Introduction
Surgical teams are always looking for ways to enhance patient safety, and improving the patient experience is increasingly recognised as an important factor, not least with the impact it can have on recovery.
A pioneering consultant plastic surgeon at Frimley Health NHS Foundation Trust (FHFT) has addressed both of these aspects in the development of new equipment in the field of hand surgery.
The key is enabling patients to be in a sitting position during their procedure - but until recently, operating table attachments to allow this did not exist. Undeterred, Plastics Consultant Mr Matthew Gardiner, who is also Associate Medical Director for Research at the Trust, started to sketch out his ideas for a new hand table that would solve the problem.
To bring his concept to fruition, he then needed a manufacturing partner with both vision and expertise: Anetic Aid is proud to have taken part in a collaboration which led to the unveiling of the Gardiner Hand Surgery System™ at the British Society for Surgery of the Hand, held in Glasgow in November 2023.
As the project has developed, anticipated - and additional - benefits have been identified:
patients in the sitting position who are awake, can interact with the surgical team more easily and discuss their procedure and rehabilitation during surgery
the position is safer for patients having General Anaesthesia (GA) if they are obese or have respiratory problems
the upright position enables patients to see their hand during the preparations for surgery and the new-style flexible screen, incorporated within the equipment, means patients can choose whether or not to watch their procedure at any stage, giving them greater understanding and making them feel more involved in their own care
the new design is less than half the weight of traditional tables, attaches with just one clamp and requires no supporting leg, making it easy to manoeuvre and popular with staff, particularly from the manual handling perspective.
Traditional hand surgery: restrictions and disadvantages
Over 100,000 elective and trauma hand surgery procedures are performed each year in the UK, and traditionally, the patient lies flat during surgery, which has many disadvantages, which are compounded if they have General Anaesthesia (GA).
The problem with the globally traditional supine position is that recovery takes longer because patients have to re-acclimatise to being upright again and, particularly older patients, have increased risk of fainting / disorientation.
Being flat is also an issue for obese patients or those with respiratory problems, and generally makes people feel vulnerable and impairs communication with healthcare staff.
Despite these disadvantages being well known, before 2022, there was no hand surgery table on the market that would allow the patient to have their surgery sitting upright.
There was, however, a move to carry out more hand surgery under local anaesthetic, which accelerated during the COVID-19 pandemic and became a recognised technique known as 'Wide Awake local Anaesthetic No Tourniquet' (WALANT). This works on the basis that the adrenaline in local anaesthetic reduces bleeding making it possible to operate without using a tourniquet.
What is WALANT? - Wide-awake Local Anaesthesia No Tourniquet (WALANT) is a surgical technique that relies on local anaesthetic and haemostatic agents to provide conditions suitable for hand surgery without sedation and tourniquet. Also known as WALANT, it can be performed in the operating room or in an ambulatory setting, such as the office, to treat conditions commonly affecting the upper extremity, especially the hand. It provides a multitude of benefits, including improved patient safety and access to surgical care.
Developing the new concept
After exhaustive searches to check there was indeed no commercially available hand table that would offer the facility, and multiple conversations with patients, theatre staff and surgeons to confirm that they would be open to a new approach, Mr Gardiner began a project to develop new equipment to fill the gap in the market.
His initial drafts, drawing on his passions for both research and hand surgery, began to take shape and comprised:
A contoured table using just one clamp to attach to the surgical platform, making it possible to accommodate the upright / sitting position
A separate, flexible screen, enabling the patient to choose whether or not to watch their procedure at any stage.
Armed with his sketches, Mr Gardiner approached his Theatre Manager at Heatherwood Hospital, Colin Brady, to see if he could suggest a manufacturing partner for the idea, and it was he who recommended Anetic Aid.
Explained Mr Gardiner: 'There is a lot of hand surgery in plastics - it is a fascinating area area because of the complex anatomy involved and the impact successful surgery can have for patients: nearly every aspect of life involves using the hand.
The Trust already had a relationship with the company, and we had many items of Anetic Aid equipment, including Operating Table Accessories - among them traditional hand tables.
There was a lot of resonance for us because they are a British Designer / Manufacturer producing high quality theatre equipment and clearly passionate about what they do. They also have a reputation for working with clinicians to develop new ideas, and as soon as I got in touch, I found I was pushing at an open door!'
Taking the lead from Mr Gardiner's sketch, the development team at Anetic Aid including Product Manager Mark Lee, Head of Design Steve Goldacre and CEO Guy Schofield set to work to turn the concept into a working prototype. As well as commitment from the company, finance from the Trust's Change Challenge Fund was used to support the project and the development of prototypes which have evolved and refined the design.
