ORIGINAL ARTICLE
Do Micropauses Prevent Surgeon’s Fatigue and Loss of Accuracy
Associated With Prolonged Surgery?
An Experimental Prospective Study
Dominique Dorion, MD, MSc, and Simon Darveau, MD
Objective: This prospective experimental study evaluates the effectiveness
of micropauses (MPs) to prevent muscular fatigue and its deleterious effect
on surgeons during prolonged surgical procedures.
Background: Operating is a hazard for surgeon’s health. Beyond acute
injuries and blood-borne infections, back and neck pain is a poorly
recognized factor causing chronic ailment in more than half the surgeons
surveyed. MP, a 20-second break every 20 minutes, is an accepted strategy
used widely in the workplace.
Methods: Wedesignedacrossoverexperimentalstudy.Sixteensurgeonswere
tested 3 times: once in a control situation before any surgery (CTL) and
twice after a prolonged, reproducible operation (at least 2 hours), 1 of these
with formal MP (WMP) the other without (WOMP). Muscular fatigue was
tested by holding a 2.5-kg weight as long as possible with a stretched arm.
Accuracy was evaluated with a device, measuring the mistakes made when
following a predetermined path on a board. Finally, discomfort was
measured by visual analog scale.
Results: We found a statistically and more importantly clinically significant
difference between the CTL and WOMP groups in all 3 tests. MPs
prevented completely or almost completely the effects of fatigue associated
with surgery [accuracy (No. errors) CTL: 1.1, WOMP: 7.7, WMP: 1.7;
fatigue (seconds) CTL: 137, WOMP: 92, WMP: 142].
Conclusions: Surgical procedures are associated with significant muscular
fatigue that can be measured simply and which has a direct effect on
comfort and surgical accuracy. More important, this effect is completely or
almost completely prevented by MPs.
Keywords: micropause, surgical precision, surgical fatigue, experimental
study, surgical education
(AnnSurg 2013;257: 256–259)
O
peratingisahazardforasurgeon’shealth.Beyondacuteinjuries and
blood-borne infections, back and neck pain is a poorly
recognized factor potentially causing chronic ailment. Although it is
an established occupational disease for many professions, very few
studieshavelookedattheprevalenceofthisproblemamongsurgeons.
Babar-Craig and collaborators1 found a prevalence of 72% of back
or neck pain or even both among otolaryngologists in the United
Kingdom. Of those with pain, 53% attributed their symptoms
directly to surgery. This certainly demonstrates a lack of adequate
training, and improvement is needed to prevent long-term disability.
Beyond
From the Division of Otolaryngology/Head and Neck Surgery, Department of
Surgery, University of Sherbrooke, Sherbrooke, Quebec, Canada.
Disclosure: The authors have no conflicts of interest to report. However, the
project was funded in part by the Department of Surgery, University of
Sherbrooke.
Reprints: Dominique Dorion, MD, MSc, Division of Otolaryngology/Head and
Neck Surgery, Department of Surgery, University of Sherbrooke, 3001, 12th
Ave N, Sherbrooke, Quebec J1H 5N4, Canada. E-mail: Dominique.Dorion@
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
USherbrooke.ca.
Copyright 2013 by Lippincott Williams & Wilkins
ISSN: 0003-4932/13/25702-0256
DOI: 10.1097/SLA.0b013e31825efe87
this, we were also concerned with the immediate effects of
prolonged surgery on technical performance. Although these issues
are new in the health care environment, ergonomics in the
workplace have certainly been studied extensively in the last 50
years. Micropause (MP), a formal 20-second break every 20
minutes of work, is a widely accepted strategy to optimize
performance, especially in sedentary work, for example, working in
front of a computer. The objective of this research project was,
therefore, to test our hypothesis that MP would (a) decrease the
feeling of discomfort and (b) improve strength and (c) precision by
comparing the performance of surgeons who had or had not taken
MP during a long procedure.
MATERIALS AND METHODS
The project was approved by the Ethics Review Board of the
University of Sherbrooke. Once collected, data were stored securely
and analyzed in a blinded fashion by the authors.
