Psychological and physical stress in surgeons operating in a standard or modern operating room

Strain on the surgeon: a systematic review of the methods of measuring strain in abdominal and thoracic surgery

INTRODUCTION

Surgery can be arduous to the operating surgeon - both in terms of cognitive and physical strain. Ergonomic strain has been recognised to drive absenteeism, reduce career longevity and cause injuries. This systematic review aims to 1. Outline the nature of ergonomic strain in the context of abdominal and thoracic surgery, regardless of surgical approach 2. Identify the qualitative and quantitative measures of surgical strain.

METHODS

A systematic review was conducted using Pubmed, MEDLINE and Ovid EMBASE databases (date range: 1990 to Sep 2024). Of the initial 1288 articles identified, a final 71 studies were included in this review (quantitative measures = 36, qualitative measures = 49, of which 14 studies overlapped with the papers reviewed in the quantitative measures section).

RESULTS

The quantitative measures used to measure ergonomic strain included electromyography, electrocardiography, gravimetric position sensors, skin conductance and inertial measurement units. Laparoscopic surgery caused less physical strain than open surgery, however more cognitive strain during the learning curve. Robotic surgery yielded conflicting data in terms of muscle activation when compared to laparoscopic surgery however reported less cognitive and cardiovascular strain. The qualitative measures of strain included a range of self-reported questionnaires, demonstrating important gender differences and scores that typically correlated with objective physical strain.

DISCUSSION

The studies show wide variation in measuring ergonomic strain. Avenues for further research include measuring the impact of learning curves, patient factors on ergonomic strain and the impact of gender.

Unpacking the Broad Landscape of Intraoperative Stressors for Clinical Personnel: A Mixed-Methods Systematic Review

Purpose

The main goals of this mixed-methods systematic review are to identify what types of intraoperative stressors for operating room personnel have been reported in collected studies and examine the characteristics of each intraoperative stressor.

Methods

With a systematic literature search, we retrieved empirical studies examining intraoperative stress published between 2010 and 2020. To synthesize findings, we applied two approaches. First, a textual narrative synthesis was employed to summarize key study information of the selected studies by focusing on surgical platforms and study participants. Second, a thematic synthesis was employed to identify and characterize intraoperative stressors and their subtypes.

Results

Ninety-four studies were included in the review. Regarding the surgical platforms, the selected studies mainly focused on minimally invasive surgery and few studies examined issues around robotic surgery. Most studies examined intra-operative stress from surgeons' perspectives but rarely considered other clinical personnel such as nurses and anesthetists. Among seven identified stressors, technical factors were the most frequently examined followed by individual, operating room environmental, interpersonal, temporal, patient, and organizational factors.

Conclusion

By presenting stressors as multifaceted elements affecting collaboration and interaction between multidisciplinary team members in the operating room, we discuss the potential interactions between stressors which should be further investigated to build a safe and efficient environment for operating room personnel.

A systematic review of biological changes in surgeons' acute stress levels during surgery

Background

While a degree of stress facilitates learning and task performance, excessive stress in surgeons may lead to poor patient outcomes, with maladaptive stress as a risk factor for surgeon burnout or self-harm through mechanisms including substance abuse, and suicide. We aim to systematically review publications investigating how measures of surgeons' acute biological stress change during surgery.

Methods

Medline, Embase, Cochrane library, and The United States, Australian, and European clinical trials registries were searched using the terms stress; surgeon; cortisol; skin conductance; and heart rate. Studies had to report at least one measure of biological stress related to surgery or simulated surgical exercise and have been published between January 1996 to June 2022.

Results

Twenty-eight studies with a total of 433 participants met inclusion criteria with cortisol, heart rate, heart rate variability, and electrodermal activity being reported. Salivary cortisol was measured in four studies with conflicting directional changes reported. Mean heart rate increased in nine studies (by 6-22 beats/minute), however the impact of the physical work of surgery was not reported. Heart rate variability, as measured by low-frequency to high-frequency ratio, was significantly increased in three of six studies. One study measured electrodermal activity reporting significant increase in skin conductance in a simulation setting.

