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Surg Endosc (2014) 28:456–465
DOI 10.1007/s00464-013-3213-z
Comparative assessment of physical and cognitive ergonomics
associated with robotic and traditional laparoscopic surgeries
Gyusung I. Lee • Mija R. Lee • Tamera Clanton •
Erica Sutton • Adrian E. Park • Michael R. Marohn
Received: 15 May 2013 / Accepted: 5 September 2013 / Published online: 3 October 2013
Ó Springer Science+Business Media New York 2013
Abstract
Background We conducted this study to investigate how
physical and cognitive ergonomic workloads would differ
between robotic and laparoscopic surgeries and whether
any ergonomic differences would be related to surgeons’
robotic surgery skill level. Our hypothesis is that the unique
features in robotic surgery will demonstrate skill-related
results both in substantially less physical and cognitive
workload and uncompromised task performance.
Methods Thirteen MIS surgeons were recruited for this
institutional review board-approved study and divided into
three groups based on their robotic surgery experiences:
laparoscopy experts with no robotic experience, novices
with no or little robotic experience, and robotic experts.
Each participant performed six surgical training tasks using
traditional laparoscopy and robotic surgery. Physical
workload was assessed by using surface electromyography
Presented at the SAGES 2013 Annual Meeting, April 17–20, 2013,
Baltimore, MD.
G. I. Lee (&)
M. R. Lee
M. R. Marohn
Department of Surgery, The Johns Hopkins University School of
Medicine, 600 N. Wolfe Street, Blalock Building, Room 1210,
Baltimore, MD 21287, USA
e-mail: gyusunglee@jhu.edu
T. Clanton
Department of Surgery, University of Maryland School of
Medicine, Baltimore, MD, USA
E. Sutton
Department of Surgery, University of Louisville School of
Medicine, Louisville, KY, USA
A. E. Park
Department of Surgery, Anne Arundel Medical Center,
Annapolis, MD, USA
123
and Other Interventional Techniques
from eight muscles (biceps, triceps, deltoid, trapezius,
flexor carpi ulnaris, extensor digitorum, thenar compart-
ment, and erector spinae). Mental workload assessment
was conducted using the NASA-TLX.
Results The cumulative muscular workload (CMW) from
the biceps and the flexor carpi ulnaris with robotic surgery
was significantly lower than with laparoscopy (p \ 0.05).
Interestingly, the CMW from the trapezius was signifi-
cantly higher with robotic surgery than with laparoscopy
(p \ 0.05), but this difference was only observed in lapa-
roscopic experts (LEs) and robotic surgery novices. NASA-
TLX analysis showed that both robotic surgery novices and
experts expressed lower global workloads with robotic
surgery than with laparoscopy, whereas LEs showed higher
global workload with robotic surgery (p [ 0.05). Robotic
surgery experts and novices had significantly higher per-
formance scores with robotic surgery than with laparos-
copy (p \ 0.05).
Conclusions This study demonstrated that the physical
and cognitive ergonomics with robotic surgery were sig-
nificantly less challenging. Additionally, several ergonomic
components were skill-related. Robotic experts could
benefit the most from the ergonomic advantages in robotic
surgery. These results emphasize the need for well-struc-
tured training and well-defined ergonomics guidelines to
maximize the benefits utilizing the robotic surgery.
Keywords Laparoscopy
Robotic surgery

Ergonomics
Cognitive workload
Physical
workload
Electromyography
The term ‘‘ergonomics’’ has increasing become a key
factor in workplace safety and manufacturing. In fact, it has
become one of the most essential characteristics of any new
Surg Endosc (2014) 28:456–465
commercial products. Ergonomic theory, design, and
applications play an important role in everyday life, as
evidenced by accumulating research on many different
topics, ranging from the effect of computer keyboard
designs on users with upper extremity musculoskeletal
disorders [1] to the design of comfortable and ergonomi-
cally sound car seats using motion capture and pressure
sensors [2]. The International Ergonomics Association
defines ergonomics (or human factors) as ‘‘the scientific
discipline concerned with the understanding of the inter-
actions among humans and other elements of a system, and
the profession that applies theoretical principles, data, and
methods to design in order to optimize human well-being
and overall system performance’’ [3].
When ergonomics is addressed, there are five main
principles to consider: safety, comfort, ease of use, pro-
ductivity and performance, and aesthetics. Ergonomics
consists of physical, cognitive, and organizational ergo-
nomics, thus applying to all aspects of human activity [3].
