THE INTERNATIONAL JOURNAL OF MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERY ORIGINAL ARTICLE

Int J Med Robotics Comput Assist Surg 2013; 9: 142147.

Published online 26 March 2013 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/rcs.1489

Ergonomic assessment of the surgeons physical

workload during standard and robotic assisted
laparoscopic procedures

1,3
N Hubert Abstract
2
M Gilles
2
K Desbrosses Background Standard laparoscopy is responsible for musculoskeletal prob-
2 lems because of surgeons anti-ergonomic positions. Robot-assisted laparoscopy
JP Meyer
3 seems to reduce these musculoskeletal disorders thanks to the surgeons seated
J Felblinger
1,3 position. The objective of this study is to evaluate the muscular strain and
J Hubert * cognitive stress induced by these two techniques during real operations
1 conducted on the pig.
Urology Department, CHRU Nancy-
Brabois, rue du Morvan54511, Methods Electromyographic activities, heart rate, physical and mental work-
Vanduvre-les-Nancy, France loads (NASA Tlx and Borg CR-10) were recorded.
2
Laboratoire de Physiologie du Travail,
Institut National de Recherche et Results Physical workload and perception of the effort invested was signi-
Scurit (INRS) Lorraine, 1 rue du cantly greater during the standard laparoscopies (p<0.05). Mental stress
Morvan, BP 27, 54501, Vanduvre- was however identical for the two techniques. In Standard Laparoscopic group,
les-Nancy Cedex, France greater physical activity was found for trapezius and dorso-lumbar muscles,
3
IADI-INSERM U947, CHRUNancy- and signicant appearance of fatigue of the trapezius muscles should also
Brabois, rue du Morvan, 54511, be noted. Finally, heart rate during standard laparoscopy was increased
Vanduvre-les-Nancy, France (92.1 1.6 bpm vs 83.7 1.8, p<0,01), conrming greater physical
expenditure.
*Correspondence to: Professor
Jacques Hubert, Urology Conclusions Robot-assisted laparoscopy is a less physically stressful
Department, CHRU Nancy-Brabois, surgical technique than standard laparoscopy. Copyright 2013 John Wiley &
rue du Morvan, 54511 Vanduvre- Sons, Ltd.
les-Nancy, France.
E-mail: j.hubert@chu-nancy.fr
Keywords ergonomy; robotics; laparoscopy; physical stress; subjective workload

