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


The database search identified 7844 articles, of which 345 were primary research articles addressing physical ergonomics in MIS. Cross-reference checking identified 4 additional articles. Evaluation of full-text manuscripts led to the final inclusion of 35 studies. Figure 1 shows the PRISMA flow chart with detailed information regarding the selection process.

Figure 1.

PRISMA flow diagram.

Study appraisal yielded an average STROBE score of 17.5 (range 11 to 20) out of 22. Efforts to address potential sources of bias were poorly explained in the method sections, with only 2 articles successfully fulfilling this item. In addition, 7 articles failed to report the sample size, and 13 articles did not address the study limitations.

All included articles described survey studies, mainly using self-composed questionnaires. Four surveys reported integration of the Standardized Nordic Questionnaire for Musculoskeletal Symptoms[30] (NMQ) or a modified version.[31–34] Five surveys[25,35–38] integrated the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) ergonomic questionnaire, as developed by the SAGES Ergonomic Task Force.[39] To some extent, all studies subdivided the involved body regions, or enabled the respondents to describe the affected body parts. The articles widely differed in the terminology used for MSDs (eg, musculoskeletal symptoms, discomfort, injuries, or problems) and in the descriptors used to characterize the nature of the MSDs (eg, pain, numbness, stiffness, and fatigue). Moreover, the time period for occurrence of complaints ranged from a point prevalence (during or immediately after surgery), to a 12-month prevalence, to having ever experienced symptoms. The marked duration or emergence of musculoskeletal symptoms also varied from intraoperatively; shortly after surgery; up to recurrent, persistent, or chronic.

Response rates ranged from 6.1% to 100%, with an average of 40.2%. Overall, the reviewed studies included 7112 respondents who were mainly laparoscopic surgeons who performed procedures in general surgery, gynecology, and urology in both adult and pediatric patients. Three studies also included a subset of respondents (N = 378) that were (scrub) nurses, general physicians, anesthesiologists, or orthopedists.[13,40,41] Where possible, data from those respondents were excluded from our meta-analyses.

Table 1 provides an overview of included studies with itemized primary and other relevant outcomes. Of the included articles, 26 reported an overall MSD prevalence among surgeons performing any type of minimally invasive abdominal surgery, which ranged from 20% to 100% with an average of 74%, and a 95% CI of 65 to 83 (Figure 2).[13,14,16–20,25,32–34,37,38,41–53] We found high inconsistency across the study results, with an I2 value of 98.3%. Assuming that all nonresponders had never experienced physical complaints, the overall percentage would be 22% (95% CI 16–30). Among the laparoscopic surgeons with MSDs, the rate of chronic pain ranged from 10.8% to 51.5% with an average of 27% (95% CI 7–54).[16,18,19,32,53] The remaining 9 reviewed studies did not report an overall MSD prevalence, but rather reported MSD prevalence rates for specific body parts.[31,35,36,40,54–58] The body parts most commonly affected with discomfort or pain were the neck with 53% (95% CI 42–63),[14,16–18,20,25,31–34,36,40,41,43,47,49,51,53,54,56,57] back with 51% (95% CI 34–68),[14,17,18,25,36,43–45,47,49,53,54,56,58] shoulders with 51% (95% CI 41–60),[14,17,18,20,31,32,34,36,43,44,47,49,51,53,55–57] and hands with 33% (95% CI 14–55).[18,36,43,51,53,56] The inconsistency of the above-reported prevalence rates across studies was similar to that of the overall MSD prevalence.

Figure 2.

Overall MSD prevalence.

Seven studies, including 1852 respondents, reported the prevalence of physical complaints related to robotic surgery.[16,17,32,33,46,48,54] These studies reported a 56% (95% CI 32–78) overall prevalence of complaints associated with robotic surgery.[16,17,32,33,48] Considering the defined time-frames in these studies, 52.8% of respondents reported ever experiencing physical discomfort,[32,33,48] and 50.4% of surgeons reported complaints or discomfort during robotic surgery.[16,17,33] Franasiak et al[32] and Plerhoples et al,[16] respectively, reported 11.9% and 5% rates of chronic or persistent strain due to robotic surgery. Robotic surgery was most commonly related to discomfort in the neck and in the hand/wrist region, including thumbs and fingers. On the basis of ergonomic considerations, respondents preferred the robotic operative modality compared with either open or laparoscopic surgery,[32,54] and expressed that robotic surgery can be helpful for improving ergonomics.[18,55] Accordingly, Plerhoples et al[16] reported that among MSD sufferers, 8.3% attribute their physical complaints to robotic surgery, 36.3% to open surgery, and 55.4% to conventional laparoscopic surgery. Moreover, the difference in MSD prevalence is reportedly dependent on the body region.[16,17,34,55] Another 3 studies specifically determined the overall percentages of physical complaints during or after open surgery, reporting rates of 56.5%, 65%, and 85.4%.[16,17,55] Among the 5 reviewed studies that reported prevalence numbers for both open and laparoscopic surgery, all showed a higher prevalence of complaints in laparoscopic surgery than open surgery.[16,17,54–56]

