Patients Benefit While Surgeons Suffer:

An Impending Epidemic
Adrian Park, MD, FACS, Gyusung Lee, PhD, F Jacob Seagull, PhD, Nora Meenaghan, MD,
David Dexter, MD

BACKGROUND: The widely held belief that laparoscopy causes greater strain on surgeons’ bodies than open
surgery is not well documented in scope or magnitude. In the largest North American survey to
date, we investigated the association of demographics, ergonomics, and environment and
equipment with physical symptoms reported by laparoscopic surgeons.
STUDY DESIGN: There were 317 surgeons identified as involved in laparoscopic practices who completed the
online survey. Data collected from this comprehensive 23-question survey were analyzed using
chi-square.
RESULTS: There were 272 laparoscopic surgeons (86.9%) who reported physical symptoms or discomfort.
The strongest predictor of symptoms was high case volume, with the surprising exceptions of
eye and back symptoms, which were consistently reported even with low case volumes. High
rates of neck, hand, and lower extremity symptoms correlated with fellowship training, which
is strongly associated with high case volume. Surprisingly, symptoms were little related to age,
height, or practice length. The level of surgeons’ awareness of ergonomic guidelines proved to be
somewhere between slightly and somewhat aware. A substantial number of respondents re-
quested improvements in regard to both the positioning and resolution of the monitor.
CONCLUSIONS: Far beyond previous reports of 20% to 30% incidence of occupational injury, we present
evidence that 87% of surgeons who regularly perform minimally invasive surgery suffer such
symptoms or injuries, primarily high case load-associated. Additional data accrual and analysis
are necessary, as laparoscopic procedures become more prevalent, for improvement of surgeon-
patient and surgeon-technology interfaces to reverse this trend and halt the epidemic before it
is upon us. (J Am Coll Surg 2010;210:306–313. © 2010 by the American College of Surgeons)

Twenty years after the introduction of the first laparoscopic
techniques to North American surgical audiences, mini-
mally invasive surgery (MIS) has become mainstream. Al-
though no longer considered revolutionary, laparoscopic
surgery is still widely acknowledged to have revolutionized
the delivery of surgical care.1 By mid 2009, it could safely
be claimed that millions of patients around the world have
benefited from the reduced perioperative morbidity, the
enhanced postoperative recovery, and the cosmetic advan-
tages associated with laparoscopic over open surgical tech-
niques.2 Society at large has derived benefit from the advent
Disclosure Information: Nothing to disclose.
Presented at the American College of Surgeons 94th Annual Clinical Con-
gress, San Francisco, CA, October 2008.
Received September 12, 2009; Revised October 22, 2009; Accepted October
27, 2009.
From the Department of Surgery, University of Maryland School of Medi-
cine, Baltimore, MD.
Correspondence address: Adrian Edward Park, MD, FACS, University of
Maryland Med Center, Room S4B14, 22 South Greene St, Baltimore, MD
21201-1595.
of MIS in the form of productivity gains related to a faster
return to work after laparoscopic surgery. In addition, in a
time of increasingly constrained health care resources, MIS
has facilitated a greater number of patients having opera-
tions without a concomitant rise in hospital bed occupancy
because many procedures can be performed on an outpa-
tient basis.
