662 Tool-tissue Forces in Surgery: A Systematic Review

Abstract

Introduction Excessive tool-tissue interaction forces in surgery may result in tissue damage and intraoperative complications, while insufficient forces prevent the completion of the task. Method A systematic review of studies exploring tool-tissue forces applied during surgery was performed in accordance with PRISMA guidelines. Results 45 studies discussing tool-tissue forces during surgical procedures or tasks were included. Mean forces per speciality were as follows: ophthalmology (0.04N), vascular (0.7N), neurosurgery (0.68N), cardiothoracic surgery (1.5N), general surgery (4.7N), otorhinolaryngology (8.5N), obstetrics & gynaecology (mean 8.7N), urology (9.8N) and orthopaedic surgery (210N). Senior surgeons applied 25% less force than novice surgeons, and feedback (haptic, visual or audio) reduced force application by 40% - across specialities and tasks. Nervous tissue required the least amount of force to manipulate (0.4N, n = 17), followed by epithelial (3.8N, n = 18), muscle (4.1N, n = 4) and connective tissue (45.8, n = 10). For manoeuvres, retraction-with-grasping recorded the highest forces (3.65N, n = 13), whilst vessel clamping recorded the lowest (0.5N, n = 2). Conclusions The measurement of tool-tissue forces is a novel but rapidly expanding field. Knowledge of the safe range of surgical forces will improve surgical safety whilst maintaining effectiveness. Measuring surgical forces may provide an objective metric for training and assessment. Development of smart instruments, robotics and integrated feedback systems will facilitate this.