Strain on the surgeon: a systematic review of the methods of measuring strain in abdominal and thoracic surgery Nainika Menon a, Nadia Guidozzi b , Sivesh Kathir Kamarajah c , Rohan Gujjuri d , Sheraz R. Markar a,* a Surgical Intervention Trials Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom b Department of General Surgery, University of Witwatersrand, Johannesburg, Republic of South Africa c NIHR (National Institute for Health and Care Research) Doctoral Fellow, NIHR Global Health Research Unit on Global Surgery, School of Health Science, University of Birmingham, United Kingdom d College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom A R T I C L E I N F O Handling editor: D.G. Healy Keywords: Strain Surgeon A B S T R A C T Introduction: Surgery can be arduous to the operating surgeon – both in terms of cognitive and physical strain. Ergonomic strain has been recognised to drive absenteeism, reduce career longevity and cause injuries. This systematic review aims to 1. Outline the nature of ergonomic strain in the context of abdominal and thoracic surgery, regardless of surgical approach 2. Identify the qualitative and quantitative measures of surgical strain. Methods: A systematic review was conducted using Pubmed, MEDLINE and Ovid EMBASE databases (date range: 1990 to Sep 2024). Of the initial 1288 articles identified, a final 71 studies were included in this review (quantitative measures = 36, qualitative measures = 49, of which 14 studies overlapped with the papers reviewed in the quantitative measures section). Results: The quantitative measures used to measure ergonomic strain included electromyography, electrocardi- ography, gravimetric position sensors, skin conductance and inertial measurement units. Laparoscopic surgery caused less physical strain than open surgery, however more cognitive strain during the learning curve. Robotic surgery yielded conflicting data in terms of muscle activation when compared to laparoscopic surgery however reported less cognitive and cardiovascular strain. The qualitative measures of strain included a range of self- reported questionnaires, demonstrating important gender differences and scores that typically correlated with objective physical strain. Discussion: The studies show wide variation in measuring ergonomic strain. Avenues for further research include measuring the impact of learning curves, patient factors on ergonomic strain and the impact of gender. 1. Introduction The risk of musculoskeletal injuries amongst healthcare pro- fessionals is a well-established issue, particularly impacting the neck, lower back and shoulders [1–4]. Surgery requires long hours of oper- ating, often in unnatural positions, with notable physical and mental strain. The ergonomic stress experienced by surgeons while operating has been identified as a major cause of absenteeism in the workplace and an important factor in reducing surgical career longevity [1]. For those without a specific isolated injury, chronic fatigue and pain from years of operating can have a significant impact on surgeons, including early retirement [1]. There has been a clear interest in identifying risk factors for injuries to the surgeon during operative procedures, and a focus on comparing open and minimal invasive surgery for these at-risk behaviours. With the expanding realm of minimal invasive surgery, laparoscopic, robotic and endoluminal/endovascular surgery can possibly offer improved ergo- nomics for surgeons, particularly with an increasing overweight popu- lation. Whilst laparoscopic surgery offers many benefits to the patient, it is thought to increase cognitive strain on the surgeon, thereby poten- tially increasing their risk of musculoskeletal injuries due to diverted attention [5–7]. Moreover, robotic surgery is deemed to be less physi- cally demanding for the surgeon offering some improvements to the traditional limitations of laparoscopic surgery, namely decreased range * Corresponding author. Surgical Intervention Trials Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom. E-mail address: sheraz.markar@nds.ox.ac.uk (S.R. Markar). Contents lists available at ScienceDirect The Surgeon journal homepage: www.thesurgeon.net https://doi.org/10.1016/j.surge.2025.04.015 Received 24 December 2024; Accepted 14 April 2025 The Surgeon 23 (2025) 257–264 Available online 30 April 2025 1479-666X/© 2025 The Authors. Published by Elsevier Ltd on behalf of Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. This is an open access article under the CC BY license ( http://creativecommons.org/licenses/by/4.0/ ). https://orcid.org/0000-0002-9336-9127 https://orcid.org/0000-0002-9336-9127 https://orcid.org/0000-0002-2748-0011 