Accepted: 25 January 2013
Copyright 2013 John Wiley & Sons, Ltd.
Introduction
Standard laparoscopy (SL) is nowadays an indispensable surgical technique
because of the clear advantages it provides to the patient. However, the
surgeon has to adapt to a completely new working environment, the source
of greater physical stress and strain than open surgery, which can negatively
impact on the quality of the surgical act (1). Pain and neck, back and shoulder
fatigue are frequently described by 30% of laparoscopic surgeons (2), caused
or aggravated by the operating conditions. It appears that some surgeons
may choose the surgical technique according to the musculoskeletal problems
they experienced (3).
Apart from ergonomic recommendations already formulated (47), it seems
to be necessary to extensively modify the working environment so as to optimise
the working conditions of the surgeon, while maintaining the advantages of
the minimally-invasive approach (8,9).
With a seated position and brow and arm-rests, robot-assisted laparoscopy
(RAL) considerably modies the laparoscopic surgeons working environment.
143
Ergonomy & physical stress better in robotics than in laparoscopy
Recent surveys and experimental studies (on pelvitrainers
and/or by novice operators) show that RAL is associated
with a signicant reduction in neuromuscular pain in
the shoulder and back and with reduced overall physical
activity (2,1013). This technique seems therefore to
improve the surgeons physical comfort while retaining
the advantages of the minimally-invasive approach.
The aim of this study was to assess the evolution of the
physical stress and strain of the two laparoscopic tech-
niques, classic and robot-assisted, during procedures
under genuine surgical conditions. This assessment was
made using a dual approach, subjective (strains and
workload felt) and objective (electromyography and heart
rate).
Materials and methods
Organization of the procedures
The study was conducted in cooperation with a team from
the Physiology of Work laboratory of the INRS (French
National Institute for Research and Safety, Occupational
Physiology Lab., Working Life Department, Lorraine,
France). The investigations took place in the School of
Surgery labora- tory (Faculty of Medicine, Nancy
Universities), a laboratory approved for experimental work
on living animals. The procedures were conducted on pigs
each weighing 25 kg.
This study took place over three 2-week sessions. We
were able to use a standard three arms Da VinciW system
(Intuitive Surgical, Sunnyvale) for the rst session, the
other two sessions being for standard laparoscopy. Eleven
senior surgeons (CHRU (University Hospital) Nancy,
Alexis Vautrin Centre, Nancy) volunteered to take part
in this study. All were right-handed and the mean age
was 39.6 years ( 11.8). Seven of them were general
surgeons, and the four others, urologists. Each surgeon
conducted at least one procedure with each technique.
Four types of procedures were performed,
producing four experimental situations: one RAL session
seated and
3 SL standing, depending on the abdominal area
operated
(facing the end of the table for the sub-mesocolic area,
facing the side of the table for the retroperitoneal
area
Copyright 2013 John Wiley & Sons, Ltd.
J. Hubert et143
al.
143
and perpendicular to the side of the table for the pelvic
area) (Figure 1).
The type of procedure was chosen depending on each
surgeons specialty and had to reproduce a real procedure
(fundoplication, partial nephrectomy, UPJ repair, pelvic
prolapse repair, etc.). The instruments used by all the
surgeons were identical. In SL, the height of the operating
table and its angle of tilt were adjusted for each surgeon
(5,14), while the height of the monitor was the same for
all. In RAL, eyepiece and chair were adapted to each
surgeons morphology. Each surgeon was assisted by the
same experienced assistant. The duration of procedures
was set at 80 min and the procedures had to be
discontinued once this time limit had been reached.
Analyses performed
The physical stress and strain was evaluated by two
different methods:
A subjective approach, in which the physical exertion
the surgeon felt during the procedures was assessed
by him during and after the operation and recorded.
A physiological approach, in which the heart rate was
measured and the surface electromyographic (EMG)
activity of the main muscles participating in movement
of the trunk, shoulders and wrists.
Statistical analyses were performed using Students
paired t test and analysis of variance (ANOVA) to determine
whether there was a statistically signicant difference
between the two techniques. The level of signicance was
set at P < 0.05.
Subjective analysis
During surgery, the physical difculty perceived was eval-
uated using the Borg CR-10 scale (15), the scale accepted
for evaluating the physical workload imposed on surgeons
(1618). It is based on an estimate by the surgeon of the
physical stress and strain felt, scored between 1 and 10
(1 indicating lack of strain and 10 being extremely
uncomfortable and painful strain). Seven parts of the
Int J Med Robotics Comput Assist Surg 2013; 9: 142147.
DOI: 10.1002/rcs
144
Ergonomy & physical stress better in robotics than in laparoscopy J. Hubert et144
al.
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Figure 1. Positions of the surgeon depending on the laparoscopy method and the abdominal area being operated: retroperitoneal
(Rp), sub-mesocolic (Sm), pelvic (Pv), robot-assisted (RAL)