In all, there have been three iterations of the equipment, mainly focused on the optimum shape for the flat surgical surface, and for the screen design: both elements (the latter now a flexible 'curtain') provide an extremely light-weight solution, easy to attach and remove by theatre practitioners.
The key features of The Gardiner Hand Surgery System are:
Curved triangular-shaped firm base with a cushion top tapering towards patient's elbow, for maximum surgical space
Mounting bar which can be attached to the operating table / stretcher with just one clamp aligned with the patient's shoulder to allow them to sit up
Separate surgery screen including mounting stem, flexible arm and curtain to enable the patient to choose whether or not to observe their procedure at any time.
Proving the concept
Heatherwood Hospital in Ascot is one of the FHFT hospitals where Mr Gardiner works, and he conducted initial trials in the Minor Procedures Unit there.
Among the procedures were:
Carpal / cubital tunnel release
Trigger finger
Trapeziectomy
Surgery for Dupuytren's disease
Removal of skin lesions and soft tissue tumours
Scar revision
As well as recording his own experiences as a surgeon and those of colleagues, a total of 18 patients were surveyed along with eight members of staff.
The 'surgeon experience' concluded the table was easy to adjust and provided a very versatile range of positions. It aided the ability to perform the surgery and provided more ergonomic positioning. Because no pole is required to support the table (a feature many traditional tables have), it was easy to bring in the mini C-arm x-ray machine from any angle.
Before the operation most patients did not want to watch their procedure (53%) or only watch part of it (35%). Given a choice, 18% preferred to lie flat and 71% to sit up. After the operation, no patients would have chosen to lie flat instead.
All patients strongly agreed or agreed that it was comfortable, made it easy to communicate, kept them relaxed and gave them control over watching the procedure.
One patient having a trapeziectomy (who had originally wanted a GA until reassured about the benefits of new approach), managed to read three chapters of her book while occasionally watching her surgery to understand what was happening to her hand!
The eight staff members who completed their survey all agreed or strongly agreed that the new table was easy to apply and remove from a surgical trolley or operating table, lightweight and easy to move around and to clean and that it helped to improve communication.
Free text comments were all positive.
Additional benefits include:
Patients: Abduction of the shoulder to enable positioning of the hand on standard table risks traction and potential injury of the brachial plexus - a risk removed by use of the new system
Staff: A typical handle table weighs 5-7 kg, while the new system is just 2.25 kg (or 3.25 kg including the clamp) - half the weight of standard attachments and so better for manual handling
Sustainability: Large drapes needed to cover traditional arm tables are no longer required, reducing waste and the carbon footprint of a procedure.
New concept launched at Glasgow meeting
The Gardiner Hand Surgery System™ was unveiled to a wider audience at the British Society for Surgery of the Hand, held in Glasgow in November 2023, where it attracted much positive attention from hand surgeons across the UK.
It was attached to surgical trolley - Anetic Aid's QA4™ Mobile Surgery System - with the only other accessories being an articulating leg section to convert the QA4™ into an upright 'seat' position and a simple theatre pillow with strap to keep it in place behind the patient's head.
Anetic Aid has now built five production models which has enabled further trials in Outpatient Minor Procedures, Nuffield Orthopaedic Centre, Oxford and Hand Unit Theatres, Leeds General Infirmary. A further 12 sites have also agreed to trial the system.
FHFT will continue to have commercial interest in the system which will be fully available from Spring 2024.
Additional benefits
Patients: Abduction of the shoulder to enable positioning of the hand on a standard table risks traction and potential injury of the brachial plexus - a risk removed by use of the new system.
Staff: A typical hand table weighs 5-7 kg, while the new system is just 2.25 kg (or 3.25 kg including the clamp) - half the weight of standard attachments and so better for manual handling.
Sustainability: Large drapes needed to cover traditional arm tables are no longer required, reducing waste and the carbon footprint of a procedure.
Summary
With many of the benefits of the new system already proven, it is hoped that future studies will be able to show how much time can be saved (based on faster throughput as outpatient procedures, reduced recovery time etc), which would clearly have a positive impact on hospital waiting times and healthcare costs.
There are also plans to trial the system in Emergency Departments using the Anetic Aid QA3™ Emergency Stretcher as the surgical platform.
To download the full positioning paper, click the link "Read here" to get your copy: Read here
References:
Mr Matthew Gardiner: Matthew Gardiner — The Kennedy Institute of Rheumatology (ox.ac.uk)
The Gardiner Hand Surgery System - Product Information: The Gardiner Hand Surgery System™ | AneticAid
The Gardiner Hand Surgery System - Instructions for Use: 7 (ams3.cdn.digitaloceanspaces.com)