Ergonomics in laparoscopic surgery: a work system analysis to reduce work-related musculoskeletal disorders across surgeons in Peruvian hospitals

Laparoscopic surgery, also called minimally invasive surgery, is a type of surgery in which the surgeon operates by viewing the surgery on a screen that projects images from a camera inserted into the patient's abdomen. Laparoscopic tools are long (usually up to 35 cm) and require fine motor skills and visual perception for manipulation, restricting the degrees of freedom to move within the patient. This restriction causes surgeons to operate with limited vision and restricted movement and force them to work with assistants who assist in conducting the cameras, acting as "the surgeons' eyes". Because of its minimally invasive nature, laparoscopic surgery is well accepted by patients but is challenging and complex for the surgeon. This is due to the restriction of movement and perception that forces surgeons to adopt awkward postures with high exposition, which increases the likelihood of work-related musculoskeletal disorders (WRMSD). WRMSDs are detrimental to surgeons' health and potentially may impact patient safety. Studies often highlight the problems of surgeons in high-income countries, whose solutions and clinical guides often cannot be applied to countries like Peru, which have severe deficiencies in its healthcare system. For this reason, the thesis proposes a contextualised investigation of the Peruvian surgical work system to investigate the main factors contributing to the development of WRMSD in laparoscopic surgeons, which may affect patient safety. The analysis aimed to propose possible recommendations to support redesigning the laparoscopic surgery work system in Peruvian hospitals. Five studies were developed to achieve the aims based on the Systems Engineering Initiative for patient safety model, an ergonomics model for healthcare systems analysis. The first three studies were developed parallel with a mixed convergent design approach concluding in an integrating study. The last two studies (study four and five) had a quantitative approach. The first study used a qualitative approach by collecting information through interviews with laparoscopic surgeons and observing their work in real surgeries. The second study adopted a quantitative approach through a questionnaire-based survey applied to 140 surgeons in Peru. The third study analysed the extent to which the postures adopted by surgeons in real surgeries increase the risk of WRMSD and their association with factors in the work system using the RULA method. The results of the three studies were integrated into an integrative study, concluding that the raised height of the operating table and other system factors related to tasks, person and technology raises the risk of WRMSD. Based on these results, the fourth study analysed the relationship between surgeons and operating tables to understand how many surgeons could reach suitable working heights. The study concluded that no operating table available in Peruvian hospitals nor in the market would be suitable for 90% of Peruvian surgeons. The tables were too high to accommodate surgeons with optimal working surface height to perform laparoscopic surgery. Then, a fifth study was conducted to determine an acceptable working height based on surgeon preferences and system factors and concluded that surgeons would accept a working height between 49 cm to 70 cm in height, which is lower than current operating tables. The lowest height was reached when surgeons had to operate on obese patients and perform intracorporeal suturing tasks. Finally, the thesis concludes with recommendations for redesigning working heights for 90% of the Peruvian medical population, considering work system elements of the Peruvian context

Ergonomics in laparoscopic surgery: a work system analysis to reduce work-related musculoskeletal disorders across surgeons in Peruvian hospitals

Laparoscopic surgery, also called minimally invasive surgery, is a type of surgery in which the surgeon operates by viewing the surgery on a screen that projects images from a camera inserted into the patient's abdomen. Laparoscopic tools are long (usually up to 35 cm) and require fine motor skills and visual perception for manipulation, restricting the degrees of freedom to move within the patient. This restriction causes surgeons to operate with limited vision and restricted movement and force them to work with assistants who assist in conducting the cameras, acting as "the surgeons' eyes". Because of its minimally invasive nature, laparoscopic surgery is well accepted by patients but is challenging and complex for the surgeon. This is due to the restriction of movement and perception that forces surgeons to adopt awkward postures with high exposition, which increases the likelihood of work-related musculoskeletal disorders (WRMSD). WRMSDs are detrimental to surgeons' health and potentially may impact patient safety. Studies often highlight the problems of surgeons in high-income countries, whose solutions and clinical guides often cannot be applied to countries like Peru, which have severe deficiencies in its healthcare system. For this reason, the thesis proposes a contextualised investigation of the Peruvian surgical work system to investigate the main factors contributing to the development of WRMSD in laparoscopic surgeons, which may affect patient safety. The analysis aimed to propose possible recommendations to support redesigning the laparoscopic surgery work system in Peruvian hospitals. Five studies were developed to achieve the aims based on the Systems Engineering Initiative for patient safety model, an ergonomics model for healthcare systems analysis. The first three studies were developed parallel with a mixed convergent design approach concluding in an integrating study. The last two studies (study four and five) had a quantitative approach. The first study used a qualitative approach by collecting information through interviews with laparoscopic surgeons and observing their work in real surgeries. The second study adopted a quantitative approach through a questionnaire-based survey applied to 140 surgeons in Peru. The third study analysed the extent to which the postures adopted by surgeons in real surgeries increase the risk of WRMSD and their association with factors in the work system using the RULA method. The results of the three studies were integrated into an integrative study, concluding that the raised height of the operating table and other system factors related to tasks, person and technology raises the risk of WRMSD. Based on these results, the fourth study analysed the relationship between surgeons and operating tables to understand how many surgeons could reach suitable working heights. The study concluded that no operating table available in Peruvian hospitals nor in the market would be suitable for 90% of Peruvian surgeons. The tables were too high to accommodate surgeons with optimal working surface height to perform laparoscopic surgery. Then, a fifth study was conducted to determine an acceptable working height based on surgeon preferences and system factors and concluded that surgeons would accept a working height between 49 cm to 70 cm in height, which is lower than current operating tables. The lowest height was reached when surgeons had to operate on obese patients and perform intracorporeal suturing tasks. Finally, the thesis concludes with recommendations for redesigning working heights for 90% of the Peruvian medical population, considering work system elements of the Peruvian context