Ergo. in The Operating Room PDF

ERGONOMICS IN THE OPERATING ROOM
TRANSITION FROM OPEN TO IMAGE-BASED SURGERY

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Published by Arma an Albayrak
ISBN/EAN: 978-90-5155-050-4
© 2008 Arma an Albayrak

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author.
ERGONOMICS IN THE OPERATING ROOM
TRANSITION FROM OPEN TO IMAGE-BASED SURGERY
Proefschrift
ter verkrijging van de graad van doctor

aan de Technische Universiteit Delft,
op gezag van de Rector Magnificus prof.dr.ir. J.T. Fokkema,
voorzitter van het College van Promoties,
in het openbaar te verdedigen op dinsdag 16 december 2008 om 15.00 uur
door
Arma an ALBAYRAK
ingenieur Industrieel Ontwerpen

geboren te Ankara, Turkije
Dit proefschrift is goedgekeurd door de promotoren:
Prof.dr. H. de Ridder
Prof.dr. H.J. Bonjer
Copromotor:
Dr.ir. R.H.M. Goossens
Samenstelling promotiecommissie
Rector Magnificus, voorzitter
Prof.dr. H. de Ridder, Technische Universiteit Delft, promotor
Prof.dr. H.J. Bonjer, Dalhousie University, Canada, promotor
Dr.ir. R.H.M. Goossens, Technische Universiteit Delft, copromotor
Prof.dr.ir. C.J. Snijders, Technische Universiteit Delft, Erasmus Medisch Centrum
Prof.dr. J. Lange, Erasmus Medisch Centrum
Prof. A. Melzer, University of Dundee, Scotland, UK
Dr. med. U. Matern, University of Tubingen, Germany
Prof.ir. D.J. van Eijk, Technische Universiteit Delft, reservelid
Dr. G. Kazemier heeft als begeleider in belangrijke mate aan de totstandkoming

van het proefschrift bijgedragen.
Our true mentor in life is science
Mustafa Kemal Atatürk

TABLE OF CONTENTS
CHAPTER 1 INTRODUCTION 9
1.1 LAPAROSCOPY 9
1.2 SURGICAL TEAM AND WORKING ENVIRONMENT 11
1.3 ERGONOMICS 12
1.4 AIM 13
1.5 DESIGN FRAMEWORK 13
1.6 OUTLINE OF THE THESIS 14
1.7 READING GUIDE 15
CHAPTER 2 AN OVERVIEW OF ERGONOMIC PROBLEMS DURING SURGERY 17
2.1 PHYSICAL ERGONOMICS 18

2.2 SENSORIAL ERGONOMICS 24
2.3 COGNITIVE ERGONOMICS 25
CHAPTER 3 ERGONOMICS IN THE OPERATING ROOMS OF DUTCH HOSPITALS 31
3.1 INTRODUCTION 32
3.2 MATERIALS AND METHODS 33
3.3 RESULTS 34
3.4 DISCUSSION 35
CHAPTER 4 DISCOMFORT DURING SURGERY: PRODUCT SOLUTION AND

EVALUATION 39
4.1 STUDY I: A NEWLY DESIGNED ERGONOMIC BODY SUPPORT FOR SURGEONS 41

4.2 STUDY II: IMPACT OF A CHEST SUPPORT ON LOWER BACK MUSCLES ACTIVITY DURING FORWARD
BENDING 55
CHAPTER 5 IMAGE QUALITY DURING LAPAROSCOPIC SURGERY 75
5.1 INTRODUCTION 76
5.2 MATERIALS AND METHODS 79
5.3 RESULTS 86
5.4 DISCUSSION 90
CHAPTER 6 PRACTICAL ERGONOMIC SOLUTIONS FOR THE SURGICAL TEAM 95
6.1 PHYSICAL ERGONOMICS 96

6.2 SENSORIAL ERGONOMICS 103
6.3 COGNITIVE ERGONOMICS 104
CHAPTER 7 DESIGN FRAMEWORK FOR DESIGNERS: CASE STUDIES 111
7.1 INTRODUCTION 112

7.2 CASE I: SENSORIAL ERGONOMICS ABDOMINAL WALL TENSION MEASUREMENT DEVICE 115
7.3 CASE II: COGNITIVE ERGONOMICS - IMPROVING ERGONOMICS OF MINIMALLY INVASIVE
SURGERY - GETTING THE MOST OUT OF AN INTEGRATED SUITE 122
7.4 CASE III: PHYSICAL ERGONOMICS - DESIGN OF A HANDLE FOR CURVED INSTRUMENTS 130
7.5 CONCLUSION 136
CHAPTER 8 DISCUSSION 141
8.1 DESIGN FRAMEWORK 142

8.2 SURGICAL QUALITY 145
8.3 FUTURE RESEARCH 147
SUMMARY 149
SAMENVATTING 153
REFERENCES 157
ACKNOWLEDGEMENT 163
CURRICULUM VITEA 167
OVERVIEW PAPERS 169
GLOSSARY 171
CHAPTER 1 INTRODUCTION
1.1 LAPAROSCOPY
Minimally invasive surgery is practiced by a growing number of medical disciplines

including general, orthopaedic, paediatric, thoracic and vascular surgery as well as
in gynaecology and urology. Since the inception of minimally invasive surgery in
general surgery, laparoscopic procedures have become a popular technique.
Laparoscopy refers to minimal invasive videoscopic procedures in the abdominal

cavity. The first video-laparoscopic cholecystectomy (gallbladder removal) was
performed in 1985 by the surgeon Erich Mühe in Germany (Jani et al., 2006).
Already in 1999 in the United States, 47% of in total 2.,82,308 general surgical
procedures were performed with laparoscopy (Jaspers, 2006). Over the past two
decades, laparoscopic cholecystectomy has become the gold standard for surgical
management of gallstone disease (Lichten et al., 2001). The growing interest for
this method of gallbladder removal is driven by the advantages for the patient such
as less pain after surgery, shorter recovery time, better cosmetic results and fewer
infections complications (van Veelen, 2003).
Considering that laparoscopic cholecystectomy has become the gold standard, the
basic steps of this procedure should be discussed to understand the many
advantages for the patient. A standard laparoscopic procedure starts with a small
incision in the abdominal wall, usually the umbilicus. Through a special hollow
needle, the abdomen of the patient is inflated with gas (carbon dioxide, CO2), to
create workspace for the surgeon. Through other small incisions, so-called trocars
are placed which serve as ports to introduce laparoscopic instruments into the
abdominal cavity (figure 1.1).
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ERGONOMICS IN THE OPERATING ROOM: TRANSITION FROM OPEN TO IMAGE-BASED SURGERY
Figure 1.1 During laparoscopic procedures several trocars are used which serve as entrance ports for
the laparoscopic instruments and endoscope into the abdominal cavity.
These instruments give the surgical team the ability to manipulate the organs. To
observe the abdominal cavity, an endoscope equipped with a small video camera is
inserted. The camera is attached to the camera controller (processor unit). During
laparoscopy, the surgeon uses 5 or 10 mm instruments to perform the procedure
successfully. Generally, the required equipment is placed on a laparoscopy trolley,
which holds a monitor, a camera controller, an insufflator that is used for inflation
of the abdomen and a light source to illuminate the dark abdominal cavity through
a light guide cable connected to the endoscope (figure 1.2).
Figure 1.2 Laparoscopy trolley with the required equipment to perform a laparoscopic procedure.
Laparoscopy, like open surgery, requires general or regional anaesthesia and is

therefore performed in the operating room (OR). The OR is a complex environment
equipped with all the required equipment and instruments to perform all types of
surgical procedures. The OR have a high-quality ventilation system to control and
guarantee the quality of the airflow lowering infection risk. To provide a safe and
clean environment, the ORs are divided in areas. In the next paragraph, these
different areas and the positioning of the surgical team will be introduced.
10
CHAPTER 1: INTRODUCTION
1.2 SURGICAL TEAM AND WORKING ENVIRONMENT
The operating room is the working environment of the surgical team during surgical
procedures and can be divided into three work areas (figure 1.3). The sterile area is
around the operating table and in most of the ORs positioned in the centre of the
operating room underneath the clean airflow (laminar flow). The surgeon, the
resident, and the scrub nurse are working in this sterile area on either side of the
operating table. This environment is sterile from waist to breast height of the
surgical team. The resident assists the surgeon during the procedure and the scrub
nurse is responsible for passing the required instruments to the surgeon or to the
resident. The anaesthesiology area is at the head of the patient. The
anaesthesiologist is positioned in this area and is non-sterile. The anaesthesiologist
is responsible for monitoring the patient and administering of drugs, fluid and
blood.
The rest of the non-sterile work area in the operating room forms the third area;
this area is the work environment of the circulating nurse. The task of the
circulating nurse is to supply equipment and instruments from outside the sterile
area to the surgical team and operate the equipment in non-sterile area.
Dependent on the procedure, the radiology staff, other disciplines, or guests might
also be present in this work area.
Figure 1.3 The three work areas in the operating room.
Although the principles are the same for open and laparoscopic procedures,
laparoscopy has altered the way surgeons interact with the surgical field in many
ways. Despite the changes in surgical practice due to the introduction of
laparoscopic surgery, few changes have taken place in the operating room layout,
the position, and posture of the members of the surgical team over the last 100
years. Contradictory, the operating rooms are becoming more and more technology
driven. The increasing dependency on technology to perform surgical procedures
has significant ergonomic implications for the surgical team. This introduces a
multi-disciplinary approach to deal with, focusing on one side on the technology-
11
driven trends and on the other side on the social-economic consequences in

surgery. Regardless the kind of discipline, in surgery the human plays a central
role. Surgery is practiced by humans to cure, care, and prevent the other humans
from illness. Because care, cure, and prevention are human-centred, ergonomics
plays an important role in the field of surgery.
1.3 ERGONOMICS
Ergonomics discovers and applies information about human behaviour, abilities,

limitations, and other characteristics to the design of tools, machines, systems,
tasks, jobs, and environments for productive, safe, comfortable, and effective
human use (Sanders & McCormick, 1993).
Since ergonomics has become relevant for product development and product
evaluation, the working principle is; adapt the environment to the workers, instead
of adapting the workers to their environment (Goossens & Van Veelen, 2001). On
this perspective, it is not surprising that knowledge in the field of ergonomics has
significant contributions to offer improvement of surgical quality and optimisation of
working conditions and performance of the surgical team. From ergonomic point of
view the surgical quality can be defined as; the level of efficiency, safety and
comfort of a surgical procedures (van Veelen, 2003). Efficiency is defined as the
coefficient between effort and benefit. In this definition, effort also implies e.g.
product life span and learning and understanding the use of the product (e.g. it can
take several months to learn how to perform a task without errors). Safety deals
with the wellbeing of the user (in the case of minimally invasive surgery also the
wellbeing of the patient) and the prevention of injury. Comfort can be defined as a
physical and mental state in which one is not aware of any discomfort. The surgical
quality and the working condition can be influenced by a variety of organizational
and economical aspect but also by human-error due to poor ergonomic conditions
such as excessive workload, fatigue, poor human-product interaction, poor
communication among staff, etc. (Gawande et al., 2003).
The field of ergonomics can be divided along the human functions: physical,
sensorial, and cognitive ergonomics. All three types of ergonomics are relevant
when discovering ways to improve surgical quality.
1.3.1 Physical ergonomics

Emphasis lies on the function of the human musculoskeletal system, which is used
to adopt postures, move limbs, and conduct external forces through the body. On
the product site, this covers products that support the body, tools and special
outfits (Goossens & Van Veelen, 2001).
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1.3.2 Sensorial ergonomics

In this area, the focus is on the human senses and human perception. On the
product site this includes products that support the senses and perception, such as
visual displays, but also tactile displays and auditory displays (Goossens & Van
Veelen, 2001).
1.3.3 Cognitive ergonomics
Here the emphasis lies on remembering and processing information; on learning,

decision making and judging a situation. It is based on knowledge of the
psychology of thinking and remembering. The products that support this part of
ergonomics can be schemes of structures, mnemonic devices, software to control a
process and training devices (Goossens & Van Veelen, 2001).
1.4 AIM
The aim of this thesis is to improve surgical quality through ergonomics in the
operating room. The aim can be divided into the following categories:
Gain insight into the ergonomic problems in the operating room.
Gain insight into the current state of ergonomics in the operating room.
Gain insight into the body posture and physical discomfort that surgeons may
experience during surgical procedures.
Gain insight into problems intrinsic to laparoscopic viewing regarding sensorial
and cognitive ergonomics.
Development ergonomic solutions regarding the three domains of ergonomics.
1.5 DESIGN FRAMEWORK
During this PhD-research the basic design cycle of Roozenburg and Eekels is used
as a design framework (Roozenburg & Eekels, 1995). The most fundamental model
of designing (basic design cycle) is supplemented with the Participatory Design (PD)
approach.
The medical specialists are professional users with their specific needs, work
conditions, working environment, (technical) jargon, work culture, etc. When
designing products for professional users their involvement in the design process is
crucial since designers can use their knowledge and experience to improve the
quality of the design proposal.
A methodology, which can be used from this perspective, is Participatory Design

(PD) that actively involves the user into the design process, leading to the designed
product that meets the users specific needs. PD is an approach that is
13
characterized by concern with a more human, creative, and effective relationship

between those involved in technologys design and its use (Namioka & Rao, 1996).
PD has been started in Norway in the late 60s and early 70s with the development
of the first object-oriented programming language SIMULA. Since its inception,
more and more product designers are using this approach during their product
development.
Participatory design assumes that:

Users are experts; PD acknowledges the importance of using the expertise of
users and treating them as equal partners on a development team.
Tools should be designed for the context in which they will be used;
participatory design realizes that an important step to designing new tools is to
know where they will be used and in what context, which makes it difficult to
design a tool away from the environment in which it will be used.
There should be methods for observing or interviewing end-users; to gain
an understanding of the environment in which the product will be placed and used,
there are several techniques used to watch, observe and interview users in their
workplace.
Recreating or play-acting a work situation will facilitate the design phase;
it mediates the expectations of the users by not providing a non-functional
prototype at the very beginning of the design phase.
Iterative development is essential; the ideal participatory design project has
several iterations of a design-feedback loop, where the developers ask the user for
their opinion (Namioka & Rao, 1996).
During this PhD project, the emphasise was on the user and their knowledge, the
environment wherein this knowledge was created and collecting of data from this
environment. Therefore, this PhD-research mainly consists of field studies and has
therefore a high ecological validity. Some of these field studies are supplemented
with experimental studies. During these field studies, it was difficult to control all
the preconditions of testing. As a consequence of this, the results are exploratory
and, where possible, it will be reflected on theoretical insights.
1.6 OUTLINE OF THE THESIS
This thesis is based on published or submitted articles. Some of the studies have
the same starting point but a different focus. Each of the articles was introduced
and discussed from the perspective of that particular focus. Inevitably, this has
caused some overlap in the information provided in the different chapters. We have
therefore included a reading guide for different reader groups (figure 1.5).
14
The outline of this thesis is visualized in figure 1.4. Chapter 2 gives an overview of
the ergonomic problems in surgery. In Chapter 3 the surgeons working area is
highlighted regarding the current state of ergonomics in the operating rooms.
Chapter 4 deals with the discomfort of surgeons during surgical procedures and
evaluation of the developed product solution. In Chapter 5 the focus is on the
quality of laparoscopic viewing wherein the quality measurements, the factors
describing image quality, and surgeons perception of the image will discussed.
Hereafter in Chapter 6, an overview of some practical ergonomic solutions will
described. In Chapter 7 three cases will presented within the design framework as
described in paragraph 1.5. Finally, in Chapter 8, the results of this thesis will
discussed and recommendations for future research will described. The definitions
of the terminology used in this thesis are described in the Glossary.
Figure 1.4 The outline of the thesis.
1.7 READING GUIDE
Cooperation between two different disciplines Industrial Design and Surgery is

the basis of this thesis and, therefore, two target groups were involved; medical
specialist and designers. Hence, in some of the chapters, the focus is on the
medical specialists and in others on the designers. The different studies discussed
in the chapters of this thesis might also be interesting for policymakers. In figure
1.5 a reading guide for different reader groups is shown.
Figure 1.5 Reading guide for different target readers.
15
This chapter is mainly based on the following book chapter and article:
Albayrak A and Snijders CJ. (2007). Basics of Surgery: Tools, techniques, attitude and expertise. Maarssen,
Elsevier Gezondheidszorg. 151-169.
Bonjer HJ, Albayrak A, Stassen LPS, Casseres YA, Meijer DW. Improving the endoscopic image: tips and tricks.
Submitted (2008).
16
CHAPTER 2 AN OVERVIEW OF
ERGONOMIC PROBLEMS DURING SURGERY
In the last 100 years little changes have take place in the operating room layout
while the operating rooms are become more technology driven (Albayrak et al.,
2004; Gallagher & Smith, 2003). The increasing dependency on technology to
perform surgical procedures introduced ergonomic problems for the surgical team.
In this chapter, an overview will be given of the ergonomic problems in surgery.
These problems will be discussed along the three domains of ergonomics; physical,
sensorial and cognitive. The physical ergonomics will be restricted to the strain of
the musculoskeletal system, which is relevant for neck, shoulder, arm, hand
problems, lower back, pelvis, and foot. As most of the sensorial and cognitive
problems are seen during laparoscopy this two sections will be focused on the
laparoscopic procedures.
17
2.1 PHYSICAL ERGONOMICS
2.1.1 Posture
2.1.1.1 Open surgery
Open surgery employs large incisions, which allow direct access to tissues and
organs. Through the incision, the surgeon can see, feel, and manipulate the organs
in a natural way, which means that direct sensory perceptions and feedback are
present. During open surgery, surgeons lean forward toward or across the surgical
field to see and manipulate the organs. Consequently, during open surgery the
posture of the surgeon is characterized by a head-bent and back-bent posture
(figure 2.1). The surgeons freedom of movement during open surgery is less
restricted allow for a more dynamic body posture than during minimally invasive
surgery.
Figure 2.1 The surgeons head-bent and back-bent body posture is characteristic of open surgery.
Performing open surgical procedures has almost always required standing,

uncomfortable body posture and the occasional need to exert substantial forces on
tissues (Berguer, 1999). The body posture of the surgeons during open surgery was
described as a head-bent and back-bent posture. Surgeons maintain this posture
for long periods of time with the result that they experience physical discomfort
during and after surgery. After open surgery, 36.5% of the surgeons report pain in
the lower back, 20.6% stiffness of the shoulder and 17.5% pain in the neck (Mirbod
et al., 1995). The lower back pain is caused by extending the upper body centre of
mass forwards (figure 2.2). This leaning forwards results in increased muscle
activity to balance the upper body. Finally, leading to neck and back pain, especially
in the lower back. Previous studies showed that surgeons and scrub nurses
experience substantial stress of the musculoskeletal system due to their frequent
and prolonged static flexion of the neck and lower back (Kant et al., 1992). An
OWAS-based (Ovako Working posture Analysis System) analysis of nurses working
postures, shows that in both orthopaedic and urology wards, the working posture of
the nurses was harmful to the musculoskeletal system (Engels et al., 1994).
18
CHAPTER 2: AN OVERVIEW OF ERGONOMIC PROBLEMS DURING SURGERY
Figure 2.2 Displacement of the upper body centre of mass forward is accompanied with increased
muscle activity in the lower back to balance the upper body.
2.1.1.2 Laparoscopy
During laparoscopic procedures, long instruments are used which give the surgeon
the ability to manipulate the tissue, as they were replacing the hands of the
surgeon with limited tactile feedback. In addition, the perception of the tissue is not
direct on the tissue anymore but using a monitor. Consequently, during these kinds
of procedures the posture of the surgeon is characterized by straight trunk, rotation
and flexion of the neck. The upper limbs of the surgeon are usually in excursion for
handling the long instruments (figure 2.3). During laparoscopic procedures, the
body movement of the surgeon is very limited resulting in a more static upright
body posture compared to open surgery.
Figure 2.3 During laparoscopy the straight trunk of the surgeon is often accompanied by rotation and
flexion of the neck. The upper limbs are usually in excursion for handling long instruments.
Although, during laparoscopy the posture of the surgeon is straight predominantly,

due to wrong positioning of the monitors the neck is rotated. Furthermore, the
operating table is originally designed for open surgery and is not optimal for
minimally invasive procedures regarding the height adjustability. The limited
adjustability of the operating tables causes excursion of the upper limbs for
handling long instruments. Previous studies reported that approximately 10% of
19
surgeons suffer from pain in the upper limbs and neck during and after minimally
invasive surgery (Berguer et al., 1997). The characteristic working situation during
laparoscopic procedures involves elongated instruments and limited mobility of the
surgeon during the procedure (Schurr et al., 1999). Laparoscopy requires greater
concentration and places greater mental stress on surgeons comparing to open
surgery (Berguer et al., 2001).
The surgical team consists of people of different body stature. The operating table
is adjusted in height according to the height of the surgeon. Frequently, however,
this working height is not optimal for the remaining members of the team and leads
to ergonomically poor conditions.
Laparoscopy is implemented in the operating rooms with limited adjustments. The

current operating tables are originally designed for open surgery and they are not
optimal for laparoscopic procedures regarding ergonomic guidelines (Berguer et al.,
2002; van Veelen et al., 2002b). The current operating tables are adjustable in
height between 725-1215 mm (Albayrak et al., 2004). A previous study showed
that the discomfort and difficulty ratings were lowest when instruments handles
were positioned at elbow height of the surgeon (Berguer et al., 2002). Regarding
this guideline, the ergonomically operating surface height (defined as the navel
height of the patient, lying on the operating table while the abdomen is filled with
O2) lies between 0.7 and 0.8 of the elbow height (290-690 mm) of the surgeon
(van Veelen et al., 2002b).
It should be clear that the current operating tables cannot be lowered enough to
meet these ergonomic guidelines. This causes excursion/extension of the upper
limbs for handling long instruments. Previous studies reported that approximately
10% of surgeons suffer from pain in the upper limbs and neck during and after
laparoscopic procedures (Berguer et al., 1997). The characteristic work situation
during laparoscopy involves elongated instruments and limited mobility of the
surgeon during the procedure (Schurr et al., 1999). Even if, the posture of the
surgeon is more upright during laparoscopy, however, it seems to be accompanied
by substantially less body movement and weight shifting than during open surgery
(Berguer, 1999). This situation could account for increased static postural fatigue.
The configuration of the operating room regarding the ergonomics is restricted

during laparoscopy. The percentage of total floor space occupied by personnel,
furniture and equipment during laparoscopy is increased by 10% compared with
open surgery (Alarcon & Berguer, 1996). Increasing OR crowding may present
unnecessary hazards to traffic and adversely affect the performance of the surgical
team.
20
The surgical team also has to deal with problems related to non-optimal working
height. The surgical team often consists of people with different body heights.
Frequently, the height of the operating table is adjusted according to the height of
the surgeon. However, this working height is not always optimal for the other
members of the team and can lead to poor ergonomics conditions. The working
surface height in relation to subject, performing manual work determines the upper
extremity effort and the potential of musculoskeletal injury.
Even in the most modern and well-equipped operating rooms, surgeons often face
ergonomic shortcomings. As a result, the surgeon is frequently forced to adopt
uncomfortable body postures that contribute significantly to fatigue and discomfort,
which may lead to musculoskeletal disorders.
2.1.2 Neck
A working environment regarding ergonomics dictates unobstructed line of vision in
neutral standing posture. However, in open surgery, the current position of the
resident and scrub nurse mandates back and neck torsion and flexion to allow clear
vision on the operating field (Gerbrands et al., 2004). To overcome this, most scrub
nurses and residents rotate their body towards the operating field and use a
footstool, particularly during deep intra-abdominal or intrathoracic procedures. The
current height variation of the available footstools is not sufficient for the different
body lengths in the surgical team.
Because of the position of the patient, surgeons tend to lean forward toward or
across the surgical field to see and manipulate the tissue. This body posture
resulting in physical complaints due to neck flexion (figure 2.4).
Figure 2.4 Obstructed line of vision of the resident or scrub nurse due to position of the surgeon.
21
2.1.2.2 Laparoscopy
Limited number and wrong positioning of the monitors in the operating room
results in physical complaints in the neck (flexion, extension, and rotation).
2.1.3 Shoulder/Arm

Due to the position and depth of the incision during open surgery, surgeons have
fixed work posture, tending to work with arms abducted and unsupported. A high
static load is imposed on the shoulder-neck region and shoulder joint by this
posture.
2.1.3.2 Laparoscopy
During laparoscopy, long instruments are used. Due to the fixed insertion point
(position of the trocar) of these instruments, the surgical team has manipulating
problems. Besides the manipulating problems, these instruments also cause
discomfort in the shoulder if the operating table is not adjusted optimally. Since the
operating tables are originally designed for open surgery they cannot adjust low
enough which cause excursion of the upper extremities. Besides wearing heavy
lead apron also caused physical discomfort in the shoulder-neck region (van Veelen
et al., 2003b).
2.1.4 Hand
The instruments that are used in open surgery are distinguished from instruments
for laparoscopy with simplicity of their design and favourable mechanical
characteristics. They allow the surgeons with short, solid, and direct contact with
tissues and good tactile feedback.
There are three basic grip principles to handle instruments:
Force grip; grip with fingers and thumb around an object.

