VIENNA—Efforts should be made to improve the ergonomics of laparoscopic radical prostatectomy (LRP) to relieve the physical stress of performing the procedure, according to a German urologist.

Jens Rasseweiler, MD, Medical Director and Head of the Department of Urology at SLK Kliniken Heilbronn, discussed the physical stress that accompanies this procedure here at the 7th Meeting of the European Association of Urology’s Section of Oncological Urology.

He noted that surgeons must operate in a craniocaudal-parallel axis to the patient. “Thus, ports are placed on both sides of the midline and operative work may necessitate reaching over the patient and across the midline,” Dr. Rassweiler observed. “Furthermore, the monitor is not located across the patient but positioned towards the lower extremities, causing secondary neck strain while the back and torso are already torqued toward the pelvis.”

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All of this leads to back pain, which is the type of pain most commonly experienced by urologists after performing LRP, he said.

Other physical stressors include:

  • the need to stand in a fixed position, as dictated by the trocar placement and site of the video screen; this leads to static strain of the eyes, head, neck and spine, and of the knee and foot joints;
  • the need to pivot the instruments around the trocars, which necessitates increased muscle activity and, sometimes, awkward movements of the upper limbs;
  • the fact that the force needed to control the instruments can be six times greater than that needed for open surgery, a problem magnified further by the non-ergonomic design of the handles. Badly designed instruments can even lead to “laparoscopist’s thumb,” involving damage to the nerves of the thumb and thenar space.

Since 2005 Dr. Rasseweiler and his colleagues have been using a chair that supports urologists’ knees during LRP. Other surgeons are using a specially designed instrument that supports the chest and torso (Surg Endos. 2007; 21:1835-1840).

Dr. Rassweiler conceded that the da Vinci device confers certain ergonomic advantages, including the ability to stay seated for the entire procedure and using the robotic arms, which allow the surgeon to remain in an ergonomic position. Robotic surgery can disadvantages, however, including the complete lack of tactile feedback, which thus has to be compensated for by vision.

“Even if the da Vinci device has optimized the ergonomics of lapaorscopic surgery, it also has some limitations and is not cost-effective,” he said. “Therefore, a significant effort should be invested to improve the ergonomics of laparoscopy. This should include the design of new operating room tables, supports for the surgeon with integrated food pedals, mobile high-definition television monitors, and new instrument handles that minimize mental and physical stress for the surgeon.”