**Abstract**

Applied ergonomics is very important in minimally invasive surgery (MIS), especially with the introduction of robotized techniques that have changed the surgeons' work conditions. However, the main aim remains the engineering to enable the compatibility of fulfillment of surgeons' tasks in a physical, logical, and organizational environment with security, comfort, and efficiency. Ergonomics contribution is oriented both to design and redesign utilized material and to work organization. Epidemiological studies have shown the appearance of musculoskeletal pathologies in surgeons performing MIS; therefore, it is relevant to identify the intensity, frequency, and duration of risk factors (posture, repeatability, level of effort, touch pressure, and vibration if relevant) associated with this profession. A further relevant consequence of the effort applied during MIS is local muscle fatigue (LMF), an important factor to consider in musculoskeletal pathologies. The aim of this chapter is to present different methodological approaches by employing most advanced technologies to define the most appropriate posture that surgeons should adopt during MIS to decrease LMF apparition risk level and at the same time to increase capacity to variate the posture without reducing the precision task performance.

**Keywords:** laparoscopy, ergonomics, musculoskeletal disorders

### **1. Introduction**

**Ergonomics** can be defined as an interdisciplinary field of knowledge to study the characteristics, needs, and abilities of human beings, analyzing those aspects that affect the design of products and/or production processes. In all the applications, its objective is to try to adapt products, tasks, tools, spaces, and the environment in general to the biological characteristics, the capabilities, and the needs of the people in order to guarantee the safety and health of workers, users, and consumers as well as to increase their welfare and improve the production processes' efficiency [1].

**Laparoscopic surgery** as a technique of minimally invasive surgery began to be applied in the early 1990s and refers to surgical operations in the abdomen or pelvic cavity. Although this technique is very advantageous for the patient in comparison with an "open" surgical intervention [2], it is a technically challenging one for the surgeon [3, 4].

On the other hand, the "**fine handling**" associated with the performance of laparoscopic surgery techniques, related to very low frequency and relatively small amplitude motor patterns as movements are restricted due to the fixed holes through which the laparoscopic instruments are introduced, implies maintenance of the posture during relatively long intervals of time along with high levels of musculoskeletal effort and lack of comfort sensation.

Scientific studies have shown that the use of laparoscopic instruments contributes to significantly increase the activity of the deltoid muscle and at the same time the activity of the superficial flexor and common extensor digitorum [5, 6], promoting the appearance of local muscle fatigue in the upper extremities and in the neck area as well as numbness in the fingers [7–12].

To the aforementioned, it should be added that the minimally invasive surgery techniques also involve control of the position and orientation of the trunk and head, the segments whose mass is relatively large, reaching almost 50% of the total body and therefore involving a high muscular effort during relatively long time intervals. In addition, surgeons have to manipulate instruments that are not designed with ergonomic usability criteria, since the level of force and contact pressure implied by their use (clamp and grip) are unknown. Finally, the use of monitors during surgical operations implies an additional difficulty for surgeons as there is no tactile interaction with the organs undergoing the operation [13, 14].

In this scenario, it is very common to adopt and maintain awkward postures for relatively long periods of time, which cause a high level of physical load associated with the intervention of the muscles that control the involved joints of the locomotor system. These factors can cause discomfort and musculoskeletal pain or even disorders that can lead to permanent disability and/or need for surgical intervention (**Figure 1**).

This type of pathology develops progressively in **stages**, so that in the first stage, moderate fatigue and initial discomfort that are usually moderate are observed. In the second stage, there are occasional discomforts in the posture and mild pain that disappears with a good rest. Then, as a consequence of the continued exposure to the risk factors, pain and other symptoms that persist almost throughout the day appear causing a process of progressive degradation that leads to more severe pain

**11**

motor skills.

**2. Epidemiology study**

favor their appearance [16].

(12.9 ± 6.7) hours per week dedicated to them.

*Advanced Ergonomics in Laparoscopic Surgery DOI: http://dx.doi.org/10.5772/intechopen.84233*

of risk factors for musculoskeletal pathologies.

quality of daily life.

and ends up compromising the daily activity. This ends in a chronic disability that reduces the normal physical abilities of the person and seriously affects his/her

Since two decades, the European Agency for Safety and Health at Work [15], at the request of the European Commission, has issued two reports on musculoskeletal disorders and injuries related to work. In these reports, the social and economic dimension of musculoskeletal pathologies has been confirmed as well as the need to establish standardized scientific criteria for the evaluation of their risk factors. Secondly, the reliability of the epidemiological data is questioned and the reconsideration of experimental studies is recommended as there is no consensus on the confirmation of the appearance of local muscle fatigue as a risk factor in association with the adoption of forced working postures and the performance of repetitive movements. In this sense, ergonomic intervention based on scientific work is recommended for the development of strategies for the evaluation and prevention

The objective of this chapter is, starting with the results of an epidemiological study

In this sense, the results of the research are useful to manage organizational and ergonomic decision-making with the aim of introducing an ergonomic conception of laparoscopic surgery processes to improve surgeons' occupational health and quality of life. The application of these measures requires to previously identify and evaluate the risk factors. This means to select the tasks and jobs with exposure to risk of injury, to study which is the level of exposure in each of them, and to decide

The possibilities offered by **Biomechanics** to raise and solve problems related to the improvement of health and quality of life have consolidated it as a field of knowledge in continuous expansion, capable of providing scientific and technological solutions. On the other hand, the industrial projection of Biomechanics has reached several sectors, providing the basis for the conception and adaptation of numerous products, for diagnostic techniques and for the evaluation of human

The objective of the applied research in the occupational field is to analyze working conditions, especially the interface "man-workplace" or "man-machine" as a way to prevent discomfort and/or occupational pathologies, to reduce fatigue and increase the comfort and to generate criteria for the design of tools and jobs accord-

The epidemiological study enables collection of data regarding the incidence of musculoskeletal pathologies in laparoscopic surgery and the risk factors, which

The study was conducted on a sample of 52 surgeons (35–65 years), (7.31 ± 3.30 years of experience) in the techniques of laparoscopic surgery and

ing to the characteristics of the users and the tasks to be performed.