Conclusion

While some biological measures appear able to detect changes in acute stress in surgeons (particularly heart rate), appropriate measures of stress during non-stressful and stressful surgery are yet to be fully identified. Importantly, there are no current pathways for identifying surgeons at risk of burnout or self-harm and this is a critical unmet research need.

Methods and Measures for Mental Stress Assessment in Surgery: A Systematic Review of 20 Years of Literature

Real-time mental stress monitoring from surgeons and surgical staff in operating rooms may reduce surgical injuries, improve performance and quality of medical care, and accelerate implementation of stress-management strategies. Motivated by the increase in usage of objective and subjective metrics for cognitive monitoring and by the gap in reviews of experimental design setups and data analytics, a systematic review of 71 studies on mental stress and workload measurement in surgical settings, published in 2001-2020, is presented. Almost 61% of selected papers used both objective and subjective measures, followed by 25% that only administered subjective tools - mostly consisting of validated instruments and customized surveys. An overall increase in the total number of publications on intraoperative stress assessment was observed from mid-2010 s along with a momentum in the use of both subjective and real-time objective measures. Cardiac activity, including heart-rate variability metrics, stress hormones, and eye-tracking metrics were the most frequently and electroencephalography (EEG) was the least frequently used objective measures. Around 40% of selected papers collected at least two objective measures, 41% used wearable devices, 23% performed synchronization and annotation, and 76% conducted baseline or multi-point data acquisition. Furthermore, 93% used a variety of statistical techniques, 14% applied regression models, and only one study released a public, anonymized dataset. This review of data modalities, experimental setups, and analysis techniques for intraoperative stress monitoring highlights the initiatives of surgical data science and motivates research on computational techniques for mental and surgical skills assessment and cognition-guided surgery.

Evaluating the physical, psychosocial and ergonomic burden of lead aprons among Jordanian interventionists: a nationwide study

Objectives. This study assessed the physical and psychological burden of lead apron use on Jordanian interventionists and investigated the attitudes and knowledge of interventional personnel toward ergonomic guidelines and practices. Methods. A cross-sectional investigation of a randomly sampled Jordanian cohort of interventional personnel was conducted using a self-administered questionnaire.

Results. A nationwide sample of 130 practitioners with a mean 9.3 ± 8.1 years of experience in interventional procedures participated. Practitioners were aware of their apron's weight but not of its lead equivalence (71.5%). More than 60% of respondents complained of back pain. While 66.9% did not develop musculoskeletal pathologies, 64.3% of those with already established musculoskeletal pathologies experienced worse pain due to apron usage. Despite believing in the effect of lead aprons on muscular strain and work performance, 78.5% adhere to its usage. In terms of ergonomics, only 39.2% were aware of ergonomic guidelines; however, 90.0% believe that ergonomic practices are essential as 49.2% have experienced discomfort due to bad ergonomics. In terms of psychological burden, anxiety and depression were suggested in 16.4 and 21.6% of the sample.

Conclusion. Jordanian interventionists portray positive attitudes toward lead aprons; nevertheless, their awareness of ergonomic practices warrants the implementation of evidenced-based interventions.

A Wearable Sensor-Based Platform for Surgeon Posture Monitoring: A Tool to Prevent Musculoskeletal Disorders

Surgeons are workers that are particularly prone to the development of musculoskeletal disorders. Recent advances in surgical interventions, such as laparoscopic procedures, have caused a worsening of the scenario, given the harmful static postures that have to be kept for long periods. In this paper, we present a sensor-based platform specifically aimed at monitoring the posture during actual surgical operations. The proposed system adopts a limited number of Inertial Measurement Units (IMUs) to obtain information about spine and neck angles across time. Such a system merges the reliability of sensor-based approaches and the validity of state-of-the-art scoring procedure, such as RULA. Specifically, three IMUs are used to estimate the flexion, lateral bending, and twisting angles of spine and neck. An ergonomic risk index is thus estimated in a time varying fashion borrowing relevant features from the RULA scoring system. The detailed functioning of the proposed systems is introduced, and the assessment results related to a real surgical procedure, consisting of a laparoscopy and mini-laparotomy sections, are shown and discussed. In the exemplary case study introduced, the surgeon kept a high score, indicating the need for an intervention on the working procedures, for a large time fraction. The system allows separately analyzing the contribution of spine and neck, also specifying the angle configuration. It is shown how the proposed approach can provide further information, as related to dynamical analysis, which could be used to enlarge the features taken into account by currently available approaches for ergonomic risk assessment. The proposed system could be adopted both for training purposes, as well as for alerting surgeons during actual surgical operations.

