Surgeon Discomfort Research Articles

A Comparative Study between Flapped and Flapless Surgical Techniques in Dental Implant Stability According to Resonance Frequency Analysis

Background: Recent implant surgical approach aims to cause less trauma, invasiveness and pain as much as possible and to reduce patient and surgeon discomfort, time of surgery and time needed for functional implant loading. Flapless surgical techniques considered recently as one of the most popular techniques that may achieve these aims especially enhancing osseointegration and subsequently implant stability within less time than the traditional flapped surgical technique. So this study aimed to make a comparison between flapped and flapless surgical techniques in resulted implant stability according to resonance frequency analysis RFA and in duration of surgical operation. Materials and methods: A total of 26 patients with 41 implants (one implant in the study group failed so it was excluded from the statistical analysis) were randomized into two groups: control group which involved 20 implants inserted by conventional flapped surgical approach and study group which involved 20 implants inserted by flapless surgical approach. Estimation of alveolar bone was done for study group by bone (ridge) mapping procedure. Duration of surgical operation for each implant, Implant stability was measured at three time intervals (at surgery, two months and three months after surgery). Results: After three months interval of surgery the mean implant stability of the study (flapless) group achieved significant higher implant stability than control (flapped) group (P< 0.05) and the difference in measured implant stability was (5.05) implant stability quotient(ISQ). The time of surgical operation for implants in the study group significantly was less than that of control group (P< 0.01). Conclusions:implants placed with flapless surgical technique can produce high implant stability in shorter time and consume prominently shorter time for surgical operation compared to those placed with conventional flapped technique.

Surgeons' Perspectives of Contralateral Prophylactic Mastectomy.

Contralateral prophylactic mastectomy (CPM) is commonly performed for the treatment of breast cancer, despite its limited oncologic benefit. Little is known about surgeons' perceptions of performing CPM. We hypothesized that a proportion of surgeons would report discomfort with performing CPM, particularly when there is discordance between patients' perceived benefit from CPM and the expected oncologic benefit. A survey was sent to members of the American Society of Breast Surgeons seeking self-reports of surgeons' practice patterns, perceptions, and comfort levels with CPM. Of the 2436 members surveyed, 601 responded (response rate=24.7%). The median age of respondents was 52years, and 59% of responders were women. The majority (58%) reported that 80% of their practice was devoted to the treatment of breast disease. Fifty-seven percent (n=326) of respondents reported discomfort with performing CPM at some point in their practice. While most surgeons (95%) were comfortable with CPM on a patient with a deleterious BRCA mutation, only 34% were comfortable performing CPM on an average-risk patient. The most common reasons reported for surgeon discomfort with CPM were a concern for overtreatment, an unfavorable risk/benefit ratio, and inadequate patient understanding of the anticipated risks and benefits of CPM. Despite the increasing use of CPM for the treatment of breast cancer, many surgeons report discomfort with CPM. Concerns with performing CPM predominantly focus on ambiguities surrounding the oncologic benefit and relative risk of this procedure. Further research is needed to define optimal shared decision-making practices in this area.

Unilateral paravertebral block compared with subarachnoid anesthesia for the management of postoperative pain syndrome after inguinal herniorrhaphy: a randomized controlled clinical trial.

Inguinal herniorrhaphy is a common surgical procedure. The aim of this investigation was to determine whether unilateral paravertebral block could provide better control of postoperative pain syndrome compared with unilateral subarachnoid block (SAB). A randomized controlled study was conducted using 50 patients with unilateral inguinal hernias. The patients were randomized to receive either paravertebral block (S group) or SAB (C group). Paravertebral block was performed by injecting a total of 20 mL of 0.5% levobupivacaine from T9 to T12 under ultrasound guidance, whereas SAB was performed by injecting 13 mg of 0.5% levobupivacaine at the L3 to L4 level. Data regarding anesthesia, hemodynamic changes, side effects, time spent in the postanesthesia care unit, the Karnofsky Performance Status, acute pain and neuropathic disturbances were recorded. Paravertebral block provided good anesthesia of the inguinal region without patient or surgeon discomfort, with better hemodynamic stability and safety and with a reduced time to discharge from the postanesthesia care unit compared with SAB. During the postsurgical and posthospital discharge follow-ups, rest and incident pain and neuropathic positive phenomena were better controlled in the S group than in the C group. The consumption of painkillers was higher in the C group than in the S group throughout the follow-up period. Paravertebral block can be considered a viable alternative to common anesthetic procedures performed for inguinal hernia repair surgery. Paravertebral block provided good management of acute postoperative pain and limited neuropathic postoperative disturbances.

