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Prospective Randomized Evaluation of FOOT Gel Pads for Operating Room Staff COMFORT During Laparoscopic Renal Surgery

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Prospective Randomized Evaluation of FOOT Gel Pads for Operating Room Staff COMFORT During Laparoscopic Renal Surgery
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  Laparoscopy and Robotics Prospective Randomized Evaluation of FOOT Gel Pads for Operating Room Staff COMFORT During Laparoscopic Renal Surgery Georgios Haramis, Juan Carlos Rosales, Jorge Moreno Palacios, Zhamshid Okhunov,Adam C. Mues, Diana Lee, Ketan Badani, Mantu Gupta, and Jaime Landman OBJECTIVES  We evaluated the comfort level of our laparoscopy team during and after laparoscopic renalsurgery, with or without the use of gel footpads. METHODS  Between September 2008 and April 2009 we prospectively randomized 100 consecutive laparo-scopic renal procedures to examine whether the use of a foot gel pad altered the surgical team’scomfort level. A questionnaire was used to measure the discomfort in 18 different subjects beforeand during surgery, and one day postoperatively. The procedures performed with or without thefoot gel pads were compared. RESULTS  One hundred laparoscopic procedures were randomized to being performed with and without gelpads. In 50 procedures, the foot gel pad was used. The mean age of the subjects was 36 years(range 25-52). The mean surgical experience was 7 years. The characteristics of the participantsin procedures with and without the gel pad were similar. In the immediate postoperative period,there were significantly more breaks taken ( P  .001), number of stretches ( P  .001), foot pain( P  .003), knee pain ( P  .001), back discomfort ( P  .001), overall discomfort ( P  .001),and diminished level of energy ( P  .049) in the group not using the gel pad. Of the 24-hourpostoperative time point, evaluation significantly favored the gel pads regarding foot pain ( P  .004), overall amount of discomfort ( P  .001), and energy level of the participants ( P  .044). CONCLUSIONS  The use of foot gel pads improves surgeon comfort and ergonomics during laparoscopy. The padshave been incorporated into our routine operating room set-up and may improve surgicalperformance by diminishing fatigue and discomfort.  UROLOGY  76: 1405–1408, 2010. © 2010Elsevier Inc. C omparison of general ergonomics between openand laparoscopic surgery have demonstrated in-creased surgeon discomfort during laparoscopicprocedures. 1-4 Even among experienced laparoscopic sur-geons, significant musculoskeletal complaints related tothe neck and arms appear to be common. 5-7 It has beendemonstrated that surgeons and scrub nurses exhibitedfrequent static body postures that were “distinctly harm-ful” and contributed to physical fatigue during surgery. 8,9 Several minimally invasive surgery components in-cluding long-shaft instruments, access ports, and endo-scopic image display systems have been identified ascontributing to ergonomically unfavorable postures thatare assumed and maintained by laparoscopic surgeons. 3,6,10 As such, it is clear that maintaining correct posture isvery important in minimizing physical risks associatedwith the performance of complex tasks. 11 Using a de-tailed questionnaire, we evaluated a foot gel pad to de-termine whether it offered any advantage to surgeons andoperating room staff in the setting of laparoscopic renalsurgery. MATERIAL AND METHODS Permission for evaluation was obtained from our institutionalreview board. Between September 2008 and April 2009, weperformed a pilot study and evaluated 100 procedures incorpo-rating 18 different subjects using a foot gel pad to assess comfortand fatigue level during and after surgery. The study groupincluded 5 attending physicians with more than 10 years of experience in minimally invasive surgery, 6 urology residents, 2minimally invasive urology fellows, and 5 scrub nurses from oursurgical team. All subjects were interviewed through a ques-tionnaire minutes before the start of each procedure. All par-ticipants reported to be in good general health. A computer-generated randomization sheet was used to prospectivelyestablish whether the Gelmat was to be used on a particularprocedure. All members of the surgical team were tested underthe same condition for each case. All subjects received an equalnumber of evaluations with or without the use of gel pads. Gel The authors want to declare that they have no financial relationship with the manufac-turer of the foot pads.From the Columbia University School of Medicine, Department