(Nordic Questionnaire), to present the results of the research work carried out by the collaboration between the Jesús Usón Minimally Invasive Surgery Centre and the BioẼrgon research group during the last 15 years based on the methodology of ergonomics and using the instrumental techniques of Biomechanics of Human Movement to contribute to investigate the level of physical effort borne by surgeons and to establish ergonomic criteria to improve the working conditions of surgeons, as well as to establish ergonomic design criteria for laparoscopic material by analyzing different tasks in

laparoscopic surgery in conjunction with the motor behavior of surgeons.

in which cases it is necessary to apply correction measures.

**Figure 1.** *Neck surgery (left) and Surgery training (right).*

#### *Advanced Ergonomics in Laparoscopic Surgery DOI: http://dx.doi.org/10.5772/intechopen.84233*

*Recent Advances in Laparoscopic Surgery*

intervention (**Figure 1**).

loskeletal effort and lack of comfort sensation.

the neck area as well as numbness in the fingers [7–12].

On the other hand, the "**fine handling**" associated with the performance of laparoscopic surgery techniques, related to very low frequency and relatively small amplitude motor patterns as movements are restricted due to the fixed holes through which the laparoscopic instruments are introduced, implies maintenance of the posture during relatively long intervals of time along with high levels of muscu-

Scientific studies have shown that the use of laparoscopic instruments contributes to significantly increase the activity of the deltoid muscle and at the same time the activity of the superficial flexor and common extensor digitorum [5, 6], promoting the appearance of local muscle fatigue in the upper extremities and in

To the aforementioned, it should be added that the minimally invasive surgery techniques also involve control of the position and orientation of the trunk and head, the segments whose mass is relatively large, reaching almost 50% of the total body and therefore involving a high muscular effort during relatively long time intervals. In addition, surgeons have to manipulate instruments that are not designed with ergonomic usability criteria, since the level of force and contact pressure implied by their use (clamp and grip) are unknown. Finally, the use of monitors during surgical operations implies an additional difficulty for surgeons as there is no tactile interaction with the organs undergoing the operation [13, 14]. In this scenario, it is very common to adopt and maintain awkward postures for relatively long periods of time, which cause a high level of physical load associated with the intervention of the muscles that control the involved joints of the locomotor system. These factors can cause discomfort and musculoskeletal pain or even disorders that can lead to permanent disability and/or need for surgical

This type of pathology develops progressively in **stages**, so that in the first stage, moderate fatigue and initial discomfort that are usually moderate are observed. In the second stage, there are occasional discomforts in the posture and mild pain that disappears with a good rest. Then, as a consequence of the continued exposure to the risk factors, pain and other symptoms that persist almost throughout the day appear causing a process of progressive degradation that leads to more severe pain

**10**

**Figure 1.**

*Neck surgery (left) and Surgery training (right).*

and ends up compromising the daily activity. This ends in a chronic disability that reduces the normal physical abilities of the person and seriously affects his/her quality of daily life.

Since two decades, the European Agency for Safety and Health at Work [15], at the request of the European Commission, has issued two reports on musculoskeletal disorders and injuries related to work. In these reports, the social and economic dimension of musculoskeletal pathologies has been confirmed as well as the need to establish standardized scientific criteria for the evaluation of their risk factors. Secondly, the reliability of the epidemiological data is questioned and the reconsideration of experimental studies is recommended as there is no consensus on the confirmation of the appearance of local muscle fatigue as a risk factor in association with the adoption of forced working postures and the performance of repetitive movements. In this sense, ergonomic intervention based on scientific work is recommended for the development of strategies for the evaluation and prevention of risk factors for musculoskeletal pathologies.

The objective of this chapter is, starting with the results of an epidemiological study (Nordic Questionnaire), to present the results of the research work carried out by the collaboration between the Jesús Usón Minimally Invasive Surgery Centre and the BioẼrgon research group during the last 15 years based on the methodology of ergonomics and using the instrumental techniques of Biomechanics of Human Movement to contribute to investigate the level of physical effort borne by surgeons and to establish ergonomic criteria to improve the working conditions of surgeons, as well as to establish ergonomic design criteria for laparoscopic material by analyzing different tasks in laparoscopic surgery in conjunction with the motor behavior of surgeons.

In this sense, the results of the research are useful to manage organizational and ergonomic decision-making with the aim of introducing an ergonomic conception of laparoscopic surgery processes to improve surgeons' occupational health and quality of life. The application of these measures requires to previously identify and evaluate the risk factors. This means to select the tasks and jobs with exposure to risk of injury, to study which is the level of exposure in each of them, and to decide in which cases it is necessary to apply correction measures.

The possibilities offered by **Biomechanics** to raise and solve problems related to the improvement of health and quality of life have consolidated it as a field of knowledge in continuous expansion, capable of providing scientific and technological solutions. On the other hand, the industrial projection of Biomechanics has reached several sectors, providing the basis for the conception and adaptation of numerous products, for diagnostic techniques and for the evaluation of human motor skills.

The objective of the applied research in the occupational field is to analyze working conditions, especially the interface "man-workplace" or "man-machine" as a way to prevent discomfort and/or occupational pathologies, to reduce fatigue and increase the comfort and to generate criteria for the design of tools and jobs according to the characteristics of the users and the tasks to be performed.
