applied

sciences
Article
An Ergonomic Customized-Tool Handle Design for
Precision Tools using Additive Manufacturing:
A Case Study
Alfonso González González 1, * ID
, David Rodríguez Salgado 2 , Lorenzo García Moruno 3 ID
and
Alonso Sánchez Ríos 3 ID
1 Campus of Mérida City, Department of Mechanical, Energy, and Materials Engineering,
University of Extremadura, 06800 Mérida, Spain
2 Campus of Badajoz City, Department of Mechanical, Energy, and Materials Engineering,
University of Extremadura, 06071 Badajoz, Spain; drs@unex.es
3 Department of Graphical Expression, University of Extremadura, 06800 Mérida, Spain;
lgmoruno@unex.es (L.G.M.); schezrio@unex.es (A.S.R.)
* Correspondence: agg@unex.es; Tel.: +34-924-28-93-00




Received: 12 June 2018; Accepted: 18 July 2018; Published: 22 July 2018


Abstract: A study was carried out with 135 surgeons to obtain a surgical laparoscopic grasper handle
design that adapts to the size of each surgeon’s hand, in a functionally appropriate way, and has the
sufficient ergonomics to avoid generating the problems detected nowadays. The main conclusion
of the work is the practical 3D parametric design obtained for a laparoscopic surgical graspers
handle that is scalable to fit each particular surgeon's hand size. In addition, it has been possible to
determine that the anthropometric measure of the surgeon's hand defined as Palm Length Measured
(PLM) allows the design of the 3D parametric model of the surgical handle to be conveniently scaled.
The results show that both additive manufacturing and the application of ergonomics criterion
provide an efficient method for the custom design and manufacture of this type of specialised tool,
with potential application in other sectors.

Keywords: parametric design; anthropometric; custom handle design; rapid prototyping; 3D CAD

1. Introduction
Universal object designs try to fit all users using the criterion known as “design for all” [1].
This criterion is included in the “Universal Design” guide, which in turn lists the “7 principles of
universal design” [2]. One of these principles is to facilitate “flexibility in use”. The proposal by
Mace et al. [2] was further developed by Story et al. [3], in order to make the use of products designed
for the greatest number of people, accessible [4]. To comply with this principle, hand tools in particular
should satisfy a number of guidelines in their design. These include overcoming such obstacles as age,
sex, dexterity, motor skills, etc., and whether the user is right- or left-handed, so that the handles can
be adapted to different hand sizes and shapes.
One of the fundamental problems in hand tool design is in trying to optimize the dimensions of the
tool relative to the hand anthropometry. Another fundamental challenge is faced when trying to make
sure that the shape and dimensions of the design are consistent with the type and specific functionality
of each instrument type [5]. For the instruments used in laparoscopic surgery, Alleblas et al. [6] notes the
need to assess expert opinions regarding the current designs of their handles. This is done in order to
determine surgeons’ needs and expectations with respect to the laparoscopic instruments they currently
use and the possibility of the future implementation of haptic feedback in their design. Other studies,
such as that of Stoklasek et al. [7] on tools used for the assembly of electric motors, show that while

Appl. Sci. 2018, 8, 1200; doi:10.3390/app8071200 www.mdpi.com/journal/applsci

Appl. Sci. 2018, 8, 1200 2 of 13

requirements for the functional parts of the tool (duration, making it impossible to damage the motor’s
installation, etc.) were taken into account in the design, ergonomic requirements for the gripping area
Appl. Sci. 2018, 8, x FOR PEER REVIEW 2 of 14
of the tool were not. Prolonged use of tools with poor ergonomic design was shown to cause discomfort
motors,
resulting in numbnessshow that while requirements
or paraesthesia (“pins for and
the functional
needles”)partsin theof workers’
the tool (duration,
fingers.making it
impossible to damage the motor’s installation, etc.) were taken into account in the design, ergonomic
Hand size is a determining factor in how precision tools, in particular laparoscopic graspers,
requirements for the gripping area of the tool were not. Prolonged use of tools with poor ergonomic
are used [8]. Small-handed
design was shown to surgeons experience
cause discomfort resultingmore grip problems
in numbness than those
or paraesthesia (“pinswith large hands,
and needles”) in and are
forced to hold the handle
the workers’ fingers.differently from what was originally considered in its design phase [8]. Current
Hand sizetools
surgical laparoscopic is a determining
usually come factorinin how precisionsize,
a standard tools,and
in particular laparoscopic
the surgeon must graspers, are
adapt accordingly by
used [8]. Small-handed surgeons experience more grip problems than those with large hands, and
holding and gripping them in certain ways, which a priori depend on the size of his or her hand.
are forced to hold the handle differently from what was originally considered in its design phase [8].
The Current
conventional laparoscopic
surgical laparoscopic toolssurgery
usually comegraspers shownsize,
in a standard in Figure 1 incorporate
and the surgeon must adapt a pistol grip
mechanism with finger
accordingly rings,and
by holding and a mechanism
gripping that ways,
them in certain allows fullarotation
which of the
priori depend on tip of the
the size shaft (upper
of his
part of theorgraspers).
her hand. The three images in the figure show different forms of gripping the instrument
depending onThe theconventional
size of thelaparoscopic
user’s hand. surgery graspers shown in Figure 1 incorporate a pistol grip
In the case of Figure 1a, a surgeon with a small hand holds
mechanism with finger rings, and a mechanism that allows full rotation of the tip of the shaft (upper
the handle without
part being able
of the graspers). to encompass
The three images in theall of the
figure showinstrument’s
different forms grasping
of gripping elements.
the instrumentIn Figure 1b,
the opposite case ison
depending revealed:
the size ofA thesurgeon
user’s hand.with a large
In the hand
case of is 1a,
Figure unable to make
a surgeon with asimultaneous
small hand holdsuse of most
the handle without
of those elements, and grips beingthe
ablehandle
to encompass all of the instrument’s
in a completely different grasping
way. elements.
The ideal In grip
Figurewould
1b, be that
the opposite case is revealed: A surgeon with a large hand is unable to make simultaneous use of
shown in Figure 1c, in which all the grasping elements fit the size of the hand perfectly. It is important
most of those elements, and grips the handle in a completely different way. The ideal grip would be
to note that
thatthe
showngrips in represented in Figure
Figure 1c, in which all the1grasping
are not elements
arbitrary, fit but rather
the size reflect
of the hand real situations
perfectly. It is brought
about when the size
important to ofnotethe hand
that and the
the grips dimensions
represented of the
in Figure 1 arehandle do notbut
not arbitrary, correspond.
rather reflectThese
real different
grips were situations
observed brought about
in the when the
Centro de size of the de
Cirugía hand and the Invasión
Mínima dimensionsJesús
of theUsón
handle(CCMIJU)
do not which
correspond. These different grips were observed in the Centro de Cirugía de Mínima Invasión Jesús
collaborated in the development of the present study.
Usón (CCMIJU) which collaborated in the development of the present study.

