403Ergonomic Challenges and Benefits of Visualization Adjuncts
Various forms of retraction are used during surgery to assist with exposure and
visualization. Handheld retractors, especially during long open cases, are associated
with musculoskeletal discomfort of the hands, arms, shoulders, neck, and back [ 78 ]
as well as the development of peripheral neuropathies [ 134 , 135 ]. Self-retaining
retractors are available for a wide variety of open and laparoscopic cases and allevi-
ate the need for handheld retraction [ 136 ]. Given that the flexor muscles of the hand
fatigue after only 60 s of maximal isometric contraction [ 137 ], self-retaining retrac-
tors are also more stable than handheld retractors [ 138 ]. Whenever possible, opt for
self-retaining retractors over handheld.
Loupes and microscopes are used to magnify fine detail and support proper
upright neck posture with the downward inclination of the lenses. However, there is
significant concern that loupes and microscopes are associated with career-limiting
neck pain [ 55 ]. Sivak-Callcott and colleagues showed that over half of the oculo-
plastic surgeons surveyed agreed that loupes can lead to spinal disorders and are
concerned about long-term effects that result from prolonged use of loupes [ 29 ].
This risk partially results from the weight of the loupes. The higher the magnifica-
tion of the loupes, the heavier they are. For this reason, surgical residents may find
that 2.5× magnification is adequate as well as more comfortable than higher magni-
fications [ 139 ]. The loupe frames must also be lightweight and properly fitted so
that the frame does not slip down the nose or apply too much postauricular pressure.
In addition, for proper neck posture, the angle of declination of the loupes should be
approximately 30° from the horizontal plane at the level of your eyes to lessen eye
and neck strain. Loupes must also be properly adjusted to the correct depth of con-
vergence so that the working distance, or distance from the lenses to the surgical
field, supports an ideal posture [ 139 ].
In regard to microscopes, 83% of otolaryngologists report experiencing symp-
toms during microsurgery with the most common locations being the neck, upper
back, and shoulders [ 38 ]. A common etiology of pain is the static posture of the
neck and upper body while operating under a microscope. Arm supports can
decrease upper back and shoulder tension [ 84 , 113 ]. In addition, using a microscope
with an articulated eyepiece allows for improved neck posture and the ability to
more easily change position while operating to reduce neck strain [ 38 ]. Ocular
extenders can be added to the assistant’s side to prevent neck overextension during
non-midline procedures.
Adequate light is necessary in the operating room for proper visualization of the
surgical field. Headlamps improve visualization by providing coaxial illumination
in line with the eyes which limits shadows. Unfortunately, they also add weight to
the head and increase the risk of neck and upper back pain [ 29 ]. In addition, fiber-
optic headlights limit freedom of movement since they are plugged into a light box.
It is important to ensure that, when using loupes and headlamps simultaneously,
both are properly adjusted to the same line of sight, and neither are used longer than
necessary [ 139 ].
Adequate visualization sometimes requires intraoperative imaging using fluo-
roscopy. In order to limit radiation exposure, protective aprons are worn.
22 Surgical Ergonomics