Four studies reported that a substantial number of respondents (range 16.6% to 34.8%) believed that their physical complaints affected their surgical performance or activity.[31,41,44,55] Between 6.7% and 17% decreased their surgical practice (caseload) due to their physical complaints.[18,31,34] Park et al[19] reported that 40% of respondents ignored their physical complaints during surgery. Szeto et al[34] found that 35.6% of respondents always worked through pain so that the quality of their surgical work would not suffer. Bagrodia and Raman[54] and Plerhoples et al,[16] respectively, reported that 25% and 30% of surgeons gave some consideration to their own physical discomfort when choosing an operative approach.

The reviewed studies reported several risk factors for MSD development. Sutton et al[52] specifically addressed sex as a risk factor, showing that female surgeons were significantly more likely to receive treatment for their hands and reported significantly more cases of shoulder discomfort, even with correction for glove size. Four other studies reported sex as a risk factor, showing that women were more likely to develop MSDs.[18,31,48,51] Berguer and Hreljac[42] specifically addressed the relationship between hand size and difficulty using instruments, finding that surgeons with a small glove size reported greater difficulty using all laparoscopic instruments than surgeons with a medium or large glove size (P < 0.001). Franasiak et al[18] found that increased pain symptoms were significantly associated with glove size; however, the majority of respondents in this study stated that their instruments fit "just right" (70.8% to 84.8%, depending on type of instrument).

Overall, 12 studies examined the constraints of laparoscopic instruments.[13,18–20,36,40,42,43,45,47,50,52] Three of these studies directly assessed the surgeons' perspectives regarding handle design. Handle design was reported as a cause of physical complaints by 49% of respondents in the study of Sari et al,[20] 74.4% in Park et al,[19] and 83% in Matern and Koneczny.[47] More specifically, Matern and Koneczny[47] reported that 36% of surgeons complained about pressure areas, 26% about neuropraxia, and 57% about uncomfortable posture due to instruments. Cass et al[43] found that difficulty manipulating instruments was a significant causative factor in injury of disc prolapse. Moreover, improper positioning of the surgical setup—including monitor height and position, table height, and use of foot pedals—affected the surgeons' comfort and was indicated as a risk factor for MSD development in 8 studies.[13,14,19,20,36,40,47,52]

Eight studies assessed the workload in terms of caseload or number of hours spent performing MIS. The findings on this topic were somewhat ambiguous. Six studies reported that increased laparoscopic workload was significantly related to physical complaints.[19,42,43,46,51,53] In contrast, McDonald et al[48] and Franasiak et al[18] identified no relationship between caseload and physical complaints for conventional laparoscopic procedures. However, the latter study reported that the number of cases per day and case length were significant risk factors for MSD development in robotic surgery. Plerhoples et al[16] found that surgeons with more laparoscopic cases (P < 0.0001), greater annual laparoscopic volume (P < 0.0001), or with longer career durations (P = 0.03) were more likely to attribute their pain to the laparoscopic modality.

Ten studies reported data regarding experience and age. Four studies found that less experienced surgeons were more likely to report physical complaints.[18,20,36,56] Accordingly, 4 studies reported that younger age was associated with higher rates of physical complaints.[18,20,53,56] In contrast, Stomberg et al[51] and Cass et al[43] reported that injury risk increases with age. Plerhoples et al[16] identified no relationship between age or experience and physical complaints. McDonald et al[48] reported that younger surgeons were more likely to report symptoms; however, this association disappeared with correction for sex. Park et al[19] found that age and years of practice were not correlated with physical complaints. However, they identified a significant correlation between case volume and symptoms in the neck, right hand, upper extremities, and lower extremities (all P < 0.05). They concluded that the number of cases performed per year was a stronger predictor of physical complaints than either age or years in practice.