(a) (b) (c)

Figure 1. Different forms of gripping the surgical laparoscopic tool according to the surgeon’s hand
Different
Figure 1. size. The most forms of gripping
irregular ones for thisthe surgical
grip laparoscopic
are the first tool
two (a,b). These according
usually appear to thethe
when surgeon’s
size hand
size. The most irregular
of the tool ones for
is not adapted this
to the grip
size aresurgeon’s
of the the firsthand.
twoThe(a,b).
thirdThese usually
(c) is the appearand
most common, whenthe the size of
the tool isinformation
not adapted provided directly
to the sizeby ofthe
thesurgeons indicate
surgeon’s that itThe
hand. caused the least
third (c) isinjuries.
the most common, and the
information provided directly by the surgeons indicate that it caused the least injuries.
At present, as various recent studies have observed [9–12], the instruments used in laparoscopic
surgery are characterized by being of a single size (as mentioned above) and with little ergonomy in
their design.
At present, The single
as various size ofstudies
recent minimally invasive
have surgery[9–12],
observed (MIS) instruments means that
the instruments surgeons
used in laparoscopic
have to adapt to the instruments, and different surgeons show different patterns of adaptation
surgery are characterized by being of a single size (as mentioned above) and with little ergonomy in
depending on their hand size. In spite of this adaptation, neither small- nor large-handed surgeons
their design. The asingle
can find size ofzone
comfortable minimally invasive
to grip and surgery
manipulate (MIS) instruments
laparoscopic grasping tools. means that surgeons have
This is especially
to adapt to the
true forinstruments, and different
actioning the opening and closingsurgeons
mechanismshowof the different patterns
grasper. This problem ofhasadaptation
been broughtdepending
to lightsize.
on their hand in various studies
In spite such adaptation,
of this as that of Berguer and Hreljac
neither small-[5],norwho surveyed userssurgeons
large-handed of these can find
instruments, finding that both those with large hands and those with small hands found them hard
a comfortable zone to grip and manipulate laparoscopic grasping tools. This is especially true for
to use.
actioning the Given
opening and closing
this situation, mechanism
several of the
research papers havegrasper. This problem
been published has analysing
in recent years been brought the to light
in variouscorrespondence
studies suchthat as must
that of Berguer
exist betweenand Hreljac
a user’s [5], who characteristics
anthropometric surveyed users of these
and the precision instruments,
instruments
finding that both those they use,
withwhich
largeneed to be ergonomically
hands and those withadapted to thehands
small user’s hand.
found Sancho-Bru
them hard et al.to
[13]use.
used a biomechanical model of the hand to study the appropriate diameter of a handle with
Given this situation, several research papers have been published in recent years analysing the
cylindrical grip for men and women. Other studies indicate that the shape of the handle should be
correspondence that must exist between a user’s anthropometric characteristics and the precision
instruments they use, which need to be ergonomically adapted to the user’s hand. Sancho-Bru et al. [13]
used a biomechanical model of the hand to study the appropriate diameter of a handle with cylindrical
grip for men and women. Other studies indicate that the shape of the handle should be designed to
optimize the performance of the tasks in which the tool is to be used [9], maximize the ease of use and
contact area between the hand and the handle [10,14], and to distribute pressure so as to minimize
Appl. Sci. 2018, 8, 1200 3 of 13

discomfort [11,12]. Other anthropometric studies have had the aim of determining laparoscopic surgery
instrument dimensions that adapt to different hand sizes [8,15–18]. However, it should be noted that
these last works defined three or four sizes for the handle, but listed no criterion for the design of
a handle customized for each surgeon.
There are many ergonomic directives and guides in the literature for the design of everyday
products. Examples include “Ergonomics and Design. A Reference Guide” [19] for the development of
products to improve workplace environments and the “Office Ergonomics. Guidelines for Preventing
Musculoskeletal Injuries” [20] which gives a series of guidelines to make working with computers
more comfortable. A few even appear in the healthcare sector, such as “Ergonomics Guidelines” [21]
for surgical instruments, although none specifically discuss laparoscopic graspers. Most of these
ergonomic design guides are too generic for specific applications, and there is a clear need to develop
more specific guidelines for the ergonomic design of precision MIS tools [6,22–25].
The ever more widespread application of MIS has brought to the forefront the problem of
specific injuries related to the use of laparoscopic tools. Although the techniques of MIS have already
attained a relatively high level of development, the ergonomic characteristics of the tools it uses
are still deficient [17,26–31]. Surgeons frequently complain of pressure, pain, and fatigue in their
hands while using these instruments, which frequently result in lesions [26,28,29,32–37]. According to
Trejo et al. [36], these lesions can be attributed to the repetitive and prolonged use of unergonomic
instruments. Park et al. [37] found that 87% of surgeons who regularly perform laparoscopic surgery
suffer lesions, and that the main cause is this lack of ergonomy.
Therefore several firms in the medical sector, such as Dimeda-Surgical Instruments and WISAP
Medical Technology GmbH in Germany, Medtronic in the US, and Endomexico in Mexico, have been
working to overcome the problems with the design of MIS tools.
In the circumstances, the main purpose of this paper was to design an ergonomic handle for
laparoscopic surgery tools that adapted to each surgeon based on the anthropometry of their hands.
The basis would be a parametric design of the handle that includes all the specifications needed for it
to be more ergonomic and functional than current handles. The work involved the participation of
a total of 135 surgeons, and most of it was carried out in coordination with the CCMIJU.