Yet, even though the benefits of MIS are now plain for all to
see, it is increasingly apparent in this success story that a con-
siderable unforeseen cost is borne by one key stakeholder—
the surgeon. The same vital procedures are performed in both
MIS and open surgery, but surgeons who perform a majority
of their cases laparoscopically have been aware for years that
they encounter physical stress and mental strain beyond that
which they experience performing open surgery. Reports of
such findings began emerging in the early years of the laparo-
scopic revolution.3,4
In MIS, surgeons operate with reduced access to the
patient, reduced degrees of freedom in their interventions,
and lack of direct visualization of the surgical field; an ever
growing body of literature speaks to the unique physical

© 2010 by the American College of Surgeons ISSN 1072-7515/10/$36.00

Published by Elsevier Inc. 306 doi:10.1016/j.jamcollsurg.2009.10.017
Vol. 210, No. 3, March 2010
and cognitive ergonomic challenges posed to the laparo-
scopic surgeon.4-8 Among the documented ergonomic lim-
itations affecting the minimally invasive approach are op-
erational issues with instrument design,9 stresses caused by
monitor placement,10 and perceptual challenges.11 Signifi-
cant ergonomic comparisons characterizing both open and
laparoscopic surgical performance have appeared. They are
exemplified by studies of Berguer and colleagues12 showing
surgical posture—as measured by a force plate system and
signified by the significantly reduced range of motion of
the center of pressure—during laparoscopic procedures to
be less dynamic than during open procedures. They also
demonstrated muscular activation levels from several upper
extremity muscle groups and body part discomfort scores
to be significantly higher in the case of laparoscopic com-
pared with open technique in repeated knot-tying tasks.13
Through use of mental stress skin conductance levels,
electro-oculograms, eye blink rates, and subjective reports,
an earlier study also investigated surgeons using both lapa-
roscopic and open surgical techniques to perform knot-
tying tasks; it found that the laparoscopic approach re-
sulted in fewer tied knots and correlated with significantly
higher mental stress.14
Some authors have reported MIS-related surgeon dis-
comfort rates of 40%15 to 60%7; larger survey studies on
the subject have reported symptoms (often persistent) re-
lated to MIS in the 12% to 18% range.16,17 A 15% rate
(approximately) of injury or symptoms suffered by sur-
geons is often quoted in discussions on the ergonomic risks
of MIS, as though it were the conventional wisdom on the
subject. For this and other reasons, we sought through this
study to confirm the prevalence of MIS-related operator
symptoms and discomforts within a broader population of
laparoscopic surgeons.
METHODS
Data collection
The protocol for this research study was approved by the
University of Maryland Internal Review Board. An e-mail
inviting ergonomic survey participation was sent to 2,000
active (ie, board certified) gastrointestinal and endoscopic
surgeons in North America and abroad who are members
of the Society of American Gastrointestinal and Endo-
scopic Surgeons (SAGES) to collect data representative of a
wide-ranging population of skilled, experienced laparo-
scopic or minimally invasive practitioners. The invitation
included the information that completion of the survey
was voluntary and that the survey was for research purposes
only and was devoid of any personal identifiers. A link in
the e-mail permitted access to the online survey. A week
before the survey deadline, a follow-up e-mail was sent.
Park et al Patients Benefit While Surgeons Suffer 307
Survey structure
This comprehensive ergonomic survey consisted of 23
questions grouped into 4 categories: demographics, physi-
cal symptoms, ergonomics, and environment or equip-
ment (Table 1). Some questions required single answers
such as “Have you ever had any physical discomfort or
symptoms you would attribute to your laparoscopic oper-
ating? Yes/no;” other questions allowed selection of multi-
ple applicable answers such as “Where did you acquire the
recommendations made by the field of surgical ergonom-
ics? Literature, grand rounds, surgical training, online, re-
gional or national meetings, laparoscopic product repre-
sentative, other.”
Statistical analysis
All data from this survey instrument were exported into
Microsoft Excel format and then analyzed using the Statis-
tical Package for the Social Sciences (SPSS). Data were
analyzed using chi-square and logistic regression. Univari-
ate analysis was used to examine distribution in regard to
questions allowing a single answer. Multiple response anal-
ysis was used with questions allowing multiple answers, the
resultant percentage sum of which may exceed 100%. His-
tograms were used to analyze frequency distribution. Cor-
relation analysis between two questions of interest was used
to investigate how one variable affected another variable’s
distribution. For example, correlation analysis was applied
to the first question (What is your age?) in relation to the
eighth question (Have you ever had any physical discom-
fort or symptoms you would attribute to your laparoscopic
operating?).
RESULTS
Three hundred seventeen surgeons identified as being ac-
tively and regularly involved in laparoscopic practices
completed the online survey (response rate of 14.4%).