https://orcid.org/0000-0002-2748-0011 https://orcid.org/0000-0002-3998-8162 https://orcid.org/0000-0002-3998-8162 mailto:sheraz.markar@nds.ox.ac.uk www.sciencedirect.com/science/journal/1479666X https://www.thesurgeon.net https://doi.org/10.1016/j.surge.2025.04.015 https://doi.org/10.1016/j.surge.2025.04.015 http://crossmark.crossref.org/dialog/?doi=10.1016/j.surge.2025.04.015&domain=pdf http://creativecommons.org/licenses/by/4.0/ of motion, fulcrum effect on instrumentation, elimination of tremor motion and improved surgical ergonomics [8,9]. Although there are several studies that evaluate the impact of strain on the surgeon in various subspecialties, there is a lack of an up-to-date systematic review evaluating surgical strain in the context of surgeons operating within abdominal and thoracic cavities. This encompasses a variety of surgical specialties, including general surgery, urology, gy- naecology and thoracic surgery; these are typically long operations in deep cavities with significant strain to the surgeon. The aim of this systematic review is to provide an up-to-date summary of the literature exploring the impact of abdominal or thoracic surgery on the surgeon in terms of ergonomic strain. 2. Methods The systematic review complied with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic review was conducted using Pubmed, MEDLINE and Ovid EMBASE databases (date range: 1990 to Sep 2024) using the following search strategies with standard Boolean operators: ‘surgery’, ‘opera- tion’, ‘surgeon’, ‘strain’, ‘stress’, ‘ergonomic(s)’ (n = 1267). Four re- viewers conducted the literature search (NM, NG, SKK, RG) and where there were any discrepancies, a fifth independent reviewer was con- sulted (SRM). Furthermore, the reference lists of the included articles and review articles were searched for additional studies (n = 21). This initial search yielded 1288 articles. Studies were screened to include only abdominal or thoracic surgery, regardless of surgical approach (endoscopic, laparoscopic, robotic and or open). Surgical simulation was also included as many such studies explored the impact of ergonomic changes such as table height and type of instrument on surgeon strain. Only English language studies were included in this study. The articles were reviewed based on title and abstract, resulting in 132 articles. 5 articles were excluded as the research team were unable to find full-text articles for this, despite thorough search strategies. Further articles were eliminated based on operative speciality, for describing transvaginal approaches as part of gynaecological surgery, skill performance is medical students rather than surgeons or emphasise technology development to measure strain (e.g. wearable devices). 71 articles were included in the final review once full-text articles were screened. The search strategy has been outlined in the PRISMA flow- chart below (Fig. 1). 3. Results The results have been divided into subsections describing the quantitative and qualitative measures of strain experienced by the surgeon. 3.1. Quantitative measures of strain 3.1.1. Reporting methods and domains A total of 36 papers were identified that quantitatively assessed strain using various techniques, such as EMG recording or inertial measurement units (IMUs). There were 17 papers that reviewed muscle strain in a simulated environment versus 20 studies conducted during real time surgical procedures. Table 1 outlines these articles further. 3.1.2. Surgical specialties, techniques and impact on surgeons Quantitative measures of strain have been studied across several surgical specialties, including general surgery and its subspecialties, urology, vascular surgery and gynaecology. The general surgical oper- ative approaches were either open, laparoscopic, endoscopic or robotic. Vascular surgery included endovascular surgery. A number of studies were based on simulated environments to safely study variations such as table height or laparoscopic monitor position. 3.1.2.1. Open surgery. Open surgery tended to be more physically demanding than minimally invasive surgery. Open surgery was shown to have larger neck and torso angles when compared to laparoscopic surgery, with increased time spent in high-risk postures with one study showing median percentage procedural time for the surgeon in these positions being 66 % for the neck and 24 % for the torso [8,11]. On average, surgeons spent more time with their neck flexed during open surgery (147 min) compared to robotic procedures (68 min), which was associated with increased pain during self-reported questionnaires (discussed in the ‘Qualitative Measures’ section below. [18]. There was also increased torso and neck muscle activation within the trapezius and erector spinae muscles in open surgery compared to laparoscopic sur- gery, with less muscle rest time and higher sustained low muscle ac- tivity. Open surgery leads to increased physical workload [7,14,15]. 