2. Methods

2.1. Introduction
The experimental phase of this work was conducted with surgeons in the CCMIJU. The basic
shape of the handle that was worked with to determine an ergonomic and customized design for
laparoscopic surgery graspers is shown in Figure 2. It was the result of the ERGOLAP project [38],
and is patented (Patent Number EP2471473A1). The ERGOLAP project was carried out by the authors
of the present work in coordination with the CCMIJU and with the Institute of Biomechanics of
Valencia (IBV).

2.2. Participants
The study population comprised 135 surgeons. Their ages ranged from 20 to 70 years (mean age
= 39.7 years; SD = 9.78 years), and the distribution of the sample population by sex was 69 female and
66 male. The main anthropometric data of the participants are presented in Table 1.

Table 1. Anthropometric data of the study’s participants (n = 135).

Characteristics Mean (SD) Range

Age (years) 39.7 (9.78) 20–70
Hand length (mm) 178.9 (13.08) 159.3–194.4
Palm length measured (mm) 96.5 (8.79) 87.6–111.6
Hand breadth digitized (mm) 79.9 (6,98) 71.1–86.5
Appl. Sci. 2018, 8, 1200 4 of 13

Appl. Sci. 2018, 8, x FOR PEER REVIEW 5 of 14

2.3. Experimental Task and the Parametric Prototype Handle
2.3. Experimental Task and the Parametric Prototype Handle
The design and development of the handle shown in Figure 2 was based on a study of the
The design
ergonomic and development
preferences of the
of 135 surgeons handle
during shown
their periodinofFigure 2 was
training based on a techniques
in laparoscopic study of the
in
ergonomic preferences of 135 surgeons during their period of training in laparoscopic techniques
the CCMIJU. Two of the handle design criteria were a large palmar grip surface and the combination in
the CCMIJU.and
of precision Two of the ability.
turning handle These
designcriteria
criteriaeliminated
were a large
thepalmar gripof
possibility surface anddesign
a handle the combination
with rings.
of precision and turning ability. These criteria eliminated the possibility of a handle design with rings.

Figure
Figure 2. The
The laparoscopic
laparoscopic tool
tool handle developed in the ERGOLAP project.

The resultinghandle
The resulting handledesign
designhashas been
been studied
studied andand further
further analyzed
analyzed in theinwork
the work of González
of González et
et al. [18].
al. [18].study,
In that In thata study, a first approach
first approach was to
was to define define ahandle
a grasper grasper handle
size size that
that would best would best
suit the suit the
surgeon’s
surgeon’s hand size, but without attempting to customize the design as
hand size, but without attempting to customize the design as this is the purpose of the paper this is the purpose of the
at
paper
hand, considering designs based on four hand sizes (XS, S, M, and L). The results of that workthat
at hand, considering designs based on four hand sizes (XS, S, M, and L). The results of are
work are summarized
summarized in Tablein2.Table 2. It should
It should be noted
be noted that, that, in addition
in addition to this
to this study
study ofofGonzález
Gonzálezet et al.
al. [18],
[18],
other
other workers have proposed different sizes for surgical handles and hand tools, specifically by
workers have proposed different sizes for surgical handles and hand tools, specifically by
defining
defining three
three sizes
sizes [5,16,39–41].
[5,16,39–41]. Nonetheless,
Nonetheless, given
given the
the precision
precision required
required in in surgery
surgery and and the
the many
many
hours
hours that
that some
some operations
operations last
last [36], together with
[36], together with the technological means
the technological means available
available today
today such
such asas
additive manufacturing and the development of 3D parametric design software
additive manufacturing and the development of 3D parametric design software [42], a personalized [42], a personalized
solution
solution would
would seem seem toto be
be called
called for,
for, with
with the
the handle
handle being
being designed
designed to to have
have the
the size
size ergonomically
ergonomically
best
best suited to the anthropometric dimensions of each surgeon’s hand. Recent studies, such as
suited to the anthropometric dimensions of each surgeon’s hand. Recent studies, such as that
that of
of
Zanetti et al. [43], show that the use of 3D printing can bring substantial benefits,
Zanetti et al. [43], show that the use of 3D printing can bring substantial benefits, such as customization, such as
customization,
optimization and optimization and the
the manufacture ofmanufacture
very complexofgeometries.
very complex geometries.

Table 2. Optimal
Table 2. Optimal for
for each
each of
of the
the hand size categories.
hand size categories.

Hand Size % Sex Mean Diameter (mm)

Hand Size % Sex Mean Diameter (mm)
XS 26% Both sexes 29.4
XS 26% Both sexes 29.4
11.1% M 32.9
S 11.1%
S 18.5% FM 32.9
31.7
18.5% F 31.7
24.4% M 36.4
M 24.4%
M 6.7% FM 36.4
33.1
6.7% F 33.1
L 13.3% Both sexes 37.9
L 13.3% Both sexes 37.9

The final design of the handle used in this study (Figure 2) allowed us to resolve a series of
The final
ergonomic design that
problems of the handle
existed used
with in this
other types study
of MIS(Figure 2) allowed
handles us to
which did notresolve
meet thea series
designof
ergonomic
criteria problems
obtained that existed
in ERGOLAP. with
In this otherit types
sense, shouldofbeMIS notedhandles which
that, since thedid not palm
entire meetof thethedesign
hand
criteria
is obtained in
now involved in gripping
ERGOLAP. theIn this sense,
handle, it should
it is easier be noted
to achieve that, since
a neutral the entire
position of thepalm
wrist.ofThis
the
hand is now
reduces fatigueinvolved
and theinrisk
gripping thelesions.
of thenar handle,Hence,
it is easier to achieve
the grip a neutralinposition
was designed such a way of the wrist.
that the
This reduces
pressure fatigue andevenly
is distributed the riskbetween
of thenarthe
lesions.
palmHence,
and the thefingers.
grip wasAllowing
designedgreater
in such contact
a way that of the
pressurewith
handle is distributed
the wholeevenly between
hand avoids the palm
flexing the and thestretching
wrist, fingers. Allowing
tendons,greater contact
distending theofelbow,
the handle
and
with the shoulder
limiting whole hand avoids flexing
movement. the wrist,
The length of thestretching
handle and tendons, distending
its diameter the elbow,relative
were increased and limiting
to the
handles traditionally used in MIS, as this provides a better fit for different hand sizes, and the fingers
have a larger contact surface thus reducing the pressure on localized areas, especially the thumb.
Appl. Sci. 2018, 8, 1200 5 of 13

