The term ergonomics is far from unfamiliar; it has become a fundamental feature in new products we integrate into our daily lives. Ergonomics applies scientific methods to design objects, systems, or environments for human use, with primary goals of ensuring safety, comfort, usability, performance, and productivity. A wealth of literature documents that prolonged surgical shifts in ergonomically poor postures lead to an increase in technical errors, sick leave, and discomfort among surgeons. 

Today’s study reflects the cardiothoracic community’s concern over musculoskeletal injuries resulting from suboptimal ergonomics and extended hours in the operating room. It is an anonymous survey of 33 questions designed to assess the musculoskeletal health, ergonomic perceptions, and habits of American cardiac surgeons. 

Among 600 surveyed surgeons, the prevalence of musculoskeletal injuries attributed to long hours in the OR was 64%; a third of the surgeons had to take medical leave to recover, and 20% required chronic pain management. Cervical spine injuries were the most common, affecting 35% of participants, followed by lumbar pain in 30%. Multivariable analysis identified cardiac surgery as a risk factor for these occupational injuries (OR = 1.8). Notably, 90% of surgeons believed their institutions failed to provide ergonomic education or materials for performing their duties. 

The study concludes that the incidence of occupational injuries in the cardiothoracic community is alarmingly high, leading to substantial sick leave and even early retirements. This survey underscores the need to improve postural education and adopt techniques that enhance ergonomic habits in the OR. 

COMMENTARY: 

As a congenital cardiac surgeon, I was unaware of the concept of OR ergonomics until I read this article. A subsequent Pubmed® search yielded hundreds of articles on the topic. However, it is surprising that this is the first study addressing ergonomics in the cardiothoracic community. The lack of awareness is evident in the 20% response rate from the 2,800 surveyed surgeons. The majority of respondents were male (92%), over 55 years old, with more than 20 years of experience. Female representation was low, with only 48 participants. However, they are particularly vulnerable to poor ergonomic habits as the entire OR environment is built around a typically taller male phenotype with larger hands. Alarmingly, 97% (n = 371) of surgeons with musculoskeletal injuries did not seek treatment, simply ignoring the issue. 

The article briefly mentions various strategies employed by respondents to combat these injuries. Some performed short stretching sessions during surgery, others used anti-fatigue mats. Emphasis was placed on OR table height and elbow flexion angles based on the procedure. Thoracic surgeons showed greater awareness of adopting ergonomic postures during procedures. 

Each surgical specialty has its own working style. In cardiac surgery, when a patient is connected to a cardiopulmonary bypass machine, every minute counts, and the goal is to complete the procedure as swiftly as possible. There is no time to step back and stretch your back or neck. Preparing for the toll of a typical four-hour or longer surgery begins before and continues after the OR. Like athletes, cardiac surgeons must prepare their bodies for long hours in the OR. Some colleagues engage in weightlifting, others run or swim, and some practice high-intensity interval training (Tabata) to precondition themselves and prevent injuries from our surgical practice. Our surgeries involve diverse body postures; sometimes, one can be seated, as when harvesting an internal mammary artery or performing video-assisted thoracoscopic surgery. In other cases, neck strain is necessary, as when initiating the repair of a right partial anomalous pulmonary venous drainage and placing the first intracaval shunts. Unlike thoracoscopic or robotic surgeries, our procedures rarely involve a static neck position. Constant movement is required to check hemodynamic status on the monitor, communicate with the anesthesiologist or perfusionist, or adjust focus when sutures get entangled outside the field of vision. The weight of the loupes and headlights, which have fortunately modernized with lighter materials, adds to this strain. 

Regarding loupes, there is much debate about the level of magnification. Personally, I use 2.5x magnification, which, with my focal length, allows me to operate comfortably with my elbows flexed at 90 degrees. Some surgeons prefer to have their hands closer to their faces, requiring a greater elbow flexion angle, leading each to choose a different focal length. I use this magnification for both adult congenital and neonatal surgeries. In my case, higher magnification only adds extra weight to the nose, becoming burdensome after several hours of surgery. For this reason, I prefer the headlamp on my head rather than on the loupes. Some colleagues use 3.5x magnification for neonatal surgery, while others use 4x for coronary surgery, ending up with more cervical discomfort by the end of the day due to the added weight. The magnification level is a critical ergonomic consideration based on case specifics. The situation changes when assisting instead of operating; peripheral vision is more useful than the loupe view in this role. In these cases, loupes should not obstruct the view of the surgical field. 

In conclusion, the cardiothoracic community must become more aware of OR ergonomics, adopt proper postural habits, and take appropriate measures to prevent injuries. Our bodies, like cars in a 24-hour Le Mans race, require pit stops to maintain peak performance. Ignoring this will soon condemn us to careers marred by injuries and personal lives plagued by pain. 

REFERENCE:

Mathey-Andrews CA, Venkateswaran S, McCarthy ML, Potter AL, Copeland J, Panda N, et al. A national survey of occupational musculoskeletal injuries in cardiothoracic surgeons. J Thorac Cardiovasc Surg. 2024 Aug;168(2):617-625.e3. doi: 10.1016/j.jtcvs.2023.08.038.