The demographics of the participants are summarized in
Table 2.
Physical symptoms
Two hundred seventy-two laparoscopic surgeons (86.9%)
reported that they had experienced physical discomfort or
symptoms they would attribute to performing MIS. This
rate of reported symptoms was then correlated with each of
our survey’s seven demographic factors to calculate
influence.
The study revealed a lack of symptom correlation to
measures of years in practice or age. Only hand symptoms
showed any significant relationship to age, with younger
surgeons or those over 60 years of age at highest risk for
exhibiting hand problems (left hand p ⬍ 0.006, right hand
308 Park et al Patients Benefit While Surgeons Suffer J Am Coll Surg

Table 1. Survey Structure Table 2. Demographic Information

Question Answer* Demographic factors Data
Demographics Age, y, mean (SD) 44.3 (8.4)
1. What is your age? S Height, cm, mean (SD) 69.6 (3.4)
2. What is your height? S Gender, n (%)
3. What is your gender? S Male 261 (83)
4. What is your dominant hand? S Female 54 (17)
5. How many laparoscopic cases do you perform a Dominant hand, n (%)
year? S Right 272 (86)
6. Have you completed a laparoscopic fellowship? S Left 21 (7)
7. How many years have you been practicing Ambidextrous 24 (7)
laparoscopic surgery? S Annual case volume, mean (SD) 212 (127)
Physical symptoms Fellowship experience, n (%)
8. Have you ever had any physical discomfort or Fellowship 110 (35)
symptoms you would attribute to your
laparoscopic operating? S No fellowship 207 (65)
9. If you answered yes to question 8, which of the Practice length, y, mean (SD) 9.8 (5.6)
following apply? (numbness, stiffness, fatigue,
pain, and history of treatment received for each
individual body part†) M significant correlations were discovered with regard to
10. Please describe any other injuries or conditions symptoms in the neck (p ⬍ 0.05), right hand (p ⬍ 0.001),
that were not included above. D and lower extremities (p ⬍ 0.005). Increased case volume
11. When do these symptoms or discomforts also predicted the incidence of symptoms in both upper
bother you? M and lower extremities (all p ⬍ 0.05, Fig. 2). Symptoms
12. How have you attempted to minimize these were reported with higher incidence for the surgeon’s dom-
problems or conditions? M
inant hand (significant at p ⬍ 0.05 only for right-handed
13. To which of these factors do you attribute your
physical complaints? M
surgeons).
Ergonomics
Data confirmed generally accepted gender demograph-
14. How aware are you of the recommendations
ics. Women were shorter than men (65.3 inches versus 70.4
made by the field of surgical ergonomics, its inches, p ⬍ 0.001) and reported a smaller glove size (aver-
studies and research? S age size 6.57 versus 7.85, p ⬍ 0.001). Gender was also a
15. Where did you acquire this information? M factor in that women reported more arm symptoms and
16. Have you applied any of this information to men reported more lower extremity problems.
your surgical practice? S Survey question 10 asked about physical conditions or
Environment and equipment injuries not covered by the physical discomfort and symp-
17. What references do you use when adjusting the toms addressed in questions 8 and 9. Responses varied
operating room table height? M from headaches and finger calluses to disc problems. Sev-
18. What kind of display system do you use? S eral injuries were reported by more than one participant.
19. How is your display system mounted? S Among them were carpal tunnel syndrome (4 responses),
20. Improving which of these display parameters disc problems (4), headache (3), tennis elbow (2), and
would be most helpful to you? M
shoulder muscle spasm (2).
