How to Optimize Performance and Enhance Patient Care: Ergonomics for the Modern Urologist

By: Robin Riddle, PT, DPT, University of Alabama at Birmingham | Posted on: 06 Jul 2023

As a urologist, professionalism and commitment to superior performance drive you. When you step into the surgical suite, you see the team moving quickly, preparing for the upcoming procedure. You engage the team for a brief ergonomic time-out to propose strategies ensuring comfort and safety for all in the operating room. Monitors and tables at the appropriate height, check. Estimated time of microbreaks, check. Centered, diaphragmatic breath … check. Your proactive approach optimizes your performance and ensures elite care for your patient. You are a modern surgeon.

Performing urological surgical procedures poses physical challenges that increase the risk of discomfort and work-related musculoskeletal disorders (WMSDs). Incorporating ergonomic principles such as adapt, microbreak, train, and plan is crucial to reduce musculoskeletal injury risk, alleviate discomfort, and maintain superior performance.

Adapt

Adapt the environment to the needs of your body. The diversity of urologists’ personal characteristics and procedures begets a diversity of ergonomic strategies. Precise ergonomic strategies should be selected depending upon procedure and individual traits. To prevent undue physical strain, it is important to customize your workspace. Although this report does not include personalized guidance, the Table summarizes general strategies that, when implemented, can yield significant benefits. Check with your practice regarding the availability of personalized recommendations.

Table. Summary of General Ergonomic Strategies for the Urologist^a

	Robotic-assisted	Sitting	Standing	Tips and tricks
Environmental considerations	Use adjustable high/low chair or saddle seat.	Use adjustable high/low chair or saddle seat. Position pedals to face the surgical field. Use articulating arm support when possible. Position the top of monitor at eye level (Figure 3).	Table height at 75% of distance from floor to elbow (Figure 5). Position pedals to face the surgical field. Position the top of monitor at eye level. Use stools to accommodate for varying heights of the team.	Implement an ergonomic time-out so everyone is aware of the plan. Use cues to action like a chime clock, timer, or visual cue as a reminder to microbreak. Increase base of support when standing to increase stability. Contact as many points as possible–a hip on the table, an elbow on an articulating arm support, both feet on the floor. Increased points of contact increase stability. Practice hip hinging outside the OR when you are brushing your teeth while standing, or when you are seated and using devices like your phone or tablet. Practice will make this position feel more natural and automatic (Figure 9).
Lower extremities	Keep feet flat on floor. Hips should be level or higher than knees.	Keep feet flat on floor. Hips should be level or higher than knees.	Strive for equal weight distribution. Feet face surgical field (Figure 6). Feet at least shoulder width apart.
Lumbopelvic region	Hinge at hips when leaning forward—avoid slouching. Requires strong glutes and flexible hamstrings. Position weight just anterior to ischial tuberosity (Figure 1).	Hinge at hips when leaning forward—avoid slouching. Requires strong glutes and flexible hamstrings. Position weight just anterior to ischial tuberosity.	Hinge at hips when leaning forward—avoid slouching. Requires strong glutes and flexible hamstrings (Figure 7). Keep pelvis level (Figure 8).
Cervicothoracic region	Tuck chin (Figure 2). Retract scapula. Rest forehead on headrest.	Tuck chin. Retract scapula.	Tuck chin (Figure 9). Retract scapula.
Upper extremities	Keep shoulders away from ears. Rest forearms on support pad. Maintain neutral wrist position. Hands remain level with elbows.	Keep shoulders away from ears. Rest elbows on articulating arm support. Maintain neutral wrist position (Figure 4).	Keep shoulders away from ears. Maintain neutral wrist position.
Abbreviations: OR, operating room. ^aGeneral strategies to be performed as often as possible. Some procedures will inherently require problematic positioning or use of tools that prevent implementation of strategies. During these cases especially, timed microbreaks when safe are necessary to counteract the deleterious effects of prolonged problematic positioning.

Figure 1. Position weight just anterior to ischial tuberosity.

Figure 2. Tuck chin to minimize forward head when using microscope or robotics.

Figure 3. Position the top of monitor at eye level.

Figure 4. Maintain neutral wrist position.

Figure 5. Table height at 75% of distance from floor to elbows.

Figure 6. Feet face surgical field.

Figure 7. Hinge at hips when leaning forward.

Figure 8. Keep pelvis level.

Figure 9. Tuck chin to minimize forward head.

Microbreak

While adapting the environment to promote optimal positioning is crucial, certain procedures make it difficult to achieve or maintain perfect positioning. To address this, it is prudent to incorporate microbreaks. A microbreak is a purposeful pause taken during a surgical procedure. Microbreak options that do not compromise surgical time or sterility include pausing 20 seconds every 20 minutes,¹ diaphragmatic breathing,² stretching,³ or active movements such as rotational and isometric muscle activation,⁴ or the Ipswich Microbreak Technique, a 30-second series of 3 cervical rotations, 3 chin tucks, and 3 sternum elevations.⁵ Incorporating microbreaks is a simple, effective way to improve well-being and performance during surgical procedures.⁶

Train

Train your mind and body like a modern surgeon. The notion that being a valuable surgeon requires enduring discomfort in the name of patient care is no longer reasonable. Instead, the modern surgeon believes that prioritizing their own well-being ensures they can provide optimal care to their patients. This requires training outside the surgical suite to prepare for physical demands inside the surgical suite. Many ergonomic strategies require the dynamic interplay of flexibility and stability; to maximize benefits, your training program must incorporate each element. Common shortened muscle groups of surgeons include quadratus lumborum, iliopsoas, hamstrings, suboccipitals, and pectorals. Common weak muscle groups include the anterior cervical flexors, scapula stabilizers, core, and gluteal muscles. Proactively stretching and strengthening these muscle groups will help keep your body flexible and stable in all the right places. Scan the QR code and enter access code ACZBFWYC or go to uab.medbridgego.com/m/ACZBFWYC?s=hs for a surgeon-specific movement program.

Plan

By committing to planning and implementing ergonomic strategies, you can rest assured that you are doing everything possible to prevent WMSDs. WMSDs are linked to physician burnout, early retirement, and poor patient outcomes.^7,8 However, implementing ergonomic strategies can decrease pain and fatigue, improve accuracy, and lower cortisol, which, collectively, optimize well-being and performance.^7,9,10 In addition to committing to use ergonomic strategies, effective planning also includes incorporating an ergonomic time-out before each procedure. During this time-out, the surgeon assesses the team’s setup and discusses planned breaks during surgery where microbreaks can be performed safely. Finally, installing chime clocks that automatically sound every 30 minutes or using visual cues may be an effective strategy to remind the team to adopt microbreaks.

Incorporating the ergonomic principles of Adapt, Microbreak, Train, and Plan into urology practice can help urologists improve their well-being, control their surgical performance, and ultimately provide better care for patients, resulting in long-term advantages for both urologists and their patients.

Special Considerations

Pregnancy places extra demands on the body, making it important for pregnant urologists to proactively reduce the risk of musculoskeletal injuries. Strategies include using a pelvic support band, sitting when possible, and wearing compression garments and supportive shoes. A board-certified pelvic health physical therapist can also assist during and after pregnancy; see: aptapelvichealth.org. For urologists experiencing significant musculoskeletal issues, seek medical attention before it becomes more serious and difficult to treat. By prioritizing your health, you are poised to provide the best possible care for your patients.

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