The American Journal of Surgery 182 (2001) 720 –724

An ergonomic evaluation of surgeons’ axial skeletal and upper

extremity movements during laparoscopic and open surgery
Ninh T. Nguyen, M.D.a,*, Hung S. Ho, M.D.a, Warren D. Smith, Ph.D.b,
Constantine Philippsb, Clare Lewis, M.S.b, Rodel M. De Verab, Ramon Berguer, M.D.a
a
Department of Surgery, University of Califorinia, Davis, Medical Center, 2221 Stockton Blvd., 3rd Flr., Sacramento, CA 95817-2214, USA
b
Programs in Biomedical Engineering and Physical Therapy, California State University, Sacramento, CA, USA

Manuscript received July 31, 2001; revised manuscript September 2, 2001

Presented at the 53rd Annual Meeting of the Southwestern Surgical Congress, Cancun, Mexico, April 29 –May 2, 2001.

Abstract
Background: Many surgeons have complained of fatigue and musculoskeletal pain after laparoscopic surgery. We evaluated differences
in surgeons’ axial skeletal and upper extremity movements during laparoscopic and open operations.
Methods: Five surgeons were videotaped performing 16 operations (8 laparoscopic and 8 open) to record their neck, trunk, shoulder, elbow,
and wrist movements during the first hour of surgery. We also compared postprocedural complaints of pain, stiffness, or numbness between
the two groups.
Results: Compared with surgeons performing open surgery, surgeons performing laparoscopic surgery exhibited less lateral neck flexion;
less trunk flexion; more internal rotation of the shoulders; more elbow flexion; more wrist supination and wrist ulnar and radial deviation.
There was a trend of more shoulder stiffness after laparoscopic operations than after open operations.
Conclusions: Laparoscopic surgery involves a more static posture of the neck and trunk, but more frequent awkward movements of the
upper extremities than open surgery. Ergonomic changes in the operating room environment and instrument design could ease the physical
stress imposed on surgeons during laparoscopic operations. © 2002 Excerpta Medica, Inc. All rights reserved.

Keywords: Laparoscopy; Ergonomics; Posture

Laparoscopic surgical procedures are now being performed
in all areas of general surgery. Laparoscopic advances such
as development of higher resolution video optics and im-
proved operating instruments have allowed surgeons to per-
form more advanced laparoscopic operations. However,
there have been no concomitant changes in operating room
design and video monitor set-up to ease musculoskeletal
fatigue of surgeons performing laparoscopic surgery. Ergo-
nomic studies therefore are needed to improve the operating
room environment and reduce surgical fatigue.
Ergonomics is the science of fitting the work environ-
ment to the worker [1]. Laparoscopic surgery has changed
* Corresponding author. Tel.: ⫹1-916-734-4596; fax: ⫹1-916-734-
3951.
E-mail address: ninh.nguyen@ucdmc.ucdavis.edu.
the way surgeons interact with their operative field and
hence changed their body postures and upper extremity
movements. Laparoscopic surgeons tend to maintain a more
upright position with fewer back movements and less
weight shifting than surgeons performing open surgery [2].
Static back posture during prolonged laparoscopic opera-
tions may account for the increased postural fatigue of the
back. In addition, the present design of laparoscopic instru-
ments and the awkward positions of the arms, hands, and
fingers required by laparoscopic operations can result in
pressure point injury, nerve compression, and upper extrem-
ity fatigue [3– 6]. The primary objective of this study was to
record surgeons’ axial skeletal and upper extremity move-
ments during laparoscopic and open surgery using physical-
therapy– derived guidelines for measuring posture and
movements. The secondary end point was to compare sur-
geons’ postprocedural reports of musculoskeletal pain and
stiffness after laparoscopic and open operations.

