: 5.48 ± 0.18, P = 0.002). Mean activation of the left trapezius muscle group is elevated during assisting (primary: 4.33 ± 0.26 %MVC, assistant: 5.70 ± 0.40, P = 0.024). No significance difference was noted in the other muscle groups (R deltoid, R trapezius, left [L] biceps, L triceps, and L deltoid). CONCLUSIONS: We used surface electromyography to quantify ergonomic differences between operating and assisting. Surgical assisting was associated with similar and occasionally higher levels of muscle activation compared with primary operating. These findings suggest that surgical assistants face significant ergonomic stress, just as operating surgeons do. Steps must be taken to recognize and mitigate this stress in both operating surgeons and assistants.

Evaluation of absorbable mesh fixation devices at various deployment angles.

BACKGROUND: Hernia repair failure may occur due to suboptimal mesh fixation by mechanical constructs before mesh integration. Construct design and acute penetration angle may alter mesh-tissue fixation strength. We compared acute fixation strengths of absorbable fixation devices at various deployment angles, directions of loading, and construct orientations. METHODS: Porcine abdominal walls were sectioned. Constructs were deployed at 30°, 45°, 60°, and 90° angles to fix mesh to the tissue specimens. Lap-shear testing was performed in upward, downward, and lateral directions in relation to the abdominal wall cranial-caudal axis to evaluate fixation. Absorbatack™ (AT), SorbaFix™ (SF), and SecureStrap™ in vertical (SSV) and horizontal (SSH) orientations in relation to the abdominal wall cranial-caudal axis were tested. Ten tests were performed for each combination of device, angle, and loading direction. Failure types and strength data were recorded. ANOVA with Tukey-Kramer adjustments for multiple comparisons and χ (2) tests were performed as appropriate (p < 0.05 considered significant). RESULTS: At 30°, SSH and SSV had greater fixation strengths (12.95, 12.98 N, respectively) than SF (5.70 N; p = 0.0057, p = 0.0053, respectively). At 45°, mean fixation strength of SSH was significantly greater than SF (18.14, 11.40 N; p = 0.0002). No differences in strength were identified at 60° or 90°. No differences in strength were noted between SSV and SSH with different directions of loading. No differences were noted between SS and AT at any angle. Immediate failure was associated with SF (p < 0.0001) and the 30° tacking angle (p < 0.01). CONCLUSIONS: Mesh-tissue fixation was stronger at acute deployment angles with SS compared to SF constructs. The 30° angle and the SF device were associated with increased immediate failures. Varying construct and loading direction did not generate statistically significant differences in the fixation strength of absorbable fixation devices in this study.

Pore size and pore shape--but not mesh density--alter the mechanical strength of tissue ingrowth and host tissue response to synthetic mesh materials in a porcine model of ventral hernia repair.

BACKGROUND: Over 100 types of soft tissue repair materials are commercially available for hernia repair applications. These materials vary in characteristics such as mesh density, pore size, and pore shape. It is difficult to determine the impact of a single variable of interest due to other compounding variables in a particular design. Thus, the current study utilized prototype meshes designed to evaluate each of these mesh parameters individually. METHODS: Five prototype meshes composed of planar, monofilament polyethylene terephthalate (PET) were evaluated in this study. The meshes were designed to focus on three key parameters, namely mesh density, pore size, and pore shape. The prototype meshes were implanted in the preperitoneal, retrorectus space in a porcine model of ventral incisional hernia repair, and tissue ingrowth characteristics were evaluated after 90 days. Mesh-tissue composite specimens were obtained from each repair site and evaluated via T-peel mechanical testing. Force-displacement data for each T-peel test were analyzed and five characteristics of tissue ingrowth reported: peak force (fp), critical force (fc), fracture energy (Γc), work (W), and work density (Wden). Hematoxylin and eosin (H&E) stained sections of explanted mesh-tissue composites were also assessed for characteristics of tissue response including cellular infiltration, cell types, inflammatory response, extracellular matrix deposition, neovascularization, and fibrosis, with a composite score assigned to represent overall tissue response. RESULTS: The medium-weight, very large pore, hexagonal (MWVLH) mesh performed significantly better than the light-weight, medium pore, diamond (LWMD) mesh for all parameters evaluated (fp, fc, Γc, W, Wden) and trended toward better results than the medium-weight, medium pore, diamond (MWMD) mesh for the majority of the parameters evaluated. When the data for the five meshes was grouped to evaluate mesh density, pore size, and pore shape, differences were more pronounced. No significant differences were observed with respect to mesh density, however significant improvement in mechanical strength of tissue ingrowth occurred as pore size increased from medium to very large. In addition, the hexagonal pores resulted in the strongest tissue ingrowth, followed by the square pores, and finally the diamond pores. Scores for several histological parameters were significantly different for these prototype meshes. For example, the MWVLH mesh showed significantly greater tissue ingrowth by neovascularization histological score than MWMD and MWVLS meshes (p<0.05) and significantly less fibrosis than LWMD and MWVLS meshes (p<0.05). CONCLUSION: Pore shape and pore size significantly altered the mechanical strength of tissue ingrowth and host-site integration in a porcine model of ventral hernia repair, while mesh density had no effect.

