Operating rooms (ORs) are the stuff of legend. Lives are saved, babies born, and careers (and egos) can be made or ruined with a millimetre slip of a scalpel. But as we are finding out in this time of lawsuits and budget cuts, there are too many human variables in the mix when it comes to the most important room in the hospital. So how do we go about creating better operating theatres where human factors, poor construction and quality of work are not going to affect the valuable work being done by the medical staff?

In short – how do we create a perfect operating theatre? In this issue of Practical Patient Care, we delve into an aspect of the OR and explore how it can be done better – shoulders, knees and toes. Or, as it's better known in adult parlance, ergonomics. Musculoskeletal injuries, such as neck and back pain, are unfortunately common problems that plague many surgeons.

While many efforts have been made to make the administrative office space more ergonomic, thanks to groups such as the Occupational Health and Safety Administration, less work has been done to improve surgeon posture and ergonomics in the OR.

But there is a lot that can be done from every angle. From seat heights and the floor structure of an OR, to lights and placements of ablutions, there are a variety of simple human-factor tweaks that could be undertaken to drastically improve the workplace for surgeons, nurses and others.

Surgical chairs

However, ergonomics can be a huge problem for surgeons. It’s something that’s familiar to Dr Philip Chen, assistant professor and programme director of rhinology and otolaryngology at the University of Texas Health Science Center at San Antonio.

“To complicate factors, every surgery requires somewhat different body positioning,” he explains. “More surgery is becoming ‘minimally invasive’, with increasing use of endoscopes. Typically, this means that instead of flexing the neck and looking down into a surgical field, we are often looking at a monitor, with different head, neck and eye positions. Again, experts in human factors and ergonomics have established parameters to optimise ergonomics of office chairs and computer screens, but we lack such guidance in the OR.”

Chen says that, as a seated surgeon himself, there is even less work on ergonomics when sitting down. His research has focused on ergonomics and improving surgeons’ workplaces. He believes this is important to surgical staff when designing an OR.

“Many monitors are mounted on the top of a cart,” he says, giving the example of one element that can be improved. “In our first study, based on the information that one’s eyes should be positioned just below a horizontal gaze, we found that most current setups are not ergonomically friendly for the seated endoscopic surgeon. The monitor is often too high, causing the surgeon to have excess eye and neck strain," Chen explains.

He adds that most operating tables are engineered for standing surgeons. It’s important to determine if there are operating stool and table combinations that could be adjusted for height, tilt and other factors, to allow the greatest number of surgeons to be seated comfortably and properly while performing surgery.

Main problems with ergonomics

A corporate office is typically set up for one individual, based on his or her specific body dimensions. The OR, however, is not set up for any specific individual. Instead, the same equipment is often used by different surgeons for a range of surgery.

While a certain piece of equipment may be ergonomically favourable for one surgeon, it may be unsuited for another. In an effort to contain costs, hospital administrators may be hesitant to purchase new equipment when, in their view, the current tools are perfectly adequate for the surgeon to perform operations. Of course, this mindset is understandable, but it's important that the surgeon agrees that the equipment is adequate.

So what would Chen recommend to fix these problems, and how should the designers and hospital staff go about them? “It would be great if medical device companies would work with human-factor experts and practicing surgeons when they develop their products, to optimise their use in the widest situations for the most number of surgeons,” he says.

Hospital administrators should also consult with surgeons when building operating suites to ensure the equipment meets all their needs. “For instance, not only would the surgical monitor be of high visual fidelity, but it would also be adjustable in height and angles to accommodate the surgeon’s ergonomic needs,” Chen explains.

It’s not just the doctors and nurses who benefit – the patient also does. Good surgeons spend thousands of hours perfecting their craft. Their experiences are not easily or quickly replaceable. Therefore, it is in society's best interest to create an environment that encourages their continued practice.

“If surgeons are healthy, they can operate for longer sessions and more years, which would allow them to help more patients. Also, they can focus completely on the patient when they’re comfortable, rather than thinking about sore body parts,” Chen says.

The future of the OR

So when it comes to ways of improving the OR or even of creating the ‘perfect operating theatre’, what does he think are the biggest challenges and where does he think the biggest room for improvement lies?

If surgeons are healthy, they can operate for longer sessions and more years, which would allow them to help more patients.

“It is very important to keep surgeons and experts in ergonomics involved with device manufacturers. Additionally, both should be involved in designing operating room set-up,” he says.

“I have heard of hotel architects and designers working on hospitals – that might work on the floors for the sake of patient comfort, which is great, but it is inadequate in the OR. The stakes are too high in the OR to leave design to those without a thorough knowledge of [the correct] flow and ergonomics.”

The concept that the OR needs to be optimised for ergonomics is still gaining traction, he explains. “Hopefully, with time there will be broader understanding for the need to improve the surgical environment,” he says.

“The need to have the primary stakeholders involved in the design of the ORs is so important. It is certainly easier to set up every room in the same way, but for the purposes of surgeon health, administration should be encouraged to design rooms in ways that fit their particular surgeons’ individual needs."

This could potentially decrease surgeon turnover and increase productivity. These changes can help prolong surgeons’ careers and facilitate their physical well-being, which benefits society as a whole. Then there’s also technology: new tools like surface electromyography could help us better understand muscle fatigue, economy of movements and body positioning. This information could be used in the development of medical equipment such as operating tables and stools.

So from wherever you’re standing – or sitting – the world of operating theatre ergonomics is finally awake to the news that a surgeon having a bad back is no laughing matter. Hopefully, it’ll start to improve their quality of life and lead to better care for patients.

Ergonomic must-haves for the modern operating theatre

According to ergonomic and OR-design expert Dr Sarah Cohen, from Brigham and Women’s Hospital, table height is key and surgeons should spend time making sure they get their operating tables to the optimal level. She believes there are several factors to take into account:

  • the goal should always be to minimise strain fatigue
  • instrument handles should be at elbow level to minimise upper arm and shoulder work
  • surgeons should adjust the bed and use steps to attain their desired height.

Monitor positioning is also a key area of concern for surgeons and staff. Here, Cohen recommends that staff should:

  • have the monitor straight ahead
  • have it in line with the forearm– instrument motor axis
  • avoid axial rotation of the spine
  • position the monitor lower than eye level to avoid neck extension
  • use the optimum angle of 15° downward.

Cohen has simple advice for surgeons in the OR:

  • use the ‘surgeon stance’: feet flat
  • use rubber pads to stand on and place one foot up on the step
  • keep hips level
  • avoid tilting, cocking or leaning
  • keep shoulders down and relaxed
  • keep arms by sides and elbows at 90°
  • the spine should be straight ahead, facing monitor
  • the neck should be neutral, not pushed forward
  • the gaze should be angled slightly downward.

Source: S. Cohen, 'Operating Room Set Up and Instrumentation: Making the OR Work for You', 2016 Collaborative Symposium on Minimally Invasive Gynecologic Surgery.