Physical ergonomics is concerned with how the body
interacts with tools or the environment and the effects of
those interactions on the body with regard to posture,
repetitive motion, workplace layout, material handling,
musculoskeletal stress, and any associated injuries or dis-
orders. Cognitive ergonomics refers to how mental pro-
cesses take place and is associated with memory, sensory
motor response, and perception. Organizational ergonom-
ics relates to the improvement of sociotechnical systems,
including work design, policies, and organizational
arrangements. To assess the ergonomics associated with a
specific task performance or working environment, two
workloads are commonly measured: physical and cognitive
workloads. Mental workload assesses the amount of mental
effort demanded to complete tasks, whereas physical
workload measures the amount of physical demand on the
body. The interaction between cognitive and physical
workloads can help to describe the level of overall work-
load [4].
The study of ergonomics in minimally invasive surgery
(MIS) has acquired increased importance with the advent
and widespread acceptance of various types of MIS pro-
cedures; it is well accepted that the increased workload
caused by poor ergonomics may substantially worsen the
quality of surgical performance and increase surgical
errors. Additionally, it is important to evaluate the impact
of ergonomics on surgeons as they encounter new surgical
techniques and systems. As the techniques, as well as
technologies, for laparoscopic procedures are continuously
evolving, surgical intervention through laparoscopy is now
regarded as a highly viable alternative to open surgery.
Laparoscopic surgical intervention offers notable benefits
to patients, including smaller incisions, reduced postoper-
ative pain, shorter hospital stay, increased postoperative
457
comfort, and quicker return to work [5]. However, the
physical challenges experienced by surgeons performing
laparoscopic surgery appear to be greater than surgeons
performing open surgery due to unsound ergonomic oper-
ating positions [6, 7]. Thus, laparoscopic surgeons exposed
to heavy surgical caseloads may be subjected to excessive
physical fatigue, increased mental workload, and various
physical symptoms, such as carpal tunnel syndrome [8–13].
Robotic surgery is a fast-growing area within MIS.
Approximately 450,000 robotic procedures were performed
in 2012, representing an increase of approximately 29 %
since 2011. Robotic surgery systems possess several unique
features not present in traditional laparoscopic surgery
including three-dimensional (3D) visualization, higher
degrees of freedom (DOF) with robotic instruments,
motion scaling, and tremor reduction. Among patients with
complex conditions, such as heart disease, cancers of the
prostate, cervix, uterus, and rectum, the benefits of these
uniquely robotic features include greater precision, smaller
incisions, decreased blood loss, less pain, and shorter
healing time [14–17]. Furthermore, robotic systems also
allow surgeons to sit at a remote control console as they
manipulate the robotic arms, lending support to the sur-
geon’s lower arm as well. These features may provide the
robotic surgeon with a healthier ergonomic work environ-
ment compared with traditional patient-side surgery.
Only a handful of research studies have investigated the
ergonomic advantages of robotic surgery. Lee et al. [18]
compared the postural and mental stresses of performing
simulated surgical tasks, such as passing a spherical object
through rings, running suturing, running a 32-inch-long
ribbon, and cannulation with 13 novice medical students
and residents using a Zeus surgical robotic system and
laparoscopic surgical platform. The results showed that
while mental stress occurred at similar levels, physical
stress worsened with laparoscopic surgery. Laparoscopy
caused more awkward upper-body movement, thus
increasing the potential risk of musculoskeletal injury
compared with robotic surgery. However, task performance
was faster with laparoscopy. Stefanidis et al. performed
two studies comparing performance and workload between
laparoscopy and robotic surgery and also found that robotic
surgery was less demanding in terms of mental and phys-
ical workload. In the first study, medical students per-
formed intracorporeal suturing, and it was found that
robotic suturing resulted in better task performance and
required less mental workload and a shorter learning curve
[19]. The second study was performed with the attendees at
the learning center of the Society of American Gastroin-
testinal and Endoscopic Surgeons in 2006, the majority of
whom possessed previous experience in laparoscopy. This
study demonstrated that while laparoscopic intracorporeal
suturing showed better task performance compared with
123
458
robotic suturing, it was more physically demanding and
participants preferred the robotic system [20]. In addition,
Lawson et al. investigated in their pilot study the postural
ergonomics associated with robotic and laparoscopic gas-
tric bypass surgery showed that while robotic surgery
allowed surgeons to have more ergonomically correct
positions, robotic surgery placed more stress on the neck.
In contrast, during laparoscopic surgery, higher discomfort
was reported in the upper back [21].
