Smarter Tools, Culture Shift Are Reshaping Surgical Ergonomics

Growing awareness of musculoskeletal strain among surgeons has brought new meaning to the old proverb, “Physician, heal thyself.”

Physicians, especially surgeons, are finding that if they do not take precautions, they may end up in pain, debilitated, and even in a shortened career.

By spending long hours in static positions performing repetitive, highly precise tasks over many years, more than 80% of surgeons have suffered from a work-related injury or illness.¹ Most of these injuries consist of musculoskeletal pain involving the neck, back, shoulders, and arms that can impact the surgeon’s ability to operate and could lead to spine surgery and early retirement.²

This problem traditionally has been ignored for a variety of reasons, including an intense focus on the patient and an unyielding surgeon culture.

“In the past, of course the patient’s comfort was always the most important thing, but it was to the exclusion of all else,” said Susan Carter, MD, FACS, executive director of the Office of Simulation in Medicine and Surgery at Rocky Vista University in Parker, Colorado. “You were just supposed to suck it up, and if you’re uncomfortable, that’s okay because it’s only about the patient.”

There is a growing realization, however, that when surgeons are in pain, they are not at their best, and that may not only hurt them but also could compromise the safety of their patients.

“To help our patients, we need to be at the top of our game,” said David J. Welsh, MD, MBA, FACS, a private practice surgeon and ACS Regent in Batesville, Indiana.

As new technology and equipment often exacerbate the physical strain of being a surgeon, the resulting injuries and early retirements have become hard to ignore.

“There are a significant number of surgeons who actually have to curtail their careers because of back problems or back and neck issues,” said cardiothoracic surgeon Tom C. Nguyen, MD, FACS, chair of the Department of Cardiovascular Sciences at Florida International University Herbert Wertheim College of Medicine, chief medical executive of Baptist Health Heart & Vascular Care, and the Barry T. Katzen Endowed Chair and director of minimally invasive valve surgery at Miami Cardiac & Vascular Institute, all in Miami, Florida.

Dr. Welsh said he has “close colleagues and friends who have been decimated” by ergonomic issues, including an interventional radiologist who had his first neck surgery in his 30s.

Work-related injury can take a personal toll on surgeons, negatively impacting their quality of life and contributing to burnout. When it cuts a surgeon’s career short, the financial and emotional consequences can be devastating.

“Surgeons love to operate, and they love their patients. To take away their life goal—something that fulfills them and makes them happy—is just a shame,” Dr. Welsh shared.

In addition, early retirements as a result of ergonomic issues can stress a healthcare system already facing a shortage of surgeons.

Equipment and Instruments

Outdated design of surgical equipment forces surgeons to acclimate to a potentially unsafe working environment. 

For example, the “one-size-fits-all” approach to instrumentation and other OR equipment can harm those who are outside the established “norm”—a trend that has increasingly surfaced as more women have joined the ranks of surgeons.³

Female surgeons can face ergonomic challenges in the OR due to equipment design, operating table height, and lifting requirements, which can lead to increased musculoskeletal injuries and discomfort. There is often a mismatch between standard surgical tools and the physical characteristics of many female surgeons, such as smaller hand sizes and lower overall muscle mass.

“The equipment is not for someone who is 5'6" and 135 pounds; it’s designed for someone who is 6'0" and 190 pounds with proportionately sized hands,” Dr. Welsh said.

Significantly more female than male surgeons report operation-related musculoskeletal injury, according to one study.⁴ For example, Dr. Welsh said he knows a female ear, nose, and throat specialist whose operating career was shortened by 20 years due to the debilitating strain of wearing a loupe and headlight.

Advances in surgical technology—particularly minimally invasive techniques such as laparoscopy—also can place surgeons in ergonomically challenging positions that strain the neck, back, and extremities.

Notably, research shows that 60% of surgeons report neck pain 12 months after open surgery,⁵ and 87% report pain after regularly performing minimally invasive surgery.⁶

Specialties that require longer operative times, surgical loupes, and awkward positioning are growing in practice. As minimally invasive surgery becomes more common, so do contorted hand and limb positions and uncomfortable neck angles.⁷ As a result, minimally invasive surgeons are three to five times more likely to experience neck and shoulder pain than those performing open surgery.⁸

“We need to partner with industry to develop new tools that will allow us to avoid these weird operating configurations,” Dr. Welsh said, adding that ergonomics can be an issue for other OR personnel as well—from anesthesiologists to nurses to x-ray technicians.