3.1.2.2. Laparoscopic surgery. Laparoscopic surgery has been associated with a higher fatigue level of the extensors of the wrist compared to robotic surgery, however shoulder and neck muscles as well as wrist flexors had a higher activation during robotic surgery [9]. Wang et al. Fig. 1. (legend): PRISMA flowchart demonstrating search strategy. N. Menon et al. The Surgeon 23 (2025) 257–264 258 Table 1 Summary of the quantitative studies included in the review. Study name Reporting type Surgery type Surgical approach Number of surgeons, n Armijo 2019 [9] EMG Colorectal, general surgery, bariatrics, urology, transplant Laparoscopy, robotic 16 Armijo 2022 [10] EMG Colorectal, general surgery, bariatrics, urology, transplant Laparoscopy, robotic 16 Davila 2020 [11] IMU Vascular Open, endovascular 16 Dalager 2020 [12] EMG Colorectal Laparoscopic, robotic 13 Yang 2021 [8] IMU Colorectal, head and neck, hepato-pancreatico-biliary, general surgery Open, laparoscopic 24 Thurston 2022 [13] EMG Foregut surgery Laparoscopic 5 Norasi 2021 [14] Postural monitors Vascular Open, endovascular 16 Fan 2022 [15] EMG, IMU Neck surgery, urology Open, robotic 22 Abdelrahman 2016 [16] BodyGuardian Remote Monitoring System (heart rate, salivary cortisol level) Cholecystectomy Single incision laparoscopic, conventional laparoscopic 1 Yu 2017 [17] IMU Urology – robotic assisted radical prostatectomy Robotic 10 Bigham 2021 [18] IMU Urology Open, robotic 30 Heemskerk 2014 [19] ECG (heart rate and heart rate variability) Cholecystectomy Laparoscopic, robotic 2 Kraemer 2018 [20] EMG, ECG, gravimetrical positional sensors Hysterectomy Laparoscopic, robotic 5 Meltzer 2020 [4] IMU Cardiothoracics, colorectal, general surgery, gynaecology, head and neck, hepato-pancreatico-biliary, neurosurgery, orthopaedics, plastics, urology, vascular Open, laparoscopic, endovascular 53 Kramer 2023 [21] Bipolar surface EMG, 2-dimensional gravimetric position sensors, ECG Hysterectomy Laparoscopic, robotic 8 Yang 2020 [22] IMU colorectal, cardiothoracic, general surgery, head and neck, HPB transplantation, neurology, obstetrics and gynaecology, orthopaedics, plastics, urology, vascular Open, laparoscopic and robotic 53 Szeto 2009 [7] EMG Open: colectomy, gastrectomy, mastectomy, thyroidectomy, aneurysmorrhaphy, hepatectomy, liver transplant. Endovascular: percutaneous transluminal angioplasty, carotid stenting, aortic stent graft repair. Laparoscopic: cholecystectomy, appendicectomy, colectomy, hernoplasty Open, laparoscopic and endovascular 25 Nguyen 2001 [6] Video analysis of body movements using predefined criteria from Department of Physical Therapy Abdominal surgery (Laparoscopic: oesophagectomy, Roux- en-Y gastric bypass, sigmoid colectomy, staging for oesophageal cancer, cholecystectomy Open: pancreaticoduodenectomy, Roux-en-Y gastric bypass, sigmoid colectomy, ventral hernia repair, inguinal hernia repair Laparoscopic, open 5 Lawson 2006 [23] RULA Roux-en-Y gastric bypass Laparoscopic, robotic 1 Manasnayakom 2009 [24] EMG Simulation, table height adjustments Laparoscopic 10 Matern 2004 [25] EMG Simulation, monitor positions Laparoscopic 18 Van der Schatte 2009 [26] Ambulatory monitoring system - mean square of successive difference between consecutive heartbeats (low value mean high stress), pre- ejection period, average heart rate Simulation, table height adjustments Laparoscopic, robotic 16 Berquer 2001 [27] EMG, skin conductance, accelerometer/ gravitometer sensor Simulation, varying table heights Laparoscopic 21 Berguer 1999 [28] EMG Simulation Open, laparoscopic 27 Berguer 2001 [29] EMG Simulation, varying instrument angulation Laparoscopic 8 Berguer 2001 [30] Tonic skin conductance, electro-oculogram Simulation Laparoscopic, open 28 Berguer 2003 [31] EMG Simulation Laparoscopic, open 21 Berguer 2006 [32] Orientation sensor, EMG, skin conductance Simulation Laparoscopic, robotic 10 Marquetand 2021 [33] Orthopaedic goniometer, gravimetric position sensor, EMG, laser doppler flowmetry, tissue spectrometry Simulation, 25◦ bent forward maintaining posture (table height adjustments) Open 12 Wright 2022 [34] EMG Simulation, urological procedure (seated and standing position) Ureteroscopy 3 Morales 2019 [35] EEG Simulation Laparo-endoscopic single site (LESS), multiport laparoscopic surgery 4 Di Stasi 2017 [36] Wearable eye tracker Simulation Laparo-endoscopic single site (LESS), multiport laparoscopic surgery 16 Moore 2015 [37] Impedance cardiograph (Physioflow) Simulation Laparoscopic, robotic 32 Steinhilber 2016 [38] EMG, wrist angle/posture Simulation, different instruments (rotatable vs fixed handle), different table heights Laparoscopic 57 Quick 2003 [39] EMG Simulation, different instruments (ratcheted and non- ratcheted instruments) Laparoscopic 3 Wang 2017 [40] EMG Colorectal (sigmoid colectomy) Open, laparoscopic 1 N. Menon et al. The Surgeon 23 (2025) 257–264 259 showed that laparoscopic sigmoidectomies had reduced muscle activa- tion compared to open surgery [40]. This may be due to instrument manipulation largely being performed by the hands and forearm with limited arm and shoulder engagement [40]. Whilst laparoscopic surgery had fewer neck, shoulder and torso movements, it has been shown to require more upper arm angulation and forearm and thumb muscle activation, compared to open surgery [6]. Interestingly, in the context of cholecystectomies, single incision surgery was shown to have a higher change in maximum heart rate, higher salivary cortisol level, increased prefrontal lobe activity and higher gaze entropy, compared to conventional laparoscopic surgery [16,35]. This could be because the former is a less commonly performed and technically more challenging using a single incision. In a simulated setting, laparoscopic surgery was shown to require more mental concentration, demonstrated by increased skin conduc- tance and eye blink rate [29]. However, notably, this difference was not significant amongst experienced surgeons, suggesting that the learning curve of laparoscopic surgery is likely to cause more cognitive strain in the short term but overall improvement in physical strain once the surgeon was more experienced [29]. 3.1.2.3. Robotic surgery. Manufacturers of robotic systems claim that being seated at a console improves surgeon safety with regards to injury fatigue and muscle exertion compared to laparoscopic surgery [9]. Interestingly, Armijo et al. reported that electromyography (EMG) re- cordings noted to higher muscle activation in robotic surgery compared to laparoscopic surgery for shoulder and neck muscles as well as wrist flexors [9]. Laparoscopic surgery required more muscle activation of extensor digitorum [9]. Kramer at all reported the converse, with lower EMG recorded activation of shoulder and neck muscles in robotic sur- gery and higher activation of extensor digitorum [21]. Laparoscopic surgery has high static muscle loads for the neck, trunk and legs, which is associated with musculoskeletal pain [12]. As much as the console surgeon is arguably experiencing less physical strain, it has been shown that the assisting ‘table’ surgeon has more physical demands and strain, with worse neck postures. As expected, the console surgeons experi- enced more mental strain when compared to their assisting surgeons [17]. Robotic surgery was shown to have lower EMG recordings and lower skin conductance, suggestive of lesser stress compared to laparoscopic surgery in the simulated setting [29]. In a simulated setting, impedance cardiography also showed more healthy, adaptive cardiovascular re- sponses such as a higher blood flow and lower vascular resistance compared to the laparoscopic group [37]. To our knowledge. The effect of familiarity with a procedure on stress has not been fully explored in open vs robotic surgery and would be an area for further study. 3.1.2.4. Simulation. 17 studies used laparoscopic simulation to study musculoskeletal strain and ergonomics amongst surgeons. Adjusting table height and varying monitor position has been shown to impact muscle strain. Berquer (2002), Matern (2004) and Manasnayakom (2009) et al. showed that performing simulated laparoscopic tasks at various monitor positions and table heights can minimise muscle strain, particularly neck strain, demonstrating that the ideal table height is at elbow height [24,25,27]. When the table height is above the elbow, there was increased activation of the deltoids, arm extensors, trapezius and para-spinal muscles, whereas below-elbow table heights caused lower back discomfort and increased workload in arm flexors, as measured by EMG [24,25,27]. However, there was no notable difference in mental strain, as measured by skin conductance and no notable impact on task time [27]. 3.1.2.5. Endovascular. Davila et al. showed that vascular surgeons had increased ergonomic postural risk (EPR) scores of the neck and lower back during open vs non-open surgery [11]. The EPR scores of these areas correlated to the survey findings of increased physical demand by the surgeons [11]. 