shoulder movement. The length of the handle and its diameter were increased relative to the handles
traditionally used in MIS, as this provides a better fit for different hand sizes, and the fingers have
a larger contact surface thus reducing the pressure on localized areas, especially the thumb.
Regarding the geometry of the handle design developed in the ERGOLAP project (Figure 3a),
there are three significant parameters. These are identified as the “inferior diameter” (DI ), “median diameter”
(DM ), and “superior diameter” (DS ). The median diameter (DM ) coincides with the diameter defined at
the point of inflection of the curvature of the handle (Figure 3a). It also defines the position of the hand
relative to the handle during grasping, since for all the surgeons this diameter coincides with the line
defined between the third and fourth (Figure 3b). Similarly, DS and DI correspond to the narrowest
and the broadest parts of the handle design, respectively. These diameters, as shown in Figure 3b,
in turn coincide with the lines defined between the second and third phalanges in the case of DI and
the fourth and fifth phalanges in the case of DS .
Appl. Sci. 2018, 8, x FOR PEER REVIEW 6 of 14

(a) (b)
Figure 3. (a) Parameters used in the study; (b) directives for determining the handle position.
Figure 3. (a) Parameters used in the study; (b) directives for determining the handle position.

Regarding the geometry of the handle design developed in the ERGOLAP project (Figure 3a),
◦ (Figure 3b).
there Other
are three features of thisparameters.
significant handle are These
that theareangle of the as
identified handle with thediameter”
the “inferior shaft is 45(D I), “median
This is a design
diameter” (DM), and constraint
“superior thatdiameter”
must remain unchanged,
(DS). The median regardless
diameterof (Dthe size of the handle or size of
M) coincides with the diameter
the surgeon’s
defined at the pointhand of since it is theofvalue
inflection recommended
the curvature of the by previous
handle studies
(Figure 3a). It[23]
alsoand was approved
defines the position by
allthe
of thehandsurgeons relative whotoparticipated in the ERGOLAP
the handle during grasping, sinceproject.
for all the surgeons this diameter coincides
To define a 3D parametric model
with the line defined between the third and fourth (Figure of the handle, we chose as the scaling
3b). Similarly, DS and parameter the median
DI correspond to the
diameter (D M ), since this is the most characteristic diameter of the
narrowest and the broadest parts of the handle design, respectively. These diameters, as shown in design. It is defined as the line of
the hand between the third and fourth phalanges, and which must pass
Figure 3b, in turn coincide with the lines defined between the second and third phalanges in the case through the point of inflexion
of D
of the curvature of the handle during grasping. The other parameters that have to be modified to
I and the fourth and fifth phalanges in the case of D S.
properly
Otheradapt features the of
handle to the surgeon’s
this handle are that thehandanglesizeofare
theDhandle
S , DI , Rwith
1 , andtheR2shaft
(Figure 3b).
is 45° The other
(Figure 3b).
parameters are kept invariant, affecting neither the scalability of the
This is a design constraint that must remain unchanged, regardless of the size of the handle or size of model nor the functionality of
the design, as we explain below. We reached this result by modifying
the surgeon’s hand since it is the value recommended by previous studies [23] and was approved by in various ways the physical
model
all generated
the surgeons by participated
who additive manufacturing
in the ERGOLAP [42,44], and testing it on a large number of surgeons.
project.
Physical models were manufactured
To define a 3D parametric model of the handle, we for each subject using
choserapid
as theprototyping technology
scaling parameter the for their
median
subsequent
diameter (DM evaluation.
), since thisAll is the
the handles were manufactured
most characteristic diameterwith of thea 3D printer
design. It isusing white
defined asABS plastic
the line of
and a smooth surface finish.
the hand between the third and fourth phalanges, and which must pass through the point of inflexion
of theFor simplicity
curvature of of
thethe 3D parametric
handle CAD handle
during grasping. The model, we found itthat
other parameters possible
have totorelate the values
be modified to
of D S , D I , R 1 , and R 2 , to the value of D M . The ratios between D M and
properly adapt the handle to the surgeon’s hand size are DS, DI, R1, and R2 (Figure 3b). The other the other parameters are listed in
Table 3.
parameters are kept invariant, affecting neither the scalability of the model nor the functionality of
the design, as we explain below. We reached this result by modifying in various ways the physical
model generated by additive manufacturing [42,44], and testing it on a large number of surgeons.
Physical models were manufactured for each subject using rapid prototyping technology for their
subsequent evaluation. All the handles were manufactured with a 3D printer using white ABS plastic
and a smooth surface finish.
For simplicity of the 3D parametric CAD handle model, we found it possible to relate the values
of DS, DI, R1, and R2, to the value of DM. The ratios between DM and the other parameters are listed in
Table 3.
Appl. Sci. 2018, 8, 1200 6 of 13

Table 3. Constants which relate the parameters of the handle to DM .