Design
Sixteen surgeons (10 staff and 6 residents) were recruited for
this crossover study. We evaluated each surgeon 3 times. Once
before any surgery (control), once after a common and reproducible
operation of at least 2 hours, and once after the same procedure but
this time undertaken with 20-second MP every 20 minutes. The
order of these evaluations was randomly assigned to each surgeon to
prevent a learning effect. All procedures and tests were done in the
morning in a local site adjacent to the operating room that had been
set up for this purpose. “Stressor” operations were the following:
open colon resection for general surgeons, craniotomy and
microscopic tumor resection for neurosurgeons, parotidectomy for
head and neck surgeons, and coronary artery bypass graft with
loupes for cardiac surgeons.
Micropauses
Every 20 minutes, an alarm would go off from a standard
kitchen timer. Surgeons were instructed to stop operating, pull out
of the working station, and stretch neck and shoulders. The whole
process was to take less than 20 seconds (Fig. 1).
Evaluation of Discomfort
Level of discomfort was evaluated with a simple 100-mm
visual analog scale, with specific answers for eyes, neck, upper
back, shoulders, elbows, wrists and hands, and lower limbs. This
specific test was not validated, but the relevance of using visual
analog scale to evaluate subjective variables such as pain and
discomfort is well documented in the literature. 2
Fatigue (Strength) Evaluation weight with the dominant arm fully extended at 90-degree flexion
The surgeon was asked to stand up still and hold a 2.5-kg and 15-degree abduction as long as possible without moving. This
simple test is a classic in occupational health literature. 3
256 | www.annalsofsurgery.com Annals of Surgery Volume 257, Number 2, February 2013 Annals of Surgery Volume 257, Number
2, February 2013 Do Micropauses Prevent Surgeon’s Fatigue and Loss of Accuracy?
Accuracy Test RESULTS Discomfort Levels
We used a low-tech system developed by our colleagues in Discomfortlevelswerestatisticallydifferentforallsitesamong
the Faculty of Kinesiology (Fig. 2). The surgeon was asked to hold the 3 situations, except for the lower limb, where MPs offered no
a pair of Metzenbaum scissors and follow with it a star-shaped track “protection,” and the eyes, where we did not find any difference
on a board. Contacts with the border of the track are considered between the control and the procedures with MP, although there was
errors and recorded automatically. The circuit was repeated 3 times. a difference between those 2 and the procedures without MP (Fig.
This test has been validated with a test–retest reliability of r = 3).
0.955.4
Muscular Fatigue Evaluation
Results are presented in Figure 4. Without MPs, 2-hour oper-
Statistics
Results are presented for the whole group. Small numbers of
participants prevented meaningful comparisons between age, status
(staff vs residents), or type of surgery. We used repeated-measure
analysis of variance with Bonferroni correction for multiple
comparisons.

FIGURE 3. Level of discomfort reported by surgeons. Levels are

reported on a scale of 0 to 100, where 0 is no discomfort and 100 is
maximal discomfort. For each anatomical area, the results are
reported for the control state and after a prolong operation with or
without MP. All pairwise comparisons (control vs with MP, control
vs without MP, and without MP vs with MP) were statistically
significant (P < 0.05) except those marked by an asterisk ( ∗).
Repeated-measures analysis of variance with Bonferroni pairwise
comparisons.

FIGURE 1. Active stretching of the shoulder area done during MP.

FIGURE 4. Maximal holding time of a 2.5-kg weight with dominant

FIGURE 2. Device used to test for precision of movements. arm stretched out. Results are reported in seconds. ∗P < 0.001.
Surgeons are asked to hold the Metzenbaum scissors and to follow Repeated-measures analysis of variance with Bonferroni pairwise
the star on the board without touching the outside of the shape. comparisons.

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 2013 Lippincott Williams & Wilkins www.annalsofsurgery.com | 257 Dorion and Darveau
2, February 2013
FIGURE 5. Errors made during the star-shaped precision test.
Results are reported as the average number of mistakes for 1
circuit. ∗P < 0.001, †P < 0.01. Repeated-measures analysis of
variance with Bonferroni pairwise comparisons.
ations created a reduction of 33% in the maximal holding time. MPs
completely prevented this fatigue.
Accuracy Test
Results from this test are presented in Figure 5. The average
number of errors was multiplied by 7 after operating without MPs.
