Duffy Vincent G. - Advances in Human Factors and Ergonomics in Healthcare Proceedings of the AHFE 2016 International Conference on Human Factors and Ergonomics in Healthcare, July 27-31, 2016, Walt Disney World®,

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Part I
Human Factors and Ergonomics in Surgery

Springer International Publishing Switzerland 2017

Vincent G. Duffy and Nancy Lightner (eds.) Advances in Human Factors and Ergonomics in Healthcare Advances in Intelligent Systems and Computing 10.1007/978-3-319-41652-6_1

Analysis of Surgeons Muscle Activity During the Use of a Handheld Robotic Instrument in Laparoendoscopic Single-Site Surgery

Francisco M. Snchez-Margallo 1

(1)

Jess Usn Minimally Invasive Surgical Centre, Cceres, Spain

(2)

Department of Computer Systems and Telematics Engineering, University of Extremadura, Badajoz, Spain

Francisco M. Snchez-Margallo (Corresponding author)

Email:

Juan A. Snchez-Margallo

Email:

Abstract

The objective of this study is to assess the surgeons performance and ergonomics during the use of a robotic-driven handheld laparoscopic instrument in intracorporeal suturing tasks as well as in digestive and urological laparoscopic procedures performed through single-site surgery, and comparing it with the use of conventional instruments. Seven right-handed experienced surgeons took part in this study. Four surgeons performed nine urethrovesical anastomoses on an ex vivo porcine model and three surgeons a partial nephrectomy and a sigmoidectomy on an in vivo animal model. Surgeons used both conventional laparoscopic instruments and the robotic instrument. Execution times, leakage pressure for the anastomosis, surgical complications and surgeons muscle activity were measured. Similar results in surgical performance and ergonomics were obtained using conventional laparoscopic instruments and the robotic instrument. Muscle activity of the biceps was significantly higher using the robotic instrument during both surgical procedures.

Keywords

Laparoendoscopic single-site surgery Handheld robotic instrument Ergonomics Muscle activity

Introduction

Laparoscopic surgery has experienced rapid development in recent years, providing multiple advantages for the patient such as the reduction in postoperative pain, tissue trauma and infection rate, better aesthetic results, and shortened recovery period []. In this surgical approach, a multichannel surgical port is used to have access to the abdominal cavity of the patient where articulated or prebent instruments are introduced.

LESS surgery as a new evolving surgical technique still represents a challenge for surgeons, which requires surgical expertise [].

In order to overcome some of these technical difficulties in LESS, training is necessary to become proficient in this new surgical approach as well as using its specifically designed instruments. In addition, new handheld robotic systems have been developed for laparoscopic surgery and single-site surgery []. They provide precision-driven and articulating instrument tips, which increase the triangulation, and therefore improve the performance of some surgical maneuvers. One example of these systems is Kymerax (Terumo Europe NV, Leuven, Belgium), which offers interchangeable articulating instruments controlled by its handle interface.

Apart from dealing with some of the technical limitations of LESS, the use of these handheld robotic systems could improve the ergonomic conditions as compared to conventional instruments, reducing the risk of musculoskeletal injuries, since they do not require adopting forced postures to perform certain maneuvers within the abdominal cavity. The objective of this study is to assess the surgeons performance and muscle activity during the use of a robotic-driven, handheld articulating laparoscopic instrument in intracorporeal suturing tasks as well as in digestive and urological LESS procedures, and comparing it with the use of conventional instruments.

Materials and Methods

2.1 Participants

Seven right-handed surgeons took part in this study. Four experienced surgeons in laparoscopy (>100 laparoscopic procedures) and with different experience in LESS participated in the study with the training environment. Three experienced surgeons in laparoscopy and LESS (>20 LESS procedures) and with experience using the robotic instrument participated in the study with the experimental animal model. Participants used both conventional laparoscopic instruments (Conv) and the handheld robotic instrument (Rob). The type of instrument (conventional or robotic) to start the task or surgical procedure was randomly assigned to each surgeon. All trials were performed at our centres experimental surgical theatres. Participants gave informed consent and voluntarily agreed to participate in the studies.

2.2 Handheld Robotic Instrument

The Kymerax system (Terumo Europe NV) is a handheld laparoscopic instrument with articulating and interchangeable instruments (scissors, dissector, needle holder and L-hook), which are driven by robotic technology. Surgeons control the movements of the instrument tip through the manipulation of the handle interface. The shaft diameter of its instruments is 8.8 mm.

2.3 Training Environment

The training environment consisted of a validated laparoscopic simulator (SIMULAP; JUMISC, Cceres, Spain), with a 10-mm, 30 rigid laparoscope (Karl Storz GmbH & Co. KG, Tuttlingen, Germany) as vision system, and the GelPOINT Advanced Access Platform (Applied Medical, Rancho Santa Margarita, CA, USA) as surgical access port. The laparoscope was fixed to prevent movements and changes in the instruments. Surgeons hold an angled inline laparoscopic dissector (Epix; Applied Medical) on the left hand. On the right hand, they hold a straight laparoscopic needle holder (Karl Storz GmbH & Co. KG) or the robotic instrument in its needle holder configuration for the conventional and robotic groups, respectively (Fig. ). The anastomosis was performed on an ex vivo porcine bladder using 8 simple interrupted sutures.

Fig. 1

Setup for the study in the training environment using ( left ) a conventional laparoscopic needle holder and ( right ) the robotic instrument

Fig. 2

Use of the robotic instrument during the urethrovesical anastomosis

During the first (T1) and last (T9) repetitions, execution time, leakage pressure and surgeons muscular activity were assessed. The leakage test was performed at the end of the task to test the integrity of the anastomosis. This test consisted of introducing a silicone tube connected to an insufflator (Karl Storz GmbH & Co. KG) through the end of the bladder. While the bladder was immersed in water, the pressure at which air leaked from the anastomosis was recorded. The maximum pressure was set at 30 mmHg.

2.4 Experimental Animal Model

Participants performed a partial nephrectomy and a sigmoidectomy on an experimental porcine model through LESS approach. For the partial nephrectomy, an artificial pseudotumor was previously created on the upper renal pole of the left kidney. A mixture of alginate and saline was percutaneously injected to reproduce the tumor. This study was reviewed and approved by the Institutional Review Board of the Jess Usn Minimally Invasive Surgery Centre.

Suturing tasks were analyzed during both surgical procedures. Specifically, measurements were obtained during the hemostasis in the case of partial nephrectomy and during the anastomosis between the descending colon and rectum in the sigmoidectomy procedure. The GelPOINT Advanced Access Platform (Applied Medical) was used as surgical access port. In all cases, surgeons hold an articulated laparoscopic dissector (Dissect SILS; Covidien, Mansfield, MA, USA) on the left hand. On the right hand, they hold a straight laparoscopic needle holder (Karl Storz GmbH & Co. KG) or the robotic instrument with the needle holder end-effector for the conventional and robotic groups, respectively. For each procedure, the surgery time, surgical complications and the surgeons muscular activity were measure (Fig. ).

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