Force-precision grip; force grip that allows more precision: fingers and thumb are
in-line with the forearm.
Precision grip; grip that uses the thumb and distal joints of the fingers to grasp
an object.
A common grasping and manipulating problem is that instruments are being used
differently than the way they are originally designed for. For instance, using a
precision grip on a handle of an instrument that was designed for force grip. This
unintended use of the instruments could result in physical discomfort like pressure
on the fingers, elbow- and wrist pain.
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2.1.4.2 Laparoscopy
The complexity and inefficient mechanical properties of instruments for laparoscopy
cause grasping and manipulating problems. The internal mechanical design of
instruments results in substantially diminished tactile feedback and an unfavourable
force transmission ratio from handle to tip (Berguer, 1999). In comparing with
instruments for open surgery, 4 to 6 times more force is required to complete the
same task with instruments for laparoscopy (Berguer, 1999). The most frequently
used instruments for laparoscopy can be divided in 3 groups: dissector, grasper,
and scissors. There is a variety of handle design inside this group like axial, angled
shank, multifunctional pistol and ring handle. A previous study shows the results of
an experimental comparison of various ergonomic handles and their design (Matern
et al., 1999). The objective results of this study show that pressure areas caused
by rings and pain caused by ulnar deviation occurred frequently when working with
the ring handle.
2.1.5 Lower back

Bending forward of the body during open surgery to see, feel and manipulate the
tissue better, results in increased muscle activity, especially in the lower back to
balance the upper body. Maintaining this body posture for long periods of time has
consequences for static strain and fatigue in the back muscles. The static strain
results in muscle contraction.
The generalized excitation-contraction sequence of a nerve impulse travelling from

the brain and causing a muscle contraction is as follows.
ATP (adenosine triphosphate) ADP (adenosine diphosphate) + CP (creatine

phosphate) + energy
ATP is created by the metabolism of the basic foods we eat. This metabolism can
occur in two different modes: aerobic, requiring oxygen, and anaerobic, not using
oxygen. Aerobic metabolism uses a slow biomechanical pathway. On the other
hand, anaerobic metabolism utilizes a fast glycolytic enzyme to break down the
glucose molecule into two lactate molecules and produce two ATPs. The lactate
molecule in the extracellular fluid of the body forms lactic acid, which is a direct
correlate of fatigue. Thus, the trade-off aerobic metabolism is slow but very
efficient, while anaerobic metabolism is very fast but inefficient and gives rise to
fatigue.
During muscle contraction, less blood reaches the working muscle with a
corresponding decrease in oxygen availability. This means that the muscle must
23
rely on a smaller amount of aerobic metabolism and a greater amount of anaerobic

metabolism with concurrent fatigue (Freivalds, 2004).
2.1.5.2 Laparoscopy
During laparoscopy, the body movement of the surgeon is very limited as compared
with open surgery and they have a more static upright posture. The static strain
results in muscle contraction. Maintaining this position for long periods of time
leads to fatigue in the muscles.
2.1.6 Pelvis
2.1.6.1 Open surgery, laparoscopy
During open surgery as well as laparoscopy, the surgical team tends to lean toward
the rails of the operating table since this is the only supporting surface around the
table. The solid and metal edge of this rail results in bruising in the soft tissue
around the pelvis region.
2.1.7 Foot
During open surgery, the diathermy equipment is handled by a knob, which is
integrated in the instrument. Due to manual control of this equipment, a pedal is
unnecessary.
2.1.7.2 Laparoscopy
During laparoscopy, a pedal is used to handle the diathermy and ultra-scission
equipment. The current pedals cause positioning problems due to loosing contact
which contributes to a poor body posture of the surgeon. In addition, there is a risk
of accidentally activating the wrong function (left or right) because of lack of vision.
To hold the foot above the right side of the pedal the surgeon has to keep his/her
foot generally in dorsal flexion. Due to the dorsal flexion of the foot, surgeons
weight is not equally divided over both legs and finally results in an ergonomic poor
and static body posture.
2.2 SENSORIAL ERGONOMICS
The current ergonomic layout of operating rooms with crowding of free-standing

equipment such as the laparoscopy tower, often precludes optimal placement of the
monitor in front of the surgeon (Alarcon & Berguer, 1996). Accordingly, the visual
axis between the surgeons eyes and the monitor is no longer aligned with the
hands and instruments, Furthermore, the monitor is often far removed from the
surgeon and thus the spatial location of the display system (sensory information) is
24
remote from the manipulation area at the hand level of the surgeon (Hanna et al.,
1998).
With the current monitors as the standard image display system for laparoscopic
surgery, monocular depth cues within the image are further degraded by anti-
cues arising from the monitor. These are caused by the monitor frame and the
glare and reflection from the glass of the monitor. All these factors add to the
degradation in task performance compared to open surgery with normal monocular
vision.
Since the image display system during laparoscopic procedures replaces the eye
of the surgeon, some factors influencing the image quality have to be mentioned.
The three major components describing image quality are resolution, luminance
and chroma (Hanna & Cuschieri, 2001). Image resolution determines the visibility
of details in the image and refers to the sharpness and contrast of the picture;
luminance refers to the amount of light available in the image (brightness), and
chroma denotes the colour intensity or saturation. Several optical factors may
degrade image quality (Eden et al., 1993). Resolution and contrast influence the
ability to appreciate fine details of the image.
The resolution and contrast can also be reduced by glare. Glare can be caused
either by internal reflections (on-axis glare) or by stray light entering the system
from outside the field of view (off-axis glare)(Berber et al., 2002).
2.3 COGNITIVE ERGONOMICS
(The theory explained in this section is adopted from Cuschieri, 2006a)

Humans perceive the three-dimensional world by a pair of two-dimensional retinas
that react to visible light. The resulting image recognized by the subject in the
cognitive process is known as a percept, which determines the interpretation of the
visual information (Cuschieri, 2006a). Visual psychologists distinguish two kinds of
perceptions: direct (perception of objects in 3D space) and indirect (perception of
pictures/images of objects rather than the objects themselves) (Cuschieri, 2006a).
During open surgical procedures, the surgeon can view the operating field directly.
The theory of James Gibson can elucidate the cognitive stage of direct visual
perception (Cuschieri, 2006a). This theory postulates a data-driven bottom-up
process and implies direct perception (i.e. the visual data have sufficient
information and are structured within the optical pathway before reaching conscious
perception) (Cuschieri, 2006a). Conversely, during laparoscopic procedures
surgeons must operate guided by images rather than reality (indirect perception).
25
According to Gibson, pictures and images of objects have been shown to induce
more perceptual errors than direct perception of objects because they are the result
of viewing with inadequate information (Cuschieri, 2006a). This consideration is of
paramount importance during laparoscopy since the surgical team is almost
completely dependent on the indirect perception. The monitor is hereby the only
interface between the surgical team and the surgical field and thus the main source
yielding/displaying information about the progress of the procedure. A high quality
of the image is therefore requisite to allow safe and efficient laparoscopic
procedures.
2.3.1 Image quality

The image during laparoscopy, displayed on the monitor is a product of the so-
called imaging chain consisting of light source, light guide cable, endoscope,
camera, camera unit and monitor (Schwaitzberg, 2001). This results in several
places where the image can be distorted. To be able to structure the complex
relation between the quality of the displayed image, surgeons perception of this
image, and the several components of the imaging chain as described above, the
framework of the Engeldrums Image Quality Circle (Engeldrum, 2000) could serve
as a framework. In figure 2.5 the topics, which are in the scope of this thesis, are
shown in perspective of Engeldrums Image Quality Circle. The circle on the outside
represents the original framework of Engeldrum (Engeldrum, 2000). The circle on
the inside shows the topics, which are relevant for this thesis. The technology
variables are not included in the research.
Figure 2.5 The circle on the outside represent the original framework of Engeldrums Image Quality
Circle (Engeldrum, 2000) and the circle on the inside represents the topics, which are in the scope of
this thesis. The technology variables are not included in the research.
26
The Image Quality Circle is a framework, which organizes the multiplicity of ideas
that constitute image quality. The Image Quality process begins with determining
Customer Quality Preference and in perspective of laparoscopic procedures
represents the surgeons opinion of image quality. This judgment is connected to
the third element Physical Image Parameters. These are objective measures of
image quality such as the resolution of the endoscope and monitor and
measurements of light transmission of the endoscope and light guide cables. The
last part completing the circle is the Customer Perceptions The Nesses. These
are perceptual attributes mostly visual that form the basis of the judgment of the
surgeon. (Since most visual perceptual attributes like, sharpness, brightness, etc.
end with suffix ness, this term is used as a shorthand notation to emphasise the
connection to human perception).
Laparoscopic surgery is introduced without much consideration for ergonomic

limitations. The technology that surgeons use to perform laparoscopy caused a
human-product miss-match. This has largely to do with shortcomings of the
equipment and instrumentation that surgeons have to use or interact, unforeseen
ergonomic issues (Gallagher & Smith, 2003).
2.3.2 Cognitive problems during laparoscopic procedures
There are several factors intrinsic to laparoscopic viewing that degrade the surgical
quality and enhance the probability of error during surgical procedures. Many of the
related problems are due to the perceptual and spatial factors. One of the major
perceptual problems is that the image on the flat monitor screen contains only
monocular (pictorial) depth cues of the surgical field to the surgeon (Hanna &
Cuschieri, 2001). This representation of the three-dimensional surgical field on a
two-dimensional screen may reduce depth perception since retinal disparity, and
therefore the resultant stereoscopic vision (i.e. integrated information from two
viewpoints) providing the surgeon a strong sense of depth is missing (Shah et al.,
2003).
A further perceptual problem in laparoscopy arises from scaling difficulties caused

by the magnification and the severely degraded visual image of the anatomy in
comparison to the experience of an open procedure (Gallagher & Smith, 2003).
The various spatial difficulties encountered during laparoscopy result in problems

with cognitive mapping and hand-eye coordination. The monitor presents vastly
different images of anatomy due to the perspective and magnification of objects
closest to the endoscope. Spatial discrepancies are also caused by a
misinterpretation of angular relationships (the azimuth angle), because the entry
27
points of instruments do not correspond with the optical axis of the endoscope
camera (Gallagher & Smith, 2003).
Another problem with a spatial aspect involves camera etiquette. The surgeon has
no direct control over the position or orientation of the endoscope. Instead, the
surgeon must rely on the assistant to maintain an optimal position; however,
frequently unintentional camera rotation occurs that can lead to disorientation and
misinterpretation of position of the organs.
One of the problems limiting the surgeons acquisition of skill and degrading the
surgical quality is due to the fulcrum effect. The fulcrum effect of the body wall
causes an inversion of the perceived movements. An internal movement to the
right is displayed as a movement to the left on the monitor. For an inexperienced
surgeon this results in a significantly poorer performance (Gallagher & Smith,
2003).
Some of the problems are caused due to the limitations of the components of the
imaging chain. Both light guide cables and endoscopes contain glass fibres to
transmit light. These glass fibres have a high transmission coefficient. However,
reduction of loss in light in light transmission occurs in the delivery system due to;
Differences of diameters on the connection of the light guide cable with the light
source.
Differences of diameter between the light guide cable and the endoscope.
Surface losses and bulb absorption.
Because of these losses, the transmission coefficient of this part of the imaging
channel is reduced to 20 percent in the best system. As a result of all the losses, a
typical system will deliver considerably less then 1 W of visible light from a 250 W
source lamp (Frank et al., 1997).
Additionally, loss in illumination is caused by ageing of the light source and

mechanical damage due to repetitive use and sterilization of light guide cables and
endoscopes resulting in breakage of fibres. Melted or broken fibres reduce the
illuminance of the abdominal cavity. Optimal illumination of the dark abdominal
cavity is indispensable for carrying out any minimally invasive procedure.
In an endoscope, the lenses are positioned in the centre surrounded by optical

fibres that transmit light from the light source to the surgical field (Boppart et al.,
1999). This configuration imposes certain problems. In the first place, the level of
illumination across the surgical field is uneven, that is, the periphery of the
endoscopic field is less well illuminated (Hanna & Cuschieri, 2001).
28
The coaxial alignment of optical fibres and the optical lens system also results in a
shadow less surgical field as both light directions and optical axis subtend the same
angle to the target organ. Because shadows constitute very important pictorial
depth cues, their absence detracts further from the visual information presented to
the surgeon (Hanna & Cuschieri, 2001). In the second place, the viewing angle of
the endoscope refers to the angle formed by the two outer visual limits and
determines the diameter of the field of view and the magnification. Restricted field
of endoscopic vision predispose to iatrogenic tissue injury when instruments move
outside the field of view and account for the high percentage of bile duct and bowel
injuries that are missed during laparoscopic surgery and declare themselves by
virtue of major complications in the postoperative period (Fletcher et al., 1999;
Russel et al., 1996).
The term distortion is applied to the image where lines at the edge of the image
appear curved. Outward curved lines are termed barrel distortion, often
encountered, in endoscopes. The distortion effect increases with wider field of view.
Field curvature indicates that the centre and the edge of the image are not in focus
at the same time. This is difficult to perceive during viewing by eye due to the
constant refocusing of the human ocular lens.
The ergonomic problems discussed in this chapter show how divers the problems
are that the surgical team has to deal with in their profession in daily life. The
overview also shows the opportunities to improve the surgical quality and optimize
the work conditions of the surgical team. In the next chapters, these problems will
be analyzed from a certain perspective and the solutions will be discussed.
29
This chapter is based on the following article:
Albayrak A, Kazemier G, Meijer DW, Bonjer HJ. (2004). Current state of ergonomics of operating rooms of Dutch
hospitals in the endoscopic era. Minimal Invasive Therapy & Allied Technologies. 13(3); 156-160.
30
CHAPTER 3 ERGONOMICS IN THE
OPERATING ROOMS OF DUTCH HOSPITALS
Most of the laparoscopic procedures are performed in operating rooms, which

originally have been designed for open surgery. The ergonomic layout of these
operating rooms is often not suited for laparoscopic surgery. This study reports the
current state of ergonomics of Dutch operating rooms for laparoscopic surgery. For
this purpose, twenty-nine hospitals were visited and an inventory was made of the
number of laparoscopy trolleys, presence of ceiling-mounted booms, and number,
positioning and dimension of the monitors. Additionally, the number of operating
rooms was recorded and the floor surface area of these operating rooms was
measured. Positioning of the surgical team and monitors around the operating table
were assessed and the range of height adjustment of the operating tables was
documented. Results showed that the floor space of current operating rooms is too
small to allow use of space occupying technological systems for laparoscopic
surgery. Most of the monitors were positioned on a laparoscopy trolley with a fixed
height and the operating tables cannot be lowered to a position, which allows an
ergonomic posture of the surgical team. Implications of these findings toward
positioning and posture of the surgical team are discussed.
31
3.1 Introduction
The majority of current operating rooms (ORs) have been designed in the second
half of the 20th century to allow performance of open surgery. Novel operating
techniques, such as laparoscopic and robotic surgery, differ from open surgery in
many ways. To perform these types of surgery successfully, trolleys for
laparoscopic surgery, monitors, and robotic systems are required. Laparoscopic
equipment such as camera, light source, and insufflator are usually placed on one
or more laparoscopy trolleys. This trolley-based model restricts the ergonomic
configuration of the operating room. Alarcon et al. showed that the percentage of
total floor space occupied by personnel, furniture, and equipment during
laparoscopic procedures increased by 10% over open procedures (Alarcon &
Berguer, 1996). Increasing OR crowding may present unnecessary hazards to
traffic and adversely affect the performance of the surgical team (Alarcon &
Berguer, 1996). Most references of OR design state that the minimum dimensions
for a modern OR should be 37 m2 while specialized rooms require up to 55 m2 of
floor space (Quebbeman, 1993).
A possibility for optimizing the workspace in the OR is placing laparoscopic

equipment on a ceiling-mounted boom. This increases the working space around
the operating table and will facilitate positioning of heavy trolleys, improving the
ergonomic configuration of the OR.
During laparoscopic surgery, longer instruments are used compared to open

surgery. Studies have shown that long laparoscopic instruments potentially cause
excessive flexion and ulnar deviation of the surgeons wrist and abduction of the
arms during manipulation, particularly if the operating table can not be lowered
sufficiently (Berguer, 1998; Matern & Waller, 1999). It has been reported that the
ergonomically optimal operating height is between 70 and 80 % of the height of the
elbow of the surgeon (van Veelen et al., 2002b).
Menozzi et al. advised to position the monitors in front of the viewer with a
downward gaze of approximately 100 to 250 below eye level (Menozzi et al., 1994).
To allow these conditions, monitors should be mobile and in height adjustable.
This study reports the current state of ergonomics of Dutch operating rooms for
laparoscopic surgery.
32
CHAPTER 3: ERGONOMICS IN THE OPERATING ROOMS OF DUTCH HOSPITALS
3.2 Materials and Methods
Twenty-nine Dutch hospitals have been visited. Two of the 29 visited hospitals were
academic hospitals, 12 were teaching hospitals and 15 were community hospitals.
The operating room departments of each hospital were visited and the following
items were recorded:
Number of operating rooms per hospital type.
Number of available laparoscopy trolleys.
Mid monitor height (figure 3.1).
Monitor type and dimension.
Monitor placement (either on trolley or on ceiling-mounted boom).
Operating room floor surface area in m2.
Range of height adjustment of operating tables.
Positioning of the surgical team.
Figure 3.1 Mid monitor height.
The positioning of surgical teams was registered during 48 laparoscopic

cholecystectomies and hernia repairs. To determine the optimum number and
positioning of the monitor relative to the users eyes, each positioning was
analysed.
33
3.3 Results
3.3.1 Hospitals and operating rooms

The average number of operating rooms per hospital type is presented in table 3.1.
Table 3.1 Average number of operating rooms per hospital type.
Hospital type Average number of operating rooms
University hospital 19.5
Teaching hospital 7.6
Community hospital 5.3
3.3.2 Trolleys
In the 29 hospitals visited, 69 laparoscopy trolleys were present with a median of
two and an average of 2.4 trolleys per hospital. The average number of trolleys at
university hospitals was 2, at teaching hospitals 3.25 and at community hospitals
1.7.
3.3.3 Monitors
In total 65 monitors were available at the visited hospitals. The average mid
monitor height was 163 cm (range 145-180 cm). All monitors were Cathode Ray
Tube monitors (classic monitors) except for one monitor being a 13 inch Liquid
Crystal Display. All monitors were placed on trolleys except for two, which were
attached on a ceiling-mounted boom. One of the 29 hospitals had ceiling-mounted
booms for placement of two monitors. The dimension and the number of the
monitors are shown in table 3.2. Fifty-one monitors (81%) were fixed on the top of
the trolley. Twelve monitors (19%) were attached to the trolley by a swinging arm,
allowing it to move towards or swing over the operating field.
Table 3.2 Dimension, number and mobility of monitors per hospital type.
Number of fixed monitors Number of swinging monitors

per hospital type per hospital type
Monitor
dimension Academic Teaching Community Academic Teaching Community
(inch)
13 2 5 2
14 1 1
18 2 2 1
19 4 19 12 2 1
20 4 4
21 1
34
3.3.4 Operating rooms

The average operating room floor surface area was 37.45 m2 (range 22.03 to 44.14
m2). The average operating room floor surface area at academic hospitals was 32.1
m2, at teaching hospitals 36.56 m2 and at community hospitals 38.05 m2.
3.3.5 Operating tables

The average range of height adjustability of operating tables was from 725 mm to
1215 mm.
3.3.6 Positioning of surgical teams
Five different positions of surgical teams were registered (figure 3.2). Position 1
and 4 were encountered in 12% of procedures, position 3 and 5 in 21% of
procedures, and position 2 in 67% of procedures. There was no difference in
distribution of positioning of the surgical team over each type of hospitals.
Figure 3.2 Different positions of the surgical team during laparoscopic surgery.
3.4 Discussion
Laparoscopic surgery has changed the requirements of modern operating rooms

greatly. To allow laparoscopic surgery, multiple monitors and a videoscopic working
unit, which is usually assembled in a trolley, are necessary. In the early days of
laparoscopic cholecystectomy, a monitor mounted on top of the videoscopic trolley
was the only screen available to the surgical team. Positioning the screen in line of
the surgeons eye and the target organ interfered with the operating table and the
respirator, which is commonly standing at the right shoulder of the patient. A short
swinging arm carrying the monitor mounted on the trolley can improve the degree
of freedom to some extent. Attachment of the monitor on a ceiling-mounted boom
allows a placement of the monitor without interference with operating table or
respirator. The use of ceiling-mounted booms for supply of oxygen, anaesthetic
35
gases, and electric outlets has become commonplace. Use of ceiling-mounted boom
for monitors is, however, rare, given that only one of the visited had such a setup.
The disadvantage of attaching a heavy monitor on a ceiling-mounted boom is the
necessity to install heavy-duty booms. Moving the monitor and boom requires
substantial physical strength. The latest high quality versions of flat screens, which
are low in weight, are easy to position and take up less space.
In laparoscopic surgery, members of the surgical team stand on both sides of the
table in the great majority of procedures. Assessing the position of the surgical
team from an ergonomic point of view, position 1 and 4 require one monitor (12%
of procedures), position 3 requires two monitors (11% of procedures), and position
2 and 5 require three monitors (77% of procedures) to allow unobstructed line of
vision without neck torsion by each member of the surgical team (figure 3.3).
Figure 3.3 Ergonomically optimal positioning of the surgical team and number of monitors.
To allow the surgical team to watch the screen without cervical torsion, this study
shows that employment of two or more monitors is mandatory in those instances.
In this study, only seven of 29 (24%) hospitals used multiply monitors.
When the screen is attached on a ceiling-mounted boom that can be moved up and
down, the optimal viewing angle of 10-25 degrees downward gaze can be realized
(Menozzi et al., 1994). The optimal dimension of the monitor is determined by the
distance between the surgeons eye and the screen. In the majority of the hospitals
19-inch screen were used. Considering this screen size, the average distance
36
between the surgeons eyes and the screen should be between 70-95 cm (Menozzi
et al., 1994).
The total length of the arm of the surgeon holding a laparoscopic instrument is
approximately 30 cm greater than that of a surgeons arm holding an instrument
for open surgery. Studies show that long laparoscopic instruments potentially cause
excessive flexion and ulnar deviation of the surgeons wrist and abduction of the
arms during manipulation (Berguer, 1998; Matern & Waller, 1999). The optimal
height of the operating table in open surgery is three quarters of the height of the
surgeons elbow (van Veelen et al., 2002b). Given that the average height of the
elbow of the surgeon (± SD) is 110 cm (male and female) (www.dined.nl, 2004),
the table should be positioned at a height of 82.5 cm for open surgery. Adding the
length of laparoscopic instrument converts the optimal height of the operating table
for laparoscopic surgery to 52.5 cm. To prevent undue strain of the surgeons upper
limbs, operating tables should be lowered further than currently possible. Berguer
et al. showed, using electromyography, that a mismatch between table height and
body length of the surgeon increases muscular strain (Berguer et al., 2002).
The floor surface area of operating rooms in the first half of the 20th century
tended to be greater than in the second half. In the early nineteen hundreds day
light was a main source of lighting the surgical field. Therefore, large windows were
necessary to provide sufficient exposure to day light. Furthermore, surgical
instruments in large canisters were stored in the operating room instead of in a
separate room. Due to the development of high power operating lamps and
alternative design of the operating room complex, the floor surface area of
operating rooms was reduced.
The introduction of laparoscopic surgery, image-guided surgery and other new

technologies such as ultrasonic and radiofrequency surgery to ablate tissue has
again increased the demand for space. The modern operating room should have a
surface between 37 and 55 m2 (Quebbeman, 1993). In this study, the average floor
surface area of the operating rooms was 37 m2, which indicates that half the
operating rooms are not fit for these novel technologies.
In conclusion, current operating rooms in The Netherlands are insufficient from an

ergonomic point of view to perform laparoscopic surgery. Future designs of
operating rooms and laparoscopic equipment should consider basic ergonomic
principles to prevent work related injuries and to allow optimal performance of the
entire surgical team.
37
This chapter is based on the following articles:
Albayrak A, van Veelen MA, Prins JF, Snijders CJ, de Ridder H, Kazemier G. (2007). A newly designed ergonomic
body support for surgeons. Surgical Endoscopy 21(10): 1835-1840.
Albayrak A, de Ridder H, Bonjer HJ, Goossens RHM, Snijders CJ, Kazemier G. (2006). Reducing muscle activity of
the surgeon during surgical procedures. In Proceedings of the 16th World Congress on Ergonomics, Maastricht, The
Netherlands: International Ergonomics Association.
Albayrak A, Goossens RHM, Snijders CJ, de Ridder H, Kazemier G. Impact of a chest support on lower back
muscles activity during forward bending. Submitted (2008).
38
CHAPTER 4 DISCOMFORT DURING
SURGERY: PRODUCT SOLUTION AND
EVALUATION
One of the main physical ergonomic problems during surgical procedures is the
surgeons uncomfortable body posture. Surgeons maintain this position for long
periods often resulting in physical discomfort during and after surgery.
Furthermore, people of different body height are often present within the surgical
team. During both kinds of procedures, the operating table is adjusted in height
best suiting the surgeon. Frequently, however, this working height is non-optimal
for the other members of the team.
Study I is focusing on the design process of development of a product solution that

supports surgeons during both open and minimally invasive procedures, reduces
the surgeons muscle activity in the lower back and extremities, and solves
problems related to non-optimal working height.
The aim of Study II is to investigate the impact of the developed product solution
on lower back muscle activity during forward bending and to establish a possible
relation between the supporting force and the kind of balancing strategy a person
adopts.
39
40
CHAPTER 4: DISCOMFORT DURING SURGERY: PRODUCT SOLUTION AND EVALUATION, STUDY I
4.1 Study I: A newly designed ergonomic body support for

surgeons
4.1.1 Introduction
Increasingly, more general surgeons are performing minimally invasive procedures

in addition to open surgery. Although the basics of laparoscopic and open
procedures are similar, minimally invasive procedures have altered the way
surgeons interact with the surgical field, which requires a change in the surgeons
posture. A head- and back-bent posture and a twisted torso characterize the
posture of the surgeon during open surgical procedures. Conversely, during
laparoscopic procedures, the posture of the surgeon is characterized by a head- and
back-straight posture. The poor ergonomic posture of surgeons during both kinds of
procedures can result in physical discomfort.
Due to the position of the patient during open surgery, surgeons tend to lean
forward toward or even over the surgical field to see and manipulate the tissue.
This leaning forward results in increased muscle activity to balance the upper body.
Kant et al. reported that surgeons and scrub nurses exhibited frequent static body
postures that were distinctly harmful and contributed to physical fatigue during
surgery (Kant et al., 1992). Maintaining the uncomfortable position of the body for
longer periods results in musculoskeletal fatigue and physical complaints on the
part of surgeons. After open surgery, 30% of surgeons report pain and stiffness of
shoulders, neck, and lower back (Mirbod et al., 1995). These complaints are caused
by extending the centre of gravity of the upper body forwards (figure 4.1).
Figure 4.1 Displacement centre of gravity of the upper body as a result of bending forward.
During laparoscopy, the upper extremities usually are in uncomfortable excursion

for handling the long laparoscopic instruments (figure 4.2). The upright posture
during these procedures, however, seems to be accompanied by substantially less
body movement and weight shifting than during open surgery (Berguer et al.,
41
1997). Cuschieri has described a surgical fatigue syndrome that occurs after
minimally invasive surgery has been performed for 4 hours (Cuschieri, 1995).
Figure 4.2 Uncomfortable excursion of the upper extremities as a result of using long laparoscopic
instruments.
In addition to poor posture, which can cause musculoskeletal fatigue, the surgical
team also has to deal with problems related to non-optimal working height. The
surgical team often consists of people with different body heights. Frequently, the
height of the operating table is adjusted according to the height of the surgeon.
However, this working height is not always optimal for the remaining members of
the team and can lead to ergonomically poor conditions. The working surface height
relative to a subject performing manual work determines the upper extremity effort
and the potential for musculoskeletal injury. Furthermore, operating tables were
originally designed for open surgery, they are not optimal for minimally invasive
procedures. The operating tables are adjustable in height between 725 and 1215
mm (Albayrak et al., 2004).
A previous study showed that the discomfort and difficulty ratings were lowest
when instrument handles were positioned at the elbow height of the surgeon
(Berguer et al., 2002). Regarding the guideline of positioning the instruments at
elbow height, the ergonomic operating surface height (defined as the navel height
of the patient lying on the operating table while the abdomen is filled with carbon
dioxide [CO2]) lies between 0.7 and 0.8 of the operator/assistants elbow height
(6501000 mm) (van Veelen et al., 2002b). It is obvious that current operating
tables cannot adjust low enough to satisfy the ergonomic guidelines, thus changing
the relation between the height of the surgeons hands and the desirable height of
the operating table (van Veelen et al., 2002b).
42
Crowding in the operating room and positioning of the surgical team around the
operating table also contribute to the aforementioned problems. Alarcon and
Berguer concluded that there is a significant trend toward increasing operating
room crowding during laparoscopy (Alarcon & Berguer, 1996). The percentage of
operating room space occupied by furniture, equipment, and people increased from
36% for open surgery to 41% for laparoscopy. The median number of pieces of
equipment present in the operating room increased from 6 for open procedures to
13 for laparoscopic procedures, reflecting the increased dependency of laparoscopy
on technology (Alarcon & Berguer, 1996). Additionally, the freedom of positioning
the surgical team and equipment around the operating table is limited because the
base of the operating table is usually fixed to the floor.
This study aimed to develop an ergonomic body support that supports surgeons
during both open and minimally invasive procedures, reduces the surgeons muscle
activity in the lower back and extremities, and solves problems related to non-
optimal working height.
4.1.2 Materials and methods
During the design process, the participatory design approach was used. This
approach involves the user group throughout the whole design process to help
ensure that the product designed meets their needs (Muller & Kuhn, 1993). The
surgeons of the Erasmus Medical Centre in Rotterdam were closely associated with
this study. After a literature study, observations, interviews, and analysis of the
current situation, a couple of design criteria were formulated. Based on these
design criteria, a prototype was built.
The feasibility of this prototype was assessed during surgical procedures in the
operating room, and a questionnaire was used to record the value of the prototype
as perceived by the participating surgeons. Furthermore, electromyography (EMG)
recording was accomplished with one subject using the prototype.
4.1.2.1 Design criteria

The most important design criteria were as follows:
Support for the body of the surgeon in a natural working posture.
A product suitable for use during both open and minimally invasive procedures.
Compact construction of the product because of the limited space available
around the operating table.
Comfortable and safe use of the product by both the P5-woman (5th percentile of
short women) and the P95-man (95th percentile of tall men) (percentiles of the
Dutch population with regard to body length) (www.dined.nl, 2004).
43
A height-adjustable platform to solve the problems related to non-optimal

working height.
Sufficient space for positioning of foot pedals for electro surgery.
A product mobile by means of wheels.
4.1.2.2 Supporting principles & Biomechanics

Taking for granted that surgeons have a head- and back-bent posture during open
procedures, support for the surgeons upper body is obvious. To develop a well-
considered body support, defining the optimal supporting height of the upper body
is important.
Due to their body posture, surgeons experience physical discomfort in their lower
back during and after open surgery. Accordingly, in the biomechanical model the
forces are assessed in the lower back (Snijders et al., 2004). For the analysis of
load transfer at the lumbar level, a free body diagram was made. The mass centre
of gravity of the upper body is located just below the axillaes. Here the gravity
force (Fg) is drawn. The disc L5-S1 is located in the cross-section (D) and can be
considered as the hinge of a joint (figure 4.3). The horizontal distance between
gravity force and this joint is the lever arm (a) of upper body weight. The product
of Fg and a produces moment M = Fg x a which tends to rotate the upper body
clockwise. This must be counteracted by a moment with counter clockwise
direction. This is produced by the back muscle force (Fm) with lever arm b with
respect to the middle of the disc. Additionally, the supporting force Fsupport also
produces a moment M = Fsupport x c with counter clockwise direction (c is the
distance between the centre of the chest support and the centre of the disc (D)).
Equilibrium of moments results in;
Fg . a = (Fm . b) + (Fsupport . c) or
Fm = Fg . a/b Fsupport . c/b.
Figure 4.3 Free body diagram at the lumbar level.
44
According to biomechanics, a head support is the most effective in reducing the

muscle activity in lower back since distance c is maximum. However, this way of
supporting is not desirable because the surgeons freedom of movement will be
reduced dramatically. Additionally, this also will lead to an extra couple (torque) in
the neck. Nevertheless, the upper body still must be supported as high as possible.
Supporting the upper body at chest height is a viable option because the remaining
part of the upper body consists of soft tissue. Pressure due to the supporting force
on the soft tissue will not be experienced as comfortable. Because surgeons have
an upright body posture during laparoscopic procedures, it is obvious that they
should be supported in the semi-standing position. In addition, this way of
supporting allows the surgeon to operate in the ergonomic manipulative zone
(Gerbrands et al., 2004). The choice of the chest and semi-standing support is
described in more detail elsewhere (Albayrak et al., 2006b; Albayrak et al., 2006c).
Electromyography using the chest support
The effectiveness of the chest support is evaluated by means of electromyography