In terms of performance and time, Berguer and Smith
[22] showed that robotic surgery had advantages for
complex tasks, such as suturing, but not with simple tasks,
such as pin moving. Marecik et al. [23] further supported
that robotic surgery demonstrated an advantage in suturing,
showing that the robotic suturing line using the da Vinci
system was better than laparoscopy when 15 novice resi-
dents performed intestinal anastomoses. Klein et al. com-
pared the mental workload and stress of novices when they
performed the Fundamentals of Laparoscopic Surgery
(FLS) pegboard transfer task using the laparoscopic plat-
form and the da Vinci surgical robotic system. Mental
workload levels were similar with both systems; however,
task performance with the robotic system was better and
caused less mental stress [24].
While these previous studies showed interesting
research outcomes, there were some limitations. Most of
these studies were conducted with robotic novices who
may not have possessed basic surgical skills, such as
intracorporeal suturing and knot tying. These studies also
did not account for participants’ previous surgical experi-
ence with either MIS or robotic surgery. Also, in most of
these studies, skill-related ergonomic differences were not
investigated thoroughly and the physical and cognitive
workloads were analyzed by a combined assessment tool.
To improve upon the knowledge gained from previous
research studies, we conducted this study to investigate: (1)
how physical and cognitive workloads exhibited by sur-
geons would differ between robotic and laparoscopic sur-
geries when performing both easy and complicated tasks;
and (2) whether any ergonomic differences would be
related to surgeons’ robotic surgery skill levels. Our
hypothesis was that the unique features in robotic surgery
would result in substantially less physical and cognitive
workloads while the task performance remained
uncompromised.
Materials and methods
This institutional review board-approved study was per-
formed in the Surgical Ergonomics Laboratory at Johns
Hopkins University School of Medicine and University of
Maryland School of Medicine. Surgeons were recruited
123
Surg Endosc (2014) 28:456–465
from several specialties, including general surgery, gyne-
cology, and urology. Thirteen subjects, 12 right-handed
and 1 left-handed, possessing different levels of previous
laparoscopic and robotic experience, signed an informed
consent for their participation. These subjects were divided
into three groups: (1) laparoscopic expert group (LE) with
six attending surgeons who regularly perform laparoscopy
but with no previous robotic surgery experience, (2) novice
group with four surgical residents with minimal training on
both laparoscopic and robotic surgeries, and (3) robotic
expert group with three attending surgeons who regularly
perform robotic surgery based on their previous experience
in both laparoscopic and robotic surgeries. We excluded
those who currently have physical problems, such as carpal
tunnel syndrome or serious neck or back problems.
For physical workload assessment, electromyography
(EMG) was used to measure quantitatively muscular acti-
vation level and timing. Sixteen surface electrodes of the
DelsysTM EMG system (Boston, MA) were attached to
subjects’ muscle locations before the beginning of the
surgical tasks. Electrodes were placed on the biceps and
triceps, the muscles associated with elbow movement. The
deltoid and trapezius were used for shoulder movements.
For wrist movements, electrodes were attached on the
flexor carpi ulnaris and extensor digitorum. To investigate
the thumb flexion workload, an electrode was placed over
the thenar compartment. For back movement, the erector
spinae had an EMG electrode. EMG electrodes were placed
on both the left and right sides so that the EMG signals
could be recorded from all 16 channels. Camera images
from the laparoscopic and robotic cameras, as well as an
external view of the participant’s body movements from a
separate digital camcorder, were synchronously recorded
with this EMG data.
As a reference for normalization, which permits the
comparison of activation levels between different muscle
groups, maximum voluntary contraction (MVC) levels of
each muscle group were recorded for several seconds at the
beginning of the experiment session. All EMG data were
collected at 1,000 Hz. These data were full-wave rectified
and then filtered using a second-order Butterworth low-pass
filter with cutoff frequency of 10 Hz. The EMG data col-
lected during each surgical task performance were further
processed; dividing them by MVC levels allowing the data
to be shown as % MVC. After the normalization process,
the time integral of data over performance time was taken to
calculate what we termed ‘‘cumulative muscular workload’’
(CMW) over the period of performance time. CMW gets
higher with either a high level of muscle contraction during
short activation duration or long activation duration even
with a relatively low contraction level.
Each subject performed six surgical training tasks:
simulated paraesophageal hernia repair, simulated bowel
Surg Endosc (2014) 28:456–465
Fig. 1 Six surgical training tasks. A Simulated paraesophageal hernia repair. B Simulated bowel anastomosis. C Tension running suturing.
D FLS circle cutting. E Curved wire ring transfer. F FLS pegboard transfer 553 9 232 mm (72 9 72 DPI)
Fig. 2 Experimental setup.
A Laparoscopy setup with a
height adjustable table, box
trainer, and scope and display.