An articulated handle to improve the ergonomic performance of robotic dextrous instruments for laparoscopic surgery

Abstract. Hand-held robotic instruments with dextrous end-effectors offer increased accessibility and gesture precision in minimally invasive laparoscopic surgery. They combine advantages of both intuitive but large, complex, and expensive telesurgery systems, and much cheaper but less user-friendly steerable mechanical instruments. However, the ergonomics of such instruments still needs to be improved in order to decrease surgeon discomfort. Based on the results of former experimental studies, a handle connected to the instrument shaft through a lockable ball joint was designed. An experimental assessment of ergonomic and gesture performance was performed on a custom-made virtual reality simulator. Results show that this solution improves ergonomics, demanding less wrist flexion and deviation and elbow elevation, while providing gesture performance similar to a robotic dextrous instrument with standard pistol-like handle configuration.

Role of Ergonomics in Health Care

In the health care field ergonomics has many essential roles to play like, understanding human limitations early in the development of medical devices can reduce errors and avoid performance problems exacerbated by stress and fatigue. Using ergonomics in a design process can reduce the costs of procuring and maintaining products. Ergonomics can minimise the incidence of injury or longer term malaise from poor working environments. An ergonomics task analysis can help identify key components of surgical skill, ensuring that students have affordable, appropriate, valid, and reliable training [2]. Over the period of time health care field undergone tremendous transformation in all the aspects. Despite the success of ergonomics in many areas its contribution in health care field is limited in terms of different aspects like availability, accessibility, geographical distribution, cost-effectiveness as well as user-friendliness. Laparoscopic surgery provides patients with less painful surgery but is more demanding for the surgeon. The increased technological complexity and sometimes poorly adapted equipment have led to increased complaints of surgeon fatigue and discomfort during laparoscopic surgery. Ergonomic integration and suitable laparoscopic operating room environment are essential to improve efficiency, safety, and comfort for the operating team. Understanding ergonomics can not only make life of surgeon comfortable in the operating room but also reduce physical strains on surgeon. The importance of ergonomics in the setting of laparoscopy cannot be over-emphasised. Studies have shown that correct ergonomics can reduce suturing time. Pressurerelated chronic pain among surgeons has been shown to be relieved by the use of ergonomically designed products [3]. As more complex laparoscopic procedures are performed, the need for instrumentation that improves dexterity (degrees of freedom) in an ergonomic manner becomes important [4]. In field of dentistry also ergonomics has important role to play. Proper ergonomic design is necessary to prevent repetitive strain injuries, which can develop over time and can lead to long-term disability. Literature suggests that the prevalence of musculoskeletal pain in dentists, dental hygienists and dental students ranges between 64% to 93%. The successful application of ergonomics assures high productivity, avoidance of illnesses and injuries, and increased satisfaction among workers. Unsuccessful application, on the other hand, can lead to work-related musculoskeletal disorders. Good ergonomic design of tools, processes and furniture does improve personnel comfort, health, morale, productivity and readiness. It is critical to seek prompt medical aid for symptoms of ergonomic stress/ detect risk factors [5]. To conclude, it is imperative to underline the importance of ergonomics developments in the health care field in coming future. More research in ergonomics is needed to help health care personnel to make them more efficient.

Micropercutaneous nephrolithotomy (microperc) vs retrograde intrarenal surgery for the management of small renal calculi: a randomized controlled trial

