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musculoskeletal strain. Even proper body alignment, if static and held with tension,
may decrease circulation and lead to muscle fatigue [ 70 – 72 ]. In addition, poor body
positioning can impair technical performance [ 100 ]. Ideal posture maintains neutral
joint positions with the least possible amount of strain. The Alexander technique is
an educational process to avoid muscular and mental tension through correct pos-
tural alignment [ 101 ]. A study evaluating the impact of surgeon education in
Alexander technique showed an improvement in tremor, discomfort, and fatigue
[ 102 ]. In addition to the Alexander technique, there are other ways to encourage
proper posture such as focusing on awareness of body positioning and limiting mus-
cle tension.
Proper Standing Posture
Operating while standing is ideal for cases that require large movements or signifi-
cant force. Ideal standing posture is with the head directly over the shoulders and
with the chin slightly tucked so that the neck is in a flexion of 15–25° (see surgeon
on left in Fig. 22.1) [ 103 – 105 ]. The shoulders are directly over the pelvis and the feet
are hip-width apart. The knees are soft and not locked. During laparoscopic surgery,
the shoulders should be in approximately 20° of abduction and 40° of internal rota-
tion [ 106 ]. The elbows should be flexed 90–120°, and the wrists should not exceed
greater than 15° of deviation or flexion in any direction (Fig. 22.5) [ 106 , 107 ]. To
vary position, the surgeon may place a foot on a step stool while being mindful of
maintaining pelvic girdle alignment so that weight is equally distributed between
both feet [ 108 ]. Additionally, an anti-fatigue mat may improve comfort especially
during long cases [ 109 , 110 ]. The mat acts as a cushion between the feet and hard-
surfaced floor. Anti-fatigue mats are used in many industries where workers must
stand for long periods [ 111 ] and are marketed for use in the operating room.
Correct Seated Body Alignment
Sitting while operating is ideal for cases with a small surgical window such as vagi-
nal surgery and microsurgery. Sitting is especially advantageous as it allows the
body to be supported by several surfaces such as the floor, seat, backrest, and occa-
sionally armrests. For this reason, stools and chairs with backrests are more com-
fortable than those without [ 24 ]. When seated, the feet should rest flat on the ground
with the knees flexed at an angle of 90° or greater [ 84 ]. If a foot pedal is required, it
should be placed directly in front of the working foot. Sitting may be alternated with
periods of standing as prolonged sitting is associated with low back pain [ 112 ].
Seated posture during robotic surgery is slightly different than open surgery as
the surgeon leans forward while working at the console. Prior to beginning a case,
the chair and console height should be adjusted to a comfortable viewing position.
The console is optimized for surgeons between 64 and 73 inches tall. The feet
should rest on the floor behind the pedals with the knees at a 90° or greater angle,
while the forehead rests gently on the headpiece. The forearms relax onto the arm-
rests with the arms near the body and the elbows at a 90° angle [ 82 , 84 ]. Prolonged
work with outstretched and unsupported arms loads the muscles of the trunk and
shoulder. This strain may be decreased 25% by using armrests [ 84 , 113 ]. For this
C. Ronstrom et al.