Copyright 2013 John Wiley & Sons, Ltd. Int J Med Robotics Comput Assist Surg 2013; 9: 142147.
DOI: 10.1002/rcs
body were evaluated: legs, back, neck, right and left
shoulders and right and left forearms. They were scored
every 15 min throughout each operation to obtain a
record of the evolution over time.
At the end of surgery, the surgeon evaluates his overall
workload using the NASA-TLX (Task Load Index) tool
(19,20), which is widely regarded as the strongest tool
available for reporting perceptions of workload (21). It
consists of six visual analogue scales, (physical, mental
and temporal stresses and strains and perception of the
performance achieved, the frustration felt and the effort
invested). The combination of these six items illustrates
the general aspects of the workload felt. Two additional
items were included to calibrate this tool: investment of
skills and overall load perceived.
Physiological analysis
Electromyographical analysis. Surface electromyography
reects muscular activity. The EMG signal is recorded by
two surface electrodes, placed on the middle of four
muscles (22): exor digitorum and extensor digitorum
for wrist movements, trapezius for the shoulders and
erector spinae for the back (Figure 2).
We considered that these muscles were the most
impor- tant in contributing to the movements concerning
the sur- geons posture. The EMG data were transmitted
via a WIFI system (PocketEMG, BTS SpA, Milan, Italy).
The signal was analysed by a program developed using
Labview (Na- tional InstrumentsW). After being ltered,
the data were standardised relative to the maximum
EMG activity recorded during a maximum
voluntary contraction (% MVC). The EMG parameter
that we used was the root mean square (RMS) which
represents the muscular activity.
Analysis of heart rate. The heart rate (HR), expressed as
beats per minute (bpm) is an indicator of physical load.
Figure 2. A surgeon tted up. In the circle: PocketEMG. Skin
electrodes of the trapezius (a), extensor digitorum (b) and
erector spinae (c) muscles
It was recorded throughout the experiments using a heart
rate recorder, i.e. during the whole procedure and for at
least 5 min seated rest, before and after. The mean HR
was calculated and also a mean heart rate cost (HR during
procedure-HR at rest) for the two operating methods.
Results
The mean duration of the procedures was 83.5 10.7
min, with no signicant difference between the two
techniques. The data obtained were compared for the
11 surgeons who participated in the two laparoscopic
techniques, without differentiating between the three
types of posture in SL. In total, 34 procedures were
analysed, 16 RAL and 18 SL.
In evaluating the different workloads (NASA-TLX), the
only difference observed was that of the physical compo-
nent (P <0.05), physical demands being greater in SL
than in RAL (respectively 5.7 0.5 vs 3.0 0.5). There
was no difference in the other components (P >
0.05), particularly in terms of mental demand and
investment of skills and experience (Figure 3).
When evaluating the physical difculty (Borg CR-10),
the SL posture was perceived as signicantly more stress-
ful (P <0.001) for all body areas. The greatest strains
concerned the two shoulders (SL 3.1 0.2 vs RAL
1.6 0.2), the neck (SL 3.1 0.2 vs RAL 1.7 0.2) and
the back (SL 3.1 0.2 vs RAL 1.8 0.2) (Figure 4).
In SL, there was an increase in effort with time for the
same regions of the body, while in RAL they remained sta-
ble. This trend was less pronounced for the legs and fore-
arms (Figure 5(a), (b), (c)).
The heart rate during the procedure was signicantly
higher in SL than in RAL (92.1 1.6 bpm vs 83.7 1.8 re-
spectively, P < 0.01). The mean heart rate cost was
signif- icantly higher in SL than in RAL (13.1 3.4
bpm vs
7.5 3.6 bpm, respectively, P <
0.01).
In the EMG, the RMS was higher (P <0.05) in SL than
in RAL for the erector spinae, trapezius and the exor
Figure 3. Evaluation of the different workloads (NASA-TLX).
*P <
0.05
Figure 4. Perception of effort for the different parts of the body
studied (Borg CR-10). * P < 0.05. 1 = Very little effort; 2 =
Slight effort; 3 = Moderate effort

digitorum on both the right and left, reecting the greater

muscular activity for these muscle groups.
The RMS was signicantly increased at the end of the
SL procedure for the two trapezius muscles (P <0.05),
reecting the appearance of muscle fatigue (right trape-
zius 23.5 9.3% vs 31.1 13% and left trapezius
15.8 6.6% vs 27 16.1%). These values remained
stable for the other muscles in SL and for all the muscles
in RAL (Figure 6).

Discussion
Despite the importance of laparoscopic surgery in the
range of current treatment, little improvement has been
made to the surgeons working environment to reduce the
physical stresses and strains that this technique imposes
on him. While ergonomics has become an
unquestionable concept in many professions, no priority
has been given to the changes needed to make the
laparoscopic surgeons work- ing environment less
stressful.
Robot-assisted laparoscopic surgery, with its
telesurgery approach where the surgeon sits at a work
station, has completely changed this work environment.
It has been suggested during surveys and experimental
studies that this technique would improve the surgeons
physical working conditions and that he would have less Figure 5. (a,b,c) Evolution of the perception of effort for
osteoarticular and neuromuscular pain following robot- different areas
assisted procedures compared with standard laparoscopic
surgery (2,23).
The CR-10 and NASA-TLX scales that were used proved Moreover, our physiological measurements conrm the
to be an effective reection of the real physical workload usefulness of RAL for sparing physical stress and strain:
(16,1820). We were actually able to show that for senior the decrease in heart rate cost in RAL emphasizes a lighter
surgeons during real operations, this new surgical ap- overall physical workload than in SL, an improvement
proach considerably reduces the physical stress and strain mainly due to the seated position. Analysis of muscle ac-
felt. The surgeons perception of the efforts he makes tivity conrmed the surgeons perceptions concerning
during procedures is undeniably improved during RAL, the back and shoulders. These areas, mentioned by the
not only for their global perception, but also for each of
the seven corporal areas which were studied.