To compare micropercutaneous nephrolithotomy (microperc) and retrograde intrarenal surgery (RIRS) for the management of renal calculi <1.5 cm with regard to stone clearance rates and surgical characteristics, complications and postoperative recovery. Seventy patients presenting with renal calculi <1.5 cm were equally randomized to a microperc or a RIRS group between February 2011 and August 2012 in this randomized controlled trial. Randomization was based on centralized computer-generated numbers. Patients and authors assessing the outcomes were not blinded to the procedure. Microperc was performed using a 4.85-F (16-gauge) needle with a 272-μm laser fibre. RIRS was performed using a uretero-renoscope. Variables studied were stone clearance rates, operating time, need for JJ stenting, intra-operative and postoperative complications (according to the Clavien-Dindo classification system), surgeon discomfort score, postoperative pain score, analgesic requirement and hospital stay. Stone clearance was assessed using ultrasonography and X-ray plain abdominal film of kidney, ureter and bladder at 3 months. There were 35 patients in each group. All the patients were included in the final analysis. The stone clearance rates in the microperc and RIRS groups were similar (97.1 vs 94.1%, P = 1.0). The mean [sd] operating time was similar between the groups (51.6 [18.5] vs 47.1 [17.5], P = 0.295). JJ stenting was required in a lower proportion of patients in the microperc group (20 vs 62.8%, P < 0.001). Intra-operative complications were a minor pelvic perforation in one patient and transient haematuria in two patients, all in the microperc group. One patient in each group required conversion to miniperc. One patient in the microperc group needed RIRS for small residual calculi 1 day after surgery. The decrease in haemoglobin was greater in the microperc group (0.96 vs 0.56 g/dL, P < 0.001). The incidence of postoperative fever (Clavien I) was similar in the two groups (8.6 vs 11.4%, P = 1.0). None of the patients in the study required blood transfusion. The mean [sd] postoperative pain score at 24 h was slightly higher in the microperc group (1.9 [1.2] vs 1.6 [0.8], P = 0.045). The mean [sd] analgesic requirement was higher in the microperc group (90 [72] vs 40 [41] mg tramadol, P < 0.001). The mean [sd] hospital stay was similar in the two groups (57 [22] vs 48 [18] h, P = 0.08). Microperc is a safe and effective alternative to RIRS for the management of small renal calculi and has similar stone clearance and complication rates when compared to RIRS. Microperc is associated with higher haemoglobin loss, increased pain and higher analgesic requirements, while RIRS is associated with a higher requirement for JJ stenting.

A single drop of 0.5% proparacaine hydrochloride for uncomplicated clear corneal phacoemulsification

Purpose:The purpose of this study was to compare the efficacy of a single drop of 0.5% proparacaine hydrochloride in uncomplicated cataract surgery with phacoemulsification.Materials and Methods:Two hundred and ninety five patients scheduled for the phacoemulsification were divided into 2 groups based on the anesthetic agents they were to receive: 146 patients who received a single drop of 0.5% proparacaine 2 min before the start of the surgery (proparacaine group) and; 149 patients who received supplementation of 0.5% intracameral preservative free xylocaine (xylocaine group). A single surgeon performed all surgeries. Intraoperative and post-operative pain scores were evaluated on a visual analog scale. The surgeon noted his subjective impression of corneal clarity, discomfort while performing the surgery any supplemental anesthesia required and intraoperative complications. An anesthetist noted vital parameters and the need for intravenous sedation. Total surgical time was noted. Comparison of parameters was performed with the Chi-square test, and A P value less than 0.05 was considered as statistically significant.Results:No statistically significant difference was seen in the intraoperative (P = 0.24) and post-operative (P = 0.164) pain scores between groups. There was no pain (0 score) in 41.8% of patients in the proparacaine group and 46.3% of patients in the xylocaine group. The average surgical time (P = 0.279) and surgeon discomfort (P = 0.07) were not statistically significantly different between groups. No patients required supplemental anesthesia. There were no surgical complications that could compromise the visual outcome. An equal number of patients in both groups preferred same type of anesthetic technique for the fellow eye cataract surgery (89.11% for the proparacaine group and 90.18% for the xylocaine group). No patients in either group had changes in vital parameters or required intravenous sedation.Conclusion:A single drop pre-operatively, of proparacaine hydrochloride was comparable to the intracameral supplementation of preservative free xylocaine for phacoemulsification in uncomplicated cataract surgery without compromising the visual outcome. However, we recommend individualizing the anesthetic technique according to the requirements of the surgeon.