The number of errors with the MPs was double, which was not only
significantly different from the control situation but also different
from the situation without the pauses.
DISCUSSION
This research project has identified for the first time a link
between long surgical procedures and a surgeon’s fatigue, decreased
strength, and decreased technical accuracy. More importantly, it also
found a solution to this problem. As a first level, the subjective
evaluation of discomfort was relevant because Sundelin and
Hagberg5 found that discomfort could be felt before actual muscular
fatigue could be elicited. In designing this study, we included this
aspect, as we thought that it would be more sensitive than the test
for fatigue. Despite the very significant finding on muscular fatigue,
this subjective evaluation showed interesting albeit not unexpected
results (Fig. 2). First, of significance is what we did not find:
identifying a difference in the lower limb fatigue would have cast a
doubt over our whole set of results. Junior residents learn early in
their career to move about on their feet when operating.
Furthermore, years of training standing by an operating table has
turned the immobile, erect position into a second nature. On the
positive side and, again, not surprisingly, the maximum amount of
discomfort is felt in the back and shoulders. The second point of
interest in this aspect is the fact that even MP will not totally erase
the fatigue of operating during long hours, but it will cut it roughly
by half (eg, neck: 36–17, P < 0.05; back: 53–28, P < 0.05; shoulder:
41–17, P < 0.05).
Results from the more objective maximum holding test
(muscular fatigue) went exactly in the same direction but were even
more compelling (Fig. 3). Operating on a patient will decrease
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Surgery Volume 257, Number
strength significantly (137 seconds preoperative to 92 seconds
postoperative without MP), but this can be completely prevented by
MP (142 seconds postoperative with MP, P < 0.001, compared with
postoperative without MP). Together, these 2 tests confirmed that
fatigue is significant, can be evaluated objectively and subjectively,
and can be prevented. Furthermore, we confirmed the findings of
Sundelin and Hagber that subjective discomfort is more sensitive
than muscular fatigue.
Although hoped-for, results from the accuracy test came as a
shock (Fig. 4). This of course evaluates the link between prolonged
surgery and an “artificial” accuracy test. How this decreased
performance in the test translates into “real-life” operating room
precision is yet to be elucidated. Nevertheless, to our knowledge,
this is the first time that surgical fatigue is correlated with a test
evaluating precision. Although 11 of the 16 surgeons (69%) made 1
or fewer mistakes on the test track in the control situation, none of
them made fewer than 4 errors after surgery without MP. On
average, the number of errors was multiplied by 8.5. Because the
order of the sessions was randomized, a learning bias is ruled out.
Sure enough, subjects were not blinded to the experimental arm. Is
it conceivable then that surgeons would purposefully make more
mistakes to improve the results of the “treatment” arm? Possibly,
and certainly, this remains a weakness of this project, but on a
lighter note, we propose 2 intuitive arguments to counteract this
assumption. First, we challenge anyone to find a surgeon who
would knowingly or subconsciously attempt to look clumsy with a
pair of Metzenbaum scissors. Second, when explained the project,
the experimental subjects were all skeptical as to the benefits of MP
and worried that it would break the flow of the operation (although
all surgeons approached agreed to participate). If there were a bias,
it would be in favor of the control arm.