(EMG). The muscle activity of five subjects (P5, P50, P95-woman and P50, P95-man,
Dutch population) was measured while they simulating a surgical task according to
a protocol. The measurements were done in four conditions;
Relaxed standing.
Bending forward without support on angle 1 and 2.
Bending forward with support on height h1 and angle 1 and 2.
Bending forward with support on height h2 and angle 1 and 2.
Height h1 was defined as 0.8 x shoulder height, h2 as 0.9 x shoulder height, 1 as
15º and 2 as 20º.
A selected muscle group was examined in the laboratory by means of EMG

recording according to the protocol. To normalize the data for comparison, the
maximum voluntary isometric contraction (MVIC) also was measured, obtained with
manually applied resistance (Kumar & Mital, 1996). Before the electrodes were
attached, the skin was grated, and then cleaned with alcohol. A reference electrode
was placed around the left wrist. For the MVIC and EMG recordings, a portable
physiologic measurement system, type Porti 516/ASD of TMS International B.V.
(Enschede, The Netherlands) was used. The Ag/AgCl surface electrodes with
recessed pre-gelled (hydrogel) elements (GE Medical Systems Accessories Europe)
were used to collect the EMG and MVIC signals. The raw EMG signals (DC
frequency, ~2 KHz) were processed electronically with a sample rate of 1,000 Hz,
and the cut-off frequency was 10 ± 200 Hz. The following muscles were examined:
Erector spinae muscle (back muscle, right sides about 2 cm from the midline at
the level of L5-S1) (Snijders et al., 1998).
Semitendinosus muscle (hamstring).
Gastrocnemius muscle (calf muscle, caput mediale).
45
SPSS 11.0 for Windows was used for statistical analysis of the results. The
Repeated-Measures ANOVAs, 2 (angles 1 en 2) x 3 (with/without support on
height h1 and h2) was done per muscle group. All effects were reported as
significant at p 0.05.
4.1.2.3 Development of the ergonomic surgeons body support

Based on the formulated design criteria and biomechanical analysis, different
sketches were considered. The involved surgeons of the Erasmus Medical Centre
have chosen the represented idea. Development of this idea has led to different
concepts, the most likely of which is illustrated in concept phase 1. Elaborating the
principle in more detail has resulted in the concept demonstrated in phase 2. The
final design presents the completely worked out product. Figure 4.4 shows an
impression of the design process.
Figure 4.4 Design process for the ergonomic surgeons body support.
4.1.2.4 Prototype
Further development of the concept in detail has finally led to building a functional
prototype (figure 4.5). The body support consists of different parts. The surgeon
stands on a platform that can move up and down (as directed by a remote control).
There is a chest support, which the surgeon can activate during open procedures by
leaning against it. The chest support is adjustable in height and can be removed
easily, which allows the surgeon more space during laparoscopic procedures or
46
emergency situations requiring fast removal of the support. A semi-standing

support also is integrated into the body support for use during minimally invasive
procedures. For positioning and fixation of the foot pedal, metal strips are
integrated into the platform. Wheels beneath the base make the prototype fully
mobile. When the surgeon stands on the platform, his or her bodyweight causes the
wheels to collapse because they are fixed with a spring construction. This solution
simultaneously offers stability by standing on the platform and mobility by stepping
down.
Figure 4.5 Prototype of the ergonomic surgeons body support.
4.1.2.5 Questionnaire
The feasibility of the designed ergonomic body support was assessed during several
open and laparoscopic procedures in the operating room of the Erasmus Medical
Centre (figure 4.6). For an objective assessment of the prototype, the surgeons
involved in developing the body support were excluded from the feasibility study. A
questionnaire was used to record the value of the support as perceived by the
participating surgeon.
47
Figure 4.6 Feasibility of the prototype during minimally invasive procedures (right side) and open
procedures (left side).
4.1.2.6 Electromyography using the prototype

To evaluate the effectiveness of the prototype an electromyography study has been
done by measuring the muscle activity of one subject (P50-man) while he was
simulating a surgical task according to a protocol. The measurements for chest
support were performed in four conditions:
Relaxed standing.
Bending forward without support (angle 15ºand 20º).
Bending forward with support on chest height (angle 15º).
Bending forward with support on chest height (angle 20º).
The measurements for semi-standing support were performed in two conditions:

excursion of upper extremities with and without semi-standing support. The
bending angles and the upper body extremities were measured using a digital
protractor type 106 ES (Mahr, Göttingen, Germany). The same EMG equipment has
been used which is discussed previously in this study.
4.1.3 Results
4.1.3.1 Electromyography using the chest support
The results of the EMG-recording of the three measured muscles (erector spinae,
semitendinosus, and gastrocnemius muscles) are shown in figure 4.7 as
percentages of MVC-recording. The minimal muscle activity for all of the three
muscles is during relaxed standing. During bending forward without support, the
muscle activity increases proportionally with the bending angle. The usage of the
chest support reduces the muscle activity systematically especially in the leg
48
muscles. The muscle activity reduces proportionally with increasing height of the
support. It is remarkable that increasing of the bending angle barely affect this
trend.
There was a significant interaction between the angle and height at m. erector
spinae (back muscle) (F (1.8, 7.1) = 11.19; p = 0.007). At the leg muscles, there
was a significant main effect of height: m. semitendinosus (hamstring) (F (1.0, 4.1)
= 18.23; p = 0.012); m. gastrocnemius (calf muscle) (F (1.1, 4.3) = 39.30; p =
0.002).
Figure 4.7 Results EMG-recording
4.1.3.2 Questionnaire
The results of the questionnaire completed by seven independent participating
surgeons are presented in Table 4.1. The results are divided into four categories:
personal information about the subjects, type of surgery, and the positioning of the
surgical team during the procedure, total operating time, and time of prototype
usage as a percentage of the total operating time, and finally the judgment of the
participating surgeons. The comfort judgment is based on the extent of overall
discomfort reduction using the prototype and the user friendliness of different parts
49
of the prototype. For this reason, the comfort judgment is divided in four
subgroups:
Overall comfort.
Comfort during the use of chest support.
Comfort during the use of semi-standing support.
Comfort during the use of the foot pedal.
Table 4.1 Results of the questionnaire

Subject
Personal 1 2 3 4 5 6 7
Gender F F M M F M M
Height (m) 1.80 1.66 1.88 1.90 1.60 1.82 1.80
Weight (kg) 77 52 82 85 55 80 80
Surgeon/Resident R S S R S S R
Procedure
Kind of surgery O O O O O MIS MIS
Positioning surgical team 1 1 2 2 2 3 3
Time of usage of body support
Total OR time 270 180 380 380 120 70 80
% OR time 57% 44% 27%** 63%** 68% 22% 25%
Judgment
Comfort overall Yes Yes Yes Yes Yes No Yes
Comfort chest support Yes Yes Yes Yes Yes
Comfort semi-standing
Yes Yes Yes Yes Yes No Yes
support
Comfort to use foot pedal Yes Yes
Restriction of
U U U R R R R
movement***
Future use Yes Yes Yes Yes Yes Yes**** Yes
Safety Yes Yes Yes Yes Yes Yes Yes
Simplicity Yes Yes Yes Yes Yes Yes Yes
Positioning surgical team
1 2 3
O = Open surgery
MIS = Minimally invasive procedure
** These two surgeons have alternated during the procedure
*** U = unrestricted, R = restricted
**** After processing his suggestions in the product
50
4.1.3.3 Electromyography using the prototype

The results of the EMG recording for the three measured muscles (erector spinae,
semitendinosus, and gastrocnemius muscles) with and without use of the chest
support of the prototype are shown in figure 4.8 as percentages of MVIC.
Figure 4.8 Results of electromyography (EMG) recording for one subject (P50-man) with and without
the chest support.
The minimal muscle activity for all three muscles occurs during relaxed standing.
When the surgeon bends forward without support, the muscle activity increases
proportionally with the bending angle. Use of the chest support reduces the muscle
activity systematically (Table 4.2).
Table 4.2 Reduction of muscle activity during bending forward without chest support.
Reduction of muscle activity during bending forward without chest
support
Forward bending angle with
m. erector spinae m. semitendinosus m. gastrocnemius
chest support
15º 40 % 26 % 77 %
20º 48 % 14 % 70 %
The results of the EMG recording for the three measured muscles (erector spinae,
semitendinosus, and gastrocnemius muscles) with and without the semi-standing
support are shown in figure 4.9 as percentages of MVIC.
The semi standing support is effective in reducing muscle activity in the leg
muscles, especially the calf muscle (Table 4.3).
51
Figure 4.9 Results of electromyography (EMG) recording for one subject (P50) man) with and without
the semi-standing support.
Table 4.3 Reduction of muscle activity using the semi standing support.
Reduction muscle activity (%) with regard to without semi-standing support
m. erector spinae m. semitendinosus m. gastrocnemius
With semi-
5% 12 % 50 %
standing support
4.1.4 Discussion
In general, the risk factors for musculoskeletal injury include non-ergonomic body
postures, frequent awkward repetitive movements of the upper extremities, and
prolonged static head and back postures. In addition, surgeons experience
cardiovascular stress during procedures, and the magnitude of this stress can
exceed the level of aerobic physical work performed (Berguer, 1999). The fact that
surgeons are performing surgery so concentrated that they tend to neglect their
posture increases the need for body support.
Our design vision has resulted in the development of an ergonomic body support
for surgeons that is suitable for use during both open and minimally invasive
procedures. Only a few studies have dealt with support for the surgeons body. In a
previous study, the design of an ergonomic surgeons chair was discussed, but it did
not provide any information about the effect of body support on the reduction of
muscle activity (Schurr et al., 1999).
The results of our study imply that supporting the body by means of a chest
support is effective in reducing the activity of the lower back and leg muscles
during open surgery. The desired effect of the chest support is closely related to the
optimal height of the support (Albayrak et al., 2006b; Albayrak et al., 2006c).
According to the variation in body lengths, the chest support must be adjustable in
52
a range of 40 cm (0.8 x P5-woman shoulder height and 0.9 x P95- man shoulder
height) (Albayrak et al., 2006b; Albayrak et al., 2006c). The semi-standing support
shows a trend of reduced leg muscle activity similar to that for the chest support.
Conversely, the contribution of the semi-standing support to the reduction in
activity of the erector spinae muscle is very limited.
Laparoscopy has been adopted in operating rooms without any proper adjustments
of their design and layout. Because the current operating tables are originally
designed for open surgery, they are not optimal for minimally invasive procedures
with regard to ergonomic guidelines. The current operating tables are adjustable in
height to between 725 and 1,215 mm (Albayrak et al., 2004). A previous study
showed that the discomfort and difficulty ratings were lowest when instruments
handles were positioned at elbow height of the surgeon (Berguer et al., 2002). With
regard to the guideline of positioning the instruments at elbow height, the
ergonomic operating surface height (defined as the navel height of the patient lying
on the operating table while the abdomen is filled with carbon dioxide [CO2]) lies
between 0.7 and 0.8 of the operator/assistants elbow height (6501000) (van
Veelen et al., 2002b).
It is obvious that the current operating tables cannot be adjusted low enough to
satisfy ergonomic guidelines. According to Berguer et al., redesigning of surgical
tables or the operating room workspace is required to optimize the postural
ergonomics of laparoscopy (Berguer et al., 2002). However, this is an expensive
and time-consuming approach that may interfere with adoption of this solution by
the hospitals. A much cheaper and more effective solution for this problem is to
position the surgeon on a height-adjustable platform.
The platform of the body support is adjustable in height by means of a motor that
can be operated by a remote control. This remote control is packed in a sterile
cover, allowing the surgeon to adjust the height of the platform independently of
assisting personnel during the procedures. The platform is powered from the main
supply, and the height of the platform ranges from 60 mm (minimum) to 460 mm
(maximum), meaning that 95% of the user group will have a comfortable posture
(in combination with the current operating tables). The semi-standing support at
the buttocks has a maximum height of 900 mm when the platform is positioned in
the lowest position for a tall surgeon. The height of the semi-standing support is
proportional to the height of the platform. This allows optimal placement of this
support for the whole user group.
Due to the positioning of the equipment during both kinds of procedures, surgeons
have a limited space around the operating table for movement, which elicits a static
body posture. Taking into account the limited space available in the operating
53
room, the body support must be designed as compactly as possible. The design
criteria (body support as compact as possible, comfortable and safe use by 95% of
the user group, and sufficient space allowed for positioning of the foot pedal for
electro surgery) are contradictory conditions. The platform must be large enough
for comfortable and safe standing of a tall surgeon while allowing sufficient space
for positioning of the foot pedal. On the other hand, it must be as compact as
possible considering the limited space.
Nevertheless, a compromise was reached by designing the platform with a diameter

of 55 cm. The platform is large enough for a P95 man (tall surgeon) to stand
comfortably without falling and for positioning of the foot pedal, yet sufficiently
compact to be used in the limited space around the operating table.
Despite the compactness of the prototype, all seven participating surgeons

indicated that the body support is safe in use. A remarkable outcome of the
questionnaire is the dichotomy about the restriction of the movements. However,
this cannot be dissociated from the positioning of the surgical team during the
procedure. Based on this observation, it may be concluded that the surgeons with a
negative opinion were standing very crowded.
A point of interest for the designer when users are interacting with products is the
experienced level of comfort. Van Veelen et al., reports that surgeons frequently
complain about pressure areas as well as pain and fatigue in hand and lower limb
joints from manipulation of instruments for minimally invasive surgery (van Veelen
et al., 2003a). It should be mentioned that we were particularly interested in one of
the interactions between our product and surgeons: leaning against the chest
support. This may have consequences for breathing because of the pressure on the
chest. Nevertheless, none of the surgeons has experienced discomfort using the
chest support.
Conclusions
The optimum working condition for a surgeon is a compromise between the spine
and arm positions and the effort and fatigue of their respective supporting muscular
groups. The results of this study imply that supporting the body is an effective way
of reducing muscle activity, which over the long term may reduce physical
complaints and discomfort. Additionally, the product supports the surgeon in his or
her natural posture during both open and minimally invasive procedures while
solving working heightrelated problems of the surgical team. Because of the
simplicity in its design and compactness, the ergonomic body support can easily be
adopted in the current layout of the operating room.
54
CHAPTER 4: DISCOMFORT DURING SURGERY: PRODUCT SOLUTION AND EVALUATION, STUDY II
4.2 Study II: Impact of a chest support on lower back muscles

activity during forward bending
4.2.1 Introduction
Recently, Albayrak et al. proposed a new design for an ergonomic body support for
surgeons that can be used during open as well as minimally invasive procedures
(Albayrak et al., 2007). An important element in this design is a chest support
meant to reduce lower back pain by minimizing the lower back muscles activity.
During open surgical procedures this muscle activity is caused by surgeons taking a
head- and back-bent posture for long periods of time. Such posture leads to
enhanced muscle activity to keep the upper body in balance (Albayrak et al.,
2006b). This may be regarded as one of the main causes for physical complaints in
the lower back during and after open surgical procedures.
Theoretically, the reduction in the lower back muscles force causing the increased
muscle activity can be described by a biomechanical model (Albayrak et al., 2006b;
Albayrak et al., 2006c). Figure 4.10 shows the details of such a model for bending
forward while leaning against a chest support. The upper body weight (Fg), the
back muscle force (Fm) at the level of L5 (lumbar) and the supporting force
(Fsupport) are included in this biomechanical model. Note that the model is limited to
the sagittal plane and describes a static equilibrium. A cross-section of the trunk is
made at L5-S1 (disc). The mass centre of gravity of the upper body is located near
the axillae (Snijders et al., 2004).
D = L5 S1 (disc)
= forward bending angle
a = distance between the mass centre of
gravity of the upper body and the centre of the disc (D)
b = distance between the back muscles and the centre
of the disc (D)
c = distance between the centre of the chest support
and the centre of the disc (D)
Fg = upper body weight being equal to 65 % of the
total body weight (Snijders et al., 2004)
Fm = back muscle force
Fsupport = supporting force
Figure 4.10 Biomechanical model of bending forward while leaning on a chest support. The reaction
forces (Frg, Frm, and Frs) in the disc are not drawn in this model.
55
Considering the equilibrium of moment of forces in the sagittal plane at position D,

lower back muscle force Fm can be calculated as follows:
Without Support (Fsupport = 0) (Equation 1)

Fm = Fg . (a/b)
With Support (Fsupport 0) (Equation 2)
Fm = Fg . (a/b) Fsupport . (c/b)
According to Equation 2 a fore head support might be considered most effective in

reducing the muscle force in lower back since distance c is maximal (and thus
maximises the factor Fsupport . (c/b)). However, a head support is not desirable
since the freedom of movements of the surgeon will reduce dramatically.
Furthermore, it will introduce an extra load on the neck. Nevertheless, the upper
body should be supported as high as possible. Supporting the upper body at chest
height (sternum) is a viable option since the around located tissues mainly have a
soft structure. A pressure on the soft tissue due to the supporting force will not be
experienced as comfortable.
To investigate the viability of the chest support, a prototype was built and tested
with five participants (Albayrak et al., 2006b; Albayrak et al., 2006c). The
participants were three Dutch females (P5, P50, P95-woman) and two Dutch males
((P50, P95-man), percentiles Dutch population (www.dined.nl, 2004)). The
experimental conditions consisted of two bending angles and two different heights
of the support, both within the area of the chest. The posture of the participants
simulated typical head- and back-bent posture of surgeons during surgical
procedures. The muscle activity (electromyography, EMG-recording) in the lower
back (right side of m. erector spinae) and right leg (m. gastrocnemius and m.
semitendinosus) was measured both with and without using the chest support. The
results averaged across the participants showed that muscle activity increases
proportionally with the bending angle during bending forward without chest
support. The usage of the chest support reduced the muscle activity significantly
with a major impact on the leg muscles. This reduction was found to depend on the
height of the chest support but the resulting Fm appeared almost independent of
the bending angle. According to our biomechanical model the latter would imply
that Fsupport is growing proportionally with bending angle .
Following Kumar and Mital we assume a monotone increasing relation between

muscle force and muscle activity (Kumar & Mital, 1996). The experimental results
of the above study are qualitatively in agreement with our biomechanical model
predictions for the lower back muscles (Equation 1 and 2) since (1) muscle force
Fm, and thus muscle activity, increases with bending angle (or distance a) in the
56
condition without support and (2) muscle force Fm decreases when Fsupport is larger
than zero. This effect is strengthened by increasing height (c) of the chest support.
These conclusions hold for results averaged across subjects. However, the question
rose what happens at the individual level? The model in fact incorporates two
important anthropometric variables, namely body length in parameters a and c and
body weight in parameter Fg. Hence, at individual level an additional prediction can
be formulated, namely muscle activity increases with body length and weight.
To assess the value of the biomechanical model at individual level, a comparison

was made between calculated muscle force and measured muscle activity (EMG-
recording) in the lower back during bending forward without support. Using the first
equilibrium of moment of forces, the muscle force (Fm) of the five participants was
calculated for 1 = 15º, 2 = 20º. Distance b was assumed to be constant at 5 cm
(Snijders et al., 2004). In order to normalize the EMG-recordings, the maximum
voluntary isometric contraction (MVIC) was also measured using manually applied
resistance (Kumar & Mital, 1996). The resulting calculated muscle forces Fm in
Newton (N), EMG-recordings in microvolt (mV), MVIC-recordings (mV) and Fm
expressed in percentage MVIC (% MVIC) can be found in table 4.4. Figure 4.11
shows muscle activity as a function of calculated muscle force for two bending
angles.
Table 4.4 Calculated muscle force and EMG-recordings, both in absolute values and in %MVIC, for
five participants in the condition without support and for two bending angles (15º and 20º). Data have
been taken from Albayrak et al. (Albayrak et al., 2006b).
Muscle Force (N) EMG (mV) MVIC (mV) % MVIC
Participants Body weight 15º 20 º 15º 20º 15º 20º
1 P5 (F) 50 kg 370 494 54 57 60 90 95
2 P50 (F) 70 kg 580 767 33 34 60 55 56
3 P95 (F) 76 kg 674 892 17 20 75 22 26
4 P50 (M) 80 kg 670 885 36 39 86 41 45
5 P95 (M) 90 kg 865 1144 26 31 92 28 33
F = female, M = male
57
100
P5 (F)
90 P50 (F)
P95 (F)
80 P50 (M)
P95 (M)
70
60
50
40
30
20
10
0
250 450 650 850 1050
Calculated muscle force (N)
Figure 4.11 Measured EMG-recording, expressed in %MVIC, as a function of muscle force in the
lower back calculated according to the biomechanical model without support (Equation 1) for two
bending angles. The characteristics of the subjects are presented in Table 4.4.
The biomechanical model appears to predict the conditions within subjects correctly
but has some limitations in predicting the observed differences in muscle activity
between subjects. Surprisingly, the measured muscle activity (%MVIC) seems to
decrease with increasing body length and weight (and hence muscle force) for
females as well as males. Interestingly, similar deviations of biomechanical
modelling have been reported by others (Arjmand & Shirazi-Adl, 2005, 2006;
Granata & Marras, 1995). As a possible explanation, Granata and Marras suggested
that appropriate representation of muscle area is essential to the validity and
performance of biomechanical models, because muscle force per unit area is highly
variable between subjects, depending on participant condition and natural ability
(Granata & Marras, 1995). Arjmand and Shirazi-Adl noted that in biomechanical
models of trunk load the balance of net external moments is considered only at one
cross-section rather than along the entire length of the spine (Arjmand & Shirazi-
Adl, 2006). Moreover, the evaluated muscle forces, once applied on the system
along with external loads, may not necessarily generate the same spinal kinematics
under which they were initially calculated (Arjmand & Shirazi-Adl, 2006). Hence,
due to their static and two-dimensional approach, biomechanical models seem to
have some limitations in predicting conditions between subjects. Nevertheless,
biomechanical models are useful to predict conditions within subjects.
58
Introduction of a chest support into the biomechanical model makes a univocal

prediction of the related conditions even more difficult because Fsupport in Equation
2 is not known beforehand. It is an uncertain factor because it depends on how
much the participants trust the chest support and are prepared to lean on it. One
possible way to assess the value of Fsupport is by comparing muscle activity with and
without chest support. To this end, an assumption has to be made about the
quantitative relation between muscle activity and force. Considering the relationship
observed by Bendix et al. and Kumar and Mital a linear function between EMG-
recording (E) and calculated muscle force (Fm) seems to be a good first-order
approximation (Bendix et al., 1985; Kumar & Mital, 1996), or
E = m . Fm + n, (Equation 3)
where m and n are constants. Then, the following relation holds for the condition
without support
EWOS = m . Fg .(a/b) + n, (Equation 4)
and the following relation for the condition with support
EWS = m . Fg . (a/b) - Fsupport . (c/b) + n, (Equation 5)
with EWOS and EWS being actual EMG-recordings under similar conditions
(bending angle and height of the support). Then, Fsupport can be estimated by
subtracting eq. 4 from eq. 5 resulting in the following expression
Fsupport = (EWOS - EWS) . b/(m . c) (Equation 6)
To evaluate these equations, a similar experimental set-up was used as in Albayrak

et al. (2006a; 2007), except that the range of bending angles was extended to
larger degrees. The maximum angle was raised from 20º to 40º. Additionally, the
number of participants was increased such that the total range of body lengths was
extended substantially. Finally, the number of muscles on which EMG-recording was
performed was increased to five: two muscles in the lower back, one in the
abdomen and two in the right leg. This was done since there are indications that
humans tend to follow different balancing strategies during a standing posture
(Winter, 1995). This will be reflected in the pattern of EMG-recordings from these
five muscles. In this way, a possible relation between Fsupport and the kind of
balancing strategy a person is adopting in the current set-up might be established.
The aim of the present study is to investigate how individual subjects make use of a
chest support and to study the influence on lower back muscle activity during
forward bending.
59
4.2.2 Materials and methods

4.2.2.1 Participants
In total sixteen healthy volunteers were participating in this study. Nine of the
participants were female (age 26.3 ± 2.4 yr; average length 1.66m, range min-
max 1.52-1.77m; body mass 63.2 ± 12.4 kg) and 7 male (age 28.8 ± 5.3 yr;
average length 1.79m, range min-max 1.70-1.92; body mass 75.9 ± 12.1 kg). The
percentiles of the participants were for females; P96, P91, P85, P77, P67, P43, P26, P17,
P2 and for males; P98, P76, P47, P35, P24, P15, P7 (www.dined.nl, 2004).
4.2.2.2 Protocol
A prototype of a chest support was used during the experiment. The chest support
was adjustable in height and bending angle. The chest support was revolving on its
vertical axis (figure 4.12).
Revolving chest support

Height adjustment
Bending adjustment
Figure 4.12 Experimental set-up chest support.
The muscle activities of the participants were measured by means of EMG-recording

while they were bending forward with their hands in their waists. All participants
followed the same protocol (P) consisting of thirteen conditions. Each condition was
performed during 10 seconds, followed by 15 seconds rest. Each condition was
repeated three times and the average value was determined.
60
The conditions of the protocol were:
P1; relaxed standing

P2; bending forward without support at angle 1
P6; bending forward with support at angle 1 and height h1
Height h1 was defined as 0.8 x shoulder height and h2 as 0.9 x shoulder height.
Angles 1, 2, 3, 4 were 15º, 20º, 30º, 40º respectively.
4.2.2.3 EMG-recording
A selected muscle group was examined in the lab by means of EMG-recording. In
order to normalize the data for comparison, also the maximum voluntary isometric
contraction (MVIC) was measured (Kumar & Mital, 1996). MVICs were all obtained
with manually applied resistance. Prior to attaching the electrodes, the skin was
grated and then cleaned with alcohol. A reference electrode was placed on the left
wrist. For the MVIC- and EMG-recordings, a portable physiological measurement
system, type Porti 5-16/ASD of TMS International B.V. (Enschede, The Nederlands)
was used. The Ag/AgCl surface electrodes with recessed pre-gelled (hydrogel)
elements (GE Medical Systems Accessories Europe) were used to collect the MVIC
and EMG signals. The raw EMG signals (DC frequency, ~2 kHz) were processed
electronically with a sample rate of 1000 Hz, and the cut-off frequency was 10 ±
200 Hz.
The following muscles were examined:

m. erector spinae (lower back muscles, both sides at about 2 cm from the
midline at the level of L5-S1, (Snijders et al., 1998).
m. rectus abdominis (abdominal muscle, 2 cm lateral to midline at the level of
the umbilicus, (Snijders et al., 1998).
m. semitendinosus (hamstring in the right leg).
m. gastrocnemius (calf muscle, caput mediale in the right leg).
The software program SPSS 12.0.1 for Windows is used to analyse the results
statistically.
61
4.2.3 Results
4.2.3.1 EMG-recording; general
Figure 4.13 shows the results of the EMG-recording averaged across all participants
as a function of bending angle for each muscle separately.
Figure 4.13 Results of EMG-recording averaged across all participants. Note that scales for muscle
activity differ between muscles.
62
On average, the muscle activity during relaxed standing is 6 %MVIC. The

minimal muscle activity for all measured muscles except for m. gastrocnemius is
during relaxed standing. During bending forward without support, in general muscle
activity increases proportionally with the bending angle. The only exception is m.
rectus abdominis where the muscle activity stays at the relaxed standing level. The
usage of the chest support reduces muscle activity for all angles with again the
exception of m. rectus abdominis where the muscle activity tends to increase.
To analyse the general findings statistically, a three-way full factorial within

subjects repeated measures ANOVA was conducted with main effects: muscle (5) x
angle (4) x height (3; without support and with support at two heights). The
results of this analysis are shown in table 4.5. All the main effects and interaction
effects turn out to be significant.
Table 4.5 Results of full factorial ANOVA within subjects repeated measures.
Source df df error Mean square F Sig.
Muscle 4.00 60 3175.83 11.49 .000
Height 1.16 17.47 10796.24 44.70 .000
Angle 1.87 28.11 4390.17 79.82 .000
Muscle * Height 2.04 30.62 6011.18 26.12 .000
Muscle * Angle 3.94 59.23 767.07 11.84 .000
Height * Angle 2.95 44.25 204.66 6.98 .001
Muscle * Height * Angle 5.96 89.52 92.56 2.57 .024
Main effects
Regarding the main effect muscle, both sides of m. erector spinae show most
muscle activity (right side; 17.51 %MVIC and left side; 15.98 %MVIC). The least
muscle activity was measured at m. rectus abdominis (7.28 %MVIC). The muscle
activity of m. semitendinosus and m. gastrocnemius was 11.42 and 11.60 %MVIC,
respectively. The activity of the lower back muscles differs significantly from that of
the m. rectus abdominis. Regarding the main effect height, the muscle activity
during bending forward without support (17.86 %MVIC) is significantly higher than
with support (height h1 and h2: 10.57 and 9.85 %MVIC respectively). Although, the
muscle activity during bending forward with support on height h2 was
systematically lower than on height h1, this difference was non-significant.
Regarding the main effect angle, the muscle activity increases systematically with
the bending angle: 9.56, 10.76, 13.54 and 17.17 %MVIC at 150, 200, 300 and 400
respectively. The muscle activity at the four angles differs significantly from each
other.
63
Interaction effects
The interaction between muscle and height is mainly caused by the different ways
the muscles react on the usage of the support. The activity of m. erector spinae at
both sides reduces gradually to a value of 77% of the activity without support; this
value is measured for height h2. Much larger reductions have been found for the leg
muscles towards 37% for m. semitendinosus and 19% for m. gastrocnemius. The
activity of the m. rectus abdominis increased by 25%. The interaction between
muscle and angle can be attributed to the angle at which the different muscles
recruited: both sides of m. erector spinae at 150, the m. semitendinosus at 200
and the m. gastrocnemius at 300. The activity of m. rectus abdominis hardly
changes with the angle. Finally, the interaction between height and angle can be
attributed to increasing difference between muscle activity without support and with
support as a function of angle.
4.2.3.2 EMG-recording; per muscle

