Ergonomics in Endoscopic Transsphenoidal Surgery: A Survey of the North American Skull Base Society

Background and Objective: Different surgical set-ups have been described for endoscopic transsphenoidal surgery (ETS), but studies on their ergonomics are limited. The aim of this paper is to describe present trends in surgical positioning and other ergonomics aspects of ETS.

Methods: A 33-question, web-based survey was administered to North American Skull Base Society members from January to April 2018.

Results: Out of 116 respondents, 107 reported being involved in ETS (92%) and 93 completed the survey (response rate: 87%). Most respondents were from North America (76%) in academic practice (87%), not in training (91%) and neurosurgeons (65%). Most (73%) had more than 5-year experience in ETS, received specific training (66%), and performed at least five procedures/month (55%). Mean reported time for standard and complex procedures were 3.7 and 6.3 hours, respectively. Most use image guidance (84%), use a binostril technique and work with a partner (95%). The most frequent position of the first surgeon during tumor removal is: standing (94%), holding suction (89%), and dissector (83%) or grasping forceps (38%). In some set-ups the endoscope is held by the primary surgeon (22–24%). Usually, the second surgeon holds the endoscope (72%) and irrigation (42%) or suction (37%). Most respondents position the patient in a supine position, with the head in neutral position (46%) or rotated to the side (38%). During tumor removal surgeons stand on the same side (65–66%). Most (81%) tailor surgery for ergonomic considerations and select instruments accordingly (92%). Surgical factors that are considered important for maximizing ergonomics in addition to surgical access and visualization include: sphenoidotomy (71%), septectomy (69%), removal of sphenoid septa, and sellar opening (67%) and dural opening (51%). Patient-specific factors include: modification of middle turbinate (53%) and need of septoplasty (31%). The most looked-at ergonomic attendances are: height of table/bed head (86%), monitor placement (80%), attention to posture (60%), and patient position adjustments during surgery (50%). Many respondents report strain at the dorso-lumbar (50%) or cervical (26%) level. Almost one-third incorporates a pause during surgery to stretch and move. Half of the respondents engage in physical activity to be fit for surgery and 16% sought medical attention for ergonomic-related symptoms.

Conclusion: Most responders value ergonomics as an element to be taken into consideration for ETS. The variability in surgical set-ups and the relatively high report of complaints underline the need of studies to optimize ergonomics in endoscopic transnasal skull base surgery.