Heart rate variability as a measure of mental stress in surgery: a systematic review

PURPOSE

There is increasing interest in the use of heart rate variability (HRV) as an objective measurement of mental stress in the surgical setting. To identify areas of improvement, the aim of our study was to review current use of HRV measurements in the surgical setting, evaluate the different methods used for the analysis of HRV, and to assess whether HRV is being measured correctly.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). 17 studies regarding HRV as a measurement of mental stress in the surgical setting were included and analysed.

RESULTS

24% of the studies performed long-term measurements (24 h and longer) to assess the long-term effects of and recovery from mental stress. In 24% of the studies, artefact correction took place.

CONCLUSIONS

HRV showed to be a good objective assessment method of stress induced in the workplace environment: it was able to pinpoint stressors during operations, determine which operating techniques induced most stress for surgeons, and indicate differences in stress levels between performing and assisting surgery. For future research, this review recommends using singular guidelines to standardize research, and performing artefact correction. This will improve further evaluation of the long-term effects of mental stress and its recovery.

Low back pain prevalence and risk factors among health workers in Saudi Arabia: A systematic review and meta-analysis

OBJECTIVES

Low back pain (LBP) has a major impact on health workers, and its prevalence and risk factors among them in Saudi Arabia have been investigated previously. However, the results have never been comprehensively reviewed. Therefore, the aim of this study was to perform a systematic review and meta-analysis of the available literature to identify the prevalence and risk factors of LBP among health workers in Saudi Arabia.

METHODS

MEDLINE/PubMed, Web of Science, Scopus, CINAHL, and Saudi peer-reviewed journals were searched for relevant literature. After quality assessment of the eligible articles, 18 studies targeting seven occupational categories, with a total number of 5345 health workers, were analyzed.

RESULTS

Pooled prevalence rates of 40.8% (n = 7 studies), 65.0% (n = 13 studies), and 81.4% (n = 2 studies) were obtained for week, year, and career, respectively, across all professional groups. Nurses and physical therapists were more susceptible to LBP, in that order, than the other categories considering week and career periods. Age, body mass index, and female gender were the most commonly reported individual risk factors. Occupational risk factors mainly included work-related activities requiring back bending and twisting, lifting and pulling objects, and manual patient-handling.

CONCLUSIONS

The results of this review indicate that LBP is highly prevalent among health workers in Saudi Arabia when compared with international rates. Proper prophylactic measures are necessary to reduce LBP and minimize its consequences. Further high-quality research is needed in different Saudi regions to achieve a broader understanding of LBP prevalence and causes.

Case Difficulty, Postgraduate Year, and Resident Surgeon Stress: Effects on Operative Times

OBJECTIVE

We aimed to evaluate resident operative times in relation to postgraduate year (PGY), case difficulty and resident stress while performing a single surgical procedure.

DESIGN

We prospectively examined operative times for 268 laparoscopic cholecystectomies, and analyzed relationships between PGY, case difficulty, and resident surgeon stress utilizing electrodermal activity. Each case operative times were divided into 3 separate time periods. Case Start and End times were recorded, as well as the time between the start of the operation and the time until the cystic structures were divided (Division). Case difficulty was determined by multiple trained observers with a high inter-rater concordance.

SETTING

University of Missouri, a tertiary academic medical institution.

PARTICIPANTS

All categorical general surgery residents at our institution.

RESULTS

For each operative time period examined during laparoscopic cholecystectomy, operative time increased, with each incremental increase in difficulty resulting in approximately 130% longer times. Minimal differences in operative times were seen between PGY levels, except during the easiest cases (Start-End times: 38.5 ± 10.4 minutes vs 34.2 ± 10.8 minutes vs 28.9 ± 10.9 minutes, p 0.002). Resident stress poorly correlated with operative times regardless of case difficulty (Pearson coefficient range 0.0-0.22).