Table 4.6 shows the results of two-way full factorial within subjects repeated
measures ANOVA per muscle with main effects angle (4) and height (3).
Table 4.6 Results of full factorial ANOVA within subjects repeated measures per muscle.
Source df df error Mean square F Sig.
m. erector spinae (right side)
Height 1.43 21.49 437.19 13.34 .001
Main effect
Angle 1.63 24.48 2178.93 59.7 .000
Interaction Height * Angle 3.58 53.83 25.85 2.82 .038
m. erector spinae (left side)
Height 2 30 337.09 23.57 .000
Main effect
Angle 1.31 19.66 2343.65 49.45 .000
Interaction Height * Angle 6 90 18.65 5.34 .000
m. rectus abdominis
Height 2 30 40.79 7.65 .002
Main effect
Angle 1.57 23.57 19.21 6.01 .012
m. semitendinosus
Height 1.13 16.98 5500.89 28.54 .000
Main effect
Angle 1.66 25.02 2554.54 37.74 .000
m. gastrocnemius
Height 1.03 15.47 16711.36 38.58 .000
Main effect
Angle 1.63 24.56 205.37 2.82 .088
64
The measured muscle activity of m. erector spinae at both sides shows a similar
pattern (figure 4.13). The minimal muscle activity at both sides is during relaxed
standing ( 6 %MVIC). The significant interaction effect is caused by the finding
that at 150 the muscle activity without support equals almost the activity with
support at height h1 whereas at the other angles the main reduction in muscle
activity occurred between these two conditions.
The measured activity of m. rectus abdominis remains at the level of relaxed
standing for all angles when no support was used. Contrary to the other muscles,
the activity increases when the support is used. For all angles, the activity at height
h1 is larger than at height h2. There was no interaction effect.
The minimal activity of m. semitendinosus is during relaxed standing and at

conditions with support at 150 and 200. Without support, muscle activity increases
proportionally with the bending angle. With support the muscle activity is recruited
starting from 300. The significant interaction effect between height and angle can
be attributed to this difference in the angle at which the muscle is recruited in the
conditions with and without support. The activity of m. gastrocnemius increases
with the bending angle during bending forward without support. Surprisingly, the
muscle activity during all conditions is below the activity level at relaxed standing.
The interaction is caused by the fact that activity with support is not changing with
angle whereas activity without support increases as a function of the angle.
4.2.3.3 EMG-recording; individual level

A hierarchical cluster analysis was conducted on the EMG-recording of the five
muscles to identify users with similar patterns in muscle activity. This resulted in
three clusters. The average data of these clusters can be found in figure 4.14.
Cluster 1 represents the largest group consisting of thirteen participants. The three
remaining participants had a deviant pattern and were divided in Cluster 2 (two
participants) and Cluster 3 (one participant). In figure 4.14 the EMG-recordings of
the measured muscles are represented in two parts with the left part representing
the conditions during relaxed standing (RS) and without support and the right part
the conditions using the chest support (WS = with support). The measurements for
the two different heights belonging to the same bending angle were averaged.
65
Figure 4.14 EMG-recording of the measured muscles per protocol condition. Left-hand panel:
conditions during relaxed standing (RS). Right-hand panel: conditions using the chest support (WS =
with support). The measurements for the two different heights belonging to the same bending angle
were averaged.
66
The main difference between Cluster 1 and Cluster 2 in the condition without
support is the activity of the two leg muscles. In Cluster 1, the activities in these
muscles increase systematically with the bending angle. In Cluster 2, only the m.
gastrocnemius is increasingly active at 150 and 200 and decreases in activity at
300 and 400, while at the same time the activity of m. semitendinosus increases.
Most characteristic aspect of Cluster 3 is the high activity of the two leg muscles
with respect to the relatively low activity of the lower back muscles.
The main difference between Cluster 1 and Cluster 2 in the condition with support
is that the effect of the chest support on the lower back muscle activity is relatively
small in cluster 2. Furthermore, the sudden increase of m. semitendinosus for
Cluster 2 at 300 is remarkable. Finally Cluster 3, all the muscle activities seem
hardly to deviate from that at relaxed standing except for 400.
4.2.3.4 EMG-recording and the biomechanical model

Figure 4.15 shows, per cluster, the measured EMG-recording, expressed in %MVIC,
as a function of muscle force in the lower back (m. erector spinae (right side))
calculated according to the biomechanical model without support for four bending
angles.
35
30
25
20
15
10
Cluster1
5 Cluster2
Cluster3
0
0 500 1000 1500 2000 2500
Calculated muscle force (N)
Figure 4.15 Measured EMG-recording, expressed in % MVIC, as a function of muscle force in the
lower back calculated according to the biomechanical model without support (Equation 1) for four
bending angles. The data for Cluster 1 and 2 are the averages across participants. The equations for
the fitted regression lines are:
Cluster 1; EMG = 2.8 (SD ± 6.1) + 0.016 Fm (SD ± 0.009) (Adjusted R2 = .99)
Cluster 2; EMG = 13.98 (SD ± 7.53) + 0.017 Fm (SD ± 0.006) (Adjusted R2 = .99)
Cluster 3; EMG = 17.91 + 0.003 Fm (Adjusted R2 = .93).
67
In each cluster the averaged data appear to lie on a straight line as conformed by
the linear regressions. Furthermore, figure 6 shows that the data of the different
clusters do not overlap. Data of Cluster 1 and 2 show a parallel shift. The
characteristic for the participant of Cluster 3 is the little variation of muscle activity
with respect to the model prediction. The main suggestion from this figure is that
each overall pattern of muscle activity needed for balancing the body results in a
different relation between measured muscle activity and model prediction for lower
back muscle. The observed linearity on the average level also holds on the
individual level. After analysis of the individual data for Cluster 1, no systematic
effect of P-value (comprising body length) on the relation between muscle activity
and model prediction could be observed contrary to what was found in the previous
study (figure 4.11). Furthermore, the range of measured and predicted values
between individuals was rather small. No systematic differences between males and
females were found.
Estimated supporting force

In the introduction it was suggested that different balancing strategies will affect
the way the chest support is used. In other words, one may expect the three
clusters to generate different relations between Fsupport and bending angle. To
assess the degree of use of the chest support by the participants, an estimation of
the supporting force was made by subtracting the muscle activity without support
from the muscle activity with support. According to equation 6 this should results in
an estimate of the Fsupport besides a multiplication factor. This factor was
determined from the linear regression in figure 6 (parameter m) and the height of
the chest support (parameter c) while the value of parameter b was fixed at 5 cm.
Figure 4.16 denotes the resulting Fsupport as a function of the bending angle . In
addition, figure 4.16 shows the outcome of the linear regression per cluster.
68
120
100
80
Cluster 1 (height 1)
60 Cluster 2 (height 1)
40 Cluster 3 (height 2)
20
0
0 5 10 15 20 25 30 35 40 45
-20 Bending angle (degree)
Figure 4.16 Estimated supporting force per cluster and height at corresponding bending angles
(Equation 6). The equations for the fitted regression lines are:
Cluster 1; Fsupport = 2.92 + 0.28 (Adjusted R2 = .48)
Cluster 2; Fsupport = -15.79 + 0.44 (Adjusted R2 = .51)
Cluster 3; Fsupport = 96.91 - 0.06 (Adjusted R2 = .003)
Cluster 1 (representing the majority of the participants) and Cluster 2 show a

similar pattern in that the estimated supporting force increases linearly with
bending angle. The difference between these clusters is that for Cluster 1 Fsupport is
always positive while for Cluster 2 it is mostly negative becoming neutral at 400.
Apparently, the participants of Cluster 1 increasingly rely on the chest support. The
little variation of the estimated supporting force within Cluster 1 suggests a limited
use of the chest support. The negative value of Fsupport for Cluster 2 indicates that
these two participants hardly made use of the chest support. The main exception is
the participant of Cluster 3: first, the estimated Fsupport is independent of the
bending angle, and second the value of Fsupport is significantly higher than that of
the other participants. Apparently, this participant makes strong use of the chest
support.
69
4.2.4 Discussion
During surgical procedures due to work related circumstances such as positioning of
the patient on the operating table and/or equipment in the operating room,
surgeons have an ergonomically poor body posture; head-bent and back-bent
posture. Beside surgeons there are many other professions contending with similar
problems due to poor body posture. Dentists, fruit or flower pickers, and car
mechanics for example have a comparable head-bent and back-bent posture.
Rohlmann et al. indicate that the load of the trunk is significantly increased during
flexion of the upper body (Rohlmann et al., 2001). During flexion of the upper part
of the body while standing, the pressure in the disc increased almost nearly to
216% (the intradiscal pressure was 0.50 MPa on average for standing). This value
was set to 100% and the values for all activities are related to it for 36º between
the thoracolumbar junction and the sacrum (Rohlmann et al., 2001). Maintaining
the poor body posture for long periods of time results in musculoskeletal fatigue
and experience of physical complaints. The results of our study imply that
supporting the body by means of a chest support is effective in reducing muscle
activity in the lower back and especially in leg muscles during bending forward. The
significant interaction between height and angle in the measured muscles except
for m. rectus abdominis shows that both height and angle of the support affects the
muscle activity. Optimal adjustment of height and angle is therefore essential for
the desired effect of the chest support. Providing the chest support in professions
with similar body posture as mentioned above might reduce discomfort.
Considering the results per muscle, the activity of m. erector spinae (both sides)
during all conditions is highest compared with other measured muscles (figure
4.13). This indicates that participants mainly use their lower back muscles during
bending forward. It seems that up to 300 the activity of the lower back muscles is
sufficient to keep the upper body in balance. With increasing bending angle the m.
semitendinosus is recruited to support the lower back muscles. Using the chest
support the muscle activity of m. gastrocnemius is even lower than during relaxed
standing. Despite the different roles the four muscles are playing in balancing the
body, the chest support is effective to reduce the activity of these muscles. An
aberration appears at m. rectus abdominis. The usage of the chest support is
accompanied by increasing muscle activity of m. rectus abdominis. A possible
explanation is that m. rectus abdominis activity counteract hollowing of the lumbar
spine. According to Allison and Henry, the predominant muscle action of the three
most superficial abdominal muscles (the Obliques and Rectus) have been
associated with predominantly trunk flexion activities with or without combined
rotation (Allison & Henry, 2001). In this study, also the role of the co-activation of
the antagonists (three most superficial abdominal muscles) in the spinal stability is
indicated.
70
One parameter with the potential to influence spinal mechanics and stability is
intra-abdominal pressure (IAP). IAP has the potential to substantially unload the
spine in standing and flexion tasks, a role that depends directly on the IAP
magnitude and concurrent level of co-activity in abdominal muscles (Arjmand &
Shirazi-Adl, 2005). That is, IAP could indeed even increase the back-muscle forces
when large co-activity is generated in the superficial abdominal muscles (the
Obliques and Rectus) (Arjmand & Shirazi-Adl, 2005). It seems that m. rectus
abdominis is playing a role in the spinal stability. Correspondingly, Juker et al.,
advocated that muscles of the abdominal wall (rectus abdominis, external oblique,
internal oblique, transverse abdominis) and psoas play a fundamental role for the
normal functioning of the lumbar spine (Juker et al., 1998).
Although identifying individual differences was impossible, the cluster analysis

distinguishes (figure 4.14) three user groups regarding their balancing strategies.
The participants of Cluster 1 can be mentioned as sceptical users. During
bending forward without chest support the muscle activity, except the m. rectus
abdominis, increases proportionally with the bending angle. The slightly reduction
of the muscle activity in the right part of the figure confirms the actually usage of
the chest support. The pattern of behaviour of participants in Cluster 1 was
characterized by simultaneously recruiting all the measured muscles except for m.
rectus abdominis. However, the limited decrease in the back muscle activity
indicates that participants in this cluster are sceptical about the chest support
whereby they partially manage the balancing of the upper body by themselves. The
little variation of the estimated supporting force within Cluster 1 suggests a limited
use of the chest support. However, the reduced muscle activity in the leg muscles
indicates that the subjects of Cluster 1 are standing relaxed during the use of the
chest support.
The second cluster can be identified as non-trusters. During bending forward

without support, primarily the m. erector spinae (both sides) and the m.
gastrocnemius are active to keep the upper body in balance. It is obvious that the
participants in this cluster are changed their balance strategy after the bending
angle of 20º. Hereby a reduction of the m. gastrocnemius is accompanied by an
increased activity of the m. semitendinosus. Focusing on the part with support it
becomes clear that the usage of the chest support is not optimal. Reduction of the
muscle activity, especially in the m. erector spinae is minimal. Even after reaching
the bending angle of 20º, the activity of the m. semitendinosus increases
dramatically to keep the upper body in balance. The participants of Cluster 2
primarily used the m. erector spinae during bending forward. However, recruiting of
m. semitendinosus after reaching the bending angle of 20º indicates the necessity
of additional muscle activity at increasing bending angles to keep the upper body in
balance. The minimal reduction of the muscle activity indicates that participants of
71
this cluster entirely do not trust the chest support. The negative value of the
estimated supporting force indicates that these two participants of Cluster 2 hardly
made use of the chest support.
The participant in the last cluster can be classified as fully-truster. The

participant in this cluster is keeping the upper body in balance principally with the
m. semitendinosus and m. gastrocnemius during bending forward without support.
During bending forward with support the muscle activity in all the muscles is
decreased dramatically, which shows that the participant trust the chest support
totally by leaning against it. An aberration of m. semitendinosus occurs during
bending forward with support at 40º. However, recruiting of this muscle is not
significant for the behaviour of this participant since the muscle activity is still
below the activity without support. With regard to simultaneously recruiting of
muscles, Cluster 3 shows similarities with cluster 1. However, in Cluster 3 the
activity of m. erector spinae is clearly lower than the activity of leg muscles,
indicating the balancing role of the leg muscles during bending forward. Apparently,
this participant makes strong use of the chest support since the estimated
supporting force is significantly higher than that of the other participants.
Humans tend to follow different balancing strategies during a standing posture.

Winter describes three strategies (ankle, hip and combined) in relation to
displacement of the centre of mass (COM) in an inverted pendulum model of
balance in the anteroposterior (A/P) direction (Winter, 1995). The ankle strategy
applies in quiet stance and during small perturbations and predicts that the ankle
plantar flexors/dorsi flexors alone act to control the inverted pendulum. In more
perturbed situations or when the ankle muscles cannot act, a hip strategy would
respond to flex the hip, thus moving COM posteriorly, or to extend the hip to move
the COM anteriorly. Using a computer simulation the displacement of the COM at
each of these strategies was measured. A 10 Nm (Newton meter) ankle moment
was applied for 300 ms. The total body COM displacement (posterior) was
estimated to be 1.56 cm. The same 10 Nm was applied as hip flexors to stimulate a
hip strategy and the posterior displacement of the COM was 2.04 cm. However, a
combined ankle and hip strategy was quite possible and with a 10 Nm plantar flexor
moment plus a 10 Nm hip flexor moment the COM displaced 3.53 cm after 300 ms
(Winter, 1995). The pattern of muscle activity of the identified user groups in the
current study are in agreement with the findings of Winter (Winter, 1995). Since
the activity of the m. gastrocnemius is the highest compared with other muscles
during relaxed standing (figure 4.13), the ankle strategy applies in quiet stance.
The participants of Cluster 1 were defined as sceptical users. Regarding the
simultaneously recruiting of the lower back and leg muscles and limited use of the
chest support, it is clear that the participants of Cluster 1 use the combined
strategy for balance. Cluster 2 was characterized as non trusters. It seems that
72
the two participants of this cluster hardly made use of the chest support and
adopting the hip strategy since primarily the m. erector spinae is involved for
balancing. Conversely, the participant of Cluster 3, defined as fully-truster,
balances the body using the ankle strategy since mainly the leg muscles are
recruited.
Conclusions
Supporting the body by means of a chest support shows a systematic reduction of
muscle activity in the lower back and leg muscles. Identifying three user groups
with corresponding balance strategies indicate the variety within the pattern of
behaviour of individuals. Measuring the activity of multiply muscles by means of
EMG-recording is needed to identify the pattern of behaviour of users. Although the
experimental conditions were the same, humans tend to follow different balancing
strategies. An advice for product designers is therefore that it is valuable taking the
anthropometry and the conditions of the users into account to meet their specific
needs. However, not only the anthropometric characteristics of individuals during
product development for supporting purposes need to be considered but also the
possibility for altering the posture and preferably avoid constraining the user to a
certain body posture.
Acknowledgement
The authors would like to acknowledge the contribution of the company
Professional Health Design directed by M.A. van Veelen for providing the
prototype of the chest support for this study.
73
This chapter is based on the following articles:
Albayrak A, Casseres YA, de Ridder H, Goossens RHM, Kazemier G, Meijer DW, and Bonjer HJ. Objective and
subjective evaluation of image quality during minimally invasive surgery. Submitted (2008).
74
CHAPTER 5 IMAGE QUALITY DURING
LAPAROSCOPIC SURGERY
The technology that surgeons use nowadays to perform minimally invasive surgery
(MIS) appears to cause problems for many surgeons resulting in higher
complication rates compared to open surgery. Some of these problems are intrinsic
to laparoscopic viewing that degrade the surgical quality and enhance the
probability of error during surgical procedures such as loss of three-dimensional
depth perception, scaling difficulties caused by the magnification of the operating
field and by definition degraded visual image of the anatomy (compared to the
experience during open surgery). One of the main problems is lack of national
standards for inspection and maintenance of equipment and instruments,
responsible for creating a good and adequate image. In the current study, the focus
will be on the quality of the imaging chain during a specific but representative
type of MIS, namely laparoscopy. This chapter discuss the study of objective and
subjective evaluation of image quality in 36 Dutch hospitals.
75
5.1 INTRODUCTION
Minimally Invasive Surgery (MIS) has improved recovery after surgical procedures
because of its many advantages for the patient such as reduced postoperative pain,
fewer wound-related infections, shorter recovery time and better cosmetics results
(Frank et al., 1997). At the same time, MIS has altered the way surgeons interact
with the surgical field and the patient, not only physically but also at a cognitive
level, requiring additional visual motor and learning skills besides the traditional
surgical and medical skills (Berguer, 1999). MIS is more technology-dependent
than open surgery since more equipment is needed to perform the same surgical
procedure. Furthermore, since the introduction of MIS in the mid 80s, the main
focus has been on technology with less concern about ergonomics (Gallagher &
Smith, 2003). The technology that surgeons use nowadays to perform MIS appears
to cause problems for many surgeons resulting in higher complication rates
compared to open surgery. Some of these problems are intrinsic to laparoscopic
viewing that degrade the surgical quality and enhance the probability of error
during surgical procedures such as loss of three-dimensional depth perception,
scaling difficulties caused by the magnification of the operating field and by
definition degraded visual image of the anatomy (compared to the experience
during open surgery) (Gallagher & Smith, 2003). A recently published report by the
Dutch Inspection of Health Services The underestimated risks of minimally
invasive surgery contains a list of potential problems threatening patient safety
(IGZ, 2007). One of the main problems is lack of national standards for inspection
and maintenance of equipment and instruments, responsible for creating a good
and adequate image. In the current study, the focus will be on the quality of the
imaging chain during a specific but representative type of MIS, namely
laparoscopy.
5.1.1 The imaging chain
The surgical team observes the operative field indirectly via an image on a monitor.
In order to generate the monitor image two procedures have to be combined.
Firstly, the dark abdominal cavity has to be illuminated. Secondly, the image of the
illuminated abdominal cavity has to be captured, transmitted to, and displayed on
the monitor screen. The system combining these procedures is known as the
imaging chain and consists of the following basic components; (1) light source,
light guide cable and fibre optic channel of the endoscope to illuminate the
abdominal cavity; (2) imaging optics of the endoscope, camera, camera controller
and monitor to display the image of the illuminated abdominal cavity on the
monitor (Swaitzberg, 2001). The imaging optics are positioned in the centre of the
endoscope with optic light fibres located in the periphery (Boppart et al., 1999). To
illuminate the abdominal cavity the light from the light source is transmitted
76
CHAPTER 5: IMAGE QUALITY DURING LAPAROSCOPIC SURGERY
through the light guide cable and the fibre optic channel of the endoscope. Both
light guide cables and endoscopes contain glass fibres to transmit light. In spite of
the high transmission coefficient of these glass fibres, reduction of loss in light
occurs in the delivery system (light source, light guide cable, and endoscope) due
to:
Differences of diameters on the connection of the light guide cable with the light
source (different brands).
Differences of diameter between the light guide cable and the endoscope.
Surface losses and bulb absorption.
Because of these losses, the light transmission of this part of the imaging channel is
reduced to at most 20 percent in the best imaging system. As a result of all the
losses, a typical system will deliver considerably less then 1 W of visible light from
a 250 W source lamp (Frank et al., 1997).
Additionally, loss of illumination is caused by aging of the light source, mechanical

damage due to repetitive use and sterilization of light guide cables and endoscopes
resulting in melting and/or breakage of fibres. Melted or broken fibres reduce the
illuminance of the abdominal cavity. The illuminance of the abdominal cavity is
determined by the output of the light source and the quality of light transmission of
the light guide cable and endoscope. In other words, the total illuminance of the
imaging chain is a product of the transmission of the light guide cable, the
transmission of the endoscope and the output of the light source (Albayrak et al.,
2006a). Albayrak et al. showed that the total illuminance of the abdominal cavity
was significantly correlated with these components (Albayrak et al., 2006a).
Once the light enters the abdominal cavity, the luminance is not constant as a
consequence of differences in the way organs and tissues scatter light. Human
tissues and organs could be categorized on the basis of their luminosity into three
basic groups: high luminous tissues such as fat, the stomach and the bowel;
medium-luminous organs such as diaphragm and gallbladder; and dark, mostly
parenchymatous with high blood contents organs such as the liver and the spleen
(Danis, 1998). Luminous tissue will reflect the light and illuminates the screen
intensely and conversely, dark tissue will absorb the light and reduce the brightness
of the image.
The abdominal cavity is illuminated and the resulting image is captured,

transmitted to, and displayed on the monitor. The image quality is determined by
three major parameters; image resolution, luminance and chroma (Hanna &
Cuschieri, 2001). The image resolution determines the visibility of details in the
image and refers to the sharpness and contrast of the picture (Berber et al., 2002).
Luminance refers to the amount of light available in the image signal and chroma
77
denotes the colour intensity or saturation (Hanna & Cuschieri, 2001). The monitor
has a vertical and horizontal resolution that quantifies how close lines (alternating
black and white lines) can be to each other and still be visibly resolved. The
standard monitors can resolve 600 lines and the monitor is literally the rate-limiting
step in improving image resolution (Berber & Siperstein, 2001). Additionally, the
vertical resolution is fixed at the number of scanning lines that the system uses,
but the horizontal resolution is changeable, depending on the quality of the camera,
wiring and the monitor (Berber et al., 2002).
5.1.2 Ergonomics
From a perspective of cognitive interaction between the surgeon and the observed
surgical field, there are several factors intrinsic to laparoscopic viewing that may
degrade the surgical quality and enhance the probability of error during surgical
procedures. Since the surgical team observes the surgical field via a monitor, direct
sensory perception and feedback are almost nil. Representation of a three-
dimensional environment on a two-dimensional screen has reduced the depth
perception to a set of only monocular (pictorial) depth cues of the surgical field to
the surgical team (Hanna & Cuschieri, 2001). Despite the reduced depth
perception, the human visual system is still capable of making effective depth
inferences from flat images by using visual cues such as texture gradients and
shadows provided that that abdominal cavity is well illuminated (Frank et al.,
1997). Good illumination will reduce the occurrence of incorrect inferences from the
observed monitor image. For example, when surgeons inspect the gallbladder and
surrounding structures to identify the cystic duct, the surgeons brain seeks a
pattern to match his/her mental model of the biliary anatomy stored in long-term
memory (Way et al., 2003). The match between the mental model and the
observed patterns, which are recorded by the visual system, are simplifications and
the visual perception provides therefore an estimate of reality, not an exact copy.
Way et.al., showed that 97% of the primary cause of error of bile duct injuries
stems principally from a misinterpretation of the anatomy as a result of visual
perceptual illusion (Way et al., 2003). Technical flaws were present in only 3% of
the injuries. They also provide a list with rules of thumb to help prevent bile duct
injuries (Way et al., 2003). Optimizing the image by using a high-quality imaging
system is one of the recommendations. This is essential since the imaging system
connecting the eye of the surgeon to the surgical field during MIS. Hanna et.al.,
showed that task performance of the surgeon is significantly degraded by current
video-endoscopic imaging systems compared to direct binocular vision (like during
open surgery) (Hanna & Cuschieri, 2001). Therefore, high quality image is of
paramount importance to allow safe and effective surgical procedures.
78
No studies were identified dealing with the subjective and objective image quality in
practice. The studies, which were found, were based on lab-settings and not carried
out in the operating room. Therefore, the aim of this study is to asses the quality of
illumination of the abdominal cavity by examining the transmission characteristics
of light guide cables and endoscopes. The objective measurements are performed
in a representative sample of hospitals in the Netherlands. In addition, the
correlation between illumination of the abdominal cavity and surgeons subjective
experience of this image was established.
5.2 MATERIALS AND METHODS
5.2.1 Selection of hospitals

In 2003 and 2004, 36 Dutch hospitals were visited: 5 academic hospitals, 17
teaching hospitals and 13 community hospitals. These hospitals were selected out
of 92 hospitals in the Netherlands.
5.2.2 Attended procedures
In total 65 minimally invasive procedures were attended. The type and number of
attended procedures are representative for the Dutch hospitals (www.nvec.nl,
2004). Figure 5.1 shows the registered national number of surgical procedures in
the Netherlands and the number of attended procedures (www.nvec.nl, 2004).
Lap. Appendicectomy, 1086

Attended 0 procedures Lap. Cholecystectomy
Lap. Hernia repair
Lap. Splenectomy, 70 Others, 170
Attended 2 procedures Attended 8 procedures Lap. Splenectomy
Lap. Appendicectomy
Others
Lap. Hernia repair, 999
Attended 14 procedures
Lap. Cholecystectomy,
11109
Attended 37 procedures
Figure 5.1 The registered national number of surgical procedures in the Netherlands and the number
of attended procedures (2004).
79
5.2.3 Measurements
5.2.3.1 Objective
In this study, two different objective measurements were carried out:
The illuminance (I) by the imaging chain has been measured using a digital
luxmeter (LX-107; LT Lutron, Taiwan) and is expressed in [lux]. The underlying
formula for this measurement is; ITOT = ILS . TE . TLGC. In words, total illuminance
(ITOT) of the imaging chain is a product of the output of the light source and the
light transmission coefficients of the endoscope and the light guide cable.
The resolution (RTOT) of the imaging chain and that of the endoscope (RE) have
been measured using a Borescope Test Chart (Olympus Industrial) and
expressed by lines per mm (l/mm).
5.2.3.2 Subjective
A questionnaire was used to asses the subjective impression of the surgeon of the
displayed image during the procedure. To this end, the surgeon was asked to
judge, immediately after finishing the surgical procedure, the image on the
following items: overall image quality (Q), sharpness (S), contrast (C), brightness
(B), and quality of colour (CL). A numerical scale of 1 to 10 was used to express
the judgments.
5.2.3.3 Setting
The measurements of the imaging chain took place in two settings;
In the operating room immediately after a procedure.
In the sterilization department at an arbitrary moment during the visit.
In the operating room, both objective and subjective measurements took place. In
the sterilization department only objective measurements were done.
Operating room
Immediately after a procedure was finished total illuminance (ITOT) as produced by
the imaging chain during that procedure was measured before the light guide cable
and the endoscope were detached. The endoscope was attached to a digital
luxmeter (LX-107; LT Lutron, Taiwan) (figure 5.2). In addition, the surgeon who
performed the procedure was interviewed about his/her impression of the image
displayed during the procedure. This interview was done immediately after finishing
the procedure since the image was still clear in the memory of the participating
surgeon. A questionnaire was used to asses the subjective impression of the
displayed image.
The resolution of the imaging chain (RTOT) was also measured before the light guide
cable and the endoscope were detached. RTOT was measured using a Borescope
Test Chart (Olympus Industrial). The endoscope was attached to a custom-made
80
cylinder (see figure 5.2) which positioned and fixed the endoscope at a
standardized distance of 5 cm from the Test Chart (Rosow et al., 1998). The Test
Chart was illuminated by ITOT. The image of the Test Chart was projected on the
monitor. The researchers determined the maximum distinguishable number of lines
on the monitor. This number indicates the RTOT and is expressed by lines per mm
(l/mm).
Sterilization department
The quality of light transmission of the light guide cable and the endoscope was
measured in the sterilization department. Other light guide cables and endoscopes,
which were not used during a procedure, could also be tested in the sterilization
department, except those, which were in the sterilization process or kept back for
acute procedures at the time of measurements.
To standardize the measurements of the light guide cables and endoscopes a set of
reference equipment (figure 5.2) has been used which consists of;
Light source; OES metal halide light source, CLD-S, Olympus Co., LTD. The
illumination level of this light source was adjustable. For standardized
measurements the illumination level was set on 50% (mean 84*103 lux, SD: ±
99*102 lux) .
Light guide cable; Olympus, Ø 5 mm, and 300 cm.
Monocular rigid endoscope; Olympus Ø 10 mm and viewing angle of 0º.
A digital luxmeter (LX-107; LT Lutron, Taiwan).
Custom-made cylinder for positioning and fixating the light guide cable and the
endoscope.
All these equipment were new.
Adjustable illumination level
Reference light source
Custom-made cylinder
Reference endoscope
Photosensor
Digital luxmeter
Reference light guide cable
Figure 5.2 Reference measurement equipment.
81
Light guide cables