B da Vinci robotic system
299 9 200 mm (72 9 72 DPI)
anastomosis, tension running suturing, FLS circle cutting,
curved wire ring transfer, and FLS pegboard transfer tasks
(Fig. 1). The participant performed these surgical training
tasks once using traditional laparoscopy and once with a
robotic system. The orders of surgical tasks and platforms
for each subject were randomized.
When traditional laparoscopy was the platform, the
following elements were standard: A rigid, 0° laparoscopic
camera (1088i HD camera, Stryker Inc., San Jose, CA) was
used. Video images were displayed on a standard LCD
monitor positioned at eye level in front of the participant
459
(Fig. 2A). The subjects performed the tasks with laparo-
scopic instruments (e.g., graspers or needle drivers) in a
height-adjustable training stand. For robotic surgery, a da
VinciTM robotic system (Intuitive Surgical, Inc. Sunnyvale,
CA) was used with da Vinci EndoWristTM robotic instru-
ments of graspers and needle drivers (Fig. 2B).
Paraesophageal hernia repair was simulated by using a
piece of vinyl and an Ethicon knot tying board with two
rubber tubes. The goal of this task was to suture the vinyl
onto the tubes. First, a stitch was placed through the vinyl
and the vinyl was lifted up so that the needle could pass
123
460 Surg Endosc (2014) 28:456–465

through both rubber tubes, and then the needle was pulled possible value of GPS is 600. The overall time it took to
back to the front side of the vinyl. The stitch was finished complete each training task was measured in seconds.
with an instrument tie. All instrument ties used in this study Mental workload was assessed by using the National
were the surgeon’s knot: double throws followed by a Aeronautics and Space Administration Task Load Index
single throw and another single throw. To complete this (NASA-TLX) system after task performance of each sur-
task, two more sutures were placed in the same way. Par- gical training task. NASA-TLX is a multidimensional
ticipants used two needle drivers with three monofilament assessment tool that allows participants to rate their
sutures at three suturing locations. They were asked to workloads on six scales: mental demand, physical demand,
complete this task in 10 min. temporal demand, effort, performance, and frustration
For the bowel anastomosis training task, we used two during each task execution.
Penrose drains with an opening on each. The task began
with suturing the apexes of both openings together with an Statistical analysis
instrument tie. The task continued by running sutures on
the two walls of the Penrose together. After placing sutures An overall 3 9 2 9 2 9 6 9 8 (3 subject groups 9 2
along the opening, the task was completed with an platforms 9 2 hand-sides 9 6 tasks 9 8 muscle locations)
instrument tie. Participants had 10 min for this task. Ten- and 3 9 2 9 2 9 6 (3 subject groups 9 2 platforms 9 2
sion running suturing was performed using two needle hand-sides 9 6 tasks 9 6 NASA-TLX scales) analysis of
drivers. The task began with an instrument tie at the apex variance with repeated measures designs were applied to
of the incision and then continued by placing a series of the data to investigate the physical and mental workload,
five running stitches. When the stitching reached the end of respectively. The main effects of these factors and their
the incision, it was finished with another instrument tie. interactions were then analyzed using SPSS 15.0 (Statisti-
Participants were asked to complete this task in 10 min. cal Package for the Social Sciences, SPSS Inc., Chicago,
The FLS circle cutting task was performed using a pair of IL), with the significance level set at p = 0.05.
scissors and a Maryland grasper. Participants were asked to
cut along the circle completely in 5 min. The FLS peg-
board transfer task was performed using two Maryland Results
graspers. When a ring was located on a left side peg, the
left grasper would pick up the ring and move it to the Global performance score
middle. The ring would then be transferred to the right
grasper and placed onto a peg on the right side. Participants Figure 3 shows the results of the performance evaluation
were asked to repeat this with six rings in 5 min. For the using the GPS. The overall GPS with laparoscopy
curved-wire ring transfer task, instead of straight pegs, we
used curved wires in order to evaluate the differences
resulting from laparoscopic and robotic instruments with
varying DOF. This task began with taking off orange rings
from a wire by using a grasper held in the nondominant
hand. Once a ring was taken from the wire, the ring was
placed in a bin located at the bottom of the task platform.
When all the rings were placed in the bin, participants were
asked to use the grasper in the dominant hand to return the
rings back to the curved wires. They had 5 min to complete
this task.
Percentages of task completion (PTC) and performance
errors (PEs) were measured to calculate the task perfor-
mance score (PS) for each task. PTC describes how much
of the task was completed within the given time period.