“We have to look at ergonomics for the whole system,” he explained.

Ergonomic Innovations in the OR

Numerous ergonomic innovations, including equipment that is voice-controlled, adjustable, or comes in various sizes; customized OR reconfigurations like multiple monitors and adjustable table heights; and even wearable sensors and exoskeletons, have been developed and evaluated over the years. Hospitals, especially rural hospitals, may use ergonomic-friendly setups and instruments to recruit women surgeons, Dr. Welsh said.

A big advance has been robotic-assisted surgery, which allows surgeons to operate while sitting in a workstation that can be adjusted to their personal specifications, making it ergonomically superior to open and laparoscopic surgery, according to Dr. Carter. Other benefits, like improved visualization and enhanced dexterity, also can lead to reduced physical and mental fatigue.

“Robotic surgery improves things because you’re sitting in a neutral position to perform surgery versus standing up in an awkward position,” Dr. Nguyen said.

Still, despite its benefits, rates of physical strain remain significant among surgical robotics operators and should be addressed by formal ergonomic training and adequate console familiarization.⁹

“As technology has advanced, ergonomic challenges have varied,” Dr. Carter said. “The sitting position offers different overuse issues, such as stress on the upper back and neck.”

Emerging trends in ergonomics innovation include:

• Next-generation instrument design: This design approach includes lighter, better-balanced, and more intuitive tools. For example, loupes are now angled to allow the head and neck to stay upright, eliminating the tension from bending the neck, Dr. Nguyen said. 

Many headlights now use LED lighting and are less heavy, reducing neck strain, while some laparoscopic instruments are specifically sized. “Instruments have been made with smaller handles to reduce hand fatigue and improve precision and with lighter weight material so they’re not as heavy and clunky as they used to be,” Dr. Carter said, noting that she would like surgical instruments, including laparoscopic instruments, to be available in a variety of sizes.

• Laparoscopic and robotic system refinements: These improvements feature improved console ergonomics, arm support systems, and haptic feedback technology. 

• Customized OR configurations: This design approach could include adjustable table heights, modular OR furniture, and repositionable monitors for optimal posture. Rather than depend on one scope, which requires some awkward bending and twisting, minimally invasive surgeons can now use multiple screens throughout the OR to keep their gaze horizontal and their heads and necks erect, Dr. Carter said. Table heights can be moved up and down or even tilted.

The question is—will hospitals invest in these new approaches? While Dr. Carter asserted that most “hospitals and hospital systems make an effort to improve the ergonomics,” Dr. Welsh said he believes such decisions will “come down to what can be incorporated in a cost-effective manner.”

Dr. Nguyen suggested that the case for investing in these new approaches will advance once motion studies demonstrate their benefits and ergonomics become an integral part of quality improvement and workforce sustainability.

Wearables and Data-Driven Ergonomics

Researchers are conducting motion studies to identify ergonomic weak points and opportunities to create ergonomic breakthroughs.

For example, wearable sensors and posture-tracking devices are being used to monitor surgeon movement and strain, and potentially integrate these data into training and workflow optimization.

“We can use sensors to track what some of the issues are and find ways to correct them,” said Dr. Nguyen, who is conducting such a study.

The first part of this study will measure when things derail, and the second will be interventional—the sensor will buzz to let the surgeon know they need to correct their posture or movements.

Sensors and posture tracking devices will become common in OR simulation training as well.

Meanwhile, data from these wearable sensors can be analyzed using artificial intelligence (AI) to provide real-time feedback on posture, muscle load, and OR fatigue metrics. Surgeons also can leverage AI-powered motion analysis tools to assess their ergonomics and receive detailed feedback on areas that deviate from optimal posture or technique. 

Training Surgeons to Move Smarter

More data-based research may lead to better training, helping to overcome a lack of awareness about the ergonomics problem.

Surgeons significantly underreport the incidence of work-related injuries. In some cases, surgeons may not report mild symptoms; in others, they fear that reporting symptoms could lead to missed work or be perceived as a sign of weakness.¹⁰

However, awareness of the ergonomic risks within the OR is spreading among residents, younger surgeons, and leaders of professional surgical associations, Dr. Welsh said. As a result, surgical training is shifting from ignoring stress and discouraging conversations about well-being and burnout to fostering surgeon wellness, including preventing work-related pain, injury, and burnout.⁷

Ergonomic training also may include a focus on positioning techniques and instrument handling skills. Microbreaks—brief pauses during which surgeons check their posture, relax their shoulders, and reset their positioning at the console—also are important, according to Dr. Carter.