For a standardized measurement, one end of the light guide cable was attached to
the reference light source and the other end to a custom-made cylinder which
positioned and fixed the light guide cable at a standardized distance of 5 cm from
the photosensor (Rosow et al., 1998). The transmitted light from the reference light
source through the light guide cable is measured in lux and is a measure for the
illuminance of the light guide cable of the hospital (ILGCHOS). After each
measurement of ILGCHOS also the illuminance of the reference light guide cable was
measured (ILGCREF). Since the same reference light source was used and for both
measurements, the light transmission coefficient (TLGCHOS) of ILGCHOS can be
calculated using the next formula:
ILGCHOS
.T 1
0 TLGCHOS = I LGCREF
LGCREF (1)
It was assumed that TLGCREF was constant.
Endoscope
Although endoscopes of different diameters and different angles are used in
minimally invasive surgery, 00 endoscopes with a diameter of 10 mm are most
frequently used in laparoscopy. Therefore, only the endoscopes with this dimension
were selected. For a standardized measurement, one end of the endoscope was
attached to the reference light guide cable (the light guide cable was connected to
the reference light source) and the other hand to a custom-made cylinder which
positioned and fixed the endoscope at a standardized distance of 5 cm to the
photosensor (Rosow et al., 1998). The transmitted light from the reference light
source through the reference light guide cable is measured at the end of the
endoscope indicating the illuminance of the endoscope of the hospital (IEHOS). After
each measurement of IEHOS also the illuminance of the reference endoscope was
measured (IEREF). Since the same reference light source and light guide cable was
used for both measurements, the light transmission coefficient (TEHOS) of IEHOS can
be calculated using the next formula:
IEHOS = ILGCREF . TLGCREF . TEHOS (2)

IEREF = ILGCREF . TLGCREF . TEREF (3)
IEHOS . (4)
0 TEHOS = 1
IEREF TEREF
It was assumed that TEREF was constant.
82
The same set-up as described above was used to determine the resolution of the
endoscope. The luxmeter was replaced by the Borescope Test Chart (Olympus
Industrial). The Test Chart was placed at the front of the endoscope at a
standardized distance of 5 cm (Rosow et al., 1998). The resolution of the
endoscope was measured by looking through the endoscope by the researchers.
The maximum distinguishable number on the Test Chart indicates the resolution of
the endoscope (RE) and is expressed by lines per mm (l/mm).
The different measurements are shown in figure 5.3 and table 5.1.
Figure 5.3 The points of objective and subjective measurements of the imaging chain.
Table 5.1 Overview of the different measurements

Light Light guide Endoscope Measuring at Variable Remarks
source cable point
Hospital Hospital Hospital 1 ITOT OM
TIQ, S, C,
Hospital Hospital Hospital 2 SM
B, CL
OM/Borescope
Hospital Hospital Hospital 2+4 RTOT
Test Chart
Reference Hospital 3 ILGCHOS OM

Reference Reference Hospital 1 IEHOS OM
OM/Borescope
Reference Reference Hospital 4 RE
Test Chart
Reference Reference 3 ILGCREF OM
Reference Reference Reference 2 IEREF OM
OM = Objective measurements
SM = Subjective measurements
83
5.2.3.4 Model
The aim of this study was to assess the quality of light guide cables and endoscopes
by objective measurements and establish the correlation between the illuminance
of the abdominal cavity and surgeons experience of the image. Andersons
functional measurement theory is used as inspiration to understand and evaluate
the correlation between objective and subjective measurements (de Ridder &
Majoor, 1990). This theory provides a framework for efficiently describing the
unobservable, psychological processes underlying the comparison of stimuli. An
essential assumption in functional measurement theory is that sensations evoked
by different, independent stimuli are combined to form an internal or psychological
response. Figure 5.4 illustrates the application of the functional measurement
theory within the scope of this study.
OBJECTIVE SUBJECTIVE
RTOT
S
RE
C
Q
ITOT
B
TEHOS C
TLGCH
Figure 5.4 Application of the functional measurement theory within the scope of this study.
The objective measurements RTOT, RE, ITOT, TEHOS, and TLGCHOS form the
independent psychophysical functions of the framework. These independent
psychophysical functions transform stimuli into sensations S, C, B, and CL. These
intermediate sensations are combined to form a psychological response.
Subsequently, this psychological response is transformed into overt response Q by
the judgment function.
84
In this model, the parameter light source is missing which is an essential part of the
imaging chain. This parameter is not measured directly but can be calculated by the
formula:
ITOT
ILS = (5)
TE . TLGC
SPSS 14.0 for Windows was used for statistical analysis of the results. The level of
significance that is used during all the analysis was, = .05. The next assumptions
were formulated and tested:
Assumption 1: ITOT will differ depending on the kind of hospitals and surgical
procedures.
Assumption 2: There is a correlation between the independent variables,
intermediate variables, and dependent variable (the ILS will be included in the
correlation analysis).
Assumption 3: The output of the light source ILS will be reduced in the course of
time (the reference light source will be used for analysis).
Assumption 4: RE will be higher than RTOT.
Assumption 5: The measured light guide cables and endoscopes will be
systematically lower than the reference equipment.
85
5.3 RESULTS
Overview attended procedures in different type of hospitals
Table 5.2 Specifications of the attended surgical procedures
KIND HOSPITAL
ACADEMIC HOSPITAL TEACHING HOSPITAL COMMUNITY HOSPITAL

TOTAL
N=5 N = 17 N = 13
N = 65
N=8 N = 37 N = 20
Mean = 47*103
Mean = 81*103 lux Mean = 50*103 ux Mean = 28*103 lux
lux
SEM: 23*103 SEM: 87*102 SEM: 62*102
SEM: 60*102
Q = 6,3 Q = 6,9 Q = 6,9
ITOT Q = 6,8
S = 6,5 S=7 S = 6,9
S = 6,9
C = 6,7 C = 6,8 C = 7,1
C = 6,9
B = 6,6 B = 6,6 B = 6,5
B = 6,5
CL = 6,5 CL = 7 CL = 6,9
CL = 6,9
N = 45
N=5 N = 23 N = 17
Mean = 56*103
Mean = 121*103 lux Mean = 67*103 lux Mean = 30*103 lux
lux
SEM: 20*103 SEM: 11*103 SEM: 72*102
SEM: 76*102
Q = 6,7 Q = 6,7 Q = 6,7
ITOT Q = 6,7
S = 6,7 S = 7,2 S = 6,8
S=7
C = 6,8 C = 6,9 C=7
C = 6,9
B = 6,8 B = 6,7 B = 6,4
B = 6,6
CL = 6,8 CL = 7 CL = 6,9
CL = 6,9
N = 11
N=8 N=3
Mean = 25*103
Mean = 27*103 lux Mean = 16*103 lux
lux
SEM: 77*102 SEM: 18*102
SEM: 57*102
Q = 6,8 Q = 7,6
ITOT Q=7 N=0
S = 6,8 S = 7,5
S=7
C = 6,7 C=8
C=7
B = 6,2 B=7
B = 6,4
CL = 7,2 CL = 7
CL = 7,1
N=9
N=3 N=6
Mean = 17*103
Mean = 15*103 lux Mean = 19*103 lux
lux
SEM: 60*102 SEM: 52*102
SEM: 38*102
Q = 5,8 Q = 7,6 N=0
ITOT Q=7
S=6 S = 6,9
S = 6,6
C = 6,5 C = 6,7
C = 6,6
B = 6,2 B = 6,7
B = 6,6
CL = 5,7 CL = 6,5
CL = 6,3
ITOT = Total illuminance imaging chain visited hospital

Others = Laparoscopic Splenectomy (2) laparoscopic Nissen fundoplication (1), laparoscopic donor nephrectomy
(1), laparoscopic sigmoid resection (1), diagnostic laparoscopy (1), adjustable gastric band (1), laparoscopic
sterilization (1), and laparoscopic rectopexy (1).
86
5.3.1 Assumption 1
The averaged ITOT is divided into 3 different kind of surgical procedures
(laparoscopic cholecystectomy (Lap.Chol), laparoscopic hernia repair (Lap.Hernia),
and others) and hospitals and are shown figure 5.5.
160000
140000
120000
100000
80000
60000
40000
Lap.Chol
20000 Lap. Hernia
Others
0
Academic Teaching Community
Kind Hospital
Figure 5.5 The averaged ITOT per hospital type, divided into 3 groups (laparoscopic cholecystectomy
(Lap.Chol), laparoscopic hernia repair (Lap.Hernia), and others).
In all of the groups, there is a descending trend of ITOT from academic to

community. The ITOT is systematically the highest for academic hospitals. The ITOT
during Lap. Cholecystectomy differs significantly between the 3 kind of hospitals: F
(2, 340) = 5.67, (p < .01). The ITOT during Lap. Cholecystectomy in the category
training hospital is significantly higher than the Lap. Hernia repair; t(22) = 5.6, p <
.01. The ITOT during Lap. Cholecystectomy in the category community hospital is
significantly higher than the Lap. Hernia repair; t(16) = 4.23, p < .01.
87
5.3.2 Assumption 2
The correlation between the independent variables (ILS included), intermediate
variables and dependent variable and the corresponding correlation coefficients are
shown in figure 5.6. The C (contrast) and B (brightness) is put together since the
correlation was high and the double arrows indicating a correlation in both
directions.
r = .34
r = .34 RE RTOT
TLGCHOS
r = .46
r = .81
r = -.36 r = .91
r = -.33 TEHOS ITOT C/B Q
r = .47
r = .74 r = .44
ILS r = .59
r = .36 r = .72
S CL
r = .78
Figure 5.6 The correlation between the independent variables (ILS included), intermediate variables
and dependent variable and the corresponding correlation coefficients.
88
5.3.3 Assumption 3
The reference light source was used to analyze the effect of ageing on the level of
illuminance (figure 5.7).
120000
110000
100000
90000
80000
70000
60000
10-12-02 28-02-03 19-05-03 7-08-03 26-10-03 14-01-04 3-04-04
Date of visit
Figure 5.7 The reduction of the output of the reference light source in the course of time.
5.3.4 Assumption 4
The resolution of the monitor was 5.34 ± 0.89 lines per mm (l/mm) and that of the
endoscope was 7.13 ± 0.65 lines per mm (l/mm).
5.3.5 Assumption 5
In total 252 light guide cables of different length and diameter have been tested.
The majority, 70% (175) of the total (252) measured light guide cables had a
diameter of Ø 4.8 or Ø 5 mm. These cables are selected as the most frequently
used ones in different hospitals. Since the reference light guide cable has the
diameter of Ø 5 mm, a selection of the measured light guide cables is made with a
diameter of Ø 4.8 and Ø 5 mm to compare with the reference light guide cable.
The illuminance of the reference light guide cable on average was 83*103 ± 12*103
lux. The results of the illuminance of the selected light guide cables show that 93%
of the measured light guide cables had an illuminance less than the reference light
guide cable.
89
In total, 166 endoscopes have been tested. The illuminance of the reference
endoscope on average was 56*103 lux. The results of the illuminance of the
measured endoscopes show that 91% of the measured endoscopes had an
illuminance less than the reference endoscope.
5.4 DISCUSSION
The advanced technology that surgeons use nowadays during MIS has become
complex and has altered the interaction between the surgeon and the equipment.
Frequently, this interaction is unnatural and cause problems contributing to the
medical errors rates (Verdaasdonk et al., 2007). Some of these errors during
surgery are influenced by or related to several factors intrinsic to laparoscopic
viewing. Laparoscopic viewing is only possible by the imaging chain and the
image displayed on the monitor will be as good as the imaging chains weakest
component (Swaitzberg, 2001). This image is the critical source of information to
the surgeon. From this perspective, a subjective and objective evaluation of the
image quality in practice is essential.
The results of the objective measurements of this study show that total illuminance
of the imaging chain (ITOT) differ systematically between the different types of
hospitals. This indicates a diversity of the imaging chain systems used in the
hospitals. In general, each hospital prefers a certain brand to purchase, but in
practice it is likely to use different brands of light source, light guide cable and
endoscope as one system. While using different brands of equipment as one system
it should be considered that these components have to fit properly to each other to
prevent light loss due to differences in diameters (Frank et al., 1997).
Further evaluation of ITOT shows that ITOT during Lap. Cholecystectomy differs
significantly between the three kinds of hospitals. The descending trend of ITOT from
academic to community shows that surgeons working at academic hospitals may
prefer higher light intensities during surgical procedures.
A remarkable finding was that the total illuminance during Lap. Cholecystectomy
was significantly higher than during Lap. Hernia repair. According to Danis there are
differences in the way that organs and tissues scatter light and makes herein a
division of high luminous tissues such as fat, the stomach and the bowel; medium-
luminous organs such as diaphragm and gallbladder; and dark, mostly
parenchymatous organs such as the liver and the spleen (Danis, 1998). During Lap.
Cholecystectomy mainly the gallbladder (medium-luminous organ) and the liver
(dark organ) are in sight and during Lap. Hernia mainly the fat and the bowel are in
view. The intensity of light reflected by the gallbladder and liver is lower than fat
and bowel. This means that under same ITOT conditions the image during Lap.
90
Cholecystectomy will be less bright than during Lap. Hernia repair. It seems that
surgeons adjusting the light intensity intuitively depending on the kind of organs
and tissues which are visible during the surgical procedure.
In most of the hospitals, it was observed that the light guide cables and endoscopes
were packed separately. Before a surgical procedure starts the necessary
instruments and equipment was selected and putted ready for use. It seems that
the selection of the light guide cables and endoscopes occurs independently since
no correlation was found between these two components. However, a significant
correlation between the ITOT and the light transmission coefficients of the
endoscope (TEHOS) and light guide cable (TLGCHOS) was found indicating that ITOT is a
product of the transmission of the light guide cable and endoscope, and output of
the light source (Albayrak et al., 2006a). The total illuminance depends on the light
transmission quality of the light guide cable and endoscope. Although, there was no
correlation between the light guide cable and the endoscope the TEHOS was
systematically lower than the TLGCHOS. Both light guide cables and endoscopes
contain glass fibres to transmit light but the amount of glass fibres in the light
guide cables are more than that of the endoscope. In addition, the transmission
coefficient of the endoscope is determined at the end of the imaging chain, which
means that a reduction of loss in light was occurred in the delivery system.
A well-known phenomenon during minimally invasive procedures is that the
surgeon is confronted with a suboptimal-lighted image. In a situation like this the
surgical team have the tendency to turn the knob of the light source to a higher
light intensity, mostly up to 100%. This observed phenomenon is in line with the
findings of this study. The negative correlation between the illuminance of the light
source and transmission coefficient of the light guide cable indicates when a light
guide cable have a poor light transmission quality the light intensity of the light
source is increased to compensate the light loss. Frequently, this situation results in
an overexposed image. However, the results of a previous study show that the 40%
of hyper illuminated area can be thus appreciated as the critical limit of hyper
illumination (Danis, 1998). Hyper illumination has to be avoided to prevent damage
on the fibres of the light guide cable and endoscope due to heat development.
In this study, the image quality was assessed by asking the participating surgeon to
judge the displayed image in terms of: overall image quality (Q), sharpness (S),
contrast (C), brightness (B), and quality of colour (CL). According to Hanna et.al.,
the image quality is determined by three major parameters; image resolution,
luminance and chroma (Hanna & Cuschieri, 2001). The resolution determines the
visibility of details in the image and refers to the sharpness and contrast of the
image and the luminance refers to the brightness (Hanna & Cuschieri, 2001). The
results show that each parameter was correlated to each other and with the overall
image quality judgment (Q). The high correlation between the contrast and
91
brightness judgment could indicate that surgeons do not make a distinction

between contrast and brightness of an image. Hanna et.al also shows that chroma
denoting the colour intensity or saturation is a major parameter of the image
quality (Hanna & Cuschieri, 2001). However, the findings of this study could not
confirm this strongly since the colour judgment was lowest correlated with Q.
The quality judgment of the surgeons was influenced by the total illuminance
measured during surgical procedure. This is not surprising since ITOT is the amount
of light entering the abdominal cavity and the judgment of the surgeon is actually
based on the image wherein this amount of light is reflected/absorbed by the
surrounding organs and tissues. The negative correlation between ITOT, Q, C and B
indicates that surgeons do not appreciate high levels of illuminance as a
consequence of hyper illumination of the image.
The output of the reference light source is reduced in the course of time. This could
be caused by ageing of the light source, surface losses and/or bulb absorption. The
surgical team should be aware of this phenomenon. Regularly inspection and
maintenance of the light source and replacement of the bulb on time could prevent
unnecessary light loss during surgery.
The resolution of the monitor was systematically lower than the resolution of the
endoscope. This is in line with the findings of Berber, which states that the monitor
is the rate-limiting step in improving the image resolution (Berber & Siperstein,
2001). However, it seems that the resolution of the endoscope (RE) can be
improved by a higher ITOT and a light guide cable with a high light transmission
coefficient since a positive correlation was found between RE, ITOT and TLGCHOS. By
improving the resolution of the endoscope, also the resolution of the monitor will be
slightly improved since these two are correlated to each other.
Furthermore, the illuminance of the measured light guide cables and endoscopes
were systematically lower than the reference equipment. During the time of visits,
it was observed that the hospitals did not have the equipment to test these
components.
All components of the imaging chain gradually deteriorate during the lifetime.
Therefore, regularly inspection and maintenance of these components is essential
for quality assurance of the system. Hence implementation of guidelines for
inspection, maintenance and replacement of laparoscopic instruments and related
equipment is necessary in each hospital to improve patient safety (IGZ, 2007).
Although a high illuminance of the abdominal cavity is not appreciated by surgeons,

during Lap. Cholecystectomy the illuminance was significant higher than during
Lap. Hernia repair. It seems that surgeons are seeking for an image, which is the
92
optimum in their opinion. According to Way identification of structures, take place

by matching the patterns, which is sawn to the mental model of that structures
stored in long-term memory (Way et al., 2003). Since surgeons generally perform
each surgery under same conditions and with same equipment, they probably have
a clear view of the expected/familiar image based on their previous experiences. It
seems therefore that they are comparing the actual image with the
expected/familiar image and use this experience to form their judgment. In this
study a questionnaire was used immediately after finishing the surgical procedure
to assess surgeons subjective impression of the displayed image during the
procedure. This way of evaluation have its limitations since surgeons will namely
remember the last part of the image and use this as a reference for their judgment.
Further research should be done on surgeons subjective experience of the
displayed image. Other methodology and evaluation techniques should be used
which gain more insight into the cognitive processing of judgment.
Acknowledgement
The authors would like to acknowledge the contribution of the participated hospitals
to this study.
93
This chapter is based on the following studies:
Albayrak A, and Snijders CJ. (2007). Ergonomy in the OR. In JB Trimbos & GCM Trimbos Kemper (Eds.), Basics of
surgery: Tools, techniques and expertise (pp. 151-169). Maarssen: Elsevier gezondheidszorg.
Bonjer HJ, Albayrak A, Stassen LPS, Casseres YA, Meijer DA. Improving the endoscopic image: tips and tricks.
Submitted (2008).
94
CHAPTER 6 PRACTICAL ERGONOMIC
SOLUTIONS FOR THE SURGICAL TEAM
In chapter 2, the ergonomic problems of the surgical team were discussed. In this
chapter an overview of practical solutions regarding the encountered problems in
Chapter 2, are given. The emphasis is on the application of the solutions in daily
practice. These solutions will be discussed along the three domains of ergonomics;
physical, sensorial and cognitive. The physical ergonomics will be restricted to the
strain of musculoskeletal system which is relevant for neck, shoulder, arm, hand
problems, lower back, pelvis and foot. As most of the sensorial and cognitive
problems are seen during laparoscopy this two sections will be focusing on
laparoscopic procedures.
95
6.1 PHYSICAL ERGONOMICS
6.1.1 Neck
Problem: Uncomfortable body posture
Solution
An ergonomic work environment requires unobstructed line of vision in neutral
standing posture with a natural viewing angle between 10º and 25º below the
horizontal in the sagittal plane and 30º to left and right (figure 6.1) (Gerbrands et
al., 2004).
Figure 6.1 Ergonomic viewing guidelines.
Another solution to prevent physical discomfort in the neck due to obstructed line of
vision is the use of an adjustable body support. In addition, problems arising from a
non-optimal working height will also solved since the body support is adjustable in
height and suitable for users with different body height (figure 6.2).
Figure 6.2 Adjustable body support with semi-standing support.
96
CHAPTER 6: PRACTICAL ERGONOMIC SOLUTIONS FOR THE SURGICAL TEAM
6.1.1.2 Laparoscopy
Problem: Limited number and incorrect positioning of monitors results in physical
discomfort in the neck (flexion, extension, and rotation).
Solution
The members of the surgical team stand on both sides of the operating table in the
majority of the procedures. Assessing the position of the surgical team from an
ergonomic point of view, each member of the surgical team should have an
unobstructed line of vision without neck torsion. Figure 6.3 shows the ergonomically
optimal positioning of the surgical team and the corresponding number of monitors
with respect to positioning of the surgical team (Albayrak et al., 2004).
Figure 6.3 Ergonomically optimal positioning of the surgical team and number of monitors.
6.1.2 Shoulder/Arm
Problem: Due to the position and depth of the incision during open surgery,
surgeons have fixed work posture, tending to work with arms abducted and
unsupported. A high static load is imposed on the shoulder-neck region and
shoulder joint by this posture.
97
Solution
Optimal positioning of the operating table in height (approximately at the height of
umbilicus of the surgeon) as well as in axis (e.g. head-down or head-up, tilt) with
respect to the altering body posture of the surgeon during the procedure.
6.1.2.2 Laparoscopy
Problem: Manipulating problems of laparoscopic instruments and wearing heavy
lead aprons.
Solution
Lowering the height of the operating table to counterbalance the increased length
of the instruments is a practical solution. The operating table should be adjusted in
height regarding the tallest person present in the surgical team (shorter persons
can use a footstool) to reduce strain on the shoulders. Creating an optimal working
height for the surgical team will also decrease manipulation problem of the
instruments. The discomfort and difficulty ratings were lowest when instruments
handles were positioned at elbow height (Berguer et al., 2002). Regarding the
guideline of positioning the instruments at elbow height the ergonomically
operating surface height (defined as the navel height of the patient, lying on the
operating table while the abdomen is filled with CO2 gas) lies between 0.7 and 0.8
of the elbow height of the surgeon/resident (van Veelen et al., 2002b) (figure 6.4).
Elbow height Operating

surface height
Figure 6.4 The optimal posture of the surgeon/resident during laparoscopy.
In practice, this means for laparoscopy adjusting the operating table on pubic
height of the tallest person in the surgical team.
Most of the lead aprons, which are currently in use, consist of one part. Replacing
these by a lead vest and lead skirt will reduce the weight on the shoulder.
98
6.1.3 Hand
Problem: Grasping and manipulating problems (unintended use) of instruments by
using these differently than the way they are originally designed for.
Solution
Avoid unintended use of instruments.
6.1.3.2 Laparoscopy
Problem: Grasping and manipulating problems due to the complexity and
inefficient mechanical properties of instruments.
Solution
Based on an ergonomic approach the new action criteria for laparoscopic
instruments are summarized in Table 6.1 (van Veelen, 2003).
Table 6.1 New action criteria of laparoscopic dissection forceps.

New action criteria for design of laparoscopic dissection forceps
Posture of hand The angle between handle and shaft must be between 14º and 50º
and arm When the handle is manipulated with a precision grip, wrist excursion
must be neutral for 70% of the manipulation time
When the handle is manipulated with a force grip, wrist excursion must
be neutral for 70% of the manipulation time
Forces in hand The grip opening must be between 60 and 80 mm
and arm Any disturbances (e.g. friction and spring forces) must be avoided to
enable an optimal force feedback of tissue on the surgeons hands: if the
handle is manipulated in free spaces, no friction must be experienced
Compressive The handle must have a minimum width of 10 mm to prevent extreme
force on the contact area pressure
hand
Finger The instrument must be provided with a rotation knob to allow rotation
movement of the instrument tip. This control switch must be manipulated with
thumb or 2nd finger and when the instrument is manipulated in free
spaces, no friction must be experienced
Left-handers The handle must allow left- and right-handed manipulation
Anthropometrics The dimension of finger ring must be: inner length min. 30 mm, inner
width min. 24 mm
Function handle The handle of a dissection forceps has to support a precision as well as
an force grip for manipulation
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6.1.4 Lower back

Problem: Static strain and fatigue in the back muscles due to uncomfortable body
posture.
Solution
There are two solutions available. The first one is rest by stretching the upper body
upright. During shorter bouts of work, only ATP, CP, and some of the oxygen stored
in muscle (myoglobulin) is utilized. During the rest breaks, these sources were
replenished with minimal penalty. For longer bouts of work, the muscle utilized the
glycolytic process to produce energy quickly at the penalty of elevating blood
lactate and incurring fatigue. Thus, the optimum arrangement of work is to have
short, frequent work-rest cycles (Freivalds, 2004).
The second solution is supporting the body by means of an ergonomic body support
(Albayrak et al., 2006b, 2007) (figure 6.5).
Chest support
Semi-standing support
In height adjustable
platform
Figure 6.5 Ergonomic body support.
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The platform is adjustable in height by means of a motor, which can be operated by

a remote control. The height of the platform ranges from 60 mm (minimum) to 460
mm (maximum), 95% of the user group will have a comfortable posture (in
combination with the current operating tables). The semi-standing support at the
buttocks has a maximum height of 900 mm (when the platform is positioned in the
lowest position for a tall surgeon). The height of the semi-standing support is
proportional to the height of the platform. This allows correct placement of this
support for the whole user group. During open surgery, the surgeon uses the chest
support by leaning against it and during minimally invasive surgery the semi-
standing support can be used (Albayrak et al., 2007).
6.1.4.2 Laparoscopy
Problem: Limited body movement and static upright posture.
Solution
The two solutions that are discussed in the open surgery section are also valid for
laparoscopic surgery. Rest by stretching the upper body upright during the
procedure and the use of an ergonomic body support.
6.1.5 Pelvis
6.1.5.1 Open surgery, laparoscopy