CONCLUSIONS

Operative times are longer with increasing case difficulty. PGY level and resident surgeon stress appear to have minimal to no correlation with operative times, regardless of case difficulty.

Surgeon symptoms, strain, and selections: Systematic review and meta-analysis of surgical ergonomics

Background

Many surgeons experience work-related pain and musculoskeletal symptoms; however, comprehensive reporting of surgeon ailments is lacking in the literature. We sought to evaluate surgeons' work-related symptoms, possible causes of these symptoms, and to report outcomes associated with those symptoms.

Materials and methods

Five major medical indices were queried for articles published between 1980 and 2014. Included articles evaluated musculoskeletal symptoms and ergonomic outcomes in surgeons. A meta-analysis using a fixed-effect model was used to report pooled results.

Results

Forty articles with 5152 surveyed surgeons were included. Sixty-eight percent of surgeons surveyed reported generalized pain. Site-specific pain included pain in the back (50%), neck (48%), and arm or shoulder (43%). Fatigue was reported by 71% of surgeons, numbness by 37%, and stiffness by 45%. Compared with surgeons performing open surgery, surgeons performing minimally invasive surgery (MIS) were significantly more likely to experience pain in the neck (OR 2.77 [95% CI 1.30–5.93]), arm or shoulder (OR 4.59 [2.19–9.61]), hands (OR 2.99 [1.33–6.71], and legs (OR 12.34 [5.43–28.06]) and experience higher odds of fatigue (8.09 [5.60–11.70]) and numbness (6.82 [1.75–26.65]). Operating exacerbated pain in 61% of surgeons, but only 29% sought treatment for their symptoms. We found no direct association between muscles strained and symptoms.

Conclusions

Most surgeons report work-related symptoms but are unlikely to seek medical attention. MIS surgeons are significantly more likely to experience musculoskeletal symptoms than surgeons performing open surgery. Symptoms experienced do not necessarily correlate with strain.

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68% of surveyed surgeons reported experiencing generalized pain from operating.

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Minimally-invasive surgeons were more likely to report pain, fatigue, and numbness.

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Only 29% of surgeons reported seeking treatment for symptoms.

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No association between objective strain on muscles and reported symptoms was found.

Two-Incision Laparoscopic Cholecystectomy: Reducing Scars in a Simple Way

BACKGROUND

About 20% of the population has cholelithiasis and this is the main abdominal cause of hospitalization in developed countries. Considering that only in the United States about 700,000 cholecystectomies are done each year, it is possible to estimate the importance of the problem for public health.

OBJECTIVE

To describe a two-incision laparoscopic cholecystectomy (TILC) technique using only conventional material, without increasing complications or operative time.

MATERIALS AND METHODS

A consecutive and prospective case series compared to another historical operated by conventional laparoscopic cholecystectomy (LC). The TILC was performed with three trocars in two incisions, two trocars in umbilical incision, and one in epigastrium.

RESULTS

A total of 72 patients were operated on by the same surgeon (36 in each group). There were no significant differences between groups for gender, mean age, body mass index, or length of hospital stay. The procedures were classified by the surgeon according to surgical difficulty and 58.3% (n = 42) were considered low grade, 9.7% (n = 7) difficult, and the other were intermediaries, with no difference between the series (P < .05). There were minor complications in 6.94% (n = 5) procedures. There were no differences between mean operative time (P = .989), which was 49 (95% confidence interval [CI] 42-56) minutes in LC and 40 (95% CI 35-44) min in TILC. There was no need for additional trocars in any case or for conversion to open surgery.

CONCLUSIONS

TILC is feasible, safe, and with good aesthetic result, using the same instruments of LC, without increasing operative time.

Surgeons' and surgical trainees' acute stress in real operations or simulation: A systematic review

BACKGROUND AND PURPOSE

Acute stress in surgery is ubiquitous and has an immediate impact on surgical performance and patient safety. Surgeons react with several coping strategies; however, they recognise the necessity of formal stress management training. Thus, stress assessment is a direct need. Surgical simulation is a validated standardised training milieu designed to replicate real-life situations. It replicates stress, prevents biases, and provides objective metrics. The complexity of stress mechanisms makes stress measurement difficult to quantify and interpret. This systematic review aims to identify studies that have used acute stress estimation measurements in surgeons or surgical trainees during real operations or surgical simulation, and to collectively present the rationale of these tools, with special emphasis in salivary markers.