Parameter (mm) Parametric Ratio

DM 1
DI 0.80
DS 1.15
R1 1.25
R2 4.48

2.4. Anthropometric Relationship between the Surgeon’s Hand and the Size of the Handle
In this subsection, we shall describe the study that we carried out to relate the anthropometry of
the hand to the size of the handle. The aim was to determine which hand measurements are related to
the size of the surgical handle developed in this paper to scale the parametric model of the handle to
the size most appropriate for each surgeon’s hand.
To this end, we started from the base of previous studies of anthropometric dimensions of the
hand for the optimal design of everyday utensils. In this sense, one of the most thorough-going works
is entitled “Hand Anthropometry of U.S. Army Personnel” [45]. This reports the statistical results
of data collected in an anthropometric study of the hands of US Army personnel in 1987 and 1988.
The population of that study consisted of 1003 men and 1304 women. The 86 hand dimensions analyzed
in the report consisted of 64 measurements obtained photometrically, and 22 direct measurements.
Figure 4 shows some of these dimensions which have been widely used in anthropometric and
ergonomic studies of the hand [5,16,41,46,47].
Greiner’s study is of great importance given the sparsity of the literature that includes any
analyses of such a large number of anthropometric parameters of the hand. Such is the case for the
design of hand tools whose design can make use of a large number of anthropometric parameters such
as the finger length, the width of the hand, and the length of the hand [5,16,41,46–48]. As a complement
to this anthropometric study, we also analyzed papers that studied the relationship of the dimensions
of the hand with the ergonomic use of hand tools. For example, Matern and Waller [49] presented
a detailed analysis of the concave surface of the hand with respect to its longitudinal and lateral
dimensions which has a correspondence with the generatrix used in the present work (Figure 3b).
Using data from the work of Greiner [45], DiMartino et al. [16] defined three categories of hand tools
(small, medium, and large) in accordance with hand length. To reduce the number of anthropometric
data that we needed to employ in this study, we carried out a comparative study of the different
lengths studied by Greiner [45] and those studied by González et al. [18].
In accordance with the aspects indicated above in Section 2.3 that the handle design must meet,
the following two criteria were established to determine the most appropriate hand measurements to
be analyzed:

• Measurements related to the palm support of the handle—these correspond to the importance
of having greater contact between hand and handle, and are therefore related to the breadth of
the hand.
• Measurements related to the diameter of the handle—these correspond to the handle appropriately
fitting the different types of hand, allowing the fingers to have a greater contact surface, and are
therefore related to the total length of the hand and the length of the palm.
Appl. Sci. 2018, 8, 1200 7 of 13
Appl. Sci. 2018, 8, x FOR PEER REVIEW 8 of 14

Figure 4. (a) Hand Length Digitized (58); (b) Hand Length Measured (59); (c) Palm Length Measured
Figure 4. (a) Hand Length Digitized (58); (b) Hand Length Measured (59); (c) Palm Length Measured
(61); (d) Hand Breadth from Digitizer (62); (e) Hand Breadth Measured (63); (f) Crotch 1 Height (69);
(61); (d) Hand Breadth from Digitizer (62); (e) Hand Breadth Measured (63); (f) Crotch 1 Height (69);
(g) Crotch 2 Height (70); (h) Crotch 3 Height (71); (i) Crotch 4 Height (72).
(g) Crotch 2 Height (70); (h) Crotch 3 Height (71); (i) Crotch 4 Height (72).
Based on the above and on the anthropometric measurements of the hand that have already
been
Basedanalyzed
on the in other and
above works
onontheergonomics, in the present
anthropometric work we analyzed
measurements the following
of the hand three
that have already
anthropometric parameters of the hand:
been analyzed in other works on ergonomics, in the present work we analyzed the following three
•
anthropometric parameters
Hand Length of the hand:
from Digitizer (HLD) (Figure 4a).
• Palm Length Measured (PLM) (Figure 4c).
• •Hand Length
Hand from
Breadth Digitizer
from (HLD)
Digitizer (HBD)(Figure
(Figure4a).
4d).
• Palm Length Measured (PLM) (Figure 4c).
To investigate the correspondence between hand size and handle size, we analyzed the
• Hand Breadth from Digitizer (HBD) (Figure 4d).
anthropometric data for the 135 surgeons who participated in this study, as summarized in Table 1.
From the values obtained, we first calculated HLD, PLM, and HBD (Table 4, columns 3 to 5) for each
To investigate the correspondence between hand size and handle size, we analyzed the
sex and each hand type as defined in González et al. [18], and then, in order to have parameters that
anthropometric data for the 135 surgeons who participated in this study, as summarized in Table 1.
are very similar in value for any hand size, calculated the ratios between these three sets of
Fromanthropometric
the values obtained, we first calculated HLD, PLM, and HBD (Table 4, columns 3 to 5) for each
values and the optimal median diameter of the handle (Table 4, last three columns).
sex and each
The last two rows of Tablein4González
hand type as defined et al. [18],
give the mean and
values andthen, in order
standard to have parameters
deviations of these ratiosthat are
very weighted
similar inaccording
value fortoany
thehand size, calculated
population of each sexthe
andratios
hand between
type (see these three
Table 2). Onesets of anthropometric
observes that, of
values
theand theanthropometric
three optimal median diameter
ratios, that of of the (a
PLM handle
measure(Table 4, last
of the innerthree columns).
length of the palm) has the
smallest
The last standard
two rowsdeviation
of Table 4(0.0113021).
give the meanWe therefore
values and concluded
standard that this ratio of
deviations would
theseberatios
the most
weighted
appropriate to use to relate a surgeon’s hand size with the best handle size of a laparoscopic
according to the population of each sex and hand type (see Table 2). One observes that, of the three grasper,
and hence ultimately
anthropometric theof
ratios, that best
PLMcustom handle of
(a measure design.
the inner length of the palm) has the smallest standard
deviation (0.0113021). We therefore concluded that this ratio would be the most appropriate to use to
relate a surgeon’s hand size with the best handle size of a laparoscopic grasper, and hence ultimately
the best custom handle design.
 Appl.
Appl.
Appl. Sci.
Appl.
Appl.
Appl.
Sci. 2018,
Sci.
Sci.
Sci. Sci.8,8,
2018,
2018, x8,x
2018,
2018,
2018,
FORFOR
x8,
8, x8,
FOR xPEER
xFOR
FOR
PEER REVIEW
PEER
PEER
FOR PEER
PEER REVIEW
REVIEW
REVIEW
REVIEW
REVIEW 9 9of9of914
9 14
of 9of
of 1414
14
14of