Various types of PEs, such as tissue damage, deviation
between premarked dots and actual needle in and out
locations, broken suture, and dropped rings were counted
as well. The PS for each task was calculated by multiplying
the number of PEs by five and subtracting that from PTC.
The global performance score (GPS) was obtained by Fig. 3 GPS from three subject groups with robotic and laparoscopic
adding the six PS from each of the six tasks. The maximum surgeries. 129 9 128 mm (300 9 300 DPI)

123
Surg Endosc (2014) 28:456–465 461

(455.5 ± 28.4) was not statistically different than the
GPS with robotic surgery (504.6 ± 17.2) [F(1,10) = 3.78,
p = 0.081]. Platform 9 group interaction was found to be
significant [F(2,10) = 6.42, p \ 0.05]. Further data ana-
lysis showed that the NV and RE exhibited higher GPSs
with robotic surgery (497.2 ± 29.8 and 569.4 ± 34.4 for
the novices and robotic experts, respectively) compared
with the performance with laparoscopy (428.8 ± 49.2 and
425.5 ± 56.8). The GPS from the LE, however, was higher
with laparoscopy (512.1 ± 40.1) than robotic surgery
(447.2 ± 24.3).
Muscular workload
The CMW from the eight muscles were calculated for our
EMG data analysis and are summarized in Table 1. The
difference in the overall CMW between laparoscopy
(67675.7 ± 4389.5 %) and robotic surgery (72434.1 ±
7065.9 %) was not significant. However, significant plat-
form 9 muscle interaction [F(7,63) = 4.008, p \ 0.05]
showed that individual muscle groups have different acti-
vation patterns in the CMW when performing tasks in two
different surgical platforms. To investigate further, the
CMWs between laparoscopic and robotic surgeries were
statistically compared for each of eight muscle groups. It was
found that the CMW of the biceps was significantly higher
with laparoscopy (46346.7 ± 11289.3 %) than with robotic
surgery (32593.1 ± 6169.6 %) [F(1,9) = 5.347, p \ 0.05].
A similar result was found with the flexor carpi ulnaris.
The CMW of the flexor carpi ulnaris, when performing
tasks in laparoscopy (84778.6 ± 19472.1 %), was signifi-
cantly greater than when performing with robotic surgery
(60268.0 ± 14030.3 %) [F(1,9) = 5.209, p \ 0.05].
We also found that the CMW from the trapezius during
robotic surgery performance (103180.5 ± 17881.5 %) was
significantly higher than during laparoscopy (66916.4 ±
11177.2 %) [F(1,9) = 5.265, p \ 0.05]. To further inves-
tigate whether this higher trapezius activation uniformly is
associated with different subject groups, the CMWs for
each of the subject groups were compared. Table 2 shows
the summary of this data. The CMW levels from the LE and
NV groups with robotic surgery (113838.4 ± 27106.1 and
115214.0 ± 30305.6 %, respectively) were higher than
those with laparoscopy (65946.0 ± 16943.2 and 54493.5 ±
18943.1 %). These differences were marginally significant
(p = 0.052 and 0.081 respectively). Meanwhile the RE
groups demonstrated similar levels of CMW between
robotic surgery and laparoscopy (80489.3 ± 34993.8 and
80309.7 ± 21873.6 % with p = 1.00). These results,
therefore, demonstrated that the significantly higher CMW
from the trapezius with robotic surgery were mainly caused
by higher CMW that were exhibited by LE and NV group
participants but not by the RE group subjects (Table 2).