Problem: Leaning against the solid and metal edge of the rail of the operating
table results in bruising in soft tissue around the pelvis region.
Solution
The developed hip support from foam, which can easily attach to the rails, will
prevent the bruising (figure 6.6).
Figure 6.6 Hip support.
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6.1.6 Foot
During open surgery, the diathermy is activated by pressing a button on the
instrument. Due to manual control of this equipment a pedal is unnecessary.
6.1.6.2 Laparoscopy
Problem: Positioning problems due to losing contact with the pedal and the risk of
accidentally activating the wrong function (left or right) of the pedal because of lack
of vision.
Solution
A new pedal is designed in the form of a flat round disc (figure 6.10) (van Veelen,
2003).
Figure 6.7 Pedal.
Pedal control is based on endo- and exo-rotation of the foot. The switch is activated
by positioning the foot on the disc and by rotation of the foot (leg): right rotation
activates the coagulation function, and left rotation activates the cutting function.
Since the disc is flat and thin, the user can stand on the disc during surgery with
the weight spread evenly over both feet. The advantage is that no enduring dorsal
flexion of the ankle is needed to control the switch. In addition, the pedal does not
obstruct the freedom of movements because the user will not erroneously push the
wrong switch (Van Veelen et al., 2003c).
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6.2 SENSORIAL ERGONOMICS
Problem: Alignment problems of the monitor with the hands and instruments.
Solution
Adopting the optimal/ergonomically viewing guidelines in the operating room will
reduce overburdening the surgeon (figure 6.8) (Matern et al., 2005; Van Veelen et
al., 2002a; van Veelen et al., 2002b).
Figure 6.8 Ergonomic viewing guidelines. Combination of semi-standing support of the buttocks and
platform adjustable in height.
Additional to this solution it is also being advised to adopt the solution described in
section 6.1.1.2.
Problem: Degradation of monocular depth cues due to anti-cues arising from the
monitor. These are caused by the monitor frame and the glare and reflection from
the glass of the monitor.
Solution
Performing the surgery with dimmed environmental light and correct alignment of
the visual axis with the monitor will reduce the glare and reflection from the glass
of the monitor.
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6.3 COGNITIVE ERGONOMICS
Problem: There are several factors intrinsic to laparoscopic viewing that degrade
the surgical quality and enhance the probability of error during surgical procedures.
Many of the related problems are due to the perceptual and spatial factors.
Representation of the three-dimensional surgical field on a two-dimensional
screen reduce depth perception.
Scaling difficulties caused by magnification and impaired visual image of the
anatomy in comparison to the experience of an open procedure.
The various spatial difficulties encountered during laparoscopy result in problems
with cognitive mapping and hand-eye coordination.
The surgeon has no direct control over the position or orientation of the
endoscope. Instead, the surgeon must rely on the assistant to maintain an
optimal position; however, frequently unintentional camera rotation occurs that
can lead to disorientation and misinterpretation of position of the organs.
One of the problems limiting the surgeons acquisition of skill and degrading the
surgical quality is due to the fulcrum effect.
Solution
Surgeons are trained to deal with the problems as described above. In general, the
model of Rasmussen can be used to describe human behaviour. In this model three
different levels can be distinguished: skills-, rule-, and knowledge based behaviour.
Skill based behaviour is the human behaviour whereby the task execution is highly
automated. This behaviour can be trained by means of a training in for instance a
surgical simulator, pelvitrainer and animal models (Wentink et al., 2003). Factors
that improve skill-based behaviour are active or passive feedback of the
instruments forces and increasing the number of degrees of freedom comparable
to the functions available during open surgery (Stassen et al., 2001).
During rule-based behaviour task execution is controlled by stored rules or

procedures, which have been derived from previous cases, other peoples expertise
and instructions. The procedural steps and recognition of anatomy are examples of
rule-based behavior during surgery. This behaviour can be trained and improve by
means of lectures, textbooks, video instructions, integration of per- and pre-
operative information and better logistics (Stassen et al., 2001). During MIS the
rule-based behaviour can be improved by means of improving the dept perception
(e.g. improving pictorial information, parallax and visual motor cues) and enabling
the surgeon to control the endoscope himself (Stassen et al., 2001).
During knowledge-based behaviour the task execution cannot be automated. The

aim is explicitly formulated, based on the analysis of the overall aim (Wentink et
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al., 2003) and best strategy is selected, by means of mental processing and the
appropriate actions are taken. Knowledge based behaviour can be trained during
actual procedures in the OR or via living animal models outside the OR (Wentink et
al., 2003).
Training of technical skills

Technical skills, which involve knowledge of anatomy and pathology, dexterity,
hand-eye coordination, technical proficiency, etc is essential to surgical training
(Cuschieri, 2006b; Moorthy et al., 2003b; Scott et al., 2000). In order to perform
MIS the surgeon needs highly developed motor skills (Marohn & Hanly, 2004;
Matern et al., 1999). Next to the apprenticeship model these skills can be trained in
simulated environment which gives the trainee objective and direct feedback of
their performance.
6.3.1 IMAGING CHAIN
6.3.1.1 Light source

An excellent light source is therefore mandatory for safe endoscopic surgery. The
light bulb is the most important part of the light source. An old bulb can cause
several alterations to the image quality, as darkening and blurry image. Therefore,
it is mandatory to replace the bulb after the recommended period of time (Berguer,
1996). Over a period of time, wear on the arc lamp is indicated by a decrease in
the colour temperature emitted. This gradual modification in the colour temperature
accounts for the need to adjust the white balance.
6.3.1.2 Light guide cable

It is also important to pay attention to the light guide cable, which is responsible for
transmitting light from the light source to the endoscope. Light guide cables contain
multiple glass fibres, which can melt due to heat generated during light
transmission. Another cause of loss of glass fibres is breakage due to kinking of the
light guide cable. Light guide cables should be controlled regularly. Objective
assessment of the quality of a light guide cable can be done using a lux meter that
measures transmitted light. If such a device is not available, the light cable should
be attached to the light source, which is turned on at its lowest setting. When the
end of the light cable is inspected at an angle almost parallel to its surface,
defective glass fibbers can be noted as black dots allowing estimation of the
remaining functioning fibbers (figure 6.9). Careful handling and avoiding impact will
preserve the longevity of these cables.
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Normal cable Cable with few Cable with many

broken fibres broken fibres
Figure 6.9 Schematic view of broken fibres of the light guide cable.
6.3.1.3 Endoscope
The next step is checking the endoscope. The eyepiece of the endoscope should be
inspected for obscuring spots. Glancing through the endoscope will reveal distortion
of the image or blurred spots, which require repair of the endoscope. The resolution
and distortion characteristics of the endoscope can be measured by using a test
chart. A simple rough method for determining broken or melted fibres of the
endoscope is to hold the distal tip of the endoscope in the direction of a ceiling or
operating lamp. As in the light guide cable, broken or melted fibres will be visible as
black dots at the connector for the light guide cable at the proximal part of the
endoscope (figure 6.10). The larger the diameter of the cable, the more it heats the
endoscope and thereby the more fibres will melt.
Normal endoscope Endoscope with few Endoscope with

broken fibres many broken fibres
Figure 6.10 Schematic view of broken fibres of the endoscope.
6.3.1.4 Camera
When proper functioning of the light source, light guide cable, and endoscope has
been confirmed, the camera system needs to be tested. The heart and soul of the
endoscopic image is the camera system, consisting of chip camera and camera unit.
The chip camera is exposed to repetitive mechanical injury by storing it in the
endoscopic working unit or by dropping it. Proper functioning of the chip camera
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can be assessed by employing a test chart (Berber et al., 2002). When such a test
chart is not available, the quality of the chip camera and the camera unit can be
determined by focusing the camera while not attached to the endoscope on an
object with coloured details in the operating room. When these details are not
projected with sufficient acuity on the endoscopic screen, another chip camera
should be attached to the camera unit to rule out malfunction of the chip camera. If
the poor image persists upon attachment of another chip camera, the camera unit
requires resetting or overhaul. The setting of the camera unit requires regularly
review by technicians.
6.3.1.5 Monitor
The monitor displays the final image. In general, the monitor is not subjected to as
much wear and tear as the other components of the imaging chain. The most
common problem is the manipulation of the monitor controls. Poor adjustments of
these controls can degrade an excellent quality input (Schwaitzberg, 2001). The
monitor can be easily calibrated by using the reset button on the remote control.
Newer monitors have auto calibration programs whereby the colour bars are
displayed from the camera and the calibration program properly adjusts the
brightness/contrast.
6.3.1.6 Poor image during endoscopic surgery

Fogging of the endoscope is one of the most common and annoying imaging
problems, which occurs during endoscopic surgery. It jeopardizes the safety of the
endoscopic procedure as the view of the operative field becomes unclear.
Extraperitoneal surgery appears to be complicated more frequently by fogging than
intraperitoneal surgery. Fogging is caused by deposition of vapour on the tip of the
endoscope and most often occurs when the lens tip is introduced into the
abdominal cavity where the temperature and humidity are higher than the
extracorporeal environment. To prevent fogging, heating the endoscope in a warm
water bath has been advocated but does not appear effective. Some have
suggested that insufflating cold and dry carbon dioxide should occur through a port,
which is not used for insertion of the endoscope. However, this measure does not
prevent fogging as well. A double walled tube that is slipped over the endoscope
has been developed to spray the tip of the endoscope. Use of this device requires a
12 mm trocar to allow insertion of a 10 mm endoscope with this spraying device.
Spraying saline or water through this double walled tube cleans the tip of the
endoscope but usually leaves a droplet on the lens, which distorts the image.
Another approach to the problem of fogging is the use of a specially designed
fogless laparoscope (Hashimoto & Shouji, 1997).
107
Various agents are available to clean the tip of the endoscope. Most of these agents
contain a detergent, which decreases the surface tension of fluid on the lens of the
endoscope.
The surface of the liver can be used as well to clean the tip of the endoscope unlike
other intraperitoneal structures. The nature of the cleaning capacity of the liver
surface is unknown.
A deteriorating image during endoscopic surgery can be due to increased

absorption of light by accumulated blood. Evacuating the blood can improve the
clarity of the image. Another possibility to improve the light intensity is to zoom out
as much as possible.
6.3.1.7 Sterilization
Cleaning and sterilization of the endoscope deserves special attention. In a
crossover, clinical study performed by the Departments of Surgery of the Erasmus
University Medical Centre Rotterdam and the Reinier de Graaf Gasthuis in Delft the
impact of cleaning of endoscopes was investigated. At the hospital in Rotterdam
fogging was rarely encountered while fogging was common at the hospital in Delft.
Endoscopes were exchanged between hospitals and subjected to local cleaning and
sterilization standards. After 3 to 5 cleaning and sterilization cycles in Rotterdam,
fogging of endoscopes from Delft disappeared while the opposite occurred in Delft
with the endoscopes from Rotterdam. Studying the cleaning procedures in both
hospitals revealed that endoscopes were cleaned with methylalcohol and acetone in
Delft. The endoscopes in Rotterdam were cleaned with ethylalcohol and after
sterilization, a layer of silicone was sprayed on the endoscopes. Therefore, the
cleaning process of endoscopes appears of importance. Silicone application can
prevent fogging. This is in line with the observation that the tip of the endoscope
can also rather effectively be cleaned by rubbing the tip against the surgeons glove
with contains silicone.
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6.3.1.8 Tips and tricks
Inadequate lighted image

Components Solution
Light source Set the light source on automatic or manual max. Replace bulb if
recommended period of time is reached
Light guide cable Check the light guide cable for damaged fibres
Adjust connection to the light source
Endoscope Check the endoscope for damaged fibres
Operative field Excessive blood leads to absorption of light. Proper irrigation and suction
should give a better view
Blurry image
Components Solution
Endoscope Clean the tip of the endoscope (with warm water)
Try the use of anti-fogging agents
Camera White balance the camera
Fine tune the camera
Monitor Correct adjustment of the monitor controls
Distortion of the image

Components Solution
Endoscope/camera Use a test chart to define the distortion and resolution characteristics
to assess the quality of this components
Heat generation
Check the diameters of the connectors between light source, light guide cable and
endoscope
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This chapter is based on the following book chapter:
Albayrak A, Wauben LSGL, and Goossens RHM. Ergonomics in the Operating Room Design framework. (2008).
Accepted as book chapter in Ergonomics: Design, Integration and Implementation by Nova Science Publishers, Inc.
110
CHAPTER 7 DESIGN FRAMEWORK FOR
DESIGNERS: CASE STUDIES
In this chapter three cases will be discussed which describes medical product
solutions in the three domains of ergonomics; sensorial, cognitive and physical
ergonomics. In Case 1, the design of an abdominal wall tension measurement
device will be discussed followed by the second case which shows how the
ergonomics of minimally invasive surgery can be improved by means of an
integrated surgical suite. Finally, within the physical domain, the design of a curved
instrument for minimally invasive surgery to improve surgeons body postures will
be illustrated. All the cases will be discussed along the different phases of the basic
design cycle according to Roozenburg & Eekels (Roozenburg & Eekels, 1995).
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7.1 INTRODUCTION
7.1.1 Design framework

According to Roozenburg and Eekels product development is a goal-directed
thinking process in which problems are analyzed, objectives are defined and
adjusted, proposals for solutions are developed and the quality of those solutions is
assessed (Roozenburg & Eekels, 1995). This thinking process and the procedures
that industrial designers follow can be structured by design methodology. Design
methodology provides designers with knowledge on the design process and also
provides a body of methods and rules to be used in designing. Nearly all rules and
methods for designing are heuristics; these help in finding a solution for some
problems, but do not guarantee that a solution will always be found.
Before discussing the structure of a design process, the term design has to be
defined. The focus is on designing material products and therefore design is
defined as to conceive the idea for some artifact or system and/or to express the
idea in an embodiable form (Roozenburg & Eekels, 1995).
Roozenburg and Eekels describe designing as a special form of problem solving and
reasoning which takes place from goal (the function) to means (the design)
(Roozenburg & Eekels, 1995). As in problem-solving in general, in designing many
means can realize the goal and it is initially uncertain what means is (the most)
effective. It therefore needs no further explanation that design is in essence a trial-
and-error process that consists of a sequence of empirical cycles, in which the
knowledge of the problem as well as the solution increases spirally. The basic
design cycle is illustrated in figure 7.1
Figure 7.1 Basic design cycle according to Roozenburg and Eekels (Roozenburg & Eekels, 1995).
112
CHAPTER 7: DESIGN FRAMEWORK FOR DESIGNERS: CASE STUDIES
As illustrated in figure 7.1 the design cycle consist of different stages. The stages in
the gray boxes have a divergent character, which means that the designer should
look very broadly to the content. Conversely, the white boxes have a convergent
character and define the focus of the content for the next step. The design process
is iterative and it comprises a sequence of reductive steps and deductive step
(Roozenburg & Eekels, 1995). The designer compares the so far attained results
and the desired results between these two steps. The different stages will be
discussed briefly.
7.1.1.1 Analysis phase

Generally, an assignment or a direction for a new product idea is provided whereby
also the target group is defined. In the analysis phase the designer starts to explore
the problems around the new product idea, do research on the target group and try
to get insight in their world. This explorative research will result in a problem
statement. The problem statement should reflect on, who have the problem, what
is the problem and what causes this problem. Within this problem statement the
designer and his/her team has to define their goals clearly to be able to assess later
whether the design proposal is indeed a solution of the defined problem. A list of
requirements is mostly drawn up. This is a tool to define the goal more clearly and
represents the design specifications, which define the design space for the next
step.
7.1.1.2 Synthesis phase

In this phase a provisional design proposal is generated. It is a crucial phase since
the creativity of the design team plays an important role. In this phase, the
designer makes a synthesis of the separate ideas, solutions, and present
information to make an integral solution. The design proposal generated in this
phase is a possibility to solve the problem of which the value will be assessed in the
later phases of the design cycle.
7.1.1.3 Simulation phase

According to Roozenburg and Eekels simulating is forming an image of the
behaviour and properties of the designed product (Roozenburg & Eekels, 1995). In
product development often the term prototype is used which represents the
properties of the new product idea as closely as possible. These properties are
related to technical functioning, ergonomics, and the semantic and aesthetic values
of the product idea. Simulation of the product gives the design team an impression
of the expected functioning in a certain context. This can be done in many different
ways but user research gives the design team a well-considered feedback about the
expectations of the user of the product, the actually usage, the interaction,
anthropometrics and technical functioning.
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7.1.1.4 Evaluation phase

In this phase the value of the provisional design proposal is assessed by testing,
which means the expected properties are compared with the desired properties as
formulated in the design specifications.
7.1.1.5 Decision
The expected and desired properties will always differ from each other but it is
important to decide if those differences are acceptable or have to be redefined.
Since the design cycle is iterative the design team can return to the synthesis
phase, for example to generate a better design proposal or to define different
design specifications which fit better or formulate recommendations to approve the
design proposal.
The basic design cycle as illustrated in figure 7.1 is the most fundamental model of
designing and it can be perfectly used with different kind of methodologies.
7.1.2 Methodology
The medical specialists are professional users with their specific needs, work
conditions, language, culture and work environment. When designing products for
professional users their involvement in the design process is crucial since designers
can use their input to improve the design proposal. A methodology, which can be
used from this perspective, is Participatory Design which actively involves the
user into the design process, leading to the designed product that meets the users
specific needs.
Participatory Design (PD) is an approach that is characterized by concern with a

more humane, creative, and effective relationship between those involved in
technologys design and its use (Namioka & Rao, 1996). PD is started in Norway in
the late 60s and early 70s with the development of the first object-oriented
programming language. Since its inception more and more product designers are
using this approach during their product development. PD assumes that:
Users are experts; PD acknowledges the importance of using the expertise of
users and treating them as equal partners on a design team.
Tools should be designed for the context in which they will be used; PD realizes
that an important step to designing new tools is to know where these will be
used and in what context. This makes it difficult to design a tool away from the
environment in which it will be used.
There should be methods for observing or interviewing end-users; to gain an
understanding of the environment in which the product will be placed and used,
there are several techniques used to watch, observe, and interview users in their
workplace.
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Recreating or play-acting a work situation will facilitate the design phase; it

mediates the expectations of the users by not providing a non-functional
prototype at the very beginning of the design phase.
Iterative development is essential; the ideal PD project has several iterations of a
design-feedback loop, where the designers ask the user for their opinion.
Hereafter three cases will be discussed regarding the three domains of ergonomics
and the phases of the design cycle.
7.2 CASE I: SENSORIAL ERGONOMICS Abdominal wall tension

measurement device
Text is based on and drawings are derived from the master thesis of N.A. Alvarez. Graduation project
Delft University of Technology, Faculty of Industrial Design Engineering. (Alvarez, 2006).
7.2.1 Analysis Phase
The abdominal wall is an important structure serving many different functions

(Grässel et al., 2005). The two major functions are movements of the trunk and
regulation of intra abdominal pressure. Moreover, it supports respiration and plays
a role in stabilization of the spine. All these functions are facilitated by the
coordinated and task specific activation pattern of the abdominal muscles. Due to
its vital related functions, the abdominal wall is impossible to keep motionless even
for a short period (Junge et al., 2001).
7.2.1.1 Intra Abdominal Pressure (IAP)

Intra Abdominal Pressure (IAP) is the internal force that counteracts with the
abdominal wall tension. As defined by the World Society of the Abdominal
Compartment Syndrome IAP is the pressure concealed within the abdominal
cavity (www.wsacs.org) (figure 7.2) .
Figure 7.2 Intra Abdominal Pressure (IAP).
115
As mentioned before, muscles and IAP are directly related to each other (changes
in posture and actions that involve abdominal muscles activation have an effect on
the IAP). When IAP is measured in healthy non-obese adults during 13 different
actions, the highest IAP was generated while coughing and jumping. It was also
found that IAP correlated with the Body Mass Index (BMI) (Cobb et al., 2005).
7.2.1.2 Palpation
There are different methods of physical examination of the abdomen: observation
(inspection), percussion, auscultation (listening to the internal sounds of the body)
and palpation. During superficial palpation the specialist assesses the abdominal
area by evaluating with his/her hand the tension (tonus), tenderness and soreness
of the abdominal wall as well as the presence of superficially localized resistances.
The quality of the examination depends on specialists experience and the
cooperation of the patient during this examination (figure 7.3).
Figure 7.3 Palpation of the abdomen.
7.2.1.3 Problem statement

From literature it can be concluded that the abdominal wall tension is related with
the IAP, which can influence the wound healing process. Therefore, abdominal wall
tension is probably associated with development of incisional hernias (Cobb et al.,
2005; Park et al., 2006; Song et al., 2006).
IAP is currently measured by means of the bladder pressure, performed invasively

with a urinary catheter and is considered an important element to be controlled
after abdominal surgeries. IAP is an active measure influenced by many different
elements such as the organs location and the abdominal walls muscular behaviour.
For research purposes the abdominal wall tension can be calculated through
mathematical models. In practice it is estimated qualitatively by means of palpation
but there are no quantitative measurements done in patients yet.
If the abdominal wall tension could be measured by means of a non-invasive

device, research could be done to evaluate its relation in the development of
abdominal conditions such as incisional hernia. Although many research would be
116
necessary to find if there is a relation between the abdominal wall tension and the
development of incisional hernias (or any other abdominal condition), the design of
a device to measure such tension could be an initial step in that direction.
The aim of this project was to design a device that measures the abdominal wall
tension non-invasively.
7.2.1.4 User research: observational research

To gain insight into the palpation process and to identify possible common
procedural elements in the patient-specialist interaction, two different specialist
were observed; an obstetrician and a gastroenterologist. Although the objectives of
the examination and the patients abdominal walls muscular behaviour are different
by these specialists, they both use their hands to evaluate the condition of the
abdominal area, and they both first asses the tension and general situation of the
abdominal wall. The observations focused on:
Actions of the specialist during palpation.
Other factors that could have an influence on the outcome of the examination,
e.g. environment, kind of patient, etc.
In addition, both specialists were interviewed before and after the examination.
The results of the observations and interviews showed:

During the examination of the abdominal wall different kinds of feedback are
used for prognoses;
Hardness of the abdomen is relatively evaluated with the reaction of the
patient.
General geometry of the abdomen, and expected situation of the structures
underneath the irregularities.
For assessment of the abdominal walls tension, both specialists pressed with a
line of fingers (one or two hands indistinctively) and evaluate the amount of
force needed to indent the fingers.
Concerning the interaction, the patient had to be kept as relaxed as possible to
perform the examination.
7.2.1.5 Technical research

The technical research aimed to answer the questions related to the
measurements: how to measure? and where to measure? Force measurement tests
were done on different points on the abdominal wall with an existing force
measurement device. These points on the abdominal wall reacted differently on the
force measurement.
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7.2.1.6 List of requirements

The requirements, expressed in terms of needs and desires, were divided in
Technical and Use because these were the two main concern areas for the
design of the device.
Technical requirements were derived from the technical research and were
complemented with those necessary to enable the usage of the tool in a clinical
research setting. Grouped in Input, Data processing and Output, these
requirements were addressed mainly to software qualities, although the inclusion of
the position measurement involved usage qualities with impact either on the
hardware and/or the software.
The applied requirements (grouped in specialist and patient) included those

elements that would have an indirect impact, through the actions or reactions of
the users during the measurements. From this set those requirements related to
the patient where directed to the tools aspect and interface that should point to
keep the patient relaxed.
Summarizing, the concept development should focus on a design for a device to

measure the abdominal wall tension by means of force and distance. To facilitate
research purposes, the possibility to record elements correlated with the basic
measurements, as well as the option to measure and tracks one to seven different
points on the abdomen should be included. Such device should be possible to be
used in a clinical setting (e.g. intensive care unit, examination room), considering
the patients reaction on the measurements.
7.2.2 Synthesis Phase

Based on the list of requirements four concepts were developed. The main intention
was to explore and define the interaction between the specialist, the device, and
the patient. The main aim was to consider different possible ways in which the
measurements could be performed in a fast and efficient way while the patient was
relaxed. These concepts were evaluated afterwards concerning their feasibility to be
made into prototypes in a short time.
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Table 7.1 Concepts

Concepts Mean features
Concept 1 Soft, warm and semi transparent material containing an
array of coupled force and distance sensors.
One side ended in the microprocessor, which included input
(touch screen or buttons) and output (screen, USB port to
download information, etc.) and on the opposite side a
counter weight fixed the belt.
As the different sensors were fixed on the belt, which at the
same time was centre with the middle line and the navel,
there was no need to leave marks on the patient or on the
device to recognize the points measured the previous time.
Concept 2 A pair of glove like devices with the sensors in the core
and an external replaceable latex protection, which can be
used in a similar way as current palpation procedure.
On the navel a kind of Global Positioning System (GPS)
tracked the position of the measurements every time the
hand sensors were activated, sending the sensors
information along with the relative coordinates.
All the components were linked to a microprocessor to
control the sensors and store the obtained data.
Concept 3 A soft blanket of an elastic material, located over the
patients abdomen to keep the abdomen warm, intended to
enable the specialist to measure on the entire surface as it
tracked the point where the pressure was applied.
The hand held device measured distance and the blanket
measured force and position.
Information from the hand device was transmitted wireless
to the microprocessor.
The big surface area covered sufficiently both thin and big
abdomens.
Concept 4 One hand tool with one pair of force and distance sensors
held by the specialist over the patients abdomen.
For tracking the points, a grid of silicone with wholes that
recorded the position of the measurement.
Also connected to a microprocessor.
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7.2.2.1 Concept evaluation

For the evaluation of the four concepts a selection of the list of requirements was
made. The concepts were evaluated regarding: cost, availability of components,
amount of parts, easiness of use and technical complexity. The fourth concept was
chosen, as it contained the fewer components, which were commercially available
(except from the positioning grid). Another important feature of the chosen concept
was its possibility to be modified, as the hand tool could be updated without
necessarily affecting the software.
7.2.3 Simulation Phase

The chosen concept was re-evaluated and the functions were divided into hardware
and the software, looking for flexibility, efficiency, and possible cost reduction. One
of the main changes made during detailing was the elimination of the silicone-
positioning surface. Its functions were reassigned. Regarding the internal detailing,
once the sensors were defined and their dimensions known, sketches were done to
define the structure. A prototype of the design proposal was built to evaluate the
dimensions, construction, and function of the internal structure (figure 7.4). The
final shell was made by means of rapid prototyping for user research. Figure 7.4
presents the prototype and figure 7.5 a rendering of the final design.
Figure 7.4 Prototype
Figure 7.5 Rendering of the final design.
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7.2.4 Evaluation Phase

The prototype was evaluated in an experimental setting (figure 7.6). Eight different
points were measured regarding the exerted force and the distance. The prototype
was connected to a PC for data recording.
Figure 7.6 User research.
The prototype could transport the recorded values of force and distance correctly to
the PC. The prototype was used without any problems.
7.2.5 Decision Phase
During this phase several recommendation were made:

The force sensor used in the user research should be replaced with a calibrated
one and the software should be detailed to subtract the resistance of the spring
in the measurements.
The interface has to be transferred from a desktop version to the pocket PC
version. This interface is necessary if the test is going to be done in the clinical
setting.
In a clinical setting the prototype should be evaluated to assess how patient
characteristics like BMI, age, gender, etc influence the measurements. This test
could be used to estimate the possibilities and limitations of the tool.
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7.3 CASE II: COGNITIVE ERGONOMICS - Improving ergonomics of

minimally invasive surgery - getting the most out of an
integrated suite
Text is based on and drawings are derived from the master thesis of G. Scheepens, graduation project
Delft University of Technology, Faculty of Industrial Design Engineering (Scheepens, 2007).
7.3.1 Analysis Phase

The Karl Storz OR1 integrated suite is implemented in one of the ORs of a teaching
hospital. This integrated suite is capable of providing an ergonomically sound
working environment, but now it is not used to its full potential. An explorative
observational study showed that indeed the positioning of supporting equipment is
a major source of physical inconvenience for the surgical team. Therefore, this
project focused on the positioning of surgical monitors. During the developments of
the concepts two surgical procedures were kept in mind, laparoscopic
cholecystectomy (LC) and gastric bypass. These procedures were chosen because
the LC takes only 45 minutes and are performed mostly by novice surgeons while
the gastric bypass takes up several hours and is performed by an expert surgeon.
During these procedures the designed product needs to ensure an ergonomically
sound surgical monitor placement.
The aim of this project was to improve patient safety by enhancing the working
environment of the surgeon, creating an ergonomically sound workspace for the
surgical team, focusing on the positioning of surgical monitors, where correct
positioning is defined as compliance with the ergonomic guidelines. Many other
factors influence the working environment, ranging from the design of instrument
handles to the illumination of the operating room.
The problem to solve within this project reads as follows:

Design of a product that supports users in placing monitors in an ergonomically
optimal position. It should work with or be an add-on to the Karl Storz OR1
integrated suite. A connection needs to be made between the ergonomic
possibilities the integrated suite offers and OR staff who actually uses these
possibilities.
The main problems identified were:

Awareness: Observance of ergonomic guidelines during surgery needs to be
enforced and encouraged. This includes communicating that there is a possibility to
adjust the settings and why it is important to do so.
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Interaction: Optimal configuration of the equipment needs to be apparent during

its positioning. This includes feedback about what the correct settings are, what
these are for and how these can be adjusted.
Continuity: For every MIS procedure correct positioning is needed and therefore
must invoke its use every time a procedure is prepared.
To solve the problem, its sub-problems have been divided over the seven
characteristics of good interaction design to provide focus points during the
synthesis (Saffer, 2007). The characteristics are of equal importance.
1) Trustworthy
The product should prove that it is capable of helping the circulating nurse the
monitors, it will be likely that there will be surgeons that demand a different
setting than the optimal.
Availability of the product is essential, it should always work and be present and
not be especially be switched on or fetched from afar.
To get the surgical team to trust the product, results are essential, on short term
in the form of feeling of working in an environment adapted to them and in long
term as decrease of physical complaints.
2) Appropriate
The product should fit with the OR environment and work within its boundaries.
Its communication should be innovative, inviting and effective; it should not take
away attention from more important informational devices.
The boundaries of OR1 should also be respected (not hinder other functionalities
of OR1).
Although the product should somewhat force its use on the users, it should allow
its users to have the freedom to do what they like.
The desire to use the product should be directed at the surgical team and the
circulating nurse, while the how of the use should be directed towards the
circulating nurse.
The product should be self-explanatory.
3) Smart
The product should support its users in doing that what can be difficult in the
demanding OR environment, remembering to position monitors, guidance in
where monitors should be placed and propagate the need for positioning the
monitors.
The positions for the monitors are not absolute and need to be adjusted to the
surgeon, specific procedures and to other equipment. Not always is the most
ideal position the most optimal position. It is up to the product to direct towards
preferred positions and prevent incorrect positioning.
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There are many skills that are better developed in humans than in machines and
the products responsibilities should not try to replace those skills.
4) Responsive
The product should communicate incorrect positions as well as correct positions,
without annoying users by creating saturated feedback in which important
changes are difficult to detect.
5) Clever
Using the product should ease workload, by taking away confusion and
disagreement about what the correct positions of the equipment are. Taking
away confusion about how settings relate to the human body and who has set
specific preferences and what these are as well.
6) Lucid (playfulness)
Making errors in positioning monitors should be made difficult instead of
displaying warnings. The opportunity to undo and redo actions is also important,
so the users cannot get the feeling that pressing a button can get them trapped
in a part of the system they do not need to visit. Confirming key actions comforts
the users and reassures them that accidentally pressing a wrong button cannot
lead to serious consequences. This last option gives them the opportunity to use
and learn the system by browsing around, without it having serious
consequences.
7) Pleasurable
There are two sides to pleasure in using products: aesthetic and functional.
People are more easily content with the performance of a beautiful product,
products that look good are more pleasurable in use and will be used more and
better (Tractinsky et al., 2000). Not neglecting this quality needs to be combined
with the product functioning properly, obviously improper functionality leads to
frustration and irritation in product use.
The product does not need to fit the visual aesthetics of OR1s software since
these are about to change drastically in the near future.
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This list of requirements is based on the problem definition and design vision and
Bittermans specific conditions and restrictions typical for the OR (Bitterman, 2006).
1. The product will need to be used by inexperienced and experienced users, since
in some hospitals the employee directory can change rapidly.
2. During some procedures two people view one monitor.
3. The maximum time during which the product can be used is three minutes.
4. There is no time for users to learn how to use the product.
5. Before the first trocar is inserted the preparation of the procedure needs to be
complete, this includes equipment positioning which should not hinder other
parts of the preparation.
6. During the procedure the system should not hinder any activities and should
comply in case of unforeseen events (e.g. converting a MIS procedure to an open
procedure).
7. Therefore the product should
a be silent.
b not take up much space.
c not cause electromagnetic disturbances.
d not interfere with sterility during the procedure.
e not affect the OR temperature.
f not interfere with the illumination of the procedure (cast shadows, etc.).
g not be visually distracting.
8. The products performance should not be affected by the characteristics of the
OR environment. The product should be able to withstand
a the vapours caused by surgery.
b moisture deposits on it.
c thorough cleaning activities
9. The product should always be directly available, charged and switched on when
OR1 is in use.
10. The product should posses a possibility to have its standard settings changed
and have personalized settings created.
11. The life span of the product should be longer than at least ten years.
7.3.2 Synthesis phase
7.3.2.1 Idea evaluation