If this study is the first to document in such a complete
fashion the relationship between surgery and its deleterious
consequences, a large body of evidence explores its
pathophysiology. Static exercises of which surgery is the epitome
will cause muscular tension associated with decrease blood flow,
metabolites accumulation, and energy depletion. This, in turn, will
lead to discomfort and muscular fatigue. 3,6,7 We have all experienced
this when reading at a desk, working on a computer, or driving a car
for a long ride. This chain of events is deleterious to surgeons who
dive into this “toxic soup” 10 to 30 hours per week throughout their
career. The results of this specific study do not allow us to make the
next step and link these recurrent episodes of muscular fatigue and
discomfort with chronic pain, but others have looked at this
relationship before. Galinsky et al 8 have documented that chronic
musculoskeletal disorders are the result of the cumulative effect of
repeated microtraumas presenting as lightto moderate-intensity
discomfort at the time of the original task. This study documented
for the first timemoderate discomfort and, therefore, “trauma”
associated with surgery. Although formal causality is still numerous
studies away, this could provide an intriguing insight into the high
percentage of surgeons affected by chronic pain. 1
Fatiguepotentiallycausingchronicpainisasignificantconcern
for surgeon’s quality of life and, therefore, health care delivery, but
it becomes also relevant to actual patient care because Voight et al 9
have shown in a different environment that this fatigue will decrease
accuracy. Our results confirm this for the first time in the context of
the operating room. From almost none to an average of 8 mistakes
is a major difference. Identifying and quantifying the problem are
important, but finding a solution is much more gratifying. We
simply followed the path set by a voluminous body of literature:
numerous studies have demonstrated in different environments that
MPs can break the vicious cycle of static exercises leading to acute
discomfort (eventually chronic pain) and decreased accuracy. 7,10–18
 Acompletereviewoftheliteratureonmicropause/microbreaks is
beyond the scope of this article, and the interested reader will find a qualities are needed for these breaks to be successful: (a) they must
258 | www.annalsofsurgery.com 2013 Lippincott Williams & Wilkins Annals of Surgery Volume 257, Number 2, February 2013
Do Micropauses Prevent Surgeon’s Fatigue and Loss of Accuracy?
be active rather than passive20 and (b) they must be much more
frequent than intuitively required. In other words, if one is left to
decide when to pause, breaks will become too few and too far apart,
and the interval too long. 14,21 As a matter of fact, Rohmert 11 has
demonstrated that the time for recuperation is exponentially related
to the degree of fatigue, which is a combination of intensity and
duration of the exercise. An increase of 50% in the duration of
exercise requires a recuperation period 4 times longer. Furthermore,
recuperation is much faster in the early part of the break. 11 This is
why we chose the format of 20 seconds every 20 minutes, which is
supported widely in the literature mostly involved with computer
work. Feedback was formally sought from the surgeons who
participated in the experience. The consensus was that early in the
operation, pauses seemed to be coming too frequently. After the first
hour on the other hand the regular breaks were welcome and even
anticipated. Certainly, nobody felt that it impaired performance, but
the rule was clear: you have to quit whatever you are doing when
the alarm goes off. This study was not designed to evaluate formally
the effect of stopping for 1 minute every hour on the workflow in
the operating room. After the work of Zheng et al, 22 who have
reported that workflow during an operation is interrupted on
average 4.1 minutes per hour because of personnel or equipment-
related events (shift change, equipment missing, repositioning,
pagers), we have found, in practice, that nursing staff will use the
MP to take care of many of these potential disruptions. Further
studies are needed to elucidate the role, positive or negative, of MP
on operating room workflow.
Workflow is but the tip of the iceberg when it comes to
implementing MP. Interestingly, despite the spectacular results and
the very positive response we had when discussing the results with
the surgeons involved, few of them have continued to use MPs
spontaneously. The authors (S.D. and D.D. are staff
otolaryngologists) confess not to adhere to this habit as religiously
as they should for short cases, but the more senior author, now in
his late 40s, has come to rely on MPs for major head and neck
cases. The reasons for this low compliance are not easy to identify,
but they probably include a feeling of invincibility, a lack of
awareness, a touch of laziness, and a leave-me-alone attitude. In
summary, we are dealing with surgeons. To overcome these
obstacles, we have found that the nursing staff has to buy in
completely. The circulating nurse must “enforce” the breaks, which
set the rhythm of the operation. Finally, contrary to the standard
reflex, first-time users should start MPs with longer, more complex
operations, where the benefits will be immediately palpable.
In conclusion, we have studied the effect of MPs on the
strength, precision, and fatigue associated with long (>2-hour)
operations. We found a significant improvement in all variables
studied with mandatory 20-second breaks every 20 minutes. This
translates into better surgeon comfort and, we hope, potentially
decreased longterm chronic pain and disability. The effect on
surgical precision, complications, and a potential link with
outcomes remains to be evaluated.
ACKNOWLEDGMENTS
Dr Darveau was involved in elaborating the protocol and
writing the manuscript. He was the primary individual in charge of
collecting and interpreting the data. Dr Dorion was involved in all
aspects of the project and primary individual in charge of the
redaction of the manuscript.
