In laparoscopic surgery, gall bladders are removed, stomachs are constricted and tumors are excised through small incisions that mean less pain and shorter hospital stays. But while the patients are benefiting, the procedures are causing injuries in surgeons themselves.
Doctors stand still for hours in awkward postures, repeating the movements for minimally invasive operations several times a day. A growing number are experiencing symptoms from neck strain to carpal tunnel syndrome - and that threatens to chase some from the business.
A new study from the University of Maryland School of Medicine shows almost 87 percent of laparoscopic surgeons surveyed across the nation have experienced discomfort they attribute to performing the procedures.
"Nothing less than the career longevity of surgeons is at risk if we don't start getting some attention to the problem," said the study's principal author, Dr. Adrian E. Park, chief of general surgery at the University of Maryland Medical Center and vice chair of the surgery department in the School of Medicine.
Past estimates indicate that less than a third of laparoscopic surgeons had had a job-related injury. But the substantial increase seen in the new, more thorough survey is not surprising to study authors or other surgeons not associated with the research, who acknowledge pain is common though infrequently discussed.
"A tennis player can have his swing analyzed, but we have no body of knowledge on this," said Park, who is also executive director of the Maryland Advanced Simulation, Training, Research and Innovation Center. It is the nation's first facility to focus on surgical movement.
For the study, which appears in the March issue of the Journal of the American College of Surgeons, Park collected surveys from 317 laparoscopic surgeons. Of those, 272 reported discomfort, including eye strain and hand, neck, back and leg pain. Also reported were headaches, finger calluses, disc problems, shoulder-muscle spasm and carpal tunnel syndrome.
Younger surgeons and those over age 60 had the most problems with their hands, but other pain did not appear age-related. Those who performed more procedures had more problems.
Doctors responding to the survey blamed instrument design, operating table setup and location of display monitors.
The majority said they didn't know what they should do to alleviate the pain, and about 40 percent said they ignored pain. Others said they changed position, changed instruments or took a break.
There is no universal set of guidelines for surgeons to follow, but even if there were, it's not clear doctors would heed it or talk about any pain they have, said some surgeons who read the study but didn't participate, including Dr. Peter Geis, who heads the Division of Minimally Invasive Laparoscopic Surgery at Northwest Hospital in Randallstown.
Maybe they fear losing positions or business, but more likely it's because of culture, said Geis, a pioneer in laparoscopic procedures.
"It's like a pro athlete saying, 'Oh my gosh, I'm losing my balance every time I start to run,' " he said. "It's not good for their image."
Geis said equipment improvements have eased the burden a bit during the two decades during which laparoscopic surgery has become mainstream.
In such surgery, there is less pain, bleeding and recovery time because small incisions are made in a patient's abdomen instead of larger openings.
But the smaller space in which doctors can work has meant they stand much more still, possibly at an odd angle, and make repetitive motions with their hands as they focus their eyes on a computer screen often above their heads.
Some advances have eased the strain on doctors. Specialized instruments placed in patients through the incisions have become more flexible and easier on the hands. Monitors, once affixed high atop towers, are now attached to arms that adjust in height and reduce neck craning. Tables raise and lower. Cushioning is available for the floor.
Still, not all hospitals have made upgrades and not all surgeons can or will take advantage of improvements. Even Geis, who leads a laparoscopic surgery fellowship program at Northwest, admits that he only discusses proper positioning for the operations themselves and not for ergonomics.
"The good news is this is being discussed in the open now, and I give Dr. Park credit for that," Geis said.
"This is an opportunity for surgeons to legitimize their own symptoms and have the nerve to say something so they can keep on operating longer into the future. I guarantee I'm going to start talking about it."
Other laparoscopic surgeons agree that more needs to be done to prevent injury, including Dr. Daniel B. Jones, chief of Minimally Invasive Surgical Services at Beth Israel Deaconess Medical Center in Boston and an associate professor of surgery at Harvard Medical School.
Jones said he does try to adjust equipment before surgery for his comfort, but not midsurgery, and not if the patient's needs get in the way. He also tries to stretch between surgeries and get enough rest, but that sometimes gives way to his schedule.
Parts wear down
And if he has pain, the only one likely to hear about it is his wife, because "there's no glory in admitting you have a sore neck."
Still, Jones said, "We've got to remember that even if we were made out of steel, parts used over and over again are going to wear down."
He noted operations are frequently six hours or longer and he sometimes does several in a day. He said he knows many surgeons who have needed neck surgery. At 45, he's trying to avoid that fate by paying more attention to his position and equipment.
At the same time, those who make and maintain that equipment are trying to improve on the technology.
Tables, monitors and surgical devices have become more flexible, but manufacturers can only improve on them when they know what's wrong, said Robert Bain, president of the Baltimore Medical Engineers and Technicians Society, whose members repair and test medical equipment.
Developing guidance for manufacturers and doctors is next for Park, who has been studying surgical ergonomics for several of his 18 years in the laparoscopic field. He'd like to lure others into helping because a lot more research is needed.
"We don't know yet what recommendation to make," said Park, who plans to use a laparoscopic training lab he developed years ago for such study.
"I'm trying to fill a void. The first step is awareness that there's a problem."
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