Simulation has become an increasingly important component of surgical training, extending to ergonomics and posture awareness.

“A simulator is a perfect way for surgeons to recognize and develop self-awareness of their ergonomic deficits,” Dr. Carter said.

The ACS has brought surgeons and engineers together to discuss surgical simulation. Among the topics the College is exploring: using AI-driven sensors to develop feedback for surgeons about what they’re doing incorrectly and how to feel more comfortable.

“The robotic simulator feels remarkably close to the real thing,” Dr. Carter said. “You quickly realize how certain movements or postures can create extra strain on your joints and muscles.”

Ergonomics training can ingrain good ergonomic habits early that could extend surgeons’ careers, she added.

Cultural Shift: From Stoicism to Wellness

Surgeon ergonomics will improve not just through better training and equipment, but also by changing the cultural belief that enduring pain is a mark of toughness. Ergonomics must be recognized as part of surgical professionalism.

In fact, the hesitancy to seek help, compounded by long work hours, poor nutrition, lack of sleep, and poor conditioning, creates the perfect storm for injury.

“Stop suffering in silence,” Dr. Nguyen said. “Ergonomics should be discussed and studied, not stigmatized. Surgeons need to shift from stoicism to proactive self-care, and we should view and treat ourselves as athletes. It’s how you practice, rest, and recover that wins the game. But we surgeons are not very good at that.”

Similar to high-performance athletes, surgeons need to train intently, and be ready to execute precise movements, avoid errors, and maintain excellence. They need to build strength and flexibility to perform well even in the face of fatigue and inadequate hydration.¹¹

A taekwondo enthusiast, Dr. Welsh said some of his warmup exercises—which focus on maintaining core strength and staying limber—also are recommended for surgeons by the ACS Surgical Ergonomics Committee (he and Dr. Carter are members). 

In addition, stretching, deep breaths, microbreaks, shrugging shoulders, and flex extensions are all simple moves that surgeons can do before, during, and after they operate, Dr. Carter shared.

The Surgical Ergonomics Committee recently published Surgical Ergonomics Recommendations, featuring general suggestions (e.g., optimal OR table height) that are applicable across different surgical disciplines, along with surgical technique-specific recommendations (e.g., optimal monitor positioning for laparoscopic surgery). The document also includes different stretching exercise protocols that can be implemented in the OR, between cases, or at home. Various subject matter experts, including experienced surgeons, physical and cognitive ergonomics and human factors researchers, an industrial and systems engineer, occupational safety scientist, health design architect, and physical therapist, contributed to these best practice recommendations, which are available on facs.org.

What’s Next?

Future ergonomics developments in surgical equipment and environments include adaptive OR setups, exoskeletons, voice-controlled interfaces, and AI-guided motion coaching.

• Exoskeletons, which are frequently used in industry, are being increasingly adopted in surgery to mitigate musculoskeletal strain. These wearable devices support the arms, shoulders, and back, and can help reduce pain, fatigue, and improve precision during long and demanding surgical procedures. Studies have shown that exoskeletons can lead to decreased muscle activation and improved posture for surgeons.¹²

• Surgical instrument sensors and connectivity are poised to significantly enhance surgeon ergonomics by providing a more comfortable, intuitive, and efficient surgical experience. These smart instruments can recognize different tissue types, temperatures, and tactile pressures, and offer real-time feedback, such as warning surgeons not to get too close to an organ, vessel, or nerve, Dr. Carter said.

• Personalized ergonomics, including advanced materials and 3D printers, could help tailor instruments and OR setups to individual surgeon profiles.

• Better imaging, such as more precise resolution on OR monitors, allows surgeons to zoom into minute areas of the body with amazing clarity. In addition, surgeons can expect augmented reality, 3D visualization, and rotational vision.

According to Dr. Welsh, surgeons who recognize that ergonomics is fundamental to surgical safety, efficiency, and career sustainability can “help ourselves, help each other, and help our patients.”

Jim McCartney is a freelance writer.

References

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