Additionally, it was noted that the CMW of the thenar
compartment with the robotic surgery (11801036 ±
15931.6 %) was higher than that with laparoscopy
(96867.6 ± 10290.0 %) with marginal significance
[F(1,11) = 4.409, p = 0.06]. During the task performances
of simulated paraesophageal hernia repair, tension sutur-
ing, and FLS circle cutting, robotic surgery caused signif-
icantly higher CMW (21297.8 ± 28014.1, 144578.8 ±
22137.7, and 50564.6 ± 8706.7 %, respectively) at the
thenar compartment than laparoscopy (174504.8 ±
18262.6, 105069.9 ± 12931.0, and 28322.2 ± 4376.5 %,
respectively). Uniquely, significant hand main effect
[F(1,11) = 8.255, p \ 0.05] showed that the thenar’s
CMW of the nondominant hand (127671.3 ± 17256.5)
was significantly higher than that of the dominant hand
Table 2 CMW of the trapezius for three subject groups
Laparoscopic Robotic surgery p value
surgery
Average 66916.4 ± 11177.2 103180.5 ± 17881.5 \0.05*
Laparoscopic 65946.0 ± 16943.2 113838.4 ± 27106.1 0.052
expert
Novice 54493.5 ± 18943.1 115214.0 ± 30305.6 0.081
Robotic 80309.7 ± 21873.6 80489.3 ± 34993.8 1
expert
*Statistically significant

Table 1 CMW from eight

muscles during task
performance using laparoscopic Average from eight muscles
system and robotic surgery
system Biceps
Triceps
Deltoid
Trapezius
Flexor carpi ulnaris
Extensor digitorum
Thenar compartment
Erector spinae
*Statistically significant
Laparoscopic surgery Robotic surgery p Value
67675.7 ± 4389.5 72434.1 ± 7065.9 [0.05
46346.7 ± 11289.3 32593.1 ± 6169.6 \0.05*
29019.0 ± 4776.1 32187.7 ± 4965.4 [0.05
30232.0 ± 2720.2 24516.7 ± 4367.4 [0.05
66916.4 ± 11177.2 103180.5 ± 17881.5 \0.05*
84778.6 ± 19472.1 60268.0 ± 15030.3 \0.05*
94479.2 ± 14800.3 95986.1 ± 15821.2 [0.05
99679.6 ± 10014.5 118394.9 ± 17419.8 [0.05
89953.9 ± 3916.1 112345.6 ± 15506.2 [0.05

123
462
Fig. 4 Global and individual scale scores of the NASA-TLX
cognitive workload assessment. MD mental demand, PD physical
demand, TP temporal demand, PR performance, EF effort, FR
frustration. 122 9 128 mm (300 9 300 DPI)
(87266.8 ± 10479.3) regardless of the surgical platform
used for task performance.
Cognitive workload
The results of the NASA-TLX cognitive workload assess-
ment are shown in Fig. 4. It was found that the global
NASA-TLX score with laparoscopic surgery (40.9 ± 3.7)
was significantly higher than that with robotic surgery
(31.9 ± 3.4). This result demonstrated that the overall
workload that was experienced by surgeons during lapa-
roscopic task performance was significantly higher than
robotic task performance [F(1,10) = 10.93, p \ 0.05].
Additionally, significant platform 9 group interaction
[F(2,10) = 10.50, p \ 0.05] showed that the change in the
global score between two surgical platforms revealed dif-
ferent patterns among the three subject groups. The global
scores of the NASA-TLX from the three subject groups are
shown in Fig. 5. This graph shows that RE and NV group
participants exhibited higher global workloads with lapa-
roscopy (40.5 ± 7.3 and 44.1 ± 6.4, respectively) than
those with robotic surgery (24.4 ± 6.7 and 26.3 ± 5.8,
respectively). However, LE group demonstrated a similarly
high workload in both surgical platforms (laparoscopic
surgery: 38.2 ± 5.2 and robotic surgery: 45.1 ± 4.8).
Platform 9 scale interaction was also found to be signifi-
cant [F(5,50) = 5.044, p \ 0.05], so individual scale
scores were further investigated. Figure 4 shows the
NASA-TLX scores of six individual scales.
123
Surg Endosc (2014) 28:456–465
Fig. 5 NASA-TLX global scores from three subject groups. LE
laparoscopic experts, NV novices, RE robotic experts. 124 9 128 mm
(300 9 300 DPI)
Our results showed that the NASA-TLX scores on the
physical demand, temporal demand, and frustration were
significantly higher with laparoscopy (p \ 0.05). The
results from each of these three individual scales were
further examined to determine whether these significantly
higher workloads were exhibited consistently for all three
subject groups. Figure 6 shows the physical demand
reported by the three subject groups. Our analysis showed
that the physical demand with laparoscopy (46.8 ± 4.0)
was significantly greater than with robotic surgery
(28.2 ± 4.8) [F(1,10) = 21.899, p \ 0.05]. It also was
found that for the RE and NV group participants the
physical demands (48.1 ± 8.1 and 50.6 ± 7.0, respec-
tively) during laparoscopic task performance were greater
than the physical demands during robotic task performance
(20.3 ± 9.7 and 23.8 ± 8.4, respectively). However, the
LE group subjects showed similarly high levels of physical
demand in both platforms (laparoscopy: 41.7 ± 5.7 and
robotic surgery: 40.6 ± 6.8). The analysis on the temporal
demand showed similar results (Fig. 7). The temporal
demand with laparoscopy (37.5 ± 5.3) was again signifi-
cantly higher than with robotic surgery (31.1 ± 4.7)
[F(1,10) = 6.859, p \ 0.05]. The RE and NV participants
had greater temporal demand with laparoscopy (33.3 ±
10.6 and 44.7 ± 9.2, respectively) than they had with
robotic surgery (20.3 ± 9.4 and 27.1 ± 8.1, respectively).