0002-9610/01/$ – see front matter © 2002 Excerpta Medica, Inc. All rights reserved.
PII: S 0 0 0 2 - 9 6 1 0 ( 0 1 ) 0 0 8 0 1 - 7
 N.T. Nguyen et al. / The American Journal of Surgery 182 (2001) 720 –724 721

Materials and methods Table 1

Ergonomic evaluation during eight laparoscopic and eight open
operations
We videotaped five surgeons performing eight laparo-
scopic and eight open operations. Surgeons’ neck, back, and Type of operation Procedure
upper extremity movements exhibited during the laparo- Laparoscopic operations Esophagectomy (n ⫽ 2)
scopic operations were compared with those during the Roux-en-Y gastric bypass (n ⫽ 1)
open operations. The video provided only a single frontal Sigmoid colectomy (n ⫽ 1)
view of the surgeon’s head to pelvis. Only the first hour of Staging for esophagus cancer (n ⫽ 2)
Cholecystectomy (n ⫽ 2)
surgery was videotaped and analyzed due to limited time for
Open operations Pancreatoduodenectomy (n ⫽ 2)
review of the tapes. Immediately after the surgery, one of Roux-en-Y gastric bypass (n ⫽ 3)
two physical therapy students (CP, RDV) from the Program Sigmoid colectomy (n ⫽ 1)
of Physical Therapy at California State University, Sacra- Ventral hernia repair (n ⫽ 1)
mento, administered a questionnaire to each surgeon. The Inguinal hernia repair (n ⫽ 1)
questionnaire asked for the presence of, the location of
(neck, back, shoulder, hand/wrist on a drawing of a human
laparoscopic and open surgery is shown in Fig. 1. During
body), and the severity of pain, stiffness, or numbness on a
laparoscopic procedures, surgeons made significantly fewer
scale of mild, moderate, and severe.
lateral neck flexions than during open procedures (P
The physical therapy students reviewed all videotapes
⬍0.01). In open surgery, there was a non-statistically sig-
and recorded the numbers of neck, trunk, shoulder, elbow,
nificant trend toward a higher number of neck rotations but
and wrist movements using predefined criteria developed by
fewer neck flexions.
the Department of Physical Therapy. A single specific
The mean number of movements of the trunk during
movement of the neck, back, shoulder, elbow, or wrist was
laparoscopic and open surgery is shown in Fig. 2. Surgeons
defined as a deviation of the body posture from the neutral
made significantly fewer trunk flexions during laparoscopic
upright body position and included its return to the neutral
than during open operations (P ⫽ 0.05). There was a trend
body position. For example, a single movement of wrist
toward fewer trunk rotational movements during laparo-
supination was any rotational movement from the neutral
scopic operations than during open operations.
position going in the direction of supination and back to the
The mean number of dynamic movements of the shoul-
neutral position. Neck movements were categorized as flex-
der during laparoscopic and open surgery is shown in Fig. 3.
ion, extension, lateral flexion, and rotation. Trunk move-
The number of internal rotation movements of the shoulder
ments were categorized as flexion and rotation. Shoulder
was significantly higher during laparoscopic than during
movements were categorized as flexion, abduction, and in-
open surgery (P ⫽ 0.02). There was, however, no signifi-
ternal rotation. For elbow movements, the total number of
cant difference in the number of shoulder flexions and
flexion movements (including both ⬍90° and ⬎90°) were
extensions between surgeons performing laparoscopic and
counted. Wrist movements were recorded as pronation, su-
open procedures.
pination, flexion, extension, ulnar deviation, and radial de-
The mean number of movements of the elbow during
viation.
laparoscopic and open surgery is shown in Fig. 4. Surgeons
Data were given as the mean number of specific move-
exhibited significantly more elbow flexions during laparo-
ments ⫾ standard deviation for each body part for both
scopic than during open operations (P ⬍0.01).
laparoscopic and open operations. Comparison of the num-
ber of movements during laparoscopic and open surgery
was performed using unpaired t tests or Mann-Whitney U
tests for nonparametric data. The percentage of surgeons in
the two groups with postoperative pain and stiffness was
compared using Fisher’s exact tests. Statistical evaluations
were performed using standardized software (Stat-View,
SAS Institute Inc., Cary, North Carolina). A P value less
than 0.05 was considered significant.