Quantitative posture analysis of 2D, 3D, and optical microscope visualization methods for microsurgery tasks

The purpose of this paper is to present a quantitative posture analysis of microsurgery tasks performed with different visualization methods. Microsurgery is traditionally performed using a binocular microscope; however surgeons are constrained by the optical eyepieces and are forced to assume joint angles that deviate away from neutral postures. This may be especially problematic for the neck and can increase surgeon discomfort and fatigue. Alternative visualization methods may improve surgeon posture by eliminating the constraints imposed by the microscope. This study examines both 2D and 3D heads-up displays as possible alternatives. Six subjects performed microsurgical tasks with each visualization methods for four hours. Quantitative posture analysis was done using Maxtraq software that tracks reflective markers on the subjects. The initial analysis of neck, upper arm, and elbow angles found significant differences between each display. A biomechanical analysis found that the differences in angles can result in loads on the neck joint that are twice as high in the microscope than the headsup displays. Although the alternative displays can result in better postures, improvements the display technology is needed to improve microsurgical task performance.

The aching surgeon: a survey of physical discomfort and symptoms following open, laparoscopic, and robotic surgery.

There is increasing interest in understanding the toll that operating takes on a surgeon's body. The effect of robotic surgery on surgeon discomfort has not been studied. We sought to document the discomfort of robotic surgery compared with open and laparoscopic surgery and to investigate the factors that affect the risk of physical symptoms. Nineteen-thousand eight-hundred and sixty-eight surgeons from all specialties trained in the use of robots were sent a 26-question online survey and 1,407 responded. One-thousand two-hundred and fifteen surgeons who practiced all three approaches were used in the analysis. Eight-hundred and seventy-one surgeons had physical discomfort or symptoms attributable to operating. Of those with symptoms, 55.4% attributed most of the symptoms to laparoscopic surgery, 36.3% to open surgery, and 8.3% to robotic surgery. A higher case load was predictive of increased symptoms for open and laparoscopic surgery, but not for robotic surgery. Robotic surgery was less likely than open or laparoscopic surgery to lead to neck, back, hip, knee, ankle, foot, and shoulder pain and less likely than laparoscopic surgery to lead to elbow and wrist pain. Robotic surgery was more likely than either open or laparoscopic surgery to lead to eye pain, and more likely than open surgery to lead to finger pain. Nearly a third (30.3%) of surgeons admit to giving consideration to their own discomfort when choosing an operative modality. Robotic surgery has promise in reducing the risk of physical discomfort for the operator. This is important as more surgeons consider their own health when choosing a surgical modality.

Comparison of second-generation hand-assisted laparoscopic devices for surgeon pain and arm circulation

Objectives To compare two second-generation hand-assist devices (HADs) for surgeon pain and manual blood flow over time in an in vitro model. Methods Nineteen participants placed their nondominant hand through both the LapDisc and GelPort into a pneumoperitoneum chamber with an insufflation pressure of 15 mm Hg for a 2-hour test period. Pain, on a 10-point visual analog scale, and manual blood flow to the index finger using a laser Doppler skin probe were measured at 10 points during the 2 hours. Participants completed a questionnaire regarding hand comfort and the physical effects of the HAD. Results At 30, 45, and 60 minutes after hand insertion, the pain scores were significantly greater for the GelPort than for the LapDisc ( P = 0.04, P = 0.01, and P = 0.03, respectively). The GelPort caused an immediate reduction in manual blood flow, and the LapDisc caused a small initial increase in manual blood flow ( P = 0.03) and, thereafter, a decrease in blood flow. Three participants voluntarily removed their hand at 30, 45, and 60 minutes owing to the pain from GelPort use. No participant withdrew from the LapDisc because of pain. Conclusions Both HADs resulted in surgeon discomfort in our in vitro model. The GelPort resulted in more subjective pain compared with the LapDisc. Both HADs caused a reduction in manual blood flow. However, compared with the LapDisc, the GelPort caused significantly more reduction in manual blood flow. Surgeon comfort is only one parameter to consider when choosing a HAD.

Comparison of Neuromuscular Injuries to the Surgeon during Hand-Assisted and Standard Laparoscopic Urologic Surgery