of Urology, NewYork, NY, USAReprint requests: Jaime Landman, 161 Fort Washington Avenue, Room 1154, NewYork, NY 10032. E-mail: landman.jaime@gmail.com © 2010 Elsevier Inc. 0090-4295/10/$36.00  1405 All Rights Reserved doi:10.1016/j.urology.2010.01.018  pads were kindly donated (Gelpro, Austin, TX) and we used thecommercially available basket weave design 20  60-inch mats(average price $USD200). The mats were introduced into theoperating room with the permission of the operating roomdirector and were cleaned and processed by standard techniquebetween surgical cases.The questionnaire administered included subjects’ age, yearsperforming operating room activities, last day vigorous exercisewas performed, and day/week of exercise. A scale of discomfort/pain was used, with values ranging from 1 (minimal discomfortor no pain) to 10 (severe discomfort or pain). The question-naires were applied before, immediately after, and 24 hours aftersurgery. We also recorded the type and length of the procedure,the time spent in standing and sitting positions, and the dura-tion of the whole process. An independent observer docu-mented the number of intraoperative postural changes, thenumber of stretching events, and the number of breaks taken fordiscomfort during the procedure. The subjects were also askedto report whether they felt they changed their posture more orless frequently than usual and whether they were more or lessfatigued. Finally, we asked them to subjectively report thenumber of errors made as a result of fatigue or discomfort duringthe procedure.A comparison was made between subjects who performedprocedures with the gel pad and those who did not, in an effortto identify whether its use improved the surgical team’s perfor-mance and surgical ergonomics. Continuous and categoricalvariables were analyzed with Student’s  t -test and the chi-squaretest, respectively. Two cross tabulations were made to compareboth groups regarding perception of fatigue and number of errors made after each procedure. The statistical package usedwas SPSS 17 (SPSS, Inc., Chicago, IL). As a pilot study, noformal power evaluation was performed and we randomly as-sessed 100 procedures. RESULTS A total of 100 procedures were evaluated. The charac-teristics of our sample are summarized in Table 1. Themean age was 36.2 years (range 25-52). Mean surgicalexperience was 7.1 years and the mean last day of exer-cise was 6.4 days. All subjects evaluated in this study didexercise at least once per week.The surgical procedures included in our study werelaparoscopic partial nephrectomies (LPN; n  31), lapa-roscopic cryoablations (LCA; n  36), laparoscopic rad-ical nephrectomies (LRN; n    28), and robotic renalprocedures (n  5). Fifty of the above mentioned proce-dures were randomized to use of the gel-mat pads wereapplied to improve the participants’ comfort (Fig. 1).During robotic procedures, only bedside assistants wereevaluated as the surgeon was sitting at the console.There were no differences in participants’ preoperativecharacteristics between the 2 groups (Table 2). Regard-ing the immediate postoperative evaluation, the resultsbetween the 2 groups were statistically significant for anadvantage with gel pad use in the number of timesstretched ( P  .001), number of breaks taken ( P  .001),foot discomfort/pain ( P  .003), knee discomfort/pain( P    .001), and back discomfort/pain ( P    .001),respectively. The overall amount of discomfort ( P   .001) and level of energy ( P    .049) are depicted inTable 3. We also observed differences 24 hours post-operatively in foot discomfort/pain ( P  .004), overalldiscomfort ( P  .001), and level of energy ( P  .049)(Table 4).Cross tabulation regarding perception of fatigue aftereach procedure between gel-mat and nongel-mat groupswas made. We found less fatigue in the gel-mat group(n    41, 82%) compared with that in the nongel-matgroup (n    29, 58%) ( P    .001). Finally, a cross tabu-lation was also performed regarding perceived surgicalerrors made during each procedure between gel-mat andnongel-mat groups. In accordance with the previous re-sults, there were more errors in the nongel-mat group(n  6, 12%) ( P  .041). Table 1.  Operating room team characteristicsVariables Mean Range SDAge (yrs) 36.29 25-52 4.93Surgical experience (yrs) 7.16 1-19 3.57Last day exercise 6.46 1-75 10.94d/wk exercise 1.01 1-5 1.13 Figure 1.  Members of the surgical team standing on thegel mat. Table 2.  