METHODS

A search strategy was implemented to retrieve relevant articles from MEDLINE and SCOPUS databases. The 738 articles retrieved were reviewed for further evaluation according to the predetermined inclusion/exclusion criteria.

RESULTS

Thirty-three studies were included in this systematic review. The methods for acute stress assessment varied greatly among studies with the non-invasive techniques being the most commonly used. Subjective and objective tests for surgeons' acute stress assessment are being presented.

CONCLUSION

There is a broad spectrum of acute mental stress assessment tools in the surgical field and simulation and salivary biomarkers have recently gained popularity. There is a need to maintain a consistent methodology in future research, towards a deeper understanding of acute stress in the surgical field.

Correlative Evaluation of Mental and Physical Workload of Laparoscopic Surgeons Based on Surface Electromyography and Eye-tracking Signals

Surgeons’ mental and physical workloads are major focuses of operating room (OR) ergonomics, and studies on this topic have generally focused on either mental workload or physical workload, ignoring the interaction between them. Previous studies have shown that physically demanding work may affect mental performance and may be accompanied by impaired mental processing and decreased performance. In this study, 14 participants were recruited to perform laparoscopic cholecystectomy (LC) procedures in a virtual simulator. Surface electromyography (sEMG) signals of the bilateral trapezius, bicipital, brachioradialis and flexor carpi ulnaris (FCU) muscles and eye-tracking signals were acquired during the experiment. The results showed that the least square means of muscle activity during the LC phases of surgery in an all-participants mixed effects model were 0.79, 0.81, and 0.98, respectively. The observed muscle activities in the different phases exhibited some similarity, while marked differences were found between the forearm bilateral muscles. Regarding mental workload, significant differences were observed in pupil dilation between the three phases of laparoscopic surgery. The mental and physical workloads of laparoscopic surgeons do not appear to be generally correlated, although a few significant negative correlations were found. This result further indicates that mental fatigue does markedly interfere with surgeons’ operating movements.

Do No Harm, Except to Ourselves? A Survey of Symptoms and Injuries in Oncologic Surgeons and Pilot Study of an Intraoperative Ergonomic Intervention

BACKGROUND

Occupational symptoms and injuries incurred over a surgical career are under- reported, yet they have an impact on daily surgical practice. We assessed the frequency, consequences, and risk factors for occupational injury in oncologic surgeons and evaluated the feasibility of intraoperative foot mat use to mitigate occupational symptoms.

STUDY DESIGN

Oncologic surgeons completed a survey of demographic information and occupational symptoms and injuries. Multivariate logistic regression was used to identify factors associated with occupational symptoms and injuries. A randomized cross-over pilot study of intraoperative foot mat use was conducted.

RESULTS

One hundred twenty-seven surgeons completed surveys (response rate: 58%). The most commonly reported symptoms were fatigue, discomfort, stiffness, and back pain. An occupational injury was reported by 27.6% of surgeons. Of those injured, 65.7% received treatment, with 17.4% of those treated requiring surgery for their injury. In multivariate analysis, factors significantly associated with occupational injury were male sex (odds ratio [OR] 3.00, 95% CI 1.08 to 8.38), mean case length of 4 hours or more (OR 2.72, 95% CI 1.08 to 6.87), using a step to operate (OR 3.06, 95% CI 1.02 to 9.15), and neck pain (OR 4.81, 95% CI 1.64 to 14.12). In the foot mat pilot study (n = 20), mat use was associated with discomfort (OR 7.57, 95% CI 1.19 to 48.00), but no significant differences in leg volume change due to mat use were found.

CONCLUSIONS

Most oncologic surgeons experience musculoskeletal symptoms from operating. Of the 28% of surgeons with an occupational injury, most required treatment. Intraoperative foot mat use was associated with increased discomfort.