3.1.3. Study types and measures of strain EMG used on specific muscle groups can identify muscle activation during various types of surgery as well as maximal voluntary muscle contraction [9]. Median frequency (MDF) of EMG signals can be used to assess muscle fatigue, with a decreased MDF of the power spectrum correlating with increased muscle fatigue [9]. Inertial muscle unit sensors can be used to measure body posture angles by collecting data from an accelerometer, magnetometer and gyroscope within each sensor. The time spent in a specific range of risk categories for each body segment can be used to stratify risk for ergo- nomic injury [4]. A modified rapid upper limb assessment (RULA) can also be used to categorise postural angles into high-risk positions. High risk positions refer to >20◦ for the neck and torso and >45◦ for both shoulders [8]. Some studies used electrocardiography (ECG) or wearable cardiac monitors to monitor heart rate and rate variability as a measure of cognitive strain or stress. Other wearables such as eye trackers and video analysis of body movements during surgery were used as quantitative measures of ergonomic strain. Electroencephalography (EEG) has also been used sparingly to measure cognitive strain (see Table 1). Whilst skin conductance has been used a measure of mental stress but measuring sympathetic activation, it has limitations as it also increases during attention and focus. 3.1.3.1. Use of adjuncts. More than just the associated postural strain during various surgical procedures, the use of adjuncts such as loupes, headlights and lead aprons can also lead to associated increased muscle strain [4]. Meltzer et al. showed that the use of surgical loupes and headlamps were associated with unfavourable neck positions (with loupes 85,2 % vs without 58.1 % and with headlamps 79.9 % vs without 62.2 %.) [4]. 3.2. Qualitative measures of strain 3.2.1. Reporting methods and domains For the qualitative component of the systematic review, 49 studies were included. Of these 49 studies, 14 studies overlapped with the ar- ticles in the quantitative section. These studies summarised different use of reporting measures and impact to surgeons (Table 2). Most of the studies used self-reported questionnaires to assess a range of ergonomic issues, musculoskeletal symptoms, workload, and discomfort among surgeons. These domains covered were extensive, including visual symptoms, neck and shoulder problems, muscle effort, fatigue, cognitive cost, workload, and intraoperative posture. These self- assessments provided valuable subjective data on the physical and mental strains experienced by surgeons during various surgical pro- cedures. For instance, Bigham et al. utilised self-reported neck pain scores to assess chronic neck pain among surgeons, highlighting the prevalence and impact of such discomfort on surgical performance and career longevity [18]. Similarly, Hotton et al. used Borg’s CR-10 scale to quantify the physical exertion and strain experienced by surgeons dur- ing standard laparoscopy, underscoring the high levels of physical de- mand associated with this technique [75]. 3.2.2. Surgical specialties and techniques The studies encompassed a wide array of surgical specialties such as minimally invasive surgery (MIS), bariatric surgery, laparoscopic sur- gery, vascular surgery, breast surgery, endourology, gynaecologic sur- gery, urologic surgery, thoracic surgery, and oncologic surgery. The operative approaches evaluated included laparoscopic, robotic, open, endovascular, and thoracoscopic surgery. N. Menon et al. The Surgeon 23 (2025) 257–264 260 3.2.3. Study types and measures of strain The review included various study designs, ranging from surveys and interventional studies to prospective randomized evaluations and pilot studies. Sample sizes varied significantly, from small-scale surveys to large-scale investigations involving hundreds of surgeons. Strain mea- sures were diverse, including muscle effort, workload, discomfort, pain, and posture, often quantified through self-assessment scales, motion Table 2 Summary of the qualitative studies included in the review. Study name Reporting type Surgery type Surgical approach Number of surgeons, n Moore 2015 [37] State-Trait Anxiety Inventory Any Laparoscopic; Robotic 32 Berquer 2002 [27] VAS to rate MSK discomfort at different table height levels NR Laparoscopic 21 Di Stasi 2017 [36] NASA-TLX NR Laparoscopic 10 Hallbeck 2020 [41] NASA-TLX Breast Open NR Kramer 2023 [21] NASA-TLX Any Laparoscopic; Robotic 5 Lau 2020 [42] NASA-TLX Any Laparoscopic; Robotic 16 Law 2020 [43] NASA-TLX Colorectal Laparoscopic; Robotic 7 Aaron 2021 [44] Self-developed questionnaire Any NR 91 Alhusuny 2021 [45] Nordic Musculoskeletal Questionnaire (NMQ) Any Laparoscopic; Robotic 290 Alsabah 2019 [46] Adapted Nordic