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


To summarize the overall MSD prevalence among surgeons performing MIS, we conducted a systematic review following the PRISMA guidelines. The search strategy was developed by CA, AdM, and TN in consultation with a research librarian at the Radboud University Library. On April 15 2016, we performed a search in PubMed, EMBASE, the Cochrane Library, Web of Science, CINAHL, and PsychINFO. The following search terms were used (as Medical Subject Headings and Title/Abstract words): "Human Engineering" OR "ergonomics" OR "human factors" OR "occupational health" OR "workload" AND "surgical procedures, minimally invasive" OR "minimally invasive surgery" OR "minimal access surgery" OR "laparoscopy" OR "endoscopy" OR "Surgery, Computer-Assisted" OR "Robotics." Appendix 1, includes the full search strategies per database. We set no limits regarding year of publication, language, or publication status and we applied no other additional filters after running the search in the consulted databases.

Our present review focused on MIS performed in the abdominal cavity—including general, gynecological, and urological surgery. This limitation was applied because these specializations entail similar task-physical and environmental characteristics and, therefore, carry similar risk factors for developing physical complaints. For inclusion, studies had to address physical ergonomics as a determinant, report the prevalence of MSDs (or physical complaints) as a study outcome, and be published as full-text articles in a peer-reviewed journal.

All studies identified in the initial database search were independently reviewed by 2 researchers (CA and AdM). First, the titles and abstracts were screened to identify all articles related to physical ergonomics in MIS. Next, the full-text articles were obtained to determine eligibility for final inclusion in the synthesis. Disagreements were discussed with a third researcher (TN), and resolved by consensus. Finally, the references of the included articles were checked for additional articles of interest.

We recorded the following data from the included studies: year of publication, population/sample size/response rate, type of surgery, applied questionnaire, and primary and other relevant outcome measures. The primary summary measure was the reported prevalence of physical complaints. Secondary summary measures included predictors for symptom development and impact on surgical performance.

To evaluate the conduct of the included studies, we used the 22-item Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist.[26,27] Each reviewed article was assessed for all 22 items with 1 point given for each successfully addressed item, and a total score calculated as the sum of all items. Finally, we calculated the average score for all reviewed articles.

Finally, we performed random effects meta-analyses for both overall prevalence of physical complaints and body part specific prevalence. We calculated exact binomial confidence intervals (CIs) for the individual studies, and performed an arcsine transformation of the proportions for the meta-analyses. We expected to find high heterogeneity due to differences in the utilized questionnaires (validated or not validated), in the MSD definitions, and in the study time frames. Therefore, we pooled the individual prevalence rates using the Hartung-Knapp-Sidik-Jonkman (HKSJ) method for random effects.[28] Heterogeneity was measured based on I2 and prediction intervals. Analyses were conducted in R (version 3.0.1; R Core Team 2012), using the meta package.[29]