21. What size surgical gloves do you wear? S
22. Do you feel that the laparoscopic instrument
handles are: S Symptom timing and minimization
23. If available, would you utilize laparoscopic Efforts to specifically isolate the times that symptoms were
instruments in more lengths? S bothersome are illustrated in Table 3. Overall, 58% (184 of
*Answer: (S) single answer, (M) multiple selections available, (D) descriptive. 272 of the 317 participants) reported they were aggravated
†
Body parts: eyes, neck, upper back, lower back, hips, knees, ankles, feet, (the by symptoms or discomforts that they associated with per-
left and right side of ) shoulder, elbow, wrist, thumb, other fingers.
forming MIS. Sixty-two percent of those also reported that
their symptoms or discomforts continued after performing
p ⬍ 0.029; Fig. 1). Annual case volume of laparoscopic operations. About a quarter of those who experience symp-
procedures did, however, provide a key to predicting phys- toms or discomforts while and after performing surgery
ical symptoms. When fellowship was equated in terms of also reported having these problems persistently. Twenty-
case volumes (average volume nonfellow, 192; fellow, 249), four percent of all participants indicated that symptoms or
Vol. 210, No. 3, March 2010 Park et al Patients Benefit While Surgeons Suffer 309

Figure 2. Reports of symptoms in neck and upper and lower ex-

Figure 1. Age and incidence of complaints for right and left hand
(showing significant age effects) and neck, back and lower extremity
symptoms, which did not show age-related differences. Left hand,
blue diamond; right hand, pink square; neck, yellow triangle; back,
turquoise stars; lower extremity, purple star.
discomforts were experienced immediately after but not
while performing operations, although the majority of
these respondents (95%) did not relate that these problems
were persistent. About 15% of all participants answered
that they did not experience symptoms or discomfort at
any time.
When asked how they have attempted to minimize these
problems or conditions, 84% of participants answered that
they did so by changing postural position. For approxi-
mately 30% of all survey respondents, actions such as
changing instruments or taking a break were reported as
minimization techniques. Forty percent of all participants
answered that they would just ignore any such problem.
tremities as plotted against increasing annual case volume of lapa-
roscopic procedures. Left hand, blue diamond; right hand, pink
square.
Asked what operating room factors they would attribute
their physical complaints to, 74.4% of all participants in-
dicated instrument design. Two factors—operating room
table setup and display monitor location—were cited by
40% of participants, and type of display system was iden-
tified as contributory by 12% of all those reporting.
Ergonomic knowledge
Five discrete levels (not aware to very aware) were available
to describe the degree of awareness the responding sur-
geons possessed in regard to recommendations that have
been put forth by researchers in the field of surgical ergo-
nomics. Participant answers are shown in Figure 3. More
than half (58.7%) of participating surgeons reported being
slightly or not aware of the recommendations. The average
level of awareness at 2.37 fell between slightly and some-

Table 3. Time Frames Associated with Symptom Experience

When do the symptoms or discomforts
bother you? Frequency, n %
While performing surgery, immediately after,
and persistently 26 8.2
While performing surgery, immediately after
but not persistently 88 27.8
While performing surgery, not immediately
after, still persistently 4 1.3
Only while performing surgery 66 20.8
Not while performing surgery but immediately
after and persistently 4 1.3
Only immediately after and not persistently 71 22.4
Nothing bothers me 47 14.8
Not answered 11 3.4
Figure 3. Surgeon respondents’ reported levels of awareness in
Total 317 regard to ergonomic knowledge.
310 Park et al Patients Benefit While Surgeons Suffer
Figure 4. Sources from which surgeon respondents acquired job-
relevant ergonomic information.
what aware. Overall, grand rounds were revealed to be the
least effective source for learning about ergonomic recom-
mendations (Fig. 4). Surgeons who reported any level
(slightly aware to very aware) of ergonomic knowledge had
primarily acquired such information from literature
(66.8%) and from regional or national meetings (54.6%).
The correlation of the responses given in regard to aware-
ness level with the responses given about source of infor-
mation indicated that those who had rated themselves as
very aware had obtained their ergonomic information from
surgical training (43.8%). The correlation rate significantly
decreased when surgical training as a source of ergonomic
knowledge was calculated for those reporting a lower level
of awareness (11.9%). When all participants reporting any
level of ergonomic knowledge were taken into account,
only 60% answered that they had applied such information
to their surgical practices. When we isolated only those
who were very aware of ergonomic information, however,
the rate of application to practice significantly increased, to
93.3%.