Musculoskeletal Questionnaire (NMQ) Bariatric Laparoscopic 113 Armijo 2022 [10] Piper Fatigue Scale-12 (PFS- 12) Any Laparoscopic 5 Armijo 2019 [9] Piper Fatigue Scale-12 (PFS- 12) Any Laparoscopic; Robotic 5 Berguer 1999 [28] SAGES developed questionnaire Any Laparoscopic 27 Cass 2014 [47] Self-developed questionnaire Neurosurgery Laparoscopic 19 Davila 2021 [11] Self-developed questionnaire Vascular Open 16 Dianat 2018 [48] Nordic Musculoskeletal Questionnaire (NMQ) NR NR 312 Healy 2011 [49] Self-developed questionnaire Urology Laparoscopic 600 Hokenstad 2021 [50] Cornell Musculoskeletal Discomfort Questionnaire Gynaecology Robotic 6 Lee 2017 [51] Self-developed questionnaire Gynaecology Robotic 289 Liang 2013 [52] SAGES developed questionnaire Urology Laparoscopic 241 Miller 2012 [53] SAGES developed questionnaire Any Laparoscopic 61 Morandeira- Rivas 2012 [54] SAGES developed questionnaire Any Laparoscopic 78 Norasi 2021 [14] Self-developed questionnaire, NASA-TLX Vascular Open NR Plerhoples 2012 [55] Self-developed questionnaire Any Open; Laparoscopic; Robotic 871 Singh 2016 [56] Body discomfort score & Surgical task load index. Gynaecology Open 4 Table 2 (continued ) Study name Reporting type Surgery type Surgical approach Number of surgeons, n Singh 2019 [57] Body discomfort score Gynaecology Open 4 Sutton 2014 [58] Self-designed Any Open; Laparoscopic; Robotic 314 Szeto 2009 [7] Self-designed Any Open; Laparoscopic 135 Tarr 2015 [59] Body part discomfort, NASA-TLX Gynaecology Laparoscopic; Robotic 16 Welcker 2012 [60] Self-designed questionnaire Thoracic Thoracoscopic 120 Yang 2020 [22] Wearable sensor & Borg pain scale Any NR 53 Yang 202 [40] Wearable sensor & NASA-TLX questionnaire Any Open; Laparoscopic 24 Yu 2017 [17] Surg-TLX workload Urology Robotic 10 Yu 2016 [61] NASA-TLX workload questionnaires Any Laparoscopic 8 Davis 2014 [62] Self-designed questionnaire Any NR 260 Hemal 2001 [63] Self-designed questionnaire Urology Open; Laparoscopic 204 Indramohan 2012 [64] Self-designed questionnaire Any Open; Laparoscopic 200 Park 2009 [65] Self-designed questionnaire Any Open; Laparoscopic 317 Kaya 2008 [66] Self-designed questionnaire Any Laparoscopic 82 Santos- Carreras 2012 [67] Self-designed questionnaire Any Open; Laparoscopic; Robotic 49 Soueid 2009 [68] Self-designed questionnaire Any NR 130 Szeto 2010 [7] EMG & Self- designed questionnaire Vascular Open; Laparoscopic 25 Craven 2013 [69] RULA & Strain Index (SI) Gynaecology Robotic 5 Graversen 2011 [70] Self-designed questionnaire Urology Laparoscopic 11 Haramis 2010 [71] Self-designed questionnaire Urology Laparoscopic NR Klein 2010 [72] Self-designed questionnaire NR Open; Laparoscopic 10 Nguyen 200 [6] Neck, trunk, shoulder, elbow, and wrist movements using predefined criteria developed by the Department of Physical Therapy. NR Open; Laparoscopic 5 Reddy 2011 [73] Self-designed questionnaire NR Laparoscopic 7 Hilt 2024 [74] RULA and Surgery Task Load Index Bariatric Robotic, laparoscopic 5 N. Menon et al. The Surgeon 23 (2025) 257–264 261 tracking sensors, or physiological measurements. These varied meth- odologies ensured a comprehensive understanding of the ergonomic challenges faced by surgeons. 4. Impact on surgeons Prolonged surgeries were particularly associated with an increased risk of musculoskeletal injuries, including vertebral disc prolapse [47]. The use of robotic surgery was identified to improve ergonomic issues compared to laparoscopic surgery, but still posed challenges, particu- larly with muscle activation, as described above. Manufacturers of ro- botic systems claim that being seated at a console improves surgeon safety with regards to injury, fatigue, and muscle exertion [76]. Gender-specific differences in muscle effort and ergonomic strain were noted, suggesting that ergonomic designs need to consider these differences to ensure equity and safety for all surgeons [10,58]. For instance, women experienced more ergonomic strain compared to men, with increased muscle activation during laparoscopic surgery, particu- larly of the upper trapezius and extensor digitorum, measured using EMG [10]. Smaller glove sizes (more commonly in women) were asso- ciated with increased shoulder and neck strain [58]. Even for the same glove size, women self-reported more discomfort in their upper limbs, neck and back compared to men [58]. Effective interventions such as ergonomic console configurations and gel foot pads were highlighted as beneficial in reducing physical strain [70]. These tools helped improve surgeon comfort and reduced the risk of musculoskeletal injuries during prolonged surgical procedures. 