Preoperative evaluation of participants assignedin gel-mat and non-gel mat groupsVariableGel-matGroupNongel-matGroup P  ValueNo subject 50 50 NAAge (mean) 36.3 31.2 .06Surgical experience(years)7 7.2 .255d/wk exercise 1.02 1 .153Feet 1.68 1.42 .062Ankle 1.22 1.26 .458Knees 1.44 1.44 .905Hips 1.36 1.20 .085Back 1.66 1.94 .111Neck 1.56 1.52 .935Overall discomfort 1.56 1.96 .071 1406  UROLOGY 76 (6), 2010  COMMENT Laparoscopic surgery in urology is more physically chal-lenging and demanding than traditional open surgery.Ergonomics is a relatively new field of science that hasrecently gained popularity. 1,2 The science of ergonomicsanalyzes the surgical challenges and formulates guidelinesfor creating a work environment that is safe and com-fortable for its operators while effectiveness and efficiencyof the process are maintained. 12 A growing amount of literature raised concerns about the ergonomic problemsof video endoscopic surgery teams. 3,5-7 Gofrit and col-leagues reported neuromuscular and arthritic symptomsin 30% of urologists regularly performing laparoscopicprocedures. 13 In addition, it is also known that mainte-nance of correct body posture is a very important ergo-nomic factor credited not only with minimizing physicaldiscomfort but also with improvement of task perfor-mance. 14-16 In other words, maximizing surgeons’ com-fort level results in better technical performance andreduces the margin of error.Most work done to date has been focused on theimprovement of working conditions in the operatingroom and thus the improvement in productivity. Ourmain goal in this study was to see whether our dedicatedsurgical team could achieve an improved comfort level atthe operating room by the simple application of a gel-matpad.We evaluated our team, which consisted of 18 peoplewith different roles, including 5 attending surgeons withmore than 10 years of experience in minimally invasivesurgery. The rest of the group included 6 urology resi-dents from our department, 2 fellows from the minimallyinvasive urology program, and 5 scrub technicians andcirculating nurses working regularly as part of our team inthe operating room. All participants reported to be ingood health and physical condition. Each subject wasgiven a tutorial regarding which condition was regardedas discomfort/pain before each minimally invasive proce-dure. Most of the procedures were lengthy (  2 hours)and included multiple types of minimally invasive sur-gery, including complex laparoscopic ablative and recon-structive procedures, as well as robotic and endoscopicprocedures. During the 5 robotic procedures, only bedsideassistants were evaluated (represent more traditionallaparoscopic challenges).Subjectively, our team felt strongly that the gel padapplication during laparoscopic renal surgery was veryadvantageous. Most participants perceived a better levelof energy and less discomfort in immediate postoperativetime ( P    .001) and 24 hours after the procedure ( P   .046). Similar ergonomic studies have been performedwith metrics including electromyography and other so-phisticated technologies. However, these metrics aremore expensive, less practical, and have never been val-idated and shown to be superior to subjective assessmentsin this capacity. 11 We believe that the most importantparameter is the surgical teams’ subjective evaluation of their own condition. However, although intuitively acomfortable surface would seem to optimize surgeon com-fort, the “placebo effect” of the Gelmat must be consid-ered because we did not have a control to eliminate thispossibility.The posture of the surgeon and the operating team isaffected by 4 major factors: the height of the operatingtable, the design of the instruments, the position of themonitor, and the foot pedals. Height is not always opti-mal for the remaining members of the team and can leadto ergonomically poor conditions. The working surfaceheight, relative to a subject performing manual work,determines the upper extremity effort and the potentialfor musculoskeletal injury. 5,17 Several different ergo-nomic body support devices have been used by laparo-scopic surgeons in an effort to reduce muscle activity anddiminish, over the long term, physical complaints anddiscomfort. 18 However, these are expensive and seem lesspractical equipment. 19 Laparoscopic surgery requires a high proportion of static neck and back postures. 20 We introduced in oureveryday practice a simple, cost-effective, and easilymaintained device that improved the tolerability of ourprocedures. The use of a gel-mat pad seems to offer a Table 3.  