Transplant in a patient with comorbid psychiatric illness: an ethical dilemma.

This article addresses a difficult ethical dilemma that transplant surgeons may potentially encounter: whether a patient with a psychiatric illness is a good candidate for a liver transplant. This case study illustrates the challenges involved when considering the ethical principles of patient self-determination, distributive justice of scarce medical resources, "social worth," and protection of vulnerable patient populations. Are patients with psychiatric illness able to provide consent for transplantation? Is it possible to avoid misallocating valuable donor organs and, at the same time, fairly allocate these resources? This article seeks to answer these questions and provide insight into this ethical dilemma.

Ergonomic analysis of robot-assisted and traditional laparoscopic procedures.

INTRODUCTION: Many laparoscopic surgeons report musculoskeletal symptoms that are thought to be related to the ergonomic stress of performing laparoscopy. Robotic surgical systems may address many of these limitations. To date, however, there have been no studies exploring the quantitative ergonomics of robotic surgery. In this study, we sought to compare the activation of bilateral biceps, triceps, deltoid, and trapezius muscle groups during traditional laparoscopic surgery (TLS) and robot-assisted laparoscopic surgery (RALS) procedures, as quantified by surface electromyography (sEMG). METHODS: One surgeon with expertise in TLS and RALS performed 18 operative procedures (13 TLS, 5 RALS) while sEMG measurements were obtained from bilateral biceps, triceps, deltoid, and trapezius muscles. sEMG measurements were normalized to the maximum voluntary contraction of each muscle (%MVC). We compared mean %MVC values for each muscle group during TLS and RALS with unpaired t-tests and considered differences with a p value <0.05 to be statistically significant. RESULTS: Muscle activation was higher during TLS compared to RALS in bilateral biceps (L Biceps RALS:1.01%MVC, L Biceps TLS:3.14, p = 0.01; R Biceps RALS:1.81%MVC, R Biceps TLS:4.53, p = 0.0002). Muscle activation was higher during TLS compared to RALS in bilateral triceps (L Triceps RALS:1.73%MVC, L Triceps TLS:3.58, p = 0.04; R Triceps RALS:1.59%MVC, R Triceps TLS:5.11, p = 0.02). Muscle activation was higher during TLS compared to RALS in bilateral deltoids (L Deltoid RALS:1.50%MVC, L Deltoid TLS:3.68, p = 0.03; R Deltoid RALS:1.19%MVC, R Deltoid TLS:2.57, p = 0.01). Significant differences were not detected in the bilateral trapezius muscles (L Trapezius RALS:1.50 %MVC, L Trapezius TLS:3.68, p = 0.03; R Trapezius RALS:1.19%MVC, R Trapezius TLS:2.57, p = 0.01). DISCUSSION: We have quantitatively examined the ergonomics of TLS and RALS and shown that in a single surgeon, TLS procedures are associated with significantly elevated biceps, triceps, and deltoid activation bilaterally when compared to RALS procedures.

FLS tasks can be used as an ergonomic discriminator between laparoscopic and robotic surgery.

INTRODUCTION: Robotic surgery may result in ergonomic benefits to surgeons. In this pilot study, we utilize surface electromyography (sEMG) to describe a method for identifying ergonomic differences between laparoscopic and robotic platforms using validated Fundamentals of Laparoscopic Surgery (FLS) tasks. We hypothesize that FLS task performance on laparoscopic and robotic surgical platforms will produce significant differences in mean muscle activation, as quantified by sEMG. METHODS: Six right-hand-dominant subjects with varying experience performed FLS peg transfer (PT), pattern cutting (PC), and intracorporeal suturing (IS) tasks on laparoscopic and robotic platforms. sEMG measurements were obtained from each subject's bilateral bicep, tricep, deltoid, and trapezius muscles. EMG measurements were normalized to the maximum voluntary contraction (MVC) of each muscle of each subject. Subjects repeated each task three times per platform, and mean values used for pooled analysis. Average normalized muscle activation (%MVC) was calculated for each muscle group in all subjects for each FLS task. We compared mean %MVC values with paired t tests and considered differences with a p value less than 0.05 to be statistically significant. RESULTS: Mean activation of right bicep (2.7 %MVC lap, 1.3 %MVC robotic, p = 0.019) and right deltoid muscles (2.4 %MVC lap, 1.0 %MVC robotic, p = 0.019) were significantly elevated during the laparoscopic compared to the robotic IS task. The mean activation of the right trapezius muscle was significantly elevated during robotic compared to the laparoscopic PT (1.6 %MVC lap, 3.5 %MVC robotic, p = 0.040) and PC (1.3 %MVC lap, 3.6 %MVC robotic, p = 0.0018) tasks. CONCLUSIONS: FLS tasks are validated, readily available instruments that are feasible for use in demonstrating ergonomic differences between surgical platforms. In this study, we used FLS tasks to compare mean muscle activation of four muscle groups during laparoscopic and robotic task performance. FLS tasks can serve as the basis for larger studies to further describe ergonomic differences between laparoscopic and robotic surgery.