Prevalence of Musculoskeletal Disorders Among Surgeons Performing Minimally Invasive Surgery

A Systematic Review

Chantal C. J. Alleblas, MSc; Anne Marie de Man, BSc; Lukas van den Haak, MD; Mark E. Vierhout, MD, PhD; Frank Willem Jansen, MD, PhD; Theodoor E. Nieboer, MD, PhD


Annals of Surgery. 2017;266(6):905-920. 

In This Article

Learning Objectives

After participating in this activity, the reader should be better able to:

  1. Recall both the significance of ergonomics in minimally invasive surgery and the symptoms associated with musculoskeletal disorders.

  2. Critically appraise the ergonomics of one's own surgical work environment.

  3. Anticipate or intervene in the occasion of experiencing physical fatigue or musculoskeletal disorders.

The laparoscopic approach has become standard for many surgical interventions due to its benefits compared with open surgery, which include less postoperative pain, faster recovery, shorter hospital stay, and improved cosmetic results.[1–3] Widespread implementation of laparoscopic procedures has led to increased studies of ergonomics in surgery. The field of ergonomics deals with the design and evaluation of job tasks, products, and environments to improve their compatibility with people's needs, abilities, and limitations. In particular, physical ergonomics focuses on human anatomical, anthropometric, physiological, and biomechanical characteristics as related to physical activity.[4]

The field of minimally invasive surgery (MIS) is continuously evolving. Newer techniques, such as natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS), have greater benefits for the patient,[5,6] but may increase the physical workload for the surgeon.[7–9] On the contrary, robotic approaches have been introduced. Debates surrounding robotic surgery mainly focus on the costs and patient benefits. However, another important issue is that robotic approaches may provide ergonomic benefits to the surgeon—enabling the surgeon to operate from a seated posture, and allowing more degrees of freedom for instrument movement and 3D vision.[10,11]

Several ergonomic studies reveal that during laparoscopic surgery, surgeons face multiple constraints that directly expose them to risk factors for developing musculoskeletal disorders (MSDs).[12–14] These risk factors include static body posture, repetitive upper extremity movements, and force exertion from adverse positions. Moreover, the workload is increased by the high level of task precision and time pressure. Physical demands differ between open and laparoscopic surgery and comparative studies have reported higher prevalences of physical complaints for laparoscopic surgeons.[15–17] Recent studies report MSD prevalence rates of 73% to 88% among specialists in MIS.[18–20] Relative to the general population, these numbers are excessively high. The Fourth European Survey on Working Conditions presents the prevalences of several MSDs, reporting a 24.7% prevalence of backache, 22.8% prevalence of muscular pain, and 23% prevalence of neck and shoulder pain.[21] A US-based study of a large occupational population reported a 20.8% prevalence of lower back pain.[22] MSDs develop gradually and can affect different parts of the musculoskeletal system, including muscles, joints, and nerves. Laparoscopic surgeons mainly report issues involving their neck, back, shoulders, wrists, and thumbs. Symptoms associated with these MSDs predominantly include fatigue, pain, stiffness, and numbness. Such symptoms can affect task accuracy,[23,24] potentially having an indirect impact on patient safety, which is the main priority in surgery.

In our present systematic review, the primary objectives were to determine the overall prevalence of MSDs among surgeons performing minimally invasive abdominal surgery, and to determine whether MSD prevalence varies according to body region and minimally invasive surgical method. The secondary objectives were to identify how MSD prevalence among surgeons impacts surgical performance, and to identify additional risk factors beyond the general ergonomic risk factors. Our present findings will provide insight into the contemporary magnitude and characteristics of MSDs among surgeons, which will help to design interventions, increase awareness, and to develop recommendations for clinicians and medical technicians.[25]