Table
Table
Table 4. Relationships
Table
Table 4.
Table
4. 4. between
4. Relationships
Relationships
Relationships
4. Relationships
Relationships betweenthethe
between
between Hand
the
between
between
thethe Length
Hand
Hand from
Length
Length
the Length
Hand
Hand Hand from
Length
Length Digitizer
from
from
from from (HLD),
Digitizer
Digitizer
Digitizer
Digitizer
Digitizer Palm
(HLD),
(HLD),
(HLD),
(HLD),
(HLD), Palm
Palm Length
Palm
Palm
PalmLength
Length Measured
Length
Length
Length Measured
Measured
Measured (PLM),
Measured
Measured
(PLM),
(PLM),
(PLM), andand andand
(PLM),
(PLM),
and
Hand
Hand Hand
and
Hand Breadth
Hand
Hand
Breadth
Breadth
Breadth from
from from
Breadth
Breadth
from Digitizer
from
from
Digitizer
Digitizer
Digitizer (HBD)
Digitizer
Digitizer
(HBD)
(HBD)
(HBD) dimensions
(HBD)
(HBD) andand
dimensions
dimensions
dimensions and
andand and8 of 13
dimensions
dimensions
Appl. Sci. 2018, 8, 1200
the
thetheoptimal
the
the the median
optimal
optimal
optimal
optimal
optimal median
median diameters
median
median
median of
diameters
diameters a
diameters
diameters
diameters laparoscopic
of
of a
a
of surgery
laparoscopic
laparoscopic
a
of aoflaparoscopic
a laparoscopic handle.
surgery
surgery
laparoscopic
surgery
surgery handle.
handle.
surgery handle.
handle.
handle.

Ø ØØØ
ØØ
Table 4. Relationships between the Hand Length from Digitizer (HLD), Palm Length Measured (PLM), and Hand Breadth from Digitizer (HBD) dimensions and the
Hand
Hand
Hand Length
Hand
Hand
Hand Length
Length
Length Length
Length Palm
Palm
Palm Length
Palm
Palm
PalmLength
Length
LengthLength
Length
optimal median diameters of a laparoscopic surgery handle.
Hand
Hand
Hand
Hand
Hand Breadth
HandBreadth
Breadth
Breadth
Breadth
Breadth Optimum
Optimum
Optimum
Optimum
Optimum
Optimum
HSC
HSCHSC
HSC
HSC
HSC SexSex
Sex
Sex
Sex Sex from
from
from
from
from Digitizer
from Digitizer
Digitizer Measured
Measured
Measured
Digitizer Measured
Digitizer
Digitizer from
Measured from
Measured from
from
from Digitizer
from Digitizer
Digitizer Diameter
Digitizer
Digitizer
Digitizer Diameter
Diameter
Diameter
Diameter
Diameter Anthropometric Relationship
Anthropometric
Anthropometric
Anthropometric
Anthropometric
Anthropometric Relationship
Relationship Factor
Relationship
Relationship Factor
Factor
Relationship Factor
Factor
Factor
(HLD)(HLD)
(HLD)
(HLD)
(HLD)
(HLD)Hand Length (PLM)
(PLM)
(PLM)
(PLM)
(PLM)
Palm (PLM)
Length (HBD)
(HBD)
Hand (HBD)
(HBD) of
(HBD) of of
(HBD)
Breadth handle
of
Øofofhandle
handle
handlehandle
handle
Optimum
HSC Sex from Digitizer Measured from Digitizer DD DM
DMD D
Diameter
M M M Mof Anthropometric Relationship Factor
(HLD) (PLM) (HBD) handle DM 𝑯𝑳𝑫𝑯𝑳𝑫
𝑯𝑳𝑫
𝑯𝑳𝑫
𝑯𝑳𝑫 𝑯𝑳𝑫 𝑷𝑳𝑴
𝑷𝑳𝑴 𝑷𝑳𝑴
𝑷𝑳𝑴
𝑷𝑳𝑴 𝑷𝑳𝑴 𝑯𝑩𝑫
𝑯𝑩𝑫 𝑯𝑩𝑫
𝑯𝑩𝑫
𝑯𝑩𝑫𝑯𝑩𝑫
Unitsininin
Units
Units
Units
Units
Units mmmm
in
inmmmm
mm
in mm
Units in mm 𝑫 𝑫𝑫𝑫
HLD
𝑫𝑴𝑫𝑴𝑴
D𝑴𝑴𝑴 𝑫
PLM 𝑫
𝑫
𝑫D𝑴𝑫𝑴𝑴𝑴𝑫
𝑴𝑴 𝑫
HBD
𝑫 𝑫𝑫
𝑫 𝑫
D 𝑴𝑴𝑴𝑴𝑴𝑴
M M M