[Intraoperative stress in orthopaedic spine surgery : Attending surgeon versus resident]

INTRODUCTION

Requirements for orthopaedic spine surgeons include occupational skills, concentration, physical fitness and psychological stress resistance, depending on the attending surgeon's or the resident's position.

MATERIAL AND METHODS

This study measured and evaluated stress-relevant cardiovascular parameters during 101 spinal surgical procedures of a 40-year old fellowship-trained spine surgeon with 12 years of practice. A training computer, personal scales and a thermometer were used to record the duration of surgery, heart rate, weight loss and calorie burning.

RESULTS

The average maximum heart rate as an attending surgeon (124 bpm) was significantly higher than the resident's heart rate (99 bmp). A higher stress level resulted in an increasingly higher average maximum heart rate according to the duration of surgery. The mean loss of body fluids at an average room temperature of 20.4 C after surgery was 0.82 kg (0 to 2.3 kg). The mean loss of body weight was calculated as 1.12% of the attending surgeon versus 0.59% of the resident.

DISCUSSION

Increasing complexity, longer duration and a higher potential of intraoperative complications arouse a strong response from the attending surgeon. The observed cardiovascular parameters are similar to those of a moderate to intense workout such as cycling. Long lasting surgeries result in a weight loss equivalent to a mild dehydration ranging from 2 to 5% of body fluids. Increasing dehydration will eventually worsen cognitive, visual and motor skills. Results of this study suggest early rehydration and utilization of mental relaxation techniques to minimize risks during prolonged, complex spine surgeries.

Laparoscopic Transversus Abdominis Release, a Novel Minimally Invasive Approach to Complex Abdominal Wall Reconstruction

BACKGROUND

Open abdominal wall reconstruction is used to repair complex abdominal wall hernias with contour abnormalities. We present a novel minimally invasive approach to address these types of defects, completed entirely laparoscopically.

METHODS

Three patients underwent laparoscopic abdominal wall reconstruction for complex hernias in August and September of 2015. Operative approach consisted of laparoscopic transversus abdominis components separation, defect closure, and wide mesh implantation in the retromuscular space.

RESULTS

Two males and one female with mean age and body mass index of 70 and 30.1, respectively, underwent a mean operation room time of 329 minutes. Estimated blood loss and length of stay were 91.7 cc and 4.7 days, respectively. No subcutaneous flaps were raised avoiding the need for subcutaneous drains. There were no perioperative complications. All of the subfascial drains were removed prior to patient discharge. On initial follow-up visit at 3 weeks, there was no evidence of wound complications, bulging, or hernia recurrences.

CONCLUSION

Laparoscopic abdominal wall reconstruction with transversus abdominis release is a unique and feasible approach to complex abdominal wall defects with the potential to reduce pain, facilitate recovery, and decrease length of hospital stay for patients.

Development and experimental evaluation of an alarm concept for an integrated surgical workstation

Alarm conditions of the technical equipment in operating rooms represent a prevalent cause for interruptions of surgeons and scrub nurses, resulting in an increase of workload and potential reduction of patient safety. In this work, an alarm concept for an integrated operating room system based on open communication standards is developed and tested.

In a laboratory experiment, the reactions of surgeons were analysed, comparing the displaying of alarms on an integrated workstation and on single devices: disruptive effects of alarm handling on primary task (ratings of perceived distraction, resumption lag, deterioration of speed, accuracy, and prospective memory), efficiency and effectiveness of identification of alarms, as well as perceived workload were included.

The identification of the alarm cause is significantly more efficient and effective with the integrated alarm concept. Moreover, a slightly lower deterioration of performance of the primary task due to the interruption of alarm handling was observed.

Displaying alarms on an integrated workstation supports alarm handling and consequently reduces disruptive effects on the primary task. The findings show that even small changes can reduce workload in a complex work environment like the operating room, resulting in improved patient safety.

Initial experience of robotic versus laparoscopic colectomy for transverse colon cancer: a matched case-control study

Background

Robotic surgery for transverse colon cancer has rarely been described. This study reports our initial experience in robotic resection for transverse colon cancer, by comparing robotic transverse colectomy (RC) to laparoscopic transverse colectomy (LC) in terms of safety, feasibility, short-term outcomes, and the surgeon’s psychological stress and physical pain.