2013 Lippincott Williams & Wilkins
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
good overview in the meta-analysis from Barredo and Mahon. 19 Two
REFERENCES
1. Babar-
CraigH,BanfieldG,KnightJ.PrevalenceofbackandneckpainamongstENT
consultants: national survey. J Laryngol Otol. 2003;117:979–982.
2. Lati C, Guthrie LC, Ward MM. Comparison of the construct validity
andsensitivity to change of the visual analog scale and a modified rating
scale as measures of patient global assessment in rheumatoid arthritis. J
Rheumatol. 2010;37:717–722.
3. Chaffin DB. Localized muscle fatigue-definition and measurement. J Occup
Med. 1973;15:346–354.
4. Savoie S, Therrien R, Prince F. Hauteur de la table d’operation et
performance´ chirurgicale. ProQuest Dissertations &Theses.
http://search.proquest.com/ docview/305456642/1311AF58F03233B4FE0.
Published 2002. Accessed 25 June, 2012.
5. Sundelin G, Hagberg M. The effects of different pause types on neck
andshoulder EMG activity during VDU work. Ergonomics. 1989;32:527–
537.
6. Chaffin DB. Static biomechanical modeling in manual lifting. In:
KarwoskiW, Marras WS, eds. The Occupational Biomechanics Handbook.
Boca Raton, FL: CRC Press LLC; 1999:933–944.
7. Jonsson B. The static load component in muscle work. Eur J Appl Physiol.
1988;57:305–310.
8. Galinsky TL, Swanson NG, Sauter SL, et al. A field study of
supplementaryrest breaks for data-entry operators. Ergonomics.
2000;43:622–638.
9. Voight ML, Hardin JA, Blackburn TA, et al. The effects of muscle fatigue
onand the relationship of arm dominance to shoulder proprioception. J
Orthop Sports Phys Ther. 1996;23:348–352.
10. Rohmert W. Problems of determination of rest allowances, part 1: use
ofmodern methods to evaluate stress and strain in static muscular work. Appl
Ergon. 1973;4:91–95.
11. Rohmert W. Problems of determination of rest allowances, part 2:
determiningrest allowances in different human tasks. Appl Ergon.
1973;4:158–162.
12. Hagberg M. Muscular endurance and surface electromyogram in isometric
anddynamic exercise. J Appl Physiol. 1981;51:1–7.
13. Hagberg M, Sundelin G. Discomfort and load on the upper trapezius
musclewhen operating a word processor. Ergonomics. 1986;29:1637–1645.
14. Henning RA, Sauter SL, Salvendy G, et al. Microbreak length,
performance,and stress in a data entry task. Ergonomics. 1989;32:855–864.
15. Henning RA, Jacques P, Kissel GV, et al. Frequent short breaks from
computerwork: effects on productivity and well-being at two field sites.
Ergonomics. 1997;40:80–91.
16. Bystrom SEG, Mathiassen SE, Fransson-Hall C. Physiological effects of mi-
¨ cropauses in isometric hand grip exercises. Eur J Appl Physiol.
1991;63:405– 411.
17. Koparadekar P, Mital A. The effect of different work-rest schedules on
fatigue and performance of a stimulated directory assistance operator’s task.
Ergonomics. 1994;37:1697–1707.
18. Genaidy AM, Delgado E, Bustos T. Active microbreak effects on
musculoskeletal comfort ratings in meatpacking plants. Ergonomics.
1995;38:326– 336.
19. Barredo RDV, Mahon K. The effects of exercise and rest breaks on
musculoskeletal discomfort during computer tasks: an evidence-based
perspective. J Phys Ther Sci. 2007;19:151–163.
20. Laporte W. The influence of a gymnastic pause upon recovery following
postoffice work. Ergonomics. 1966;9:501–506.
21. Mclean L, Tingley M, Scott RN, et al. Computer terminal work and the
benefitof micro-breaks. Appl Ergon. 2001;32:225–237.
22. Zheng B, Martinec DV, Cassera MA, et al. A quantitative study of
disruptionin the operating room during laparoscopic antireflux surgery. Surg
Endosc.
2008;22:2171–2177.
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