Eight ideas for equipment positioning were generated and evaluated along the
design vision based on the factors awareness, feedback, continuity, and viability
(figure7.7). Other factors contributing to the evaluation are the positives and
difficulties of every idea.
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Figure 7.7 First-phase ideas: Eight ideas meeting the requirements and evaluated (rating in stars) on
four aspects: Awareness, Feedback, Continuity and Viability. The italics lines capture the reasons for
the particular ratings in a single line.
Figure 7.7 provides a quick assessment of all the ideas pros and cons, but some
influence the choice for a particular idea more than others. Awareness, feedback
and continuity are equally important, but a high score on viability is essential for
the successful implementation of an idea on short term. A low-tech solution has the
most potential at the moment. The first-phase ideas (figure 7.7) are technically
quite complex and will be difficult to prototype and are more future solutions. Of
the first-phase ideas, ideas 5 and 8 seem to be the most promising. Idea 7 does
not comply with the need to be an add-on for the integrated suite and advice is a
126
relatively expensive solution (viability problems). Finally, the visual feedback

solution was chosen to elaborate.
Figure 7.8 Second-phase ideas: Evaluation on eight aspects of two promising design directions.
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7.3.3 Simulation phase

The most viable concept was the visual feedback solution in which a Light Crystal
Diode (LCD) screen on the monitors back gives feedback on the ergonomics of the
monitor position. A user research was designed mainly to test the usability of the
product. Though initially planned, approximate positioning could not be tested. The
product was validated with a simulated prototype in the hospital. The set-up
consisted of a cart that was used for MIS before the integrated suite became
available, with a boom-arm attached monitor (figure 7.9). At the back of the
monitor a small video display was attached that displayed the image from a camera
mounted on top of the monitor. A laptop was used to project an image overlay on
the video.
Figure 7.9 Set up user research.
There are several points of attention that emerged from the user research. Most
importantly, distance assessment needs to be improved. The reaction of the
surgical team towards the product (or at least towards someone looking into this
matter) is favourable. This can also be concluded from the fact that 21 subjects
participated in just a few hours and the fact that in the afternoon people started to
come in after hearing about the user research from colleagues.
7.3.4 Evaluation phase

The results of the user research are used to improve the design proposal (figure
7.10). The essential element of the final product is the LCD that communicates
ergonomic positioning of all team members to the circulating nurse. They are the
people that have the most direct need for feedback about equipment positioning
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and are most likely to welcome it. This feedback on the LCD is available during the
entire procedure; the LCDs are mounted to the monitors backs and their
illumination is therefore directed away from the surgical team.
Figure 7.10 Final design.
7.3.5 Decision phase
The final design proposal should be evaluated with the users.

Regarding the results of this user research the final design proposal should be
improved for production.
Future versions need to be integrated and joint ventures need to be considered, to
be able to provide a complete solution.
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7.4 CASE III: PHYSICAL ERGONOMICS - Design of a handle for

curved instruments
Text is based on and drawings are derived from the master thesis of F. Hoolhorst, graduation project
Delft University of Technology, Faculty of Industrial Design Engineering (Hoolhorst, 2005).
7.4.1 Analysis phase

Minimally invasive surgery (MIS) is a universally adopted way of surgery next to
the conventional open procedures. The patient benefits from MIS. However, the
disadvantage for the surgeon and his team are bad ergonomics, longer operation
times, higher budget for OR equipment, less freedom of movement and the need of
extra training. Therefore, new methods and products to improve MIS are regularly
introduced.

At this moment, most of the instruments that are used during MIS are straight and
long instruments. It is believed that curved instruments might offer a solution to
some ergonomic problems of the surgeon (figure 7.11). Especially when used in
solo-surgery, i.e. a form of surgery in which the numbers of team members is
minimized.
Figure 7.11 A curved and straight instrument.
The current curved instruments still introduce many problems in the field of
physical and cognitive ergonomics. Van Veelen states that problems in this field
may lead to higher muscle-activity of the surgeon, resulting in fatigue and
discomfort for the surgeon, excessive pressure on sensitive areas of the hand and
fingers causing nerve injuries (van Veelen, 2003). The aim of this project was to
improve the handle of a curved instrument, paying extra attention to ergonomic
problems of the current handles.

Literature was reviewed on curved instruments, handles for MIS instruments,
anatomy of the shoulder, elbow, wrist and hand and body posture. In addition, a
practical study to evaluate the use of current curved instruments in the OR was
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performed A set of requirements for the new handle was formulated. The most
important requirements are described below.
Functional requirements
The handle allows one-handed use.
The handle can be used with an existing shaft.
The handle allows force grip and precision grip.
The handle incorporates opening and closing of the tip.
The handle allows for fixation of the tip.
The relation between force exercised on the handle for opening a closing of the
tip and the force on the tip is between 1:5 and 1:7.
Ergonomic body posture and instruments comfort

The handle can be held comfortably for different rotations within certain limits.
The handle should be operated by the sensitive area of the hand.
Functional elements like buttons should be easy accessible.
The shaft of the instrument has to be in-line with rotation of the forearm.
Low muscle activity is necessary to manipulate the functional elements.
7.4.2 Synthesis phase
Based on these requirements different ideas were generated. Several product ideas
were based on a bar shaped grip (figure 7.12). Other ideas were based on pistol
handles (figure 7.13) and finally mouse handles were sketched (figure 7.14).
Figure 7.12 Product ideas for a bar shape grid.
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Figure 7.13 Product ideas for a pistol handle.
Figure 7.14 Product ideas for a mouse grip.
Based on these ideas two concepts for a new handle were introduced. The handles
shape was based on different clay models and technical principles for opening,
closing, and fixation of the instruments were made (figures 7.15 and 7.16).
Figure 7.15 Concept 1.
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Figure 7.16 Concept 2.
7.4.2.1 Idea evaluation

The concept choice is based on the evaluation of the idea regarding the general
guidelines and requirements that were defined earlier in this project. The
requirements were of equal importance. The concept meeting the most
requirements was chosen for further development. Some of the requirements could
not be used during this phase. Concept 1, based on the mouse grip, met 12 of the
important requirements, against Concept 2 that met only 10. Therefore, Concept 1
was chosen to be materialized.
7.4.3 Simulation phase
The final design was based on the grip of a ball of Ø50 mm. This ball shape has two
asymmetric surfaces, which provide the surgeon a more stable grip. Also by doing
so, the grip provides the surgeon feedback on the orientation of the tip. The shape
of the buttons has been optimized in order to improve the control. Figure 7.17
shows the final product design.
Figure 7.17 Final product design.
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7.4.4 Evaluation phase

The prototype was evaluated in a simulated environment in the OR (figures 7.18
and 7.19). The tasks of the subjects were to cut out a circle (diameter 40 mm),
which was drawn on a piece of paper. For executing this task, in the left hand the
curved instrument was held. Each subject had to perform the test twice, namely
with a straight instrument and with a curved instrument with the new handle.
During execution of the user research, the body posture was recorded with two
cameras. After the user research, the posture was visually inspected every ten
seconds during the task and the following joint angles were measured:
Angle of the elbow.
Flexion and extension of the wrist.
Horizontal flexion of the shoulder.
Pronation and supination of the forearm.
Figure 7.18 User research in a simulated OR environment.
Figure 7.19 User research during cleaning and sterilization.
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The results of the user research are shown in figure 7.20. The results are based on
a comparison, which was made with an existing straight instrument. The circle
diagrams give insight into the subjects body posture during the user research.
These show how long a certain posture was adopted. The green parts show how
long a body posture was adopted regarding the ergonomics guidelines. Practically,
no differences could be found in the elbows posture. For both instruments, the
angle between the upper arm and forearm was almost constantly held in the green
zone. It seems that instruments handles do not only influence the posture of the
elbow. Elbow posture is mainly influenced by the height and the angle of the
instruments tip. The main difference in body posture could be found in the flexion
and extension of the wrist. With the prototype, the wrist was adopted in an
ergonomic posture for 85% of the time. The horizontal flexion of the shoulder was
always within the ergonomic zones. There was a slightly difference in the pronation
and supination of the forearm. The posture using the prototype was 20% of the
time not in the ergonomic zone and for the curved instrument this was 26%.
Figure 7.20 Results of the user research.
7.4.5 Decision phase

At the end of the project it was concluded that the new handle design has many
advantages with respect to the already existing MIS handles.
7.4.5.1 General design

The new handle provides an integral design solution. The ball shape allows hiding
controls that can disturb the surgeon during his activity.
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7.4.5.2 Ergonomic comfort

The user research results indicated that many ergonomic advantages are expected
for the handle. The handle also allows the surgeon to assume a more ergonomic
posture.
7.4.5.3 Indications from the user research

Remarks of the test subjects during the research indicated that the new handle did
not cause pressure points on the hand during use. Furthermore, subjects
experienced the prototype as comfortable. Another advantage is that both hands
can use the handle.
7.5 CONCLUSION
This chapter showed the several disciplines of ergonomics and its related problems.
All of projects are developed and researched by means of the basic design cycle of
Roozenburg and Eekels as a design framework. Within each design cycle all
domains of ergonomics are included. However, the focus is different. In addition,
the problem statement and the amount of available information in analysis phase
influences the outcome of other phases. For example, in case of product redesign
information on working principles, material, production, and usage are already
available. These can be used as valuable input for the synthesis phase. In case of a
new innovative product no information is available. This has to be researched in the
analysis phase, reducing the amount of time to be spent in other phases such as
evaluation by means of user research.
This shift of focus is reflected in the three described cases. The differences are
discussed briefly.
7.5.1 Case I: Sensorial Ergonomics – Abdominal wall tension

measurement device
The starting point of this case was rather hypothetical. The assumption was that
the abdominal wall tension was probably associated with development of incisional
hernia. There was no quantitative method available to measure the abdominal wall
tension directly on patients abdomen which means that questions as: What to
measure? How to measure? and Where to measure? arise.
The hypothesis that abnormalities in the abdominal wall tension were associated
with development of incisional hernia was an answer to the question What to
measure?. By measuring the abdominal wall tension an indication of a potential
development of incisional hernia was obtained. The next question was How to
measure?. The performed observational research and interviews with the
specialists gained insight into which factors are relevant to formulate a prognosis.
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From this research it has concluded that the level of force exerted needed to indent
the fingers was a valuable feedback for the specialist. An existing force
measurement device was used to evaluate this principle. Since the abdominal wall
has different structures it was important to assess, which points will provide reliable
data. As should be clear the design team had a lack of knowledge and therefore
from a very early phase in the design process input from research and feedback
from the user was needed. The adjusted design cycle for this case is illustrated in
figure 7.21.
Input from
observational
research and
interviews
Input from technical
research performed
with an existing force
measurement device
Figure 7.21 Adjusted design cycle Case I.
The outcome of this project was a working prototype. With this working prototype
user research was performed to evaluate the design proposal. Because of the
extensive analysis phase, which was time-consuming, the user research was only
superficial. However, the design proved to be a good starting point for further
product development.
7.5.2 Case II: Cognitive Ergonomics – Improving ergonomics of minimally

invasive surgery- getting the most out of an integrated suite.
The starting point of this case was very different from the previous case. There was
already an integrated suite available and this suite was capable of providing an
ergonomically sound working environment. Therefore, define the pre-conditions of
the design proposal. However, the ergonomic possibilities were not used to its full
potential. Design teams approach was: first assess why the surgical team was not
137
using the already existing functionality and second how to convince them to use the
functionalities. After an observational study, it became clear that the positioning of
supporting equipment was a major source of physical inconvenience for the surgical
team. The focus was on positioning the surgical monitors. Anticipating on future
developments, OR aesthetics and usage, the design had to be an interface.
Therefore, approach from the interaction design was chosen as a starting point.
Seven characteristics of a good interaction design, which were already evaluated by
other experts, were used during synthesis phase to convince the surgical team
about its benefits. As should be clear the design team already knew in an early
phase of the design process what to design and therefore the project focused on
how to design. The adjusted design cycle for this case is illustrated in figure 7.22.
First feedback from

user research
Results of user
research led to
improvements of the
design proposal
Figure 7.22 Adjusted design cycle Case II.
The outcome of this project was a detailed simulation. The performed user research
with this simulation was in-depth resulting in an improvement of the design
proposal.
7.5.3 Case III: Physical Ergonomics – Design of a handle for curved

instruments
The starting point of this case was as Case I rather hypothetical. The assumption
was that curved instruments might offer a solution to some ergonomic problems
experienced by the surgeon. Although, this case had a hypothetical starting point
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there were differences with Case I. In this case, there was an existing curved
instrument, which had limitations that had to be improved. This well-defined and
focused starting point of the process increases the level of elaboration in the next
phase of the design cycle. In the synthesis phase next to the drawings, early
models (i.e. clay models) were used to evaluate the shape and some technical
principles. This gives the design team the advantage of anticipating on the future
use of the product. With the knowledge gathered from the first user research the
quality of the final design proposal was improved. The adjusted design cycle for this
case is shown in figure 7.23.
Knowledge gathered
from existing
curved instrument
User research with

early design models
to evaluate the
shape and technical
principles
In-depth user
research by
comparing the
existing curved
instruments with
the prototype
Figure 7.23 Adjusted design cycle Case III.
The outcome of this project was a detailed prototype. With this prototype, a user
research was performed whereby the existing straight instrument was compared
with the prototype of the design proposal. The results of this user research were
sufficient to evaluate the design proposal objectively.
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CHAPTER 8 DISCUSSION
The transition from open to image-based surgery has changed surgical practice in
many perspectives as a consequence of application of advanced high technology in
the operating room. The increasing dependency on technology to perform surgical
procedures has introduced ergonomic problems for the surgical team (Berguer,
1999). From this perspective it is not surprising that most of the errors in
healthcare are related to surgical procedures (Kohn et al., 2000; Moorthy et al.,
2004; Verdaasdonk et al., 2007). Therefore there is a societal motive to improve
patient safety by reducing medical error rates (IGZ, 2007). Hence both the surgical
environment and the human-product interaction have to be analyzed and improved
(Cuschieri, 2000; Verdaasdonk et al., 2007).
Patient safety and surgical quality are two notions, which are related to each other.
Patient safety can be improved by enhancing surgical quality. Surgical quality can
be influenced by a variety of organizational and social aspects such as time
pressure and inadequate team work but also by human-error due to poor
ergonomic conditions such as excessive workload, fatigue, poor human-product
interaction, etc (Moorthy et al., 2003a; Reyes et al., 2006). Improvement of
surgical quality requests a multi-disciplinary approach, focusing on technology-
driven trends and on the other side on societal motive and ergonomics. This
includes designs aimed at satisfying human needs and extending possibilities for
the medical staff, like nurses, medical specialists and for patients. Besides involving
the problems of human-product interaction and the development of new
technologies, multi-disciplinary approach also guard the improved opportunities and
working conditions of specialists.
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For the Faculty of Industrial Design Engineering (IDE) it means that it will have to
educate designers capable of translating the practical needs of the healthcare
sector into products specially designed for medical applications in low-tech as well
as high-tech applications. In this way, they can contribute to the diagnosis,
treatment and prevention of disease and disorders (Goossens et al., 2007).
8.1 Design framework
8.1.1 Methodology
At the start of a design process the design team often knows little about the user
group, the context and the interaction between the user and their environment.
When a design team is involved in the development of a healthcare system they
need to gain a total overview that often goes beyond their own knowledge (Kersten
et al., 2007). The medical specialists are professional users with specific needs,
work conditions, language, culture and work environment. For a design team the
first step to understand the problems of the user is gaining insight into the
profession of the user group. A design team will get familiar with their profession
and problems by literature study, observations, and interviews. The obtained
information from practice will be a good start for the design team in the design
process. Especially when the user group and their context are unknown for the
design team, field research is a suitable method to explore and obtain information
from the first hand (Babbie, 2004). Field research has a high ecological validity
since all restrictions and conditions from practice are involved in the research.
However, field research has its restrictions. Compared with experimental study,
field research measurements generally have more validity but less reliability. Also,
field research is generally not appropriate for statistical analysis (Babbie, 2004) but
the results of a field research are necessary to make assumptions regarding
observed problems. These assumptions can further be tested in an experimental
research. In this controlled research environment the design team can study the
relationship between independent and dependent variables (Graziano & Raulin,
2000). Experiments are suitable for the controlled testing of causal processes
(Babbie, 2004). The primary weakness of an experiment is artificiality. The results
of an experiment may not reflect the real world (external invalidity) (Babbie, 2004).
In this PhD-research both field research and experimental research is applied
(figure 8.1).
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CHAPTER 8: DISCUSSION
Figure 8.1 Overview of the research methods used in this PhD-thesis.
In Chapter 4 study on the discomfort during surgery and evaluation of the

developed ergonomic body support as a product solution is discussed. This study
starts with a field research wherein observations in the operating room and
interviews with users were done. In addition, from the early beginning of the design
process the user was involved. In the regular meetings with the users the possible
solutions and argumentations were discussed. The gathered information during
meetings with the users where used to improve the design proposal. In these
interactive meetings, feedback to the user was important to check if the knowledge
gathered from the user was interpreted correctly by the designer. Feedback from
the user provides knowledge from the professional users to the design team and
serves as an early evaluation of possible solutions. This early evaluation affects the
level of detail of the final design proposal. In the case of the body support (Chapter
4) a working prototype was built whereby different aspects of the design proposal
could be evaluated. The final evaluation of the design was done with surgeons in
the operating room. This way of user research allows the designer to validate the
design proposal within the limitations and restrictions of the operating room. Next
to the field study also an experimental study was done in a lab-setting wherein the
muscle activity was measured. The advantage of such a controlled experiment was
the possibility to look at interrelationships and validate the theoretical
biomechanical model.
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In Chapter 5 the study on image quality is discussed. This study was explorative of
character and is conducted in the operating room. During this study it was hard to
control the research set-up. Between two procedures there was limited time to do
measurements and simultaneously the patient had to be transported and the
operating room had to be cleaned and prepared for the next procedure. Collecting
data in this atmosphere was challenging. The measurements were standardized as
far as possible and therefore gain good insight into the practice. However, by
analyzing the data it became clear that some assumptions, such as the surgeons
subjective experience of the displayed image, could not be verified. Since this
research was conducted in field there were restrictions to control the research
setting. It might be interesting to study surgeons subjective experience of the
displayed image in a controlled experimental setting.
Either in field research or experimental studies, involvement of the user in an early

stage of the design process is essential. Where the user can indicate and describe
their problems and needs, the role of the design team is to discover the
relationships between product usage, context, and user problems. Both field
research and experimental studies are valuable and will provide the design team
information and new perceptions necessary for the design process.
8.1.2 The basic design cycle

The basic design cycle according to Roozenburg and Eekels is a framework that can
be used during product development. The iterative process of the basic design cycle
gives the possibility and flexibility to involve the user in each design step
(Roozenburg & Eekels, 1995).
The cases discussed in Chapter 7 show examples how user research is integrated
into the design process. These cases also show that the problem statement and the
amount of available information in the analysis phase influence the outcome of the
next phases. For example, in case of redesign, information on working principles,
material, production, and usage are already available for valuable input for the
synthesis phase. In case of innovative products no or little information is available
which has to be researched in the analysis phase, reducing the amount of time to
be spent in next phases such as evaluation by means of user research.
A hypothetical start like in Case I, extends the analysis phase. Due to lack of
existing or similar products, it is time-consuming to collect the relevant information.
Because of time constraints of the project the user research in the end of the
process could only be carried on a small amount of data. The outcome was a good
starting point for further product development.
144
A start whereby the preconditions of the design proposal are already defined but
ergonomic possibilities of the design proposal are not used to its full potential like
Case II asks for a different approach. The design team already knew in an early
phase of the design process what to design and therefore the project focused on
how to design. The outcome of this project was a detailed simulation and the user
research was in-depth resulting in an improvement of the design proposal.
In a redesign project like Case III the starting point was hypothetical but there was
an existing product, which had limitations to improve. This well-defined and focused
starting point of the process increases the level of elaboration in the next phase of
the design cycle. In the synthesis phase next to the sketches, early models (i.e.
clay models) were used to evaluate the shape and some technical principles. This
gives the design team the advantage of anticipating on the future use of the
product. With the knowledge gathered from the first user research the quality of
the final design proposal was improved. The outcome of this project was a detailed
prototype. With this prototype, a user research was performed whereby an existing
laparoscopic instrument was compared with the prototype of the design proposal.
The results of this user research were sufficient to evaluate the design proposal.
The products designed at IDE include user research in different phases of the
design cycle, in which the intended end-users are actively involved. However, this
research sometimes has to be conducted in an experimental setting. Especially
when designing products for the OR, it is difficult to test these in the sterile field.
8.2 Surgical Quality
From an ergonomic point of view the surgical quality can be defined as; the level
of efficiency, safety and comfort of a surgical procedure (van Veelen, 2003).
Efficiency was defined as the coefficient between effort and benefit. In this
definition effort also implies product life span and learning and understanding the
use of the product (e.g. it can take several months to learn how to perform a task
without errors). Safety deals with the wellbeing of the user (in the case of
minimally invasive surgery also the wellbeing of the patient) and the prevention of
injury. Comfort was defined as a physical and mental state in which one is not
aware of any discomfort.
In this PhD-thesis the relationship between the three notions of surgical quality is
interpreted as; By creating a comfortable working environment for the surgical
team the efficiency of the procedure may increase since less effort is needed to
achieve the same result. Because of the increased comfort and efficiency, patient
safety may improve since the surgical team may concentrate more undisturbed on
their primary task, namely performing a surgical procedure (figure 8.2).
145
Figure 8.2 The three notions of surgical quality.
The study on the physical discomfort of surgeons has resulted in development of an

ergonomic body support. It was well-known that surgeons had physical complaints
due to their poor body posture during surgery but a relevant product solution for
this situation was not available (Albayrak et al., 2007; Berguer, 1996, 1997;
Berguer et al., 1997; Kant et al., 1992; Mirbod et al., 1995; Nguyen et al., 2001;
Schurr et al., 1999; van Veelen et al., 2003b; Vereczkei et al., 2004; Wauben et
al., 2006). Preliminary the design proposal, analysis was done and a biomechanical
model was used to verify the supporting principle. Of the final design proposal a
working prototype was built and user research was done. During this user research
it is shown that muscle activity, which was a measure of discomfort, is reduced by
using the body support and surgeons found the body support comfortable in use.
An user research wherein the product solution was evaluated with 16 participants
shows that users adapting different balancing strategies while using the body
support. It seems that different kind of users exists and the level of experienced
comfort may depend on how the body support is used. These intra-individual
differences in usage will influence the efficiency and therefore also the safety. It is
hard to measure the improvement of surgical quality objectively. However, the
results of these studies have created awareness among the surgeons about their
poor body posture, showed that a solution is available and lead to different practical
ergonomic solutions (Chapter 6) which they can apply in the operating room.
The study on image quality was a large-scaled research in which 36 Dutch hospitals
participated. The number of the involved hospitals makes the findings
representative. In spite of the societal motive to improve patient safety it was
surprisingly to discover that at the time of visits almost none of the visited hospitals
146
tested the components of the imaging chain regularly and components were only
tested in case of malfunctioning. The results of this study shows a variety of
imaging systems used in hospitals and that a large number of endoscopes and light
guide cables had insufficient light transmission qualities. The findings of this study
have lead to the realization and the importance of introduction of a quality control
program. After the visits already some of the hospitals introduce the quality control
program in their hospital. Furthermore, a recently published report by the Dutch
Inspection of Health Services The underestimated risks of minimally invasive
surgery refers to the first publication of this study and pleads for introduction of
quality control program on national level. Since most of the errors in healthcare are
related to surgical procedures, regularly controlling the equipment is not a
redundant action and will reduce the product related problems.
8.3 Future research
During this PhD-thesis research has been done on the ergonomics in the operating
room. During the PhD-project, new research areas have been defined. The result of
the study discussed in Chapter 4 shows that users adapting different balancing
strategies while using the same product in the same context. This leads to the
question of which aspects define the intra-individual differences. A research on this
topic may gain insight into the considerations, which a user makes while using a
product. The study in Chapter 5 discusses surgeons subjective experience of the
displayed image. More research on this topic seems interesting to discover the
relation between the quality judgment of the surgeon and the arguments of making
a judgment. Finally, another interesting research area is on the applied
methodology when designing for professional. The research on this topic may lead
to improvements of design methodology for development of products for the
operating room.
147
148
SUMMARY
At several specializations, more often minimal invasive procedures are performed in

addition to open surgery. Laparoscopy is a minimal invasive technique, which is
carried out in the abdominal cavity. The first laparoscopic cholecystectomy, removal
of the gallbladder, was performed in Germany in 1985 by a surgeon named Eric
Mühe and since then this type of procedure is worldwide applied. This popular
technique has become the gold standard for gallbladder removal and provides
many advantages for the patient.
The first step of a laparoscopic cholecystectomy starts with inflating the abdomen
of the patient with carbon dioxide. By several small incisions, laparoscopic
instruments with which the surgeon performs the procedure are inserted into the
abdomen cavity. The dark abdominal cavity becomes illuminated by a light guide
cable, which is connected to one end with a light source and at the other end with
the endoscope, which is positioned in the abdomen. The endoscope transmits the
image of the abdomen of the patient by means of a camera to a monitor. The
surgeon performs the procedure based on this image. Concerning the sterility, the
required equipment is positioned on a trolley, which stands outside the range of the
surgical team.
In spite of the fact that surgical principles are the same for open and laparoscopic
procedures, laparoscopy has changed the way of interaction between the surgical
team and the operating field in many ways. These changes however have not led to
the required adaptations in the operation room to improve the surgical quality and
to optimize the work conditions of the surgical team. In this respect, ergonomics
can play a role to fit the work environment to the user and improve the surgical
quality accordingly.
The aim of this thesis is to improve the surgical quality by applying ergonomics
(physical, sensory and cognitive) in the operating room.
149
First, in chapter 2, the ergonomic problems are discussed with sub-chapters in

physical, sensory, and cognitive ergonomics. In open surgery, these problems are
frequently of a physical nature. The physical complaints are often caused by the
uncomfortable posture and the occasional need to exert substantial forces on
tissues during the surgical procedures. In comparison with laparoscopic surgery,
the sensory and cognitive problems are relative less at open surgery. By the
presence of a large incision, the surgical team can see, feel, and manipulate the
organs. This way of interaction is more natural than during laparoscopy. The
interaction between the operating field and the surgical team has changed with
laparoscopic surgery since the surgeon must manipulate the instruments and
perform the procedure by means of the image on a monitor. During a laparoscopic
procedure, the tactile feedback is limited and there is no direct perception of the
organs. Frequently, the surgeon stands uncomfortable and by the static posture,
physical complaints are experienced. The problems appear in the sensory area are
mostly caused by the incorrect positioning of the monitor, which often cannot be
positioned according to the ergonomic guidelines, namely in the field of view of the
surgeon and in line with the work area of the hands. On cognitive field problems
occur as a result of intrinsic factors of laparoscopic viewing.
In chapter 3, the current situation in the Dutch hospitals concerning ergonomics

