Articulating vs. conventional laparoscopic grasping tools—surgeons’ opinions
Introduction
Laparoscopy is a relatively recent advancement in surgery that requires no major incisions in the patient, allows for quicker healing, reduced post-operative pain and reduced wound complications such as hernia formation and infection. These benefits have made laparoscopy, and other types of minimally invasive surgery, very popular to patients. However, laparoscopy requires more effort from the surgeon than traditional open procedures (Berguer, 1998).
Laparoscopic techniques require greater concentration and place greater mental stress on surgeons than open surgery (Berguer et al., 2001b). The tools that laparoscopic surgeons must use are difficult to use and because of suboptimal design, they may actually be doing harm to the highly trained physician. Additionally, poor laparoscopic tools increase physician fatigue, creating potential for errors that may harm the patient.
Laparoscopic surgery involves making several small incisions for instrument and camera ports, as opposed to open surgery where a large incision is made. The surgeon performs the laparoscopic operation with surgical tools and video cameras that are inserted into the patient through port sites (trocars) which are 3–15 mm in diameter and then the area is inflated (insufflated). The surgical tools used in laparoscopic surgery are still being developed and many have been adapted from conventional surgical tools by adding a long (45–52 cm) stylus to fit through the trocar, putting the handle at a right angle to the long axis (shaft) of the tool. Thus, the design of these instruments should be fundamental to the result of the surgery.
Current laparoscopic instruments have been found to be very poorly designed from an ergonomic perspective and it is likely that ergonomics were not considered at all. Berguer et al. (1998) found 8–12% of practicing laparoscopic surgeons frequently experience post operation pain or numbness. This is generally attributable to pressure points on the laparoscopic tool handle. Matern et al. (1999) studied four different handle designs used on laparoscopic tools (shank, pistol, axial, and ring handle) and found that all resulted in either painful pressure spots or caused extreme ulnar deviation.
Physicians report that limited dexterity at the grasper tip can cause them to compensate with excessive, awkward arm motions (Van Veelen et al., 2001b). Articulation at the tip would enhance the capability of the surgeon by increasing the tool's degrees of freedom. An ergonomically designed handle and grasper actuation mechanism would provide a more comfortable, intuitive hand/tool interface. These additional design features would help to increase patient safety by reducing surgeon's fatigue and decreasing the need for complex cognitive planning.
Based on the findings from task analysis, consultation with laparoscopic surgeons, results of a questionnaire (previous work below) (Doné et al., 2004), and several pilot studies, a prototype articulating laparoscopic grasper was developed to include an articulating end effector, an ergonomic handle, and an intuitive hand/tool interface (Fig. 1b). In order to assess the design, evaluation of the prototype tool with respect to the current tools must be conducted. This paper investigates the evaluation of the prototype tool by surgeons and comparison with existing tools using a subjective (questionnaire) method.
Section snippets
Previous work—Questionnaire 1
Much consultation was done with surgeons before and during the design of the prototype articulating laparoscopic tool. Included in this consultation was a survey evaluating conventional grasper tools, in which 18 laparoscopic surgeons responded to a questionnaire (Doné et al., 2004). The surgeons were queried after a laparoscopic practice session using conventional tools such as those shown in Fig. 1a. These training sessions for both expert and student laparoscopic surgeons were held at the
Purpose
Using the results from the previous survey of surgeons (questionnaire 1) (Doné et al., 2004) mentioned above, along with the results of several other studies (Berguer, 1998; Berguer et al., 1999, Berguer et al., 2001a; Cacha 1999; DiMartino et al., 2004; Doné et al., 2003; Matern et al., 2001), and task analysis of laparoscopic surgery, a prototype articulating laparoscopic tool was developed. A new questionnaire (questionnaire 2) was developed for use in evaluating the new prototype and
Questionnaire 2
Questionnaire 2 was adapted from questionnaire 1 with improvements based on user feedback and clarification required by subjects when completing questionnaire 1. Questions were simplified and only those providing the most crucial information were included in questionnaire 2. The first page of the questionnaire repeated the most valuable questions from the first questionnaire. The second page asked the surgeon questions about comparing conventional tools and the prototype tool. Surgeons were
Subjects
Thirty-eight laparoscopic surgeons from all over the US who were attending advanced laparoscopic training courses at the University of Nebraska Medical Center were surveyed to compare a conventional grasper (Fig. 1a) to the prototype articulating laparoscopic tool (Fig. 1b). As shown in Fig. 1a, the conventional grasper resembles scissors at a right angle to the shaft of the tool, while the prototype design (Fig. 1b) features an ergonomic handle with a trackball-like control and a reverse pivot
Results
When surgeons were asked to indicate on a picture of a hand where they experience pain during or after laparoscopic surgery, 21 out of 38 surgeons indicated experiencing pain on the hand/fingers/wrist. The painful areas circled and rated on the hand drawing by the surgeons are listed on Table 1. The most frequently identified area was the skin surrounded the proximal phalanx of the thumb. Other areas of hand pain were thumb carpometacarpal basal joint. Most surgeons only circled the painful
Discussion
The results of this questionnaire (2) agreed with those of previous studies (Berguer, 1998; Berguer et al., 1999, Berguer et al., 2001b; Doné et al., 2004). Laparoscopic surgeons are subjected to pain and discomfort, caused by the tools they use, while performing their jobs. Each of the queried potential problem areas asked about had over a 30% positive response from surgeons, with most over 50%, all significantly greater than zero (no problem). In addition, this study showed an even larger
Acknowledgments
A special thanks to the University of Nebraska Medical Center for access to laparoscopic training sessions and use of laparoscopic training equipment.
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