Environment and equipment
A total of 67.4% of participants reported using a liquid
crystal display system, with 25% of them still using that
type of monitor mounted on a cart. Our study data showed
that the percentage of participants experiencing eye strain
and neck stiffness did not differ based on use of display type
or mounting (p ⬎ 0.05, p ⬎ 0.05). Seventy-one percent of
stationary display users and 48% of mobile mount display
users requested improvements in regard to monitor posi-
tioning. Sixty-five percent of cathode ray tube users in ad-
dition to 48% of liquid crystal display users asked for im-
proved resolution. No significant differences in terms of
demands for improvements in regard to display monitor
size, color or number were found between cathode ray tube
and liquid crystal display users.
Responses to questions about instrument handle size
revealed a general satisfaction (Table 4). Overall, 69% of
J Am Coll Surg
Table 4. Instrument Handle Size Preferences
Instrument handle Too big, % Just right, % Too small, %
Standard graspers 11 75 14
Needle drivers 15 76 9
Energy/coagulation
devices 21 68 11
Stapler 40 59 1
respondents rated the handles of four types of instruments
as “just right” for their hands. Significant differences were
evident among tool types (p ⬍ 0.001). Graspers and needle
drivers had the highest ratings as being “just right;” staplers
were reported as too big by 40% of respondents, with only
1% reporting them as too small. Seventy-nine percent of
respondents reported that they would use instruments of
different lengths if such instruments were available.
DISCUSSION
For surgeons who have been doing laparoscopic surgery for
most of the past 2 decades, it will come as no surprise that
the initially reported rates of MIS-related symptoms far
underestimate the reality experienced and reported by the
contemporary MIS surgeon. As we continue 20 years later
to use instruments not “purpose designed” for laparoscopy,
but hastily borrowed and adapted from our otolaryngology
colleagues,18 it is hardly surprising that a physical toll has
been exacted from surgeons. We continue to contort our-
selves on a daily basis—often working around or accom-
modating MIS instruments and equipment—to ensure our
patients the best outcomes possible. It is within the context
of this accepted—albeit challenging—baseline existence
that our survey explores the potential ergonomic impact of
MIS on the surgeon.
That 87% of surgeons who regularly perform MIS suffer
performance-related symptoms is without a doubt the
most startling finding in this study and underscores the
urgent need for applicable ergonomic research. Recent data
from limited studies suggest that between 40% and 60% of
MIS surgeons experience occupational injuries.7,19 Previ-
ously published surveys comparably sized to ours have re-
ported rates of MIS-related symptoms and injury in the
12% to 20% range.16,17 These latter percentages are often
those quoted in meetings during which issues of symptoms
and injury related to laparoscopic performance are dis-
cussed. Why then is there a disparity in terms of the
number—86.9%—we now report? The continuing rise in
MIS technique adoption rates, with more surgeons over
greater lengths of time performing more MIS procedures,
might be considered, even more than survey methodolo-
gies, to be a factor of influence.
Throughout the time that this study was conducted and
during its presentation at the Clinical Congress of the
Vol. 210, No. 3, March 2010
American College of Surgeons in 2008, a surprising num-
ber of surgeons from across the country have communi-
cated personally with the senior author, sharing anecdotally
the extent to which their MIS-related occupational symp-
toms have affected or even limited their (general) surgical
practices. Such accounts, though not reportable, are
noteworthy.
The data presented in this article serve as a clarion call to
improve operative working conditions for the MIS sur-
geon. Saying this does not divert us from being mindful of
study limitations. Our low initial response rate might have
occurred for any of a number of reasons. E-mail filtering
systems might have blocked our initial invitation. Our sur-
vey was lengthy because it was comprehensive, so perhaps it
was not easily responded to by surgeons caught in busy
schedules and other time demands. We might have distrib-
uted our survey at surgical conferences in addition to
e-mail. Although we cannot limit the overall effects pre-
sented by the self-selection bias that is unavoidable in any
voluntary survey methodology, we did attempt to collect
demographic data on the respondents so that we could
assess symptom prevalence in well-described cohorts. We
also attempted to include all relevant factors suspected of
contributing to symptom prevalence to be able to deter-
mine the effects of such factors. Our sample does include
respondents of both genders, with a range of ages, years in
practice, and case volumes. Examining these four contrib-
uting factors does limit selection bias effects in the suba-
nalysis of groups. Our data suggest that high case volume,
for example, will lead to more symptoms, though this re-
lationship cannot be proved to be causal within the current
methodology.
Routinely, laparoscopic surgeons face challenges in con-
ducting operations that are not encountered by their col-
leagues performing open procedures. Having lost direct
visual connection to the operative field, MIS surgeons
work in three dimensions while guided by two dimensional
images, meaning that their visual axes (eyes to monitor) are
at odds with working or motor axes (instruments to target
anatomy).20 The surgeon must move the instrument han-
dle “south,” and to dissect in an “easterly” direction the
hand pieces must be moved “westward” (the fulcrum ef-
fect), as laparoscopic instruments are fixed in the abdomi-
nal wall by means of a trocar such that to move a grasper tip
“north.” These most fundamental movements are counter-
intuitive to those learned for open surgery performance,
still laparoscopic surgeons daily perform marvelous, com-
plex procedures, having adjusted to the loss of the more
than 20 degrees of freedom associated with the hand and
used during open surgery, with the result being that they
are limited to fewer than six degrees of freedom.21
Park et al Patients Benefit While Surgeons Suffer 311
Although ergonomic sizing has been incorporated into
objects as mundane as office equipment, it has yet to be
achieved with respect to surgical instruments. Surgical
gloves are produced in eight sizes, from 5.5 to 9.0, in in-
crements of 0.5, with all surgeons knowing their exact
glove size. Yet even with such well-documented and well-
understood differences in hand size, surgical instruments
are produced in a single size. Resolve for such equipment
issues would benefit from studies grounded in anthropo-
metric data characterizing the population of laparoscopic
surgeons in terms of body size and proportion.
The main predictor of surgeon symptoms in our study
was MIS case volume. Surgeon gender, age, height, or
handedness did not independently correlate with develop-
ment or existence of MIS-related symptoms. Analysis of
these four subgroups presents a consistent message about
the risk factors: the number of cases performed per year is a
stronger predictor of symptomology than either age or
years in practice. Some of the subgroup analyses, such as
correlation of effects of handedness with dominant hand
symptoms were limited because of the small number of
participants in the left-handed subgroup (n ⫽ 20 left
handed). Other results are likely the result of a weak or
nonexistent effect of the nonsignificant variables. The find-
ings are important because they suggest that the stresses of
surgery do not discriminate between young and old: if a
surgeon performs a sufficient volume of cases, he or she is
likely to suffer symptoms.
That there are risk factors outside of personal demo-
graphics is already well documented. van Veelen and col-
leagues22 developed ergonomic guidelines for the laparo-
scopic surgeon with five areas of focus: instrument
(handheld) design; monitor position; use and placement of
foot pedals; operating room table height; and surgeon
(static) body posture. Although their suggestions derived
from an appropriately comprehensive approach and may
provide helpful direction, the supporting data are not deep.
Hallbeck and associates23 point to new international stan-
dards governing the usability of medical instruments and
devices with the hope of increasing patient and surgeon
safety. From an ergonomic and human factors perspective,
such efforts must be expanded to optimize the interface of
surgeon, machine, and patient.
Changing postural position clearly presented as the fa-
vored method used by our respondents to minimize their
reported symptoms and discomforts. Given the static pos-
tures required by MIS performance, this is not surprising.
Fatigue decrease has been ergonomically demonstrated as
possible when laparoscopic surgeons shift posture.24 Other
research indicated that the strategic movements of a
surgeon—with an identified wrist complication—could
312 Park et al Patients Benefit While Surgeons Suffer
appear to indicate postural instability yet actually be nec-
essary for the achievement of successful task performance.25
Postural adjustments can be identified and correlated with
skill level through the recently identified analytic tool com-
prised of postural stability demand data combined with
center of mass and center of pressure data.26 The discom-
fort accompanying static laparoscopic surgical posture has
been addressed by Albayrak and colleagues,27 who re-
examined fundamentally the surgeon-patient “interface,”
with the result being their design of a new ergonomic body
support for surgeons. Although it will take time to know
whether such a fresh approach will gain traction, this type
of creativity directed toward MIS ergonomics will be nec-
essary on a broad front to solve the problems our study
identifies.
Our findings differ from those of others10 in terms of the
relative impact of monitor position (tower or suspended) or
type (cathode ray tube or flat screen) in regard to surgeon
symptoms. The reasons for this are unclear. Few would
argue against the recommendation that correct placement
of an optimized surgical image or screen plays a significant
role in surgeon comfort. Several ergonomic studies have
compared different laparoscopic display monitor locations
(in front of, to the left, or to the right of the surgeon) and
heights (eye level and hand level).28-30 These studies showed
that the surgeons’ task performance was better with a dis-
play monitor either placed in front rather than to the left or
right of the surgeon or at the surgeon’s hand rather than eye
level. Yet another study demonstrated that when the mon-
itor was at eye compared with hand level, muscular activi-
ties of the neck measured by electromyography were lower
than expected, indicating less stress.19 We found MIS sur-
geons continuing to experience eye and neck issues and
seeking improvements both in terms of the currently used
boom mount and higher resolution liquid crystal displays.
Our results suggest that more detailed ergonomic studies
investigating this still unresolved and ergonomically risky
surgeon-technology interface are necessary.
An encouraging finding of our survey was that those
possessing knowledge of MIS ergonomic recommenda-
tions were very inclined to apply such guidelines in their
practices. Still, our respondents’ low awareness level about
existing research recommendations to ergonomically im-
prove MIS surgical performance and associative symptoms
and discomforts makes clear that such guidelines must be
more appropriately and widely disseminated to practicing
surgeons.
Inevitably, many more questions are raised than are an-
swered by a study such as ours. Future research needs to go
more deeply yet broadly into the effects of surgery-related
ergonomic difficulties. Such studies should span a wide
J Am Coll Surg
range, including investigation of whether deleterious ergo-
nomic impact on surgeons ever results in patients suffering
adverse events; accumulation of knowledge about the
health and physical activity experienced by surgeons out-
side the operating room; review of occupational data relat-
ing ergonomics to unfavorable effects (eg, shortened prac-
tices and disability claims); and determination of the
incidence of ergonomic-related work leave or case cancel-
lation. A similar survey in terms of open surgery perfor-
mance could, in the future, be a source of valuable addi-
tional data. Also vital to improving the design of operative
work space, laparoscopic or open, is an understanding of
optimal surgical movement. Yet there is a marked paucity
of such knowledge. Sadly, a surgeon can much more easily
obtain a detailed ergonomic assessment and direction for
improvement of his or her golf swing31,32 than of his surgi-
cal “stance” or movement. Much work remains to be done
in the establishment of a “matrix of surgical movement.”
Now, especially in the face of an impending shortage of
general surgeons in the US,33 the last thing that we as a
society can afford is surgical careers shortened by occupa-
tionally related symptoms and conditions. That research
must more clearly and emphatically define the ergonomic
impact of MIS on the practicing surgeon (then set about
improving it) is now all too painfully clear.
Author Contributions
Study conception and design: Park Lee, Dexter
Acquisition of data: Park Lee
Analysis and interpretation of data: Park Lee, Seagull,
Meenaghan
Drafting of manuscript: Park, Lee, Seagull
Critical revision: Park, Lee, Seagull
Acknowledgments: We thank Rosemary Klein for her edit-
ing contributions.
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