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laparoscopic surgery than for open surgery. Ideal table height during laparoscopy
allows for the elbows to be flexed at an angle between 90° and 120° [ 130 ]. When
the table is too low, the elbows extend past 120° limiting the freedom of instru-
ment movement and may lead to uncomfortable, compensatory flexion of the
back. When the table is too high, the shoulders are abducted and internally rotated,
and the wrists are in ulnar deviation. This is associated with wrist, shoulder, and
neck pain [ 71 , 107 ]. Previously, operating tables were designed solely for open
procedures and did not lower sufficiently for laparoscopic surgery [ 107 ]. To allow
for elbow flexion to be in the proper range during MIS, the operating table must
be lowered. A study performed in 2006 showed that 70% of minimally invasive
surgeons desired that the table be equipped to lower more than what was currently
possible [ 14 ]. In response, modern operating tables have been redesigned to allow
for table heights between 23 and 43 inches. Ideal height from the ground to the
operating surface, described as the level of trocar skin insertion, is 70%–80% of
elbow height and seen in Fig. 22.5 [ 107 ]. This may be approximated by position-
ing the operating surface at the height of the surgeon’s pubic bone (Fig. 22.5) [ 5 ,
107 , 130 ] and is roughly 25–30 inches from the floor depending on the surgeon’s
height [ 131 ].
Hand-Assisted Laparoscopic Surgery
Hand-assisted laparoscopic surgery (HALS) involves simultaneous aspects of open
and laparoscopic surgery; however, the ideal table height is more consistent with
that of open surgery. During simulations, Manasnayakorn et al. found that the opti-
mum table height for HALS is the height at which the laparoscopic instrument
handle is 2 inches above the elbow level. Although this height is not ideal for lapa-
roscopic surgery, during HALS, this height results in fewer errors, faster task time,
and decreased muscle workload on electromyography [ 132 ].
Appropriate Foot Pedal Placement
Foot pedals are used by 87% of laparoscopic surgeons [ 14 ]. Over half of surgeons
who use foot pedals find them uncomfortable and annoying [ 14 , 133 ]. Van veelen
et al. found that one third of surgeons allow the surgical nurse to position the foot
pedal. Often, the foot pedal is under the operating table or sterile sheet and unable
to be directly visualized [ 133 ]. This results in 75% occasionally hitting the wrong
switch and 91% occasionally losing contact with the foot pedal. In addition, 100%
believe the foot pedal limits their freedom of movement resulting in a static posture
[ 133 ]. Often, the surgeon maintains dorsiflexion of the foot over the pedal to avoid
losing contact. This results in distribution of the body weight to the standing leg
and the heel of the working foot for prolonged periods of time. These ergonomic
concerns with the foot pedal are exaggerated when the surgeon must use a step
stool as the small space further limits the ability to shift body weight, leading to a
static position [ 77 ]. Ergonomic principles to improve ease of use and discomfort
with the foot pedal include placing the pedal directly in front of the main foot and
in line with the target instruments, ideally before the operation begins, thus limit-
ing prolonged dorsiflexion of the foot and dorsiflexion past 25° [ 133 ].
C. Ronstrom et al.