5. Discussion Ergonomic strain amongst surgeons is a potential occupational risk. Whilst it is not possible to define an acceptable level of ergonomic strain, it is important to explore the nature of strain and the ways in which this can be improved. This review aims to explore the ways in which strain can be measured in the context of open and minimally invasive abdominal and thoracic surgery. The key messages highlighted from this review are: 1. Minimally invasive surgery recruits a different set of muscles compared to open surgery, with different ergonomic challenges. The learning curves of minimally invasive surgery may increase cognitive strain in the short-term but robotic surgery has lower overall cognitive and cardiovascular strain. More research is required to explore the ergonomic impact on the assisting ‘table’ surgeon in robotic cases. 2. Hand size or hand size in the context of gender can have notable ergonomic implications and is an important area of instrument development 3. Areas for future research include the role of learning curves and surgeon experience on ergonomic strain and the impact of patient factors, environmental factors and a surgeon’s pre-existing health on ergonomic strain 5.1. Minimally invasive surgery versus open surgery Traditional open surgery has been shown to be the most strenuous in terms of muscle activation and awkward posturing [7,14,15,40]. The advent of minimally invasive surgery has resulted in recruitment of a different set of muscle groups, rather than an overall improvement in musculoskeletal strain [6,9]. Laparoscopic surgery is noted to have less neck and torso muscle activation but more upper limb muscle activation and posturing [6]. It is interesting to note that the learning curve of laparoscopic surgery results in substantial cognitive strain [29]. Laparo-endoscopic single incision surgery resulted in more cognitive stress compared to conventional laparoscopic surgery, possibly because the former procedure is less commonly performed [29]. Robotic surgery was introduced and marketed as being more ergo- nomically comfortable. The data was conflicting in terms of muscle activation when compared to laparoscopic surgery but was reported to cause less cognitive and cardiovascular stress [9,21,12]. Whilst this may suggest that the console surgeon was likely to experience less strain overall, the assisting table surgeon was assisting as per conventional laparoscopic surgery and therefore, prone to the associated strain [17]. 5.2. Impact of gender/hand-size Gender differences in ergonomic strain and muscle effort raises important questions in terms of equality, particularly in the design of surgical instruments. Women are found to exhibit increased musculo- skeletal strain and discomfort, with increased muscle activation during laparoscopic surgery [10,58]. These ergonomic considerations are crucial when reviewing the impact of the operative environment on different genders. Although not particularly explored in the literature, it would be interesting to consider the role of robotic surgery for female surgeons or surgeons of any gender with small size hands as the robotic console only has finger sockets rather than laparoscopic instruments which may not accommodate different sizes or shapes of hands. 5.3. Level of experience There is a paucity of data correlating learning curves or level of expertise with strain as this would perhaps suggest that surgical training should also encompass ergonomic training and positioning. Simulation studies show that table height adjustments, monitor positions and the types of surgical instrument (e.g. ratcheted) can support surgeons in making conscious choices to be comfortable whilst operating [24,25, 27]. 5.4. Strengths and limitations of the review The strength of this review is that it consolidates the key ergonomic concerns for general surgeons across all modalities, including robotic surgery and draws comparisons between laparoscopic and robotic sur- gery. The limitations of this review are that there is notable variation when measuring strain and it is very difficult to draw meaningful comparisons across these. The long-term nature and impact of strain on the surgeon makes it methodologically challenging to design studies that explore this comprehensively. Furthermore, there are many other as- pects that significantly impact strain – table height, level of training or experience, environmental factors such as the theatre environment and situational awareness as well as patient factors such as their body mass index, technical factors which might make operations more difficult. For instance, Hilt et al. demonstrated that robotic surgery resulted in lower ergonomic stress compared to laparoscopic surgery in the context of bariatric operations