When performing micro-surgery, particularly intra-ocular surgery like cataract surgery, a high level of precision is required. The surgeon’s hand positioning is critical in order to safely and efficiently perform the procedure. Keeping in mind the principals of pivoting within the incisions and maintaining the eye in the primary position, there are ways that we can position our hands to maximize success.
Bracing the hands
The surgeon’s hands should be braced against the patient’s head or alternatively, using a wrist rest. Avoid hovering with the hands in the air since this provides no support and decreases precision. Typically, the pinky finger and/or the ring finger of each hand is used to brace the hands against the patient’s cheek, forehead, or orbital rim. This also provides a degree of safety because if there is inadvertent movement of the patient’s head, then the surgeon’s hands move as well in the same direction and at the same time.
The hands are also positioned so that the view through the microscope is not impeded or blocked by a gloved hand. If using a fixation ring for incision creation, the non-dominant hand tilts the fixation ring handle away from the surgical field while the dominant hand uses the keratome to create the phaco incision.
Using both hands together
We can also gain additional stability by using two hands to hold the instrument such as the forceps used in capsulorhexis creation. But the disadvantage is that the surgeon is unable to use each hand to do a separate task. In patients with difficulty fixating on the microscope lights, I recommend using the non-dominant hand to hold the eye by using a chopper to hook the paracentesis incision. Now the dominant hand can use the forceps to create the capsulorhexis in a perfectly still eye.
Instruments entering via incisions on the left half of the eye should generally be held primarily with the left hand, while the right hand does the same for that half of the eye. This prevents having to cross one hand over the other to access the eye.
The natural pencil grip
From a young age, we are taught to hold a pencil with a particular grip. We then spend decades writing thousands of pages of notes using this same grip, thereby building great dexterity. Keeping this same pencil grip makes for a natural transition to intra-ocular surgery. It is no coincidence that many of our key instruments such as the phaco probe are designed to function like pencils. This pencil grip is likely to give the highest level of precision for most surgeons and it is what I recommend for all beginning residents.
When dealing with injectable medications and fluids, care should be taken to hold the junction where the cannula attaches to the syringe. Some of our syringes feature locking mechanisms to prevent the cannula from becoming dislodged, while others use simply a friction fit. If the cannula is partially blocked, pushing on the plunger can create very high pressure that can cause the cannula to shoot from the tip. This acts like a projectile and can cause serious intra-ocular injury such as iris damage, lens dislocation, or vitreous cavity penetration.
Finally, remember to keep an ergonomic and comfortable position during surgery. Ophthalmologists perform tens of thousands of surgeries during the course of a career and repetitive stress injury is common and can be disabling. We want to help as many patients as possible and having proper hand positioning and good ergonomics ensures a safe and efficient surgery for our patients and a long future in the operating room for us.
Click below to learn from this video about hand positioning during cataract surgery: