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


Our present systematic review was designed to evaluate the available literature regarding physical complaints and MSDs among surgeons performing laparoscopy. We found high inconsistency across studies, along with a low overall response rate. MSD prevalence among surgeons was found to be 74% (95% CI 65–83). However, if all nonresponders were assumed to have never experienced MSDs, this prevalence was adjusted to 22% (95% CI 16–30).

Despite early reports of the physical drawbacks of laparoscopic surgery in the late 1990s,[39,56] little has improved regarding the ergonomics and physical workload for surgeons. This may be partly because the laparoscopic approach has become the preferred approach from the patients' perspective.[59–61] Furthermore, there has been clear development of greater surgical specialization. Consequently, subgroups of surgeons may spend a relatively high percentage of their daily activities performing laparoscopic procedures. Another issue is that a higher surgical caseload might actually be beneficial for several patient-reported outcome measures.[62–64] Altogether, these trends in the field have led to an overall rising caseload of laparoscopic procedures, with a correspondingly higher chance of surgeons developing MSDs.[16,18,32,34,43,48,51]

One might consider physical complaints to be a "part of the job." However, when such complaints appear to negatively influence the quality of surgical care, it becomes a matter of professional ethics. Several reviewed studies described surgeons who believed that their surgical performance was negatively affected by their own injury or pain.[31,41,44,55] In 2 studies, respondents expressed that their physical complaints influenced their choice of operative approach.[16,54] This suggests that in some cases, patients may not receive the best clinical care available due to their surgeon's physical condition. Szeto et al[34] found that 35.6% of respondents reported almost always "working through pain so that the quality of their work would not suffer." However, it remains unclear whether physical complaints really impact surgical outcomes. Especially in cases of laparoscopic hysterectomy or (hemi)colectomy—where important steps are taken late in the procedure—the physiological process underlying fatigue of the surgeon's upper extremity may play a role in complaint occurrence. Sari et al[20] found that no respondents reported any surgical complications due to their own fatigue or physical complaints; however, this could have been influenced by surgeons' reluctance to admit to such occurrences.

There remains a need for further clarification of the difference in physical complaints between the sexes. On average, female surgeons have smaller hands and glove size. Almost all laparoscopic instruments have a "one size fits all" handle, and previous studies report that such handles are less comfortable for surgeons with small glove sizes.[18,42,52] This could partially explain the higher rates of physical complaints in the upper extremity among women. This finding could also be influenced by anatomical muscular differences between the sexes. Moreover, differences in interplay between working life and private circumstances may be of influence.[65] Furthermore, it is possible that male surgeons are less aware of their complaints or more reluctant to admit that they experience physical complaints. The fact that less-experienced surgeons report more complaints justifies an enhanced focus on ergonomics during surgical residency. Junior surgeons are less familiar with laparoscopic procedures and may intrinsically experience higher mental and physical stress levels. Consequently, their main intraoperative focus will be on the surgical procedure, with less attention paid to their own physical status, surgical setup, or other ergonomic conditions. Implementing an ergonomic module for surgical residents will likely enhance their awareness of surgical conditions as a whole.

One reported benefit of the implementation of robotic surgery is that it offers superior ergonomics. However, our present review showed that sitting in the console still has its limitations, which is supported by evidence in several prior studies.[66,67] Among robotic surgeons, MSD prevalence is the highest in the neck, with up to 35% of robotic surgeons experiencing pain, stiffness, or numbness in this area.[16,17,32,33,46,54] Studies in pathologists and cytotechnologists demonstrate that prolonged use of conventional microscopes is a risk factor for developing (chronic) musculoskeletal injuries, including shoulder, neck, back pain, and fatigue.[68,69] Robotic surgery involves a similar body posture as working with a microscope. Thus, robotic surgeons may benefit from existing knowledge regarding ergonomic guidelines for prolonged microscope use.

This review has several potential limitations. First, the studies used different questionnaires and definitions of MSDs. The common use of terms, such as physical complaints, fatigue, numbness, and pain, contributed to overall inconsistency among studies. The appropriateness of pooling results obtained from various more-or-less self-composed questionnaires is scientifically debatable. However, this was regarded as the least objectionable option available for use in our present review. Furthermore, the STROBE score is not a formal tool for measuring methodological study quality, but was used in our study as a checklist for reporting several outcomes and biases. Another limitation is the possibility of recall bias. All reviewed studies were retrospective analyses, and it is possible that not all respondents were able to clearly report their physical condition. There is also a potential for selection bias, in that the respondents who had experienced physical complaints may have been more eager to complete a questionnaire on this topic. Consequently, the percentage of surgeons reporting physical complaints may be an overrepresentation within the whole population of laparoscopic surgeons. It is known that survey studies among physicians are prone to low response rates.[70] However, it is possible that those surgeons who did not experience physical complaints were reluctant to respond to the questionnaires. Therefore, we recalculated the overall prevalence rate in case the nonresponders had never experienced physical complaints. Moreover, not all studies reported whether the surgeons were asked for their opinion on whether their physical complaints were more or less directly related to MIS. Future prospective studies must focus on the distinction between any MSD versus clinically relevant MSDs with regard to patient safety.

In conclusion, the findings of this systematic review indicate that the MSD prevalence among surgeons performing MIS is likely higher than is commonly acknowledged, warranting future well-designed studies. This matter is clinically relevant, as kinesiology studies reveal that fatigue and MSDs can impact psychomotor performance. Alongside epidemiological research, future studies should also focus on evaluating surgical tasks, environment, and instrument design[40,42,52,71] Interventions, such as formal ergonomic training,[19,25,32] warm-up before surgery,[72,73] and microbreaks during surgery,[74,75] may improve surgeons' physical health and warrant further scientific evaluation.