Results

Five surgeons (4 males) with a mean age of 43 years

performed eight laparoscopic and eight open operations
(Table 1). Only the first hour of all 16 operations was Fig. 1. Neck: the mean number of movements of the neck in the first hour
videotaped. of laparoscopic and open procedures. *P ⬍0.05 versus open surgery
The mean number of movements of the neck during (Mann-Whitney U tests).
722 N.T. Nguyen et al. / The American Journal of Surgery 182 (2001) 720 –724
Fig. 2. Trunk: the mean number of movements of the trunk during the first
hour of laparoscopic and open procedures. *P ⬍0.05 versus open surgery
(unpaired t tests).
The mean number of wrist movements during laparo-
scopic and open surgery is shown in Fig. 5. A significantly
greater number of wrist movements occurred during lapa-
roscopic surgery than during open surgery for supination
(P ⫽ 0.02), ulnar deviation (P ⬍0.01), and radial deviation
(P ⫽ 0.04). There was no significant difference in the
number of wrist pronations, flexions, or extensions.
There was no significant difference in the levels of pain,
stiffness, or numbness in the neck, back, elbow, and wrist
between the two groups. Shoulder pain occurred in 2 (25%)
surgeons after 8 laparoscopic operations and in 2 (25%)
surgeons after 8 open operations (P ⫽ 0.99), but there was
a trend of more shoulder stiffness after laparoscopic than
after open operations (50% versus 0%, respectively, P ⫽
0.07).
Comments
Surgeons are at risk for development of musculoskeletal
fatigue during both open and laparoscopic operations [1,2,
Fig. 3. Shoulder: the mean number of movements of the shoulder during
the first hour of laparoscopic and open procedures. *P ⬍0.05 versus open
surgery (Mann-Whitney U tests).
Fig. 4. Elbow: the mean number of movements of the elbow during the first
hour of laparoscopic and open procedures. *P ⬍0.05 versus open surgery
(unpaired t tests).
7]. A correlation has been reported between musculoskele-
tal stress and prolonged static head-bent and back-bent
positions among surgeons and scrub nurses [7]. A high rate
of disability from cervicobrachial disorders also have been
reported among dentists, presumably related to their work-
ing postures [8]. In general, risk factors for musculoskeletal
injury include awkward body postures, frequent awkward
repetitive movements of the upper extremities, and pro-
longed static head and back postures [1]. Both open and
laparoscopic surgical operations are performed with the
surgeon in a standing, upright position; however, owing to
the constraint of the abdominal port positions during lapa-
roscopic surgery, laparoscopic surgeons sometimes adopt
awkward body positions and make certain awkward repet-
itive upper extremity movements to accomplish their oper-
ative tasks.
Neck pain and stiffness are frequent complaints after
laparoscopic operations. The Society of American Gastro-
intestinal Endoscopic Surgeons (SAGES) Task Force on
Ergonomics [9] reported an 8% to 12% incidence of pain in
the neck and upper extremities and a 9% to 18% incidence
Fig. 5. The mean number of movements of the wrist during the first hour
of laparoscopic and open procedures. *P ⬍0.05 versus open surgery
(Mann-Whitney U tests).
 N.T. Nguyen et al. / The American Journal of Surgery 182 (2001) 720 –724
of stiffness in these areas among 149 surgeons responding
to a questionnaire of body part discomfort after laparoscopic
operations. Our study demonstrated a greater frequency of
neck flexion movements during laparoscopic surgery than
during open surgery. The higher frequency of neck flexions
may occur because laparoscopic surgeons must look be-
tween the monitor and the surgical field. In addition, lapa-
roscopic surgeons had significantly fewer lateral neck flex-
ion movements, which was likely due to the fixed position
of the video display.
Static back postures also have been implicated to in-
crease surgeons’ back pain [1]. Kant et al [7] demonstrated
that static body postures were frequently displayed by sur-
geons and scrub nurses during open surgery, with up to 54%
of the time spent in a forward, bent-head stance and 27% of
the time spent in a back twisted and bent stance. Laparo-
scopic surgery seems to demand an even higher proportion
of static back postures. Rademacher et al [10] concluded
that 70% of intraoperative work postures during laparo-
scopic procedures were substantially static, and Berguer et
al [2] observed that laparoscopic surgeons often held a
head-straight, back-straight stance. Our study concurred
with these findings and demonstrated that surgeons per-
forming laparoscopic surgery have significantly less back
flexion movements than surgeons performing open surgery.
Shoulder movements during laparoscopic surgery have