such as sleeve gastrectomy and Roux-en-Y gastric bypass [74]. The role of gender is also a worthy area of surgical explo- ration. There is also little information on the impact of surgeon ergo- nomic strain on the patient [62]. These highlight key areas for future research. There is a lot more scope to incorporate surgeon comfort and ergo- nomics in instrument and theatre design. Despite plenty of research into the nature of surgeon strain, there are few tangible measures to improve this to improve performance and longevity of career. Sources of financial support Nadia Guidozzi – Ryan Hill Research Foundation. Sivesh Kathir Kamarajah – National Institute for Health and Care Research. Sheraz R. Markar – National Institute for Health and Care Research. N. Menon et al. The Surgeon 23 (2025) 257–264 262 Conflict of interest statement None of the authors have any conflicts of interest to declare. References [1] Stucky CH, Cromwell KD, Voss RK, Chiang YJ, Woodman K, Lee JE, Cormier JN. Surgeon symptoms, strain, and selections: systematic review and meta-analysis of surgical ergonomics. Ann Med Surg (Lond) 2018 Jan 9;27:1–8. https://doi.org/ 10.1016/j.amsu.2017.12.013. PMID: 29511535; PMCID: PMC5832650. [2] Franasiak J, Ko EM, Kidd J, et al. Physical strain and urgent need for ergonomic training among gynecologic oncologists who perform minimally invasive surgery. 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The Surgeon 23 (2025) 257–264 264 https://doi.org/10.1245/s10434-019-08159-0 https://doi.org/10.1245/s10434-019-08159-0 https://doi.org/10.1007/s00464-019-07038-9 https://doi.org/10.1007/s00464-019-07038-9 https://doi.org/10.1097/SLA.0000000000003173 https://doi.org/10.1371/journal.pone.0244868 https://doi.org/10.1371/journal.pone.0244868 https://doi.org/10.1007/s00420-020-01642-2 https://doi.org/10.1007/s00464-018-6460-1 https://doi.org/10.1007/s00464-018-6460-1 https://doi.org/10.3109/01443615.2013.831048 https://doi.org/10.1016/j.apergo.2017.09.011 https://doi.org/10.1089/end.2011.0128 https://doi.org/10.1089/end.2011.0128 https://doi.org/10.1016/j.jmig.2020.07.017 https://doi.org/10.3802/jgo.2017.28.e70 https://doi.org/10.3802/jgo.2017.28.e70 https://doi.org/10.1371/journal.pone.0070423 https://doi.org/10.1177/0018720812451046 https://doi.org/10.1007/s11605-012-2021-4 https://doi.org/10.1007/s11605-012-2021-4 https://doi.org/10.1007/s11701-011-0330-3 https://doi.org/10.1007/s11701-011-0330-3 https://doi.org/10.1016/j.ajog.2016.06.016 https://doi.org/10.1007/s00192-018-3619-1 https://doi.org/10.1007/s00192-018-3619-1 https://doi.org/10.1007/s00464-013-3281-0 https://doi.org/10.1007/s00464-013-3281-0 https://doi.org/10.1016/j.jmig.2014.10.004 https://doi.org/10.1016/j.jmig.2014.10.004 https://doi.org/10.1093/icvts/ivs173 https://doi.org/10.1093/icvts/ivs173 https://doi.org/10.1007/s00464-015-4634-7 https://doi.org/10.1016/j.jss.2014.03.013 https://doi.org/10.1089/089277901750299294 https://doi.org/10.1089/089277901750299294 https://doi.org/10.3109/03091902.2012.712203 https://doi.org/10.1016/j.jamcollsurg.2009.10.017 https://doi.org/10.1016/j.jamcollsurg.2009.10.017 https://doi.org/10.1097/SLE.0b013e3181569ee2 https://doi.org/10.1097/SLE.0b013e3181569ee2 https://doi.org/10.1177/1553350611413611 https://doi.org/10.1016/j.ijsu.2009.11.008 https://doi.org/10.1016/j.ijsu.2009.11.008 https://doi.org/10.1016/j.jmig.2013.04.008 https://doi.org/10.1089/end.2011.0155 https://doi.org/10.1016/j.urology.2010.01.018 https://doi.org/10.1097/SLE.0b013e3181ed851d https://doi.org/10.1097/SLE.0b013e3181ed851d https://doi.org/10.1016/j.juro.2011.04.013 https://doi.org/10.1016/j.jss.2023.08.045 https://doi.org/10.1245/s10434-022-12548-3 https://doi.org/10.1245/s10434-022-12548-3 https://www.intuitive.com/en-us/about-us/newsroom/immersive-console https://www.intuitive.com/en-us/about-us/newsroom/immersive-console Strain on the surgeon: a systematic review of the methods of measuring strain in abdominal and thoracic surgery 1 Introduction 2 Methods 3 Results 3.1 Quantitative measures of strain 3.1.1 Reporting methods and domains 3.1.2 Surgical specialties, techniques and impact on surgeons 3.1.2.1 Open surgery 3.1.2.2 Laparoscopic surgery 3.1.2.3 Robotic surgery 3.1.2.4 Simulation 3.1.2.5 Endovascular 3.1.3 Study types and measures of strain 3.1.3.1 Use of adjuncts 3.2 Qualitative measures of strain 3.2.1 Reporting methods and domains 3.2.2 Surgical specialties and techniques 3.2.3 Study types and measures of strain 4 Impact on surgeons 5 Discussion 5.1 Minimally invasive surgery versus open surgery 5.2 Impact of gender/hand-size 5.3 Level of experience 5.4 Strengths and limitations of the review Sources of financial support Conflict of interest statement References