Methods

The study population included the first 22 consecutive patients who underwent RC between March 2013 and December 2014 for histologically confirmed transverse colon adenocarcinoma. These patients were compared with 22 matched patients undergoing LC between December 2010 and February 2013. Patients were matched based on age, gender, body mass index (BMI), American Society of Anesthesiology (ASA) score, American Joint Committee on Cancer (AJCC) tumor stage, and tumor location (ratio 1:1). Mortality, morbidity, operative, and short-term oncologic outcomes were compared between groups. The operating surgeon’s stress and pain were assessed before and after surgery on a 0–100-mm visual analog scale.

Results

The demographic and preoperative characteristics were comparable between RC and LC patients. No group difference was observed for intraoperative complications, blood loss, postoperative pain, time to flatus, time to regular diet, and hospital stay. RC was associated with longer operative time than LC (260 min vs. 225 min; p = 0.014), but the overall operative and robotic time in the RC group decreased over time reflecting the increasing experience in performing this procedure. No conversion to laparotomy was observed in the RC group, while two LC patients were converted due to uncontrolled bleeding and technically difficult middle colic pedicle dissection. Postoperative complications (Dindo-Clavien grade I or II) occurred in 11.3 % of patients with no group difference. Mortality was nil. All resections were R0, with >12 lymph nodes harvested in 90.9 % of RC and 95.5 % of LC patients. The surgeon’s stress was not different between RC and LC, whereas the surgeon’s hand and neck/shoulder pain were significantly lower after RC.

Conclusions

RC for transverse colon cancer appears to be safe and feasible with short-term outcomes comparable to LC.

Decreased heart rate variability in surgeons during night shifts

BACKGROUND

Heart rate variability (HRV) has been used as a measure of stress and mental strain in surgeons. Low HRV has been associated with death and increased risk of cardiac events in the general population. The aim of this study was to clarify the effect of a 17-hour night shift on surgeons' HRV.

METHODS

Surgeons were monitored prospectively with an ambulatory electrocardiography device for 48 consecutive hours, beginning on a precall day and continuing through an on-call (17-h shift) day. We measured HRV by frequency domain parameters.

RESULTS

We included 29 surgeons in our analysis. The median pulse rate was decreased precall (median 64, interquartile range [IQR] 56-70 beats per minute [bpm]) compared with on call (median 81, IQR 70-91 bpm, p < 0.001). Increased high-frequency (HF) activity was found precall (median 199, IQR 75-365 ms2) compared with on call (median 99, IQR 48-177 ms2, p < 0.001). The low-frequency:high-frequency (LF:HF) ratio was lower precall (median 2.7, IQR 1.9-3.9) than on call (median 4.9, IQR 3.7-6.5, p < 0.001). We found no correlation between the LF:HF ratio and performance in laparoscopic simulation.

CONCLUSION

Surgeons working night shifts had a significant decrease in HRV and a significant increase in pulse rate, representing sympathetic dominance in the autonomic nervous system.

TRIAL REGISTRATION

NCT01623674 (www.clinicaltrials.gov).

Psychophysical workload in the operating room: primary surgeon versus assistant

BACKGROUND

Working in the operating room is characterized by high demands and overall workload of the surgical team. Surgeons often report that they feel more stressed when operating as a primary surgeon than in the function as an assistant which has been confirmed in recent studies. In this study, intra-individual workload was assessed in both intraoperative functions using a multidimensional approach that combined objective and subjective measures in a realistic work setting.

METHODS

Surgeons' intraoperative psychophysiologic workload was assessed through a mobile health system. 25 surgeons agreed to take part in the 24-hour monitoring by giving their written informed consent. The mobile health system contained a sensor electronic module integrated in a chest belt and measuring physiological parameters such as heart rate (HR), breathing rate (BR), and skin temperature. Subjective workload was assessed pre- and postoperatively using an electronic version of the NASA-TLX on a smartphone. The smartphone served as a communication unit and transferred objective and subjective measures to a communication server where data were stored and analyzed.