XSXS
XSXS Both
XSXS Both
Both
XS sexes
Both
Both sexes
sexes
Both sexes
sexes
sexesBoth sexes 159.3
159.3
159.3
159.3
159.3
159.3 159.3 87.6
87.6
87.6
87.6
87.6 87.6
87.6 71.171.1
71.1
71.1
71.1
71.1 71.1 29.429.4
29.4
29.4
29.429.4 29.4 5.418
5.418 5.418
5.418
5.418
5.418
5.418 2.980
2.980
2.980
2.980
2.980
2.980 2.980 2.418
2.418
2.4182.418
2.418
2.418
2.418
Male
Male
Male
Male
Male Male
Male
174.1
174.1
174.1
174.1
174.1
174.1 174.1
97.6
97.6
97.6
97.6
97.6 97.6
97.6
79.179.1
79.1
79.179.1
79.1
79.1
32.932.9
32.9
32.9
32.932.9 32.9 5.292
5.292 5.292
5.292
5.292
5.292
5.292
2.967
2.967
2.967
2.967
2.967
2.967 2.967 2.404
2.404
2.404
2.404
2.404
2.404
2.404
S SS SS S SFemale
Female
Female
Female
Female
Female Female 170.2
170.2
170.2
170.2
170.2
170.2 170.2 94.3
94.3
94.3
94.3
94.3 94.3
94.3 72.572.5
72.5
72.5
72.5
72.5 72.5 31.731.7
31.7
31.7
31.731.7 31.7 5.369
5.369 5.369
5.369
5.369
5.369
5.369 2.975
2.975
2.975
2.975
2.975
2.975 2.975 2.287
2.287
2.2872.287
2.287
2.287
2.287
Male
Male
Male
Male
Male Male
Male 188.8
188.8
188.8
188.8
188.8
188.8 188.8 107.8
107.8
107.8
107.8
107.8 107.8
107.8 86.586.5
86.5
86.586.5
86.5
86.5 36.436.4
36.4
36.4
36.436.4 36.4 5.187
5.187 5.187
5.187
5.187
5.187
5.187 2.962
2.962
2.962
2.962
2.962
2.962 2.962 2.376
2.376
2.3762.376
2.376
2.376
2.376
MMMM MM MFemale
Female
Female
Female
Female
Female Female 182.1
182.1
182.1
182.1
182.1
182.1 182.1 98.2
98.2
98.2
98.2
98.2 98.2
98.2 78.978.9
78.9
78.9
78.9
78.9 78.9 33.133.1
33.1
33.1
33.133.1 33.1 5.502
5.502 5.502
5.502
5.502
5.502
5.502 2.967
2.967
2.967
2.967
2.967
2.967 2.967 2.384
2.384
2.3842.384
2.384
2.384
2.384
LLL LL L Both
Both
Bothsexes
Both
L Both sexes
sexes
Both sexes
sexes
sexesBoth sexes 194.9
194.9
194.9
194.9
194.9
194.9 194.9 111.6
111.6
111.6
111.6
111.6 111.6
111.6 86.586.5
86.5
86.586.5
86.5
86.5 37.937.9
37.9
37.9
37.937.9 37.9 5.142
5.142 5.142
5.142
5.142
5.142
5.142 2.945
2.945
2.945
2.945
2.945
2.945 2.945 2.282
2.282
2.2822.282
2.282
2.282
2.282
𝑥 𝑥𝑥x𝑥𝑥 𝑥 5.308
5.308 5.308
5.308
5.308
5.308
5.308 2.967
2.967
2.967
2.967 2.967
2.967
2.967 2.362
2.362
2.362
2.362
2.362
2.362 2.362
𝑠 𝑠 𝑠 s𝑠𝑠 𝑠 0.1173040
0.1173040
0.1173040
0.1173040
0.1173040
0.1173040
0.1173040 0.0113021
0.0113021
0.0113021
0.0113021
0.0113021
0.0113021
0.0113021 0.0549504
0.0549504
0.0549504
0.0549504
0.0549504
0.0549504
0.0549504
 Appl.Sci.
Appl. Sci.2018,
2018,8,8,1200
x FOR PEER REVIEW 10 of13
9 of 14

3.3.Results
Resultsand
andDiscussion
Discussion
The
Themain
mainresult
resultof ofthis
thiswork
workhas hasbeen
beentotoobtain
obtainthe the3D3Dparametric
parametricdesign
design of ofaahandle
handle for forthe
the
graspers
graspers used
used in
in laparoscopic
laparoscopic surgery, in which the the parameter
parameter D DMMallows
allowsthe thedesign
designtotobebescaled
scaled
to
to adaptthe
adapt thesize
sizeofofthe
thehandle
handletotoeach
each surgeon’s
surgeon’s handhand size.
size. In
In particular, it was was found
found thatthat the
the
anthropometric
anthropometric measurement
measurement of of the
the hand
hand that
that isis most
most appropriate
appropriate to to relate
relate the
thehandle
handle size
size totothe
the
surgeon’s
surgeon’shand
handsize
sizeisisthat
thatdefined
definedby byPLM.
PLM.To Toobtain
obtainaa3D 3Ddesign,
design,first
firstthe
thesurgeon’s
surgeon’sPLMPLMvaluevalueisis
taken.
taken. This
This value
value is
is then
then divided
divided byby the
the coefficient
coefficient 2.967
2.967 (see
(see Table
Table4) 4)to
togive
givethethemost
mostappropriate
appropriate
value
valueofofthe
themedian
mediandiameter
diameterof ofthe
thehandle
handle(D(DMM).). With
Withthis
thisvalue,
value,the
the3D3Dparametric
parametricmodel
modelof ofthe
the
handle is scaled to the surgeon’s hand size. Figure 5 shows some examples of 3D
handle is scaled to the surgeon’s hand size. Figure 5 shows some examples of 3D CAD models scaled CAD models scaled
to
todifferent
differentsurgeons
surgeonsamong
amongthe theparticipants
participantsininthis
thisstudy.
study.TheThecurve
curvedrawn
drawnin inaadashed
dashedline
lineon onthe
the
different
differentcustomized
customizedmodels
modelsisisininthis
thisway
wayadapted
adaptedto tothe
thesurgeon’s
surgeon’shand
handas asshown
shownby bythe
theequivalent
equivalent
dashed
dashedline
linein
inFigure
Figure3b. 3b.

Figure 5.5. Custom

Figure Custom 3D3D Computer
Computer Architectural
Architectural Drawings
Drawings (CAD)
(CAD) models
models of
of the
the surgical
surgical handle
handle
depending on each surgeon’s PLM measurement.
depending on each surgeon’s PLM measurement.

Tocheck
To checkthe
theresults,
results,several
several3D3D CAD
CAD parametric
parametric designs
designs forfor different
different surgeons
surgeons were were fabricated
fabricated by
by additive
additive manufacturing
manufacturing (for different
(for different sexessexes
and handand hand
sizes).sizes).
FigureFigure
6 shows 6 shows
one ofone ofhandles
these these handles
made
made
for for a particular
a particular value of value
PLM, andof PLM, and with
therefore therefore with a characteristic
a characteristic value of DMvalue of Dthat
(a value M (a value that
determines
determines
the completethe complete
design of thedesign of the
handle). Forhandle).
this, firstFor
thethis, first thehand
surgeon’s surgeon’s hand was
was scanned, to scanned, to then
then obtain the
obtain
palm the palm
length (PLM),length
in this(PLM), in thisa value
case giving case giving
of 96.55a mm.
valueTheof 96.55
optimal mm. The optimal
diameter diameterfrom
was calculated was
calculated
the from theratio
anthropometric anthropometric
PLM/DM resultingratio PLM/D M resulting
in a custom in D
value of a Mcustom
= 32.54value of DM was
mm, which = 32.54
usedmm,
to
which was used to generate the parametric
generate the parametric model of the handle (Figure 6).model of the handle (Figure 6).
Tobe
To befully
fullyfunctional
functionalfor forthe
thevalidation
validationtests,
tests,the
the3D3DCAD
CADmodelmodelwas wasdesigned
designedwith
withaahollow
hollow
interior.This
interior. Thisallowed
allowedthe theshaft
shaft(the
(themetallic
metallicclip)
clip)totobe
beinserted
insertedtogether
togetherwithwiththetheopening
openingandandclosing
closing
mechanismsof
mechanisms ofthe
thegrasper
grasperandandthe
theshaft’s
shaft’srotation
rotationmechanism
mechanism(Figure
(Figure6). 6).
Appl. Sci. 2018, 8, 1200 10 of 13
Appl. Sci. 2018, 8, x FOR PEER REVIEW 11 of 14
Appl. Sci. 2018, 8, x FOR PEER REVIEW 11 of 14