Hand-assisted procedures have assumed a greater role in the practice of many laparoscopists. We surveyed major laparoscopy program directors to compare the incidence and location of neuromuscular injury to the surgeon during hand-assisted laparoscopic (HAL) and standard laparoscopic (SL) surgery. A questionnaire on neuromuscular injuries was e-mailed to 42 laparoscopic program directors. Respondents were instructed to report only injuries or pain associated with laparoscopic surgery when they were the primary responsible surgeon and not during open or endoscopic procedures. Surveys were returned from 23 attending laparoscopic surgeons and 2 laparoscopic fellows. Surgeons reported an average of 3.9 HAL and 6.3 SL cases per month as the primary surgeon. The HAL was completed with the GelPort, LapDisk, Omniport, or a combination of devices 55%, 22%, 5%, and 14%, respectively, of the time. Comparing HAL with SL, there was significantly more hand/wrist, forearm, and shoulder pain/injuries associated with HAL (P < 0.004). There was significantly more neck pain associated with SL than HAL (P < 0.003), but no significant difference in lower-back pain (P = 0.40). Comparing the two most commonly used hand-assist devices (GelPort and LapDisk), the LapDisk demonstrated significantly more hand/wrist pain or injury (P = 0.001). Hand-assisted laparoscopy is associated with more frequent neuromuscular strain to the upper extremity than SL, but SL surgeons experience more neck pain or injury. Surgeon discomfort is also dependent on the type of hand-assist device. The long-term consequences of physical strain on the laparoscopic surgeon are unknown currently, but measures to minimize neuromuscular strain should be considered.

Brachial Suction-assisted Lipoplasty and Brachioplasty

The author discusses how wide experience with lipoplasty techniques, the development of modified brachioplasty procedures, and improved understanding of skin retraction have reduced surgeon discomfort about brachial lipoplasty and brachioplasty.

Efficacy and safety of intracameral lidocaine as a supplement to topical anesthesia

Purpose: To establish the benefit of nonpreserved intracameral lidocaine 1 % as an adjunctive anesthetic agent to topical anesthesia for small incision cataract surgery and to determine the agent's safety with respect to corneal toxicity. Setting: Advanced Vision Care, West Hills, California, USA.Methods: A retrospective chart review of cataract surgery performed between January 1995 and March 1997 was done. The efficacy of intracameral lidocaine was determined by comparing the number of topical anesthesia cases (Group 1) and of combined topical and intracameral anesthesia cases (Group 2) that required conversion to a more profound level of local anesthesia, determined by patient discomfort, surgeon discomfort, or both. To determine the presence and bias of a surgical learning curve, Group 1 was subdivided chronologically into two subgroups. Corneal toxicity was assayed by the degree of clinical corneal edema noted by slitlamp examination on the first postoperative day.Results: Six hundred thirty-one charts satisfied the criteria for inclusion; 352 cases (Group 1) had topical anesthesia alone and 279 subsequent cases (Group 2), combined topical and intracameral anesthesia. In Group 1, 42.6% of cases required conversion to some form of additional local anesthesia, whereas in Group 2, less than 1.0% required conversion. In the earlier subgroup, 45.8% of cases required conversion and in the latter, 34.3%. On the first day after surgery, 88.2% of Group 2 cases and 76.7% of Group 1 cases were free from corneal edema. The difference was statistically significant but probably resulted from a change in phaccemulsification technique from sculpting to chopping in the latter cases, which were performed under combined topical and intracameral anesthesia.Conclusions: Intracameral nonpreserved lidocaine 1% appears to be both efficacious and nontoxic as an anesthetic adjunct in small incision cataract surgery.

Effectiveness of sedation in dacryocystorhinostomy surgery

chronic dacryocystitis is a common ophthalmic problem almost always requiring surgery as the only definitive treatment. to compare the perioperative outcome of external DCR surgery under local anesthesia with and without sedation. one hundred consecutive patients with chronic dacryocystitis undergoing dacryocystorhinostomy (DCR) surgery were randomly divided into two groups using computer generated random table. Group A underwent DCR under local anesthesia (LA) without sedation and group B under LA with sedation. The outcome parameters were intra-operative pain, surgeon's comfort, intra-operative complications and duration of surgery. SPSS version 11.5 software was used. Chi square test was used to compare the difference between the groups. there were 50 patients in each group. The mean age +/- SD of the patients was 34.4 +/- 12.12 years (95% CI=28.89-38.55 years). Sixty-nine percent of them were female. Significantly higher number of patients experienced pain in Group A as compared to Group B (100% vs 50%, P<0.001) Surgeon's discomfort was significantly present in group A as compared to group B (70% vs 10%), (p=0.00001). Blood loss was significantly more in group A than in group B (p=0.017). There was no significant difference in the duration of surgery. The post operative success rate in both the groups was comparable after six months of followup. the use of sedation with LA improves the perioperative outcome of DCR surgery in terms of patient's pain, surgeon's comfort and intra-operative complications.