Figure 6. Mean RMS for the different muscles studied. *P <
0.05
surgeons as being areas of signicant physical effort in SL
(7,11,24) are indeed the source of considerable physical
activity. The signicant difference in muscle load found
for the erector spinae muscles shows that the spine is
associated with anteroposterior bending movements
much more frequently and to a greater extent in SL than
in RAL. This activity is related in the rst place to an
anteroposterior imbalance in the surgeons posture in SL
and also to the operative gestures required (the surgeon
follows these actions). Secondly, in SL, manipulation of
the instruments and the interference caused by the surgi-
cal assistant (usually by his arm supporting the camera)
requires the surgeon to raise and abduct his shoulders
which explains the high muscle load on the trapezius.
The surgeons position sitting at the work-station spares
the muscular effort on these joints, which are extensively
used in SL.
It should, however, be noted that in our study the
surgeons posture in RAL did not stay optimal. Persistent
muscular activity was still recorded for these muscles,
whereas relaxed posture should be associated with almost
no recording on the EMG. This muscular load was the
result of the surgeons back, neck and shoulders being
held upright to optimise his view of the screens on the
console (3). This slight but constant activity could in the
long term be responsible for musculoskeletal discomfort
detected in some surgeons in the back and neck during ro-
botic procedures (3,23). However, this discomfort will
only be felt much later than in SL, the stresses and strains
recorded (Borg CR-10) remaining minimal and stable
throughout the RAL procedures.
The physical workload felt by the surgeon plays a
considerable role in how he views his operation. In fact
he is much more sensitive to the physical strains he
endures than to the mental stress. The experience
acquired by repeating the procedures reduces the
inuence of this mental stress, whereas the physical
strains, on the contrary, are always present and their
repercussions on the surgeons health could increase if
no preventive measures are taken. Given identical surgical
results, a surgeon with access to these two techniques will
prefer to select the one that provides the best experience
in terms of physical work. Yet an increasing number of
studies conrm the at least identical surgical outcomes
from RAL when compared with SL or open surgery
(25,26). This could be one of the reasons for the
exponential development of robot-assisted laparoscopic
surgery. The autonomous work of the surgeon at the
console and the various types of support provided
effectively relieve the back and shoulders while
maintaining sufcient mobility of the forearms and
wrists to manipulate the master controls without any
strain. The latest generation Da VinciW Si console has
in addition integrated several devices allowing the
surgeons working position to be adapted to be more
efcient (height and angle of the eyepieces, height of
the arm-rests, depth of the foot-rests). It is likely that
with these recent modications, the surgeons physical
comfort will be improved.
This study has some limitations. As it is an experimental
study, results can not be fully applied to the clinical envi-
ronment: mental stress is probably different in clinical and
experimental conditions and may be increased when de-
veloping a new technique. Therefore, all the 11 subjects
were experienced surgeons, this reducing the mental
stress related to a new surgical technique.
Thus the physical stress is more likely similar as we
took care to reproduce the same surgeons positions as in
clinical practice (cholecystectomy, nephrectomy, pelvic
surgery).
Conclusions
Observing surgeons operating using standard and robot-
assisted laparoscopic procedures and collecting information
on their experience implied that there is a difference
in working conditions between these two techniques and
in their short-term consequences. This study of the
physical strains imposed on the surgeon in each of the two
surgical approaches, by subjective (Borg CR-10 and NASA-
TLX) and physiological (EMG-ECG) analysis, objectively
demonstrates that robot-assisted laparoscopic surgery
requires less physi- cal work for the back, neck and
shoulders than standard lap- aroscopic surgery. This stable
working posture, supported by various rests, improves the
surgeons physical comfort and produces better physical
endurance, so that he could main- tain his highest quality
of surgical act whatever the type of procedure or duration
of the surgery.
Conict of interest
The authors have stated explicitly that there are no con-
icts of interest in connection with this article.
Funding
This projectwas eligible for grants from the French Minis-
try of Health: PHRC interrgional 2007 (Programme
Hospitalier de Recherche Clinique) and from the Nancy
University Hospital: CPRC 2008 (Contrat de Programme
de Recherche Clinique).
Acknowledgements
To the surgeons who participated to the study : Dr
Nicolas BILLAUT, Pr Patrick BOISSEL, Dr Guillaume
BOUDRANT, Pr Laurent BRESLER, Pr Laurent
BRUNAUD, Pr Frdric MARCHAL, Dr Nicolas REIBEL,
Dr Antony ROUERS, Dr Marie-Lorraine SCHERRER. Dr
NGuyen TRAN, technical director at the Ecole de
Chirurgie, Nancy University. Intuitive Surgical,
W Endosc 2002; 16: 416421.
Sunnyvale, made a Da Vinci system available during
the robotic 2 weeks session.
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