For the LE, however, the temporal demand was greater with
robotic surgery (45.8 ± 6.6) than with laparoscopy
(34.4 ± 7.5). The results of NASA-TLX frustration scale
Surg Endosc (2014) 28:456–465
Fig. 6 NASA-TLX scores of physical demand from three subject
groups. LE laparoscopic experts, NV novices, RE robotic experts.
122 9 128 mm (300 9 300 DPI)
Fig. 7 NASA-TLX scores of temporal demand from three subject
groups. LE laparoscopic experts, NV novices, RE robotic experts.
122 9 128 mm (300 9 300 DPI)
are shown in Fig. 8. It was noted that performance with
laparoscopy caused significantly greater frustration
(28.2 ± 3.9) compared with robotic surgery (27.0 ± 3.2)
[F(1,10) = 11.855, p \ 0.05]. Whereas the LE group
showed similar levels of frustration with two surgical
463
Fig. 8 NASA-TLX scores of frustration from three subject groups.
LE laparoscopic experts, NV novices, RE robotic experts. 122 9 128
mm (300 9 300 DPI)
platforms (laparoscopy: 33.6 ± 5.6 and robotic surgery
38.5 ± 4.5), the RE and NV groups expressed greater
frustration with laparoscopy (39.0 ± 6.8 and 41.9 ± 7.9,
respectively) than with robotic surgery (18.6 ± 5.5 and
23.9 ± 6.3 respectively).
Discussion
This study demonstrated that the physical and cognitive
ergonomics associated with performing robotic surgery
were significantly less challenging than those associated
with performing laparoscopic surgery. In addition, several
ergonomic components were noted as skill-related.
The CMWs of the biceps and flexor carpi ulnaris were
significantly higher with laparoscopy than with robotic
surgery. Our subjective cognitive workload assessment
using the NASA-TLX agreed with this result. The physical
demand reported after performing laparoscopy was sig-
nificantly greater than after robotic surgery. These results
demonstrated that the posture associated with laparoscopy
involved more elbow flexion, causing higher activation at
the biceps, and more wrist flexion, causing greater activa-
tion on the flexor carpi ulnaris. The ergonomically better
posture with robotic surgery might result from the clutch
control that is unique to the robotic surgery system. The
clutch control function allows surgeons to reposition their
control manipulator without influencing the instrument
movements whenever the hand location is less ergonomic.
123
464
In laparoscopy, this repositioning might be very limited,
achieved only by changing the operating surgeon’s stand-
ing location or adjusting the table height. An example of
surgeons’ strategic postural adjustment to better perform
laparoscopic skill tasks was published in a previous MIS
ergonomics study [25]. To address the high ergonomic
workload of traditional laparoscopy, better ergonomic
training for laparoscopic novices is needed. This training
will allow novices to learn how to achieve optimal postures
during their laparoscopic task performance.
Our cognitive workload assessment using the NASA-
TLX also demonstrated that global workload score was
greater with laparoscopy, primarily because of higher
physical and temporal demand and more frustration with
laparoscopy. When these three workload scale scores were
compared among three subject groups, our results showed
that the LE group reported similar or higher workloads
with robotic surgery, whereas NV and RE participants
showed significantly lower physical and temporal demand
and frustration with robotic surgery. This result for LE
subjects might be a result of their familiarity with the
laparoscopic system and their existing expertise in lapa-
roscopy. In addition, their unfamiliarity with the operation
of robotic systems might cause LE participants to have
higher physical and mental workloads. These higher
workloads may be experienced as an initial reaction by
surgeons already very familiar with one surgical system,
when they are exposed to a different surgical platform, and
may cause personal hesitance toward new technology.
This study also demonstrated a few potentially high
workload cases with marginal statistical significances (i.e.,
p values were slightly [0.05). During robotic task perfor-
mance, the CMW of the trapezius with robotic surgery was
higher than with laparoscopy. It also was found that this
result occurred with the LE and NV but not with RE par-
ticipants. This higher trapezius activation might be the
result of the sitting posture of LE and NV subjects who sat
with their shoulders up and put too much arm pressure on
the arm rest. This awkward sitting posture would increase
ergonomic risk by increasing muscular fatigue at the
shoulder. It seems that the LE and NV subject groups are
not familiar with how to use the arm rest effectively, so
only robotic experts fully benefited from this ergonomic
feature. This skill-related ergonomic data also supported
the need for providing ergonomic guidelines to nonexpert
robotic surgeons so that surgeons can fully utilize the
ergonomic features available and prevent misuse that might
cause unnecessary fatigue. It also was noted that the CMW
of the thenar compartment with robotic surgery was higher
than with laparoscopy with a marginal statistical signifi-
cance (p = 0.06). A possible explanation for why robotic
surgery caused higher activation level at the thenar com-
partment may be related to the needle driver and scissor
123
Surg Endosc (2014) 28:456–465
operations, because this result was observed only with most
suturing and knot tying tasks and with the FLS circle
cutting task but not with the two ring transfer tasks. Further
investigation of hand muscles using more electrodes on the
finger flexor/extensor muscles will better explain how
much each muscle contributes to the instrument operations
in robotic and laparoscopic surgeries.