not been extensively evaluated. Musculoskeletal stress upon
the shoulder during laparoscopic operations is related in part
to the operating room table height and the design of lapa-
roscopic instruments. During laparoscopic operations, the
shoulder tends to be in a slightly raised position. In addition,
the fixed position of the access ports limits the surgeons’
arm and hand movements to only 4 degrees compared with
the general 6 degrees of freedom during open operations
[10]. The combination of these factors requires laparoscopic
surgeons to make awkward movements such as internal
rotations of the shoulder to compensate for the limitations of
the abdominal ports. Our study documented a higher fre-
quency of internal rotations of the shoulder during laparo-
scopic operations than during open operations. Though not
at the level of statistical significance, there was a trend
toward a higher number of surgeons complaining of shoul-
der stiffness after laparoscopic than after open surgery (50%
versus 0%, respectively).
Wrist and hand fatigue has been reported after laparo-
scopic operations [3]. Factors contributing to wrist and hand
fatigue include the use of the laparoscopic instruments and
awkward wrist movements during laparoscopic operations.
Laparoscopic instruments are longer than open instruments
and their fulcrum point is at the port site of the abdominal
wall. Therefore, laparoscopic instruments are characterized
by an unfavorable force transmission from the handle to the
tip, such that laparoscopic surgeons must use four to six
times more force to complete the same task as in open
surgery. As a result, laparoscopic instruments require sig-
nificantly greater peak and total muscle effort of the sur-
723
geon’s forearm and thumb than open instruments, leading to
additional fatigue [1,7]. Berguer et al [9] demonstrated that
surgeons’ forearm electromyograms increased when a lapa-
roscopic grasper was used rather than a standard hemostat.
In our study, we confirmed that laparoscopic surgeons ex-
hibited more awkward wrist movements (wrist supination,
ulnar, and radial deviations) than surgeons performing open
surgery. We think this is related in part to our laparoscopic
suturing technique. Laparoscopic suturing was performed
using the Endo Stitch (United States Surgical Corp., Nor-
walk, Connecticut). The Endo Stitch facilitates laparoscopic
suturing, but its design requires the surgeon to perform
many awkward repetitive wrist movements that are not
performed routinely in conventional suturing.
Our study has limitations. The set-up of the video camera
was not ideal. At times, the assistant surgeon, scrub nurses,
and surgical drapes blocked the view of the camera. There-
fore not all body movements of the surgeons were recorded.
Our video was limited to only a single plane of view of the
surgeon. A further limitation was that the open and laparo-
scopic procedures were not matched in terms of technical
difficulty, and the study involved only the first hour of each
operation. Lastly, our study group was small, which in-
creased the chance of a type II error. Despite these limita-
tions, however, the study demonstrated significant differ-
ences in musculoskeletal movements among surgeons
performing laparoscopic and open operations. Further stud-
ies are needed to evaluate changes in the operating room
environment that might minimize laparoscopic surgeons’
musculoskeletal discomfort.
References
[1] Berguer R. Surgery and ergonomics. Arch Surg 1999;134:1011–16.
[2] Berguer R, Rab GT, Abu-Ghaida H, et al. A comparison of surgeons’
posture during laparoscopic and open surgical procedures. Surg En-
dosc 1997;11:139 – 42.
[3] Matern U, Eichenlaub M, Waller P, Ruckauer K. MIS instruments.
An experimental comparison of various ergonomic handles and their
design. Surg Endosc 1999;13:756 – 62.
[4] Neuhaus SJ, Watson DI. Laparoscopic surgeons’ thumb: is it a train-
ing phenomenon? Minim Invas Ther Allied Technol 1997;6:31–2.
[5] Horgan LF, O’Riordan DC, Doctor N. Neuropraxia following lapa-
roscopic procedures: an occupational injury. Minim Invas Ther Allied
Technol 1997;6:33–5.
[6] Berguer R. Surgical technology and the ergonomics of laparoscopic
instruments. Surg Endosc 1998;12:458 – 62.
[7] Kant IJ, de Jong LC, van Rijssen-Moll M, Borm PJ. A survey of static
and dynamic work postures of operating room staff. Int Arch Occup
Environ Health 1992;63:423– 8.
[8] Rundcrantz BL, Johnson B, Moritz U. Occupational cervico-brachial
disorders among dentists. Analysis of ergonomics and locomotor
functions. Swed Dent J 1991;15:105–15.
[9] Berguer R, Forkey DL, Smith WD. Ergonomic problems associated
with laparoscopic surgery. Surg Endosc 1999;13:466 – 8.