(a) (b)
(a) (b)
Figure 6.
Figure 6. Prototype custom
Prototype custom
6. Prototype handle.
custom handle. (a)
handle. (a) Details
(a) Details of
Details of the
of the pieces;
the pieces; (b)
pieces; (b) assembled
(b) assembled prototype.
assembled prototype.
prototype.
Figure
Figure 7 shows a surgeon using the prototype (DM = 32.54 mm) during the validation test. At the
Figure 7 shows a surgeon
surgeon using
using the
the prototype
prototype (D
(DM
M== 32.54
32.54 mm) during the validation test. At the
conclusion of the test, the surgeon confirmed that their experience using the handle was completely
conclusion of the test, the surgeon confirmed that their experience using the handle was completely
satisfactory [18]. Identical results were obtained with the surgeons whose handles corresponded to
satisfactory
satisfactory [18]. Identical
Identical results
results were obtained
obtained with the surgeons whose handles corresponded to
those illustrated in Figure 5.
those illustrated in Figure 5.

Figure 7. Prototype custom handle used in a simulation test.

Figure 7. Prototype custom handle used in a simulation test.
4. Conclusions
4. Conclusions
The main finding of this work was confirmation that it is possible to obtain 3D parametric
The main
mainfinding
findingofofthis
this work
work waswas confirmation that
confirmation it is possible to obtain 3D parametric
designs of a handle for laparoscopic graspers thatthat areit scalable
is possible totofitobtain
each 3D parametric
surgeon’s designs
hand size.
designs
of a of aforhandle
handle for laparoscopic
laparoscopic graspers graspers
that are that are
scalable to scalable
fit each to fit each
surgeon’s surgeon’s
hand size. hand size.
Furthermore,
Furthermore, it was found that a single anthropometric factor—the “Palm Length Measured”—can
Furthermore,
it it was found that a single anthropometric factor—the “Palm Length Measured”—can
bewas found
used that
to relate aany
single anthropometric
surgeon’s hand size factor—the “Palm
to the optimal Length Measured”—can
diameter of the handle. be used to relate
Functional tests
be
any used to relate
surgeon’s handanysize
surgeon’s
to the hand size
optimal to the of
diameter optimal
the diameter
handle. of the handle.
Functional tests Functional
carried intests
outadapts
the
carried out in the CCMIJU confirmed that the parametric design developed for the handles
carried
CCMIJU out in the
confirmed CCMIJU
that the confirmed
parametric that the
design parametric design developed for the handles adapts
ergonomically to different surgeon’s hand sizes.developed for the handles adapts ergonomically to
ergonomically
different to different
surgeon’s hand surgeon’s hand sizes.
sizes.
Thus, the specific contributions of this work include the following:
Thus, the specific contributions of this work include the following:
• A 3D parametric CAD design has been obtained for the handle of laparoscopic surgery graspers
•• A 3D
A 3Disparametric
parametric CAD
CAD design has
has been
designhand been obtained for the
the handle of
of laparoscopic surgery graspers
that scalable for different sizes.obtained
All of theforresulting
handlemodelslaparoscopic
personallysurgery graspers
customized for
that
that is
is scalable
scalable for
for different
different hand
hand sizes.
sizes. All
All of
of the
the resulting
resulting models
models personally
personally customized
customized for
for
each surgeon complied with the ergonomic criteria for their use.
each surgeon
surgeon complied
complied with with the
the ergonomic
ergonomic criteria
criteria for
for their
their use.
use.
• each
The results show that additive manufacturing and the application of ergonomics criterion
• The results show that additive manufacturing and the application of ergonomics criterion
provide an efficient method for the customized design and manufacture of this type of
provide an efficient method for the customized design and manufacture of this type of
specialized tools, being possible to be applicable to other sectors.
specialized tools, being possible to be applicable to other sectors.
Appl. Sci. 2018, 8, 1200 11 of 13

• The results show that additive manufacturing and the application of ergonomics criterion provide
an efficient method for the customized design and manufacture of this type of specialized tools,
being possible to be applicable to other sectors.
• The relationship between the anthropometry of the surgeon’s hand and the most suitable size of
the handle was determined, with the most suitable anthropometric parameter to measure being
the “Palm Length Measured” (PLM).

Finally, the authors consider that the customization of the geometry of a surgical tool can serve
as a reference for future research that addresses the optimal material and tools for their subsequent
production through additive manufacturing techniques.

Author Contributions: Conceptualization, A.G.G. and D.R.S.; Formal analysis, D.R.S. and A.S.R.; Investigation,
A.G.G., D.R.S. and L.G.M.; Methodology, A.G.G.; Software, L.G.M.; Validation, A.G.G., D.R.S., L.G.M. and A.S.R.;
Writing–review & editing, A.G.G. and D.R.S.
Funding: This research received no external funding.
Acknowledgments: The authors wish to acknowledge the support of this research work to the VI Regional
Research Plan and the Regional Government of Extremadura and to the Fondo Social Europeo (FEDER) linked
to the financial of the research groups Manufacturing Engineering (GR-18029) and INNOVA RNM020—Design,
Sustainability and Added Value (GR-18015). The authors are grateful for the outstanding willingness to cooperate
of the 135 surgeons who participated in the study, and for their interest in following through with the appropriate
trials so as to obtain a satisfactory outcome. In particular, they all considered it of great importance to adapt the
sizes of the handles of the tools they use to the size of their hands.
Conflicts of Interest: The authors declare no conflicts of interest.

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