and the aptitude of the operating rooms for laparoscopy is mapped out. For this
research, twenty-nine hospitals where visited and an inventory of their equipment
such as trolleys and monitors, which are necessary to perform a laparoscopic
surgery, has been made. In addition, the dimensions of the operating rooms and
height adjustments of the operating tables have been recorded. The results of this
research show that most of the operating rooms are not optimally equipped to carry
out laparoscopic procedures. They have been built initially for open procedures and
are often too small. Most of the monitors are positioned on a trolley that is not
adjustable in height, which results in the monitors not standing in an ergonomic
eye level. The operating tables could not be positioned, ergonomically seen, low
enough for laparoscopy. Mainly by the small number of monitors and their wrong
position, the surgical team frequently has an uncomfortable posture. The solutions
and directives, which were raised in this study, were related to correctly positioning
the monitors according to the ergonomic guidelines and optimizing the position of
the surgical team with respect to the present monitors.
The topics discussed in the previous chapters create an overview of the daily
ergonomic problems, which the surgical team experiences as well as the
possibilities, and insights of improving the surgical quality and work conditions of
the surgical team.
150
SUMMARY
The physical complaints and the discomfort that the surgical team experiences
during open and laparoscopic procedures has to do with uncomfortable posture,
incorrect working height, fatigue due to static body posture and raised muscle
activity to balance the body. In chapter 4, a product solution is proposed and the
evaluation of this solution is discussed. The product solution, which is discussed in
part 1 of chapter 4, is a body-support that supports surgeons at both open and
laparoscopic procedures in their natural posture. The design process is described by
means of the design cycle. A working prototype shows that the product solution
meets the requirements of compactness, mobility, adjustability and is suitable for
surgeons with different body statures. The first evaluation takes place with the
surgeons in the operating room. In part 2 of chapter 4 the biomechanics, as
underlying theory for the product solution, is deeper discussed. A research is done
on the reduction of muscle activity by product use.
Chapter 5 aims at the sensory and cognitive aspects of laparoscopic procedures and
in particular at image quality during laparoscopic surgery. This study consists of
objective and subjective measurements in thirty-six Dutch hospitals. The collected
data did show that the quality of the components of the imaging chain was not
optimal and that most hospitals did not have the equipment to test these
components. There were large differences in light intensity of the image chain
between the different hospitals and several types of surgical procedures.
Chapter 6 reflects on the problems, which are described in chapter 2, and raises
applicable practical ergonomic solutions. This chapter has been in particular
intended for surgeons who want to tackle the problems, which appear during the
procedures.
Chapter 7 on the other hand, has been intended for the designers and describes the
steps of the design cycle in a number of cases. These cases are subdivided in
physical, sensory, and cognitive ergonomics and are related to the medical product
development.
In chapter 8, different methodologies applied in this thesis are explained. Two

methods field research and experimental study are distinguished and the
advantages and disadvantages of these methods are discussed within the context
of this thesis. The design cycle of the cases, which are described in chapter 7, is
assessed. It emphasizes (i) how the different steps of the design cycle influence
each other, (ii) the role of the user research within the design cycle and (iii) how
these two influences the development level of the product solution. The influence of
the different studies, discussed in this thesis, on the improvement of the surgical
quality is evaluated and, finally, a couple of interesting research directions, which
can be studied more closely, are outlined.
151
152
SAMENVATTING
Bij verschillende specialisaties worden naast open chirurgie steeds vaker minimaal
invasieve ingrepen uitgevoerd. Laparoscopie is een minimaal invasieve techniek die
in de buikholte wordt uitgevoerd. De eerste laparoscopische galblaas verwijdering
werd in 1985 door chirurg Eric Mühe in Duitsland uitgevoerd en sindsdien wordt dit
type operaties wereldwijd steeds vaker toegepast. Deze populaire techniek is de
gold standard voor galblaas verwijdering geworden en kent vele voordelen voor
de patiënt.
De eerste stap van een laparoscopische galblaas operatie begint met het opblazen
van de buik van de patiënt met koolstofdioxide. Door kleine incisies worden
laparoscopische instrumenten in de buikholte gebracht waarmee de chirurg de
operatie uitvoert. De donkere buikholte wordt verlicht door een lichtkabel die met
het ene uiteinde verbonden is met de lichtbron en het andere uiteinde met de
endoscoop die zich in de buikholte bevindt. De endoscoop brengt het beeld via een
camera over naar een monitor waarop het inwendige van de patiënt te zien is. De
chirurg opereert aan de hand van dit beeld. De benodigde apparatuur staat op een
trolley die buiten het bereik van het chirurgisch team staat in verband met de
steriliteit.
Ondanks het feit dat de chirurgische principes hetzelfde zijn voor open en
laparoscopische ingrepen, heeft laparoscopie de manier van interactie tussen het
chirurgische team en het operatiegebied op vele manieren veranderd. Deze
veranderingen zijn echter niet gepaard gegaan met de benodigde aanpassingen in
de operatiekamer om de kwaliteit van een chirurgische ingreep te verbeteren en de
werkomstandigheden van het chirurgisch team te optimaliseren. In dit opzicht kan
ergonomie een rol spelen om de werkomgeving aan te passen aan de eisen van de
gebruiker en daarbij de kwaliteit van de operaties te verbeteren.
153
Het doel van dit proefschrift is om de kwaliteit van de operatie te verbeteren door
het toepassen van ergonomie (fysieke, sensorische en cognitieve ergonomie) in de
operatiekamer.
Als eerste worden de ergonomische problemen met een onderverdeling in fysieke,

sensorische en cognitieve ergonomie in Hoofdstuk 2 besproken. Bij open chirurgie
zijn deze problemen vaak van fysieke aard. De fysieke klachten worden vaak
veroorzaakt door de oncomfortabele houding en de noodzaak van het uitoefenen
van kracht tijdens de operaties. In vergelijking met laparoscopische ingrepen zijn
bij open operaties de sensorische en cognitieve problemen relatief minder. Door de
aanwezigheid van een grote incisie kan het chirurgisch team de organen zien,
voelen en met de hand manipuleren. Deze manier van interactie is natuurlijker dan
bij laparoscopie. De interactie tussen het operatiegebied en het chirurgisch team is
bij laparoscopische ingrepen veranderd aangezien de chirurg de instrumenten moet
manipuleren aan de hand van het beeld dat op een monitor te zien is. Bij deze
interactie is de tactiele feedback beperkt en er is geen directe perceptie van de
organen. De chirurg staat vaak oncomfortabel en door de statische houding ervaart
hij/zij fysieke klachten. De problemen die optreden in het sensorische vlak worden
veelal veroorzaakt doordat de monitor niet volgens de ergonomische richtlijnen
gepositioneerd kan worden in het zichtveld van de chirurg en in lijn met het
werkvlak van de handen. Op het cognitieve vlak treden problemen op als gevolg
van intrinsieke factoren van het laparoscopisch beeld.
In hoofdstuk 3 wordt de huidige situatie van de Nederlandse ziekenhuizen met

betrekking tot ergonomie en de geschiktheid van de operatiekamers voor
laparoscopie in kaart gebracht. Voor dit onderzoek zijn er in totaal negenentwintig
ziekenhuizen bezocht en is er een inventarisatie gemaakt van de apparatuur dat
nodig is om een laparoscopische ingreep uit te voeren zoals: trolleys en monitoren.
Hiernaast zijn de afmetingen van de operatiekamers en de hoogte instelling van de
operatietafels bepaald. De resultaten van het onderzoek tonen aan dat de meeste
operatiekamers niet geschikt zijn om laparoscopische ingrepen uit te voeren. Ze
zijn oorspronkelijk ontworpen voor open operaties en zijn daardoor vaak te klein.
De meeste monitoren zijn gepositioneerd op een trolley die niet in hoogte instelbaar
is, waardoor de monitoren niet op een ergonomisch verantwoorde ooghoogte staan.
De operatietafels kunnen ergonomisch gezien niet laag genoeg ingesteld worden
voor laparoscopie. Voornamelijk door het geringe aantal monitoren en hun
verkeerde positie, stond het chirurgisch team over het algemeen in een
oncomfortabele houding. De oplossingen en richtlijnen die in deze studie worden
aangedragen, hebben betrekking op een correcte positionering van de monitoren
volgens de ergonomische richtlijnen en optimalisatie van de positie van het
chirurgisch team ten opzichte van de aanwezige monitoren.
154
SAMENVATTING
In de voorgaande hoofdstukken is een beeld gecreëerd van de ergonomische

problemen waar het chirurgisch team dagelijks mee te maken heeft, evenals de
mogelijkheden en inzichten om werkomstandigheden van het chirurgisch team te
optimaliseren en zo de kwaliteit van de chirurgische ingreep te verbeteren.
De fysieke klachten en het discomfort dat het chirurgisch team tijdens open en
laparoscopische ingrepen ervaart heeft te maken met oncomfortabele houding,
verkeerde werkhoogte, statische belasting en verhoogde spieractiviteit om het
lichaam te balanceren. In hoofdstuk 4 wordt een productoplossing aangedragen en
de evaluatie van deze oplossing besproken. De productoplossing die in deel 1 van
hoofdstuk 4 wordt besproken is een lichaamsondersteunend product dat de
chirurgen bij zowel open als bij laparoscopische ingrepen ondersteund in hun
natuurlijke werkhouding. Het ontwerp wordt procesmatig beschreven aan de hand
van de ontwerpcyclus. Een werkend prototype laat zien dat de productoplossing
voldoet aan de eisen van compactheid, mobiliteit, instelbaarheid en geschiktheid
voor chirurgen met verschillende lichaamsbouw. De eerste evaluatie vindt plaats
met de chirurgen in de operatiekamer. In deel 2 van hoofdstuk 4 wordt dieper
ingegaan op de biomechanica als onderliggende theorie voor de productoplossing.
Een uitgebreid onderzoek wordt gedaan naar de reductie van spieractiviteit door
het productgebruik.
Hoofdstuk 5 richt zich op de sensorische en cognitieve aspecten van

laparoscopische ingrepen en in het bijzonder op de beeldkwaliteit tijdens een
laparoscopische ingreep. Deze studie bestaat uit een reeks objectieve en
subjectieve metingen in zesendertig Nederlandse ziekenhuizen. De verzamelde data
geeft aan dat de kwaliteit van de componenten van de beeldketen niet optimaal zijn
en dat er in de meeste ziekenhuizen geen richtlijnen aanwezig zijn om deze
componenten te testen. Er zijn grote verschillen in lichtintensiteit van de
beeldketen tussen de verschillende ziekenhuizen en verschillende soorten operaties.
Hoofdstuk 6 reflecteert op de problemen die in Hoofdstuk 2 zijn beschreven en

draagt in de praktijk toepasbare ergonomische oplossingen aan. Dit hoofdstuk is in
het bijzonder voor de chirurgen bedoeld die op een snelle manier de problemen
willen aanpakken die optreden bij het uitoefenen van de operaties, door het
toepassen van de besproken oplossingen.
Hoofdstuk 7 is daarentegen bedoeld voor de ontwerpers en beschrijft de stappen

van de doorlopen ontwerpcyclus aan de hand van een aantal casus. Deze casus zijn
onderverdeeld in fysieke, sensorische en cognitieve ergonomie en hebben
betrekking op de medische productontwikkeling.
155
In hoofdstuk 8 worden eerst de verschillende methodologieën die zijn toegepast in

dit proefschrift, besproken. Hierbij wordt onderscheidt gemaakt tussen field
research en experimental study en worden de voordelen en nadelen van deze
twee onderzoeksmethoden binnen de context van dit proefschrift besproken. De
ontwerpcyclus van de casus die in hoofdstuk 7 zijn behandeld wordt gediscussieerd.
Hierbij ligt de nadruk op (i) hoe de verschillende stappen van de ontwerpcyclus
elkaar beïnvloeden, (ii) de rol van het gebruiksonderzoek binnenin de
ontwerpcyclus en (iii) hoe de eerste twee het uitwerkingsniveau van het
eindproduct bepalen. Er wordt gereflecteerd op welke bijdrage de verschillende
onderzoeken hebben geleverd aan het verbeteren van de surgical quality. Tot slot
worden paar interessante onderzoeksrichtingen uitgestippeld die nader bestudeerd
kunnen worden.
156
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162
ACKNOWLEDGEMENT
It is an exceptional and a pleasant feeling to write my acknowledgement. It is

exceptional because it is introducing the end of my PhD-research and at the same
time, it is a milestone in my career. It is pleasant because I can finally thank all the
people who were involved in my PhD-research. Without their contribution and
support, I would not have been able to do my PhD-research and to write this thesis.
First of all, I would like to thank my supervisors Huib de Ridder and Jaap Bonjer for
their guidance and support during my PhD-research. Dear Huib, I have learned a lot
from your scientific character, critical and valuable feedback. You have introduced
me in the world of statistics and yes, I believe that a nice graph can tell more then
just a thousand numbers. Dear Jaap, your critical and open-minded attitude
regarding research in the medical field inspired me a lot. Nevertheless, I was the
only engineer in your research group when started my PhD-research in Erasmus MC
and from the first day, I had the feeling that I was a member of great medical
family.
My dear co-promoter Richard Goossens. You have played a multidimensional role

during my PhD-research. You are an inspiring mentor when we discussing the
research and writing an article. You are a valuable colleague when we are
discussing about education and brainstorming about new challenging studies. You
are a lovely friend who is always prepared to listen. Thanks for filling these
revealing roles and for the confidence that you had in me.
My dear mentor Chris Snijders. You were the first person who introduced me in the
academic world. You took my hand and said, you can do it, go Arma an. I always
have the feeling that I can count on you in difficult times. This has encouraged me
to keep going. Thanks for being there and for your valuable support.
163
My dear mentor Geert Kazemier. I want to thank you for initiating my PhD-research
and for your support throughout the whole process. You were a mentor who was
challenging me and stimulating me to look further than the obvious facts.
My dear collegues from Erasmus MC. I had a great time with you when I was
working at the Z-gebouw. You have included me in your group and taught me to
speak your language. The congresses that we visited together were always a
great experience! I will never forget you guys!
I would like to thank the Erasmus Medical Centre for facilitating and financing the
first two years of my PhD-research. The first year was financed by the Department
of Surgery, by my supervisor Jaap Boner and the second year by the Department of
Operating Room, by Geert Kazemier. I would also thank the employees of Erasmus
Medical Centre for their contribution to my PhD-research.
Dear Dirk Meijer. I would like to thank you for your contribution and support.
I would thank the hospitals, who participated in the studies, for their contribution
and hospitality. Their contribution was essential to collect the valuable data.
I would like to acknowledge the companies for providing me the equipment and
tools, which I have used during my studies.
Dear Sacha Silvester and Linda Roos from DDI. When I was came back to the
faculty in 2004, my first workplace was in DDI. DDI is a place where the openness,
warmness, and multidisciplinary approach of Industrial Design meet each other. It
is open because of the construction, it is warm because of the people who are
working there and it is multidisciplinary because the harmony between the different
specialisms. I had a wonderful time in DDI. Thanks for everything!
Dear Linda. In the course of time, we got closer and now you are more a friend
than a colleague for me. Our belly dance and aqua aerobics courses were a
pleasant activity during our hectic PhD-research. Our conversations were
sometimes emotional, sometimes funny and sometimes work related. We cried and
laughed together but the most important for me was that you were always there to
support me! Thanks!
Dear Sonja. I can remember our first meeting in DDI before you start with your
PhD. My first impression was, what an enthusiastic and inquisitive person. These
164
ACKNOWLEDGEMENT
characteristics made our talks never dull and we had many common issues to
discuss. Thanks for your reliable friendship!
My dear roommate Marijke. When I was employed for my new job, our ways have
met in room 3B-11. In my first year as UD, you were always there to share your
experience and gave me tips and tricks regarding the educational responsibilities. I
have discovered that you have a strong intuition on personal and professional level,
which provides me with different insights on different topics. You are the cool
mom of Elissa and I am very glad to share a room with you. Thanks for
everything!
Dear Stella and Annelise. You have warmly welcomed me in your group and the
door of your room was always open for me. You were always prepared to listen and
think along with me. You have made the difficult times easier to pass. Thanks!
Dear Martine van Veelen. I would like to thank you for your support and
contribution to my PhD-research. With your thesis, you have created a valuable
basis on which I built on.
Dear Johan, Rick, Arnold, Marijke, Iemkje and Adinda. I would like to thank you for
the nice talks that did brighten me up and provided me with new energy to go on.
Dear Daan. I am very glad to be a member of your team Applied Ergonomics and
Design. I am looking forward for to coming years because there are many
opportunities to explore together.
Dear Mirjam, Daphne, Amanda, and Monique. Our lovely secretaries of Department
ID. I would like to thank you for your support and assistance throughout the whole
project. The warmness and the smiles on your faces make you special!
Dear PhDs of the faculty. The different cultures and researches among the PhDs in
our faculty have enriched my perception in many ways. Thanks for the interesting
discussions and for the nice social events, we had. It is always fun to be with you!
My dear paranimfs, Elif and Mano. These two persons represented with their
profession, the two worlds of my PhD-research. On the one hand a designer and on
the other hand a medical specialist. These two persons are also representing a
unique friendship. Elif you are my kader arkada m. We have many familiarities
like our roots, which are in Turkey, but also like our future, which is here in
Holland, in the faculty of Industrial Design Engineering, where we are so proud of.
You are a lovely friend. Mano thanks for providing me with knowledge about the
medical world and, thanks for being my friend and my paranimf.
165
A special thanks in Turkish for my lovely parents. Canm annem ve babam. Sizin
bana olan büyük deste iniz ve ba araca ma olan inanciniz benim bu günlere
gelmemi sa lad. Sizin kznz oldu um için gurur duyuyorum. Her ey için
te ekkürler!
Dear Metin, Rina, Yasmin, Kirsten and my parents in law. It is great to have you on
my site. The difficult times would not have passed easily without your
encouragements and warm support. Thanks for everything!
My dear husband René. As none other person, you experienced the more
unpleasant side effects of being married with someone who was finishing her PhD.
Regardless of my moods, changing from emotional, stressful, bad-tempered, etc.,
you always succeed in relaxing me and gave me the comfortable feeling again. You
were always standing behind me, which makes me confident in what I was doing.
A km, thanks for being there today and in the future!
166
CURRICULUM VITEA
Arma an Albayrak was born in Ankara, Turkey on December 16th 1975. In 1993,
she finished her high school education in Izmir, Turkey. The same year she came to
Holland and did her entrance examination for a study on Delft University of
Technology. In 1994, she started with her study Industrial Design Engineering at
the Delft University of Technology. In 2002, she received her master degree at this
faculty. The same year she started with her PhD-research titled Ergonomics in the
operating room: transition from open to image-based surgery. Her PhD-research
was in cooperation with the Erasmus Medical Centre (EMC) in Rotterdam. In the
first two years of her PhD-research she was situated in EMC.
In 2004, she came back to the faculty Industrial Design to finish her PhD. Since
July 2007, she has been employed as an Assistant Professor at the department
Industrial Design, section Applied Ergonomics and Design. Her responsibilities
include both research and teaching in the field of ergonomics, medisign, usage
evaluation methodology and biomechanics.
167
168
OVERVIEW PAPERS
Albayrak A, Wauben LSGL, and Goossens RHM. Ergonomics in the Operating Room
Design framework. (2008). Accepted as book chapter on Ergonomics: Design,
Integration and Implementation by Nova Science Publishers, Inc.
Albayrak A, Goossens RHM, Snijders CJ, de Ridder H, Kazemier G. Impact of a

chest support on lower back muscles activity during forward bending. Submitted
(2008).
Albayrak A, Casseres YA, de Ridder H, Goossens RHM, Kazemier G, Meijer DW,

Bonjer HJ. Objective and subjective evaluation of image quality during minimally
invasive surgery. Submitted (2008).
Wauben LSGL, Albayrak A, and Goossens RHM. Ergonomics in the Operating Room
An overview. (2008). Accepted as book chapter on Ergonomics: Design,
Integration and Implementation by Nova Science Publishers, Inc.
Wauben LSGL, Albayrak A, de Ridder H, Jakimowicz J. LED versus Xenion surgical

lights: Product evaluation during surgery. (2008). International Conference
Healthcare Systems Ergonomics and Patient Safety June 25/28, 2008.
Albayrak A, and Snijders CJ. (2007). Ergonomy in the OR. In JB Trimbos & GCM
Trimbos Kemper (Eds.), Basics of surgery: Tools, techniques and expertise (pp.
151-169). Maarssen: Elsevier gezondheidszorg.
Albayrak A, van Veelen MA, Prins JF, Snijders CJ, de Ridder H, and Kazemier G.
(2007). A newly designed ergonomic body support for surgeons. Surgical
endoscopy and other interventional techniques, 21(10), 1835-1840.
169
Albayrak A, van Veelen MA, Prins JF, Snijders CJ, de Ridder H., Kazemier G. (2006).
Rugbelasting bij chirurgen tijdens operaties: Het effect van lichaamsondersteuning.
Tijdschrift voor Ergonomie 31 (1): 10-19.
Albayrak A, van Veelen MA, Prins JF, Snijders CJ, de Ridder H., Kazemier G. (2006).
Reducing muscle activity of the surgeon during surgical procedures. In Proceedings
of the 16th World Congress on Ergonomics, Maastricht, The Netherlands:
International Ergonomics Association.
Albayrak A, Goossens RHM, Bonjer HJ, Casseres YA, Kazemier G, de Ridder H.

(2006). Image quality during laparoscopic procedures in practice. In Proceedings of
the 16th World Congress on Ergonomics, Maastricht, The Netherlands: International
Ergonomics Association.
Albayrak A, Kazemier G, Meijer DW and Bonjer HJ. (2004). Current state of

ergonomics of operating rooms of Dutch hospitals in the endoscopic era. Minimally
invasive therapy & allied technologies, 13(3), 156-160. (TUD)
Gerbrands A, Albayrak A, and Kazemier G. (2004). Ergonomic evaluation of the

work area of the scrub nurse. Minimally invasive therapy & allied technologies,
13(3), 142-146. (TUD)
Casseres YA, Albayrak A, Schot C, Grimbergen CA, Bonjer HJ, and Meijer DW.
(2003). Kwaliteit van endoscopische apparatuur en instrumentarium: een
voorlopige rapportage. Nederlands Tijdschrift voor Heelkunde, 12(5), 171-174.
170
G L O SSAR Y
Abduction A movement of a body segment in a lateral plane away from

the midline of the body, such as raising the arm sideways.
Adduction A movement of the body segment toward the midline as
when moving the arm from the outward horizontal position
downward to the vertical position.
Assumptions Basic tenets that form the bases for more
complex scientific theory and research.
Biomechanics Application of mechanical principles on living organisms.
Cognitive The emphasis lies on remembering and processing
ergonomics information; on learning, decision making and judging a
situation. It is strongly based on knowledge of the psychology
of thinking and remembering. The products that support this
part of ergonomics can be schemes of structures, mnemonic
devices, software to control a process and training devices.
Comfort A physical and mental state in which one is not aware.
Dependent A variable assumed to depend on or be caused by another
variable (called the independent variable).
Ecological Experiments achieve ecological validity when they reproduce
validity accurately the real-life situations, thus allowing easy
generalization of their findings to the real world. External
validity and ecological validity are closely related but they are
independent.
Efficiency Efficiency is defined as the coefficient between effort and
benefit. In this definition, effort also implies e.g. product life
span and learning and understanding the use of the product
(e.g. it can take several months to learn how to perform a
task without errors).
171
Ergonomics Human factors discovers and applies information about

(human-factors) human behaviours, abilities, limitations, and other
characteristics to the design of tools, machines, systems,
tasks, jobs, and environments for productive, safe,
comfortable, and effective human use.
Experimental Set of procedures that defines a research study at the
study/research experimental level of constrain. In experimental research,
participants are assigned to groups or conditions without bias,
and all appropriate control procedures are used.
Extension A movement in the opposite direction of flexion which causes
an increase in the angle at the joint, such as straightening the
elbow.
External validity Refers to the possibility that conclusions drawn from
experimental results may not be generalizable to the real
world.
Flexion A movement of a segment of the body causing a decrease in
the angle at the joint, such as bending the arm at the elbow.
Force grip Grip with fingers and thumb around an object.
Force-precision Force grip that allows more precision: fingers are around and
grip object and the thumb is in-line with the forearm.
Independent A variable with values that are not problematical in an
variable analysis but are taken as simply given. An independent
variable is presumed to cause or determine a dependent
variable.
Laparoscopy A minimally invasive procedure within the abdomen.
Minimally Surgery performed through small skin cuts or through the
invasive surgery natural openings in the human body.
Participatory Design method that involves the user group in different
design phases of the design process.
Physical Emphasis lies on the function of the human musculo-skeletal
ergonomics system, which is used to adopt postures, move limbs, and
conduct external forces through the body. On the product
site, this covers products that support the body, tools, and
special outfits.
Precision grip Grip that uses the thumb and distal joints of the fingers to
grasp an object.
Product solution A material solution to accomplish a task.
Pronation Rotation of the hand and forearm that results in a palm-down
position.
172
GLOSSARY
Reliability That quality of measurement method that suggests that the

same data would have been collected each time in repeated
observations of the same phenomenon.
Rotation A movement of a segment around its own longitudinal axis.
Safety Deals with the wellbeing of the user (in the case of MIS also the
wellbeing of the patient) and the prevention of injury.
Sensorial In this area, the focus is on the human senses and human
ergonomics perception. On the product site, this includes products that
support the senses and perception, such as visual displays, but
also tactile displays and auditory displays.
Supination Rotation of the hand and forearm that results in a palm-up
position.
Surgical The level of efficiency, safety, and comfort of a surgical
quality procedure.
173

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ERGONOMICS IN THE OPERATING ROOM

TRANSITION FROM OPEN TO IMAGE-BASED SURGERY

© 2008 Arma an Albayrak

ter verkrijging van de graad van doctor

ingenieur Industrieel Ontwerpen

Dr. G. Kazemier heeft als begeleider in belangrijke mate aan de totstandkoming

Mustafa Kemal Atatürk

CHAPTER 2 AN OVERVIEW OF ERGONOMIC PROBLEMS DURING SURGERY 17

2.1 PHYSICAL ERGONOMICS 18

CHAPTER 3 ERGONOMICS IN THE OPERATING ROOMS OF DUTCH HOSPITALS 31

CHAPTER 4 DISCOMFORT DURING SURGERY: PRODUCT SOLUTION AND

4.1 STUDY I: A NEWLY DESIGNED ERGONOMIC BODY SUPPORT FOR SURGEONS 41

CHAPTER 5 IMAGE QUALITY DURING LAPAROSCOPIC SURGERY 75

6.1 PHYSICAL ERGONOMICS 96

CHAPTER 7 DESIGN FRAMEWORK FOR DESIGNERS: CASE STUDIES 111

7.1 INTRODUCTION 112

CHAPTER 8 DISCUSSION 141

8.1 DESIGN FRAMEWORK 142

CURRICULUM VITEA 167

OVERVIEW PAPERS 169

Minimally invasive surgery is practiced by a growing number of medical disciplines

Laparoscopy refers to minimal invasive videoscopic procedures in the abdominal

Laparoscopy, like open surgery, requires general or regional anaesthesia and is

1.2 SURGICAL TEAM AND WORKING ENVIRONMENT

Figure 1.3 The three work areas in the operating room.

driven trends and on the other side on the social-economic consequences in

Ergonomics discovers and applies information about human behaviour, abilities,

1.3.1 Physical ergonomics

1.3.2 Sensorial ergonomics

1.3.3 Cognitive ergonomics

Here the emphasis lies on remembering and processing information; on learning,

1.5 DESIGN FRAMEWORK

A methodology, which can be used from this perspective, is Participatory Design

characterized by concern with a more human, creative, and effective relationship

Participatory design assumes that:

1.6 OUTLINE OF THE THESIS

Figure 1.4 The outline of the thesis.

1.7 READING GUIDE

Cooperation between two different disciplines Industrial Design and Surgery is

Figure 1.5 Reading guide for different target readers.

2.1 PHYSICAL ERGONOMICS

Performing open surgical procedures has almost always required standing,

Although, during laparoscopy the posture of the surgeon is straight predominantly,

Laparoscopy is implemented in the operating rooms with limited adjustments. The

The configuration of the operating room regarding the ergonomics is restricted

2.1.3.1 Open surgery

Force grip; grip with fingers and thumb around an object.

2.1.5 Lower back

2.1.5.1 Open surgery

The generalized excitation-contraction sequence of a nerve impulse travelling from

ATP (adenosine triphosphate) ADP (adenosine diphosphate) + CP (creatine

rely on a smaller amount of aerobic metabolism and a greater amount of anaerobic

2.2 SENSORIAL ERGONOMICS

The current ergonomic layout of operating rooms with crowding of free-standing

2.3 COGNITIVE ERGONOMICS

(The theory explained in this section is adopted from Cuschieri, 2006a)

2.3.1 Image quality

Laparoscopic surgery is introduced without much consideration for ergonomic

2.3.2 Cognitive problems during laparoscopic procedures

A further perceptual problem in laparoscopy arises from scaling difficulties caused

The various spatial difficulties encountered during laparoscopy result in problems

Additionally, loss in illumination is caused by ageing of the light source and

In an endoscope, the lenses are positioned in the centre surrounded by optical

Ergonomics discovers and applies information about human behaviour, abilities,

Cooperation between two different disciplines Industrial Design and Surgery is