[10] Rademacher K, Pichler KV, Erbse S, et al. Using human factor
analysis and VR simulation techniques for the optimization of the
surgical work system. In: Weghorst SJ, Sieburg HB, Morgan KS,
editors. Medicine meets virtual reality: health care in the information
age. Amsterdam: IOS Press, 1996, p 533– 41.
724 N.T. Nguyen et al. / The American Journal of Surgery 182 (2001) 720 –724
Discussion
Dr. Daniel B. Jones (Dallas, TX): It was really up until
now that I thought my lower back pain, my neck stiffness,
and my wrist pain were due to being overweight and ad-
vancing age. Instead, you gave me an explanation that this
is an occupational injury. Nevertheless, there are three
things I’d like to ask you. One, you use a bunch of different
operations. Were there differences if you’re doing a lapa-
roscopic colon or a laparoscopic Roux-En-Y gastric bypass
in terms of the different motions that you’re making? You,
obviously, chose to do many procedures rather than use one
standard operation.
Second, it seems that you showed a lot of comparisons
with 50% versus 0%, but they weren’t statistically signifi-
cant and you acknowledge that there is probably a type II
error there. This being very important work, do you have
plans to continue the study and get a bigger sample size?
And most importantly, what do you think we need to do
in terms of raising the height of the bed, putting our cameras
at what optimal height? Should we be using endostitches?
Should we have a chair on the side of the table so we’re
actually in a sitting position?
Closing
Dr. Ninh T. Nguyen: There are vast differences ergo-
nomically between types of operations. For example, the
ergonomics for laparoscopic cholecystectomy are quite sim-
ple. The surgeon operates with one hand and the assistant
holds the camera and another assistant retracts the gall
bladder. There are minimal awkward movements during
that procedure.
When you perform advanced laparoscopic operations,
such as esophagectomy, gastric bypass, or colectomy, the
ergonomics change. First, you’re changing from a one-
handed to a two-handed operation. Second, suturing is dif-
ferent in laparoscopic operations than in open operations
and often requires awkward movements of the wrist.
Third, port placement is one of the most important fac-
tors in the ergonomics of laparoscopic operations. During
laparsocopy, you want to stand in a straight and upright
position and have two working ports directly in front of you
rather than have the ports on the oppostie side of the patient.
If you have to reach over the patient to perform the opera-
tion, then you have placed the ports in the wrong position.
Therefore, we elected to evaluate many different laparo-
scopic procedures with various levels of difficulty rather
than one specific operation.
All of our operations were performed with the surgeon
standing on the right side of the patient. The ergonomics
would have been different if the surgeon performed the
procedure standing between the patient’s legs. Standing
between the patients legs puts excessive stress on the back
as the surgeon leans over the patient, which is why so many
surgeons who adopt this position complain of postproce-
dural back pain.
We acknowledge the small sample size of our study, but
we have satisfied our primary objective that was to charac-
terize the different types of neck, back, and upper extremity
movements between laparoscopic and open operations.
The majority of the postoperative musculoskeletal com-
plaints were related to length of the operation. In a short
operation, few surgeons complain of musculoskeletal dis-
comfort, but when they perform a long operation such as
esophagectomy, then most surgeons will complain of post-
operative stiffness and fatigue.
Our study was an observational study. Now we can start
evaluating the necessary changes in operating room design
to improve ergonomics during laparoscopic operations.
Should the visual display be positioned in front of the
surgeon’s? Dr Cushierri reported that task performance was
improved when this visual display was closer to the opera-
tive field, but the study did not evaluate surgeons’ ergo-
nomic movements with the visual display in that position.
The optimal height of the table is another important issue
and is not the same for laparoscopic as for open operations.
For laparoscopic operations, the optimal height is lower
than that for open operations because the lower table height
reduces the tension and stress on the surgeon’s shoulder.
Another important issue for ergonomic evaluation is the
design of laparoscopic instruments. The pistol grip handle
and various types of laparoscopic instruments should be
ergonomically redesigned for the comfort of the surgeon.