Postoperative evaluation of gel-mat and nongel-mat groupsVariablesGel-matGroupNongel-matGroup P  ValueOR time (min) 106.68 110.2 .926Standing time (min) 76.5 95 .607Sitting time (min) 30.18 15.2 .001No postures changed 1.1 1.42 .873No stretched 1.28 2.8 .001No breaks taken 1 2.8 .001Feet 1 2.26 .003Ankle 1.32 1.62 .281Knees 1.28 2 .001Hips 1.2 1.3 .108Back 1 3.08 .001Shoulders 1.6 1.6 .731Neck 1.56 1.94 .069Overall discomfort 1 2.4 .001Overall level of energy 8.7 8 .049 Table 4.  Twenty-four hours postoperative evaluation of gel-mat and nongel-mat groupsVariableGel-matGroupNongel-matGroup P  ValueFeet 1.24 1.64 .004Ankle 1.24 1.28 .427Knees 1.26 1.34 .336Hips 1.24 1.26 .642Back 1.52 1.66 .394Shoulders 1.40 1.42 .917Neck 1.3 1.42 .200Overall discomfort 1.24 1.8 .001Overall level of energy 9.3 8.88 .044 UROLOGY 76 (6), 2010  1407  better body posture, while diminishing at the same timethe discomfort experienced in the back, knees, and feet.In accordance with the aforementioned findings, theoverall physical discomfort in the procedures where gelpads were not used was considerably higher ( P  .001).It became evident from our study that much of thepostural and musculoskeletal disadvantages for the sur-geon and the operating room staff related to laparoscopicsurgery can be minimized using a gel-mat pad. As such,we have incorporated the gel-mat into all our laparo-scopic procedures as a standard part of the operatingroom set-up. There were no adverse events or challengesassociated with the application of the gel-mat pads. CONCLUSIONS The application of a foot gel pad during laparoscopicrenal surgery provides a simple and effective way toreduce surgical staff discomfort. References 1. Hemal AK, Srinivas M, Charles AR. Ergonomic problems associ-ated with laparoscopy.  J Endourol.  2001;15:499-503.2. Kaya OI, Moran M, Ozkardes AB, et al. Ergonomic problemsencountered by the surgical team during video endoscopic surgery. Surg Laparosc Endosc Percutan Tech.  2008;18:40-44.3. Berguer R, Chen J, Smith WD. A comparison of the physical effortrequired for laparoscopic and open surgical techniques.  Arch Surg. 2003;138:967-970.4. Johnston WK 3rd, Hollenbeck BK, Wolf JS Jr. Comparison of neuromuscular injuries to the surgeon during hand-assisted andstandard laparoscopic urologic surgery.  J Endourol.  2005;19:377-381.5. van Veelen MA, Kazemier G, Koopman J, et al. Assessment of theergonomically optimal operating surface height for laparoscopicsurgery.  J Laparoendosc Adv Surg Tech A.  2002;12:47-52.6. Berguer R, Forkey DL, Smith WD. Ergonomic problems associatedwith laparoscopic surgery.  Surg Endosc.  1999;13:466-468.7. Wauben LS, van Veelen MA, Gossot D, et al. Application of ergonomic guidelines during minimally invasive surgery: a ques-tionnaire survey of 284 surgeons.  Surg Endosc.  2006;20:1268-1274.8. Kant IJ, de Jong LC, van Rijssen-Moll M, et al. A survey of staticand dynamic work postures of operating room staff.  Int Arch OccupEnviron Health.  1992;63:423-428.9. Vereczkei A, Feussner H, Negele T, et al. Ergonomic assessment of the static stress confronted by surgeons during laparoscopic chole-cystectomy.  Surg Endosc.  2004;18:1118-1122.10. Carswell CM, Clarke D, Seales WB. Assessing mental workloadduring laparoscopic surgery.  Surg Innov.  2005;12:80-90.11. Lee G, Lee T, Dexter D, et al. Ergonomic risk associated withassisting in minimally invasive surgery.  Surg Endosc.  2009;23:182-188.12. van Det MJ, Meijerink WJ, Hoff C, et al. Optimal ergonomics forlaparoscopic surgery in minimally invasive surgery suites: a reviewand guidelines.  Surg Endosc.  2009;23(6):1279-1285.13. Gofrit ON, Mikahail AA, Zorn KC, et al. Surgeons’ perceptionsand injuries during and after urologic laparoscopic surgery.  Urology. 2008;71(3):404-407.14. Lee G, Park AE. Development of a more robust tool for posturalstability analysis of laparoscopic surgeons.  Ann Surg Mar.  2006;243(3):329-333.15. Liao MH, Drury CG. Posture, discomfort and performance in aVDT task.  Ergonomics.  2000;43:345-359.16. Bhatnager V, Drury CG, Schiro SG. Posture, postural discomfortand performance.  Hum Factors.  1985;27:189-199.17. Manasnayakorn S, Cuschieri A, Hanna GB. Ergonomic assessmentof optimum operating table height for hand-assisted laparoscopicsurgery.  Surg Endosc.  2009;4:783-789.18. Galleano R, Carter F, Brown S, Frank T, Cuschieri A. Can armrestsimprove comfort and task performance in laparoscopic surgery? Surg Endosc.  2008;22(4):1087-1092.19. Albayrak A, van Veelen MA, Prins JF, et al. A newly designedergonomic body support for surgeons.  Surg Endosc.  2007;21:1835-1840.20. Nguyen NT, Ho HS, Smith WD, et al. An ergonomic evaluationof surgeons’ axial skeletal and upper extremity movements duringlaparoscopic and open surgery.  Am J Surg.  2001;182(6):720-724. 1408  UROLOGY 76 (6), 2010
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