Another noteworthy finding was that the thenar com-
partment’s CMW of the nondominant hand was higher than
that of the dominant hand. Considering that the dominant
hand is usually used for dynamic tasks, such as needle
driving, dissecting, or object moving, and the nondominant
hand is used mostly for less dynamic tasks, such as grasping
and retracting, it was expected that the thenar compartment
of the dominant hand would show higher activation. How-
ever, it seems that the dominant hand’s thenar activation
might be more effective than the nondominant (i.e., non-
dominant thenar compartment might not have been com-
pletely resting when it was not actively used).
Our performance analysis showed that task performance
with robotic surgery was better than with laparoscopy in
two participant groups. It was observed that that the NV
and RE participants had higher PSs with robotic surgery,
whereas the LE subjects had lower PSs with robotic sur-
gery. Our data analysis did not include performance time.
For each training task, subjects were asked to complete the
task within 5–10 min. There were some subjects who could
not complete a meaningful portion of some tasks (i.e., an
instrument tie at the top of an incision for the running
suturing and knot tying task) within the given time frame.
In these trials, it was impossible to estimate how long it
would take to complete the task, because too little was
completed within the time limit.
The majority of previous studies investigating ergo-
nomics in robotic surgery have been conducted with
robotic novices, such as medical students and junior resi-
dents. In contrast, our study employed only senior resi-
dents, fellows, and attending surgeons to ensure that
subjects would already possess the basic surgical skills
required to perform the training tasks of varying difficulty
levels. Novice surgeons not familiar with basic surgical
skills would be overtaxing their mental workloads figuring
out how to do each task, regardless of surgical platform,
thereby producing biased study results.
Our study had a few limitations. To make this study
stronger statistically, more subjects, especially in the
robotic expert group, should be recruited. To better
understand the ergonomics experienced by surgeons in
varying specialties, our suturing-focused training tasks may
need to be changed to include other training tasks that
simulate the subtasks used in other specialties, such as
GYN or urology procedures. For this study, da Vinci
standard and S systems were used. The surgeon’s consoles
Surg Endosc (2014) 28:456–465
of these systems have only one adjustable ergonomic set-
ting, which is viewer height control. The most recent sys-
tem, da Vinci Si, has several more settings, including
tilting stereo viewer, arm-rest height, and foot-pedal loca-
tion adjustments. A future study will be performed using a
da Vinci Si system so that the ergonomics in robotic sur-
gery can be evaluated when all available ergonomic setting
options are fully engaged. In addition to ergonomic setting,
a da Vinci Si system is equipped with finger clutch con-
trols, another feature that may influence the physical and
cognitive workloads associated with robotic surgery.
Our research results consistently showed that robotic
experts were able to benefit the most from the ergonomic
advantages offered by the robotic surgery platform with
uncompromised task performance. These results emphasize
the need for well-defined ergonomics guidelines to maxi-
mize the ergonomic benefits available to surgeons utilizing
robotic surgery. This inclusion of these guidelines in for-
mal robotic surgery skills training programs will ensure
that novice robotic surgeons learn to perform surgical tasks
in an ergonomically favorable work environment. Our
future research efforts will include the establishment of
robotic ergonomics guidelines to be used in basic robotic
surgery training and investigation of their influence on the
potential change in physical workload as trainees acquire
surgical skill over time.
Acknowledgments This study was supported by a clinical robotics
research Grant from the 2012 Intuitive Surgical, Inc. The authors
acknowledge the thoughtful and careful assistance of Elizabeth
Cockey and Valerie K. Scott in editing the manuscript.
Disclosures Dr. Gyusung Lee received 2012 Intuitive Surgical
Robotic Clinical Research Grant as the Principle Investigator of this
study. Drs. Mija Lee, Erica Sutton, Adrian Park, and Michael Marohn
and Mrs. Tameka Clanton have no conflict of interest or financial ties
to disclose.
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