The drawbacks of a foot pedal-controlled diathermy unit are well known among users of the technology – they limit the movement of a surgeon around a patient and can cause errors and delay. 94% of surgeons responding to the BiPAD® usability surveyᶦ reported that they had difficulties using the foot pedals, that they have pressed the wrong pedal during surgery, and that they sometimes had to stand back from the table to look for the pedal. Operating room staff admit to crawling on the floor beneath the operating table to follow the surgeon around with the foot pedal, creating trip hazards out of both the equipment and themselves. The hygiene of such practices is questionable, and the occupational risk is clear.
Hand-controlled diathermy units have been used for monopolar diathermy for many years, but the unique movements necessary for bipolar forceps have meant that a hand-held solution has been trickier. When undertaking extremely fine work, any change in pressure or hand position could cause inadvertent movement of the forceps, and so any solution requires careful ergonomic design.
In the operating room, a surgeon needs to be able to concentrate on the work their hands are doing, and to pay constant visual attention to the task. When they also need to control another function of their equipment, an innovative approach is necessary. As electrosurgical techniques became more commonplace in the 1960s, it is perhaps no coincidence that the solution to multi-factor control reflected another increasingly widespread technical user interface; the car. Surgery and car-driving both require constant visual and physical attention, both hands to be in careful use at the same time, and precise operation of foot pedals. Inattention or restriction in either could be catastrophic.
There the similarities end, however. In a car, the driving position and controls placement are stationary and the user is seated. A surgeon needs to be free to move around and to be on their feet – and on and off one or more pedals – for extended periods of time. Having three limbs continuously available for delicate movement is clearly impractical and unsafe in an operating theatre, and without intuitive design leads to strain and fatigue at the very leastᶦᶦ. A shocking 95% of surgeons report musculoskeletal pain from maintaining the postures necessary for surgeryᶦᶦᶦ, and there is a strong correlation between surgeons’ foot pedal use and pain in the legs and feetᶦᵛ.
Attempts have been made to streamline the design of footplates used for surgical controls. Time and resources have been spent studying the ergonomics of surgical equipment; the shape and height of foot pedals, the amount of grip underfoot, the required pressure for action and the strength of recoil. Having a pedal with the same function on either side of the table is another possible solution to the physical restrictions of foot controls – an attempt to reduce the amount of time a member of the team spends underneath the table ensuring that the pedal follows the surgeon. More recent advances in safe and intuitive foot pedal operation have included the use of visual cues on a monitor relating to the pedals in useᵛ.
A questionnaire-led study of surgeons’ self-reported issues with diathermy foot plates found that 93% of respondents wanted a better solutionᵛᶦ. The result of this was a new design of foot plate – a circular model which could be effectively depressed from any direction, rather than the single-hinge designs previously. This allowed for some further flexibility and movement around the patient. Every attempt to use ergonomic principles to improve working conditions is laudable, but there was one key finding from the questionnaire that this design could not address: 75% of surgeons questioned wanted fully hand-controlled diathermy. The study, published by Van Veelen et alᵛᶦᶦ in 2003, set out to improve foot pedals used in surgery based on emerging ergonomic principles, and succeeded both in making those essential changes, and in identifying further room for improvement.
Over time, many attempts have been made to improve ergonomics for surgical instruments, particularly driven by a trend towards minimally invasive surgery creating usability issues for surgeonsᵛᶦᶦᶦ. As these instruments are continually refined, taking the surgeons’ own wishes into account should be paramount – if three quarters of surgeons would like hand-controlled diathermy forceps, then the logical next step is to include hand controls.
BiPAD® provides a solution in the form of a detachable hand switch, with ergonomics and usability by design.
Interoperability with existing diathermy forceps means that surgeons can stay with their personal preference of tools, adding a safe, comfortable, and user-friendly alternative to a foot pedal. The future of surgery looks like science fiction, with remote and robotic surgery becoming ubiquitous ᶦˣ; there is no reason – no excuse – for basic legacy technology like diathermy forceps to lag behind. At least now diathermy forceps control can move into the 21st century while retaining the tried-and-tested ergonomics of the equipment.
ᶦᶦVan Veelen, M. A., Jakimowicz, J. J., & Kazemier, G. (2004). Improved physical ergonomics of laparoscopic surgery. Minimally Invasive Therapy & Allied Technologies
ᶦᶦᶦMemnon, A. G., Naeem, Z., Zaman, A., & Zahid, F. (2016). Occupational health related concerns among surgeons. International journal of health sciences, 10(2), 279–291.
ᶦᵛLee, S. R., Shim, S., Yu, T., Jeong, K., & Chung, H. W. (2017). Sources of pain in laparoendoscopic gynecological surgeons: An analysis of ergonomic factors and proposal of an aid to improve comfort. Plos one, 12(9), e0184400. https://doi.org/10.1371/journal.pone.0184400
ᵛKondo, A., Nishizawa, Y., Horikiri, Y. et al. (2019) A novel device designed to improve the operability of energy devices with foot pedals in endoscopic surgery: the Foot-Site Monitor. Surg Today
ᵛᶦVan Veelen, M. A., Snijders, C. J., Van Leeuwen, E., Goossens, R. H. M., & Kazemier, G. (2003). Improvement of foot pedals used during surgery based on new ergonomic guidelines. Surgical Endoscopy And Other Interventional Techniques
ᵛᶦᶦᶦJanki, S., Mulder, E. E., IJzermans, J. N., & Tran, T. K. (2017). Ergonomics in the operating room. Surgical endoscopy
ᶦˣLongmore, S. K., Naik, G., & Gargiulo, G. D. (2020). Laparoscopic robotic surgery: Current perspective and future directions. Robotics