RESULTS

Working as a primary surgeon did not result in higher workload. Neither NASA-TLX ratings nor physiological workload indicators were related to intraoperative function. In contrast, length of surgeries had a significant impact on intraoperative physical demands (p < 0.05; η(2) = 0.283), temporal demands (p < 0.05; η(2) = 0.260), effort (p < 0.05; η(2) = 0.287), and NASA-TLX sum score (p < 0.01; η(2) = 0.287).

CONCLUSIONS

Intra-individual workload differences do not relate to intraoperative role of surgeons when length of surgery is considered as covariate. An intelligent operating management that considers the length of surgeries by implementing short breaks could contribute to the optimization of intraoperative workload and the preservation of surgeons' health, respectively. The value of mobile health systems for continuous psychophysiologic workload assessment was shown.

Relax, it's just laparoscopy! A prospective randomized trial on heart rate variability of the surgeon in robot-assisted versus conventional laparoscopic cholecystectomy

BACKGROUND

Laparoscopic surgery might be beneficial for the patient, but it imposes increased physical and mental strain on the surgeon. Robot-assisted laparoscopic surgery addresses some of the laparoscopic drawbacks and may potentially reduce mental strain. This could reduce the risk of surgeon's fatigue, mishaps and strain-induced illnesses, which may eventually improve the safety of laparoscopic surgical procedures.

METHODS

To test this hypothesis, a randomized study was performed, comparing both heart rate and heart rate variability (HRV) of the surgeon as a measure of total and mental strain, respectively, during conventional and robot-assisted laparoscopic cholecystectomy.

RESULTS

Both heart rate and HRV (the low-frequency band/high-frequency band ratio) were significantly decreased when using robotic assistance.

CONCLUSIONS

These data suggest the use of the daVinci® Surgical System leads to less physical and mental strain of the surgeon during surgery. However, assessing mental strain by means of HRV is cumbersome since there is no clear cutoff point or scale for maximum tolerated strain levels and its related effects on surgeon's health.

Operating room of the future

Development of surgical care in the 21st century is increasingly dependent on demonstrating safety, efficacy and cost effectiveness. Over the past 2 decades, the potential role of simulation in surgery has been explored with encouraging results; this can now be linked to direct improvement in the quality of care provision. Computer-assisted surgical platforms, such as robotic surgery, offer us the versatility to embrace a host of technical and technological developments. Rapid development in nanomedicine will expand the limits of operative performance through improved navigation and surgical precision. Integration of the multiple functions of the future operating room will be essential in optimising resource management. The key to bringing about the necessary paradigm shift in the design and delivery of modern surgical care is to appreciate that we now function in an information age, where the integrity of processes is driven by apt data management.

Real-time observations of stressful events in the operating room

Aim:

To identify and quantify factors causing stress in the operating room (OR) and evaluate the relationship between these factors and surgeons’ stress level.

Methods:

This is a prospective observational study from 32 elective surgical procedures conducted in the OR of King Khalid University Hospital, Riyadh, Saudi Arabia. Before each operation, each surgeon was asked of stressors. Two interns observed 16 surgeries each, separately. The interns watched and took notes during the entire surgical procedure. During each operation, the observer recorded anxiety-inducing activities and events that occurred in real time by means of a checklist of 8 potential stressors: technical, patient problems, teamwork problems, time and management issues, distractions and interruptions, equipment problems, personal problems, and teaching. After each operation, surgeons were asked to answer the validated State-Trait Anxiety Inventory questionnaire and self-report on their stress level from the 8 sources using a scale of 1–8 (1: stress free, 8: extremely stressful). The observer also recorded perceived stress levels experienced by the surgeons during the operation.

Results:

One hundred ten stressors were identified. Technical problems most frequently caused stress (16.4%) and personal issues the least often (6.4%). Frequently encountered stressors (teaching and distractions/interruptions) caused less stress to the surgeons. Technical factors, teamwork, and equipment problems occurred frequently and were also a major contributor to OR stress. All patients were discharged in good health and within 1 week of surgery.

Conclusion:

Certain stressful factors do occur among surgeons in the OR and can increase the potential for errors. Further research is required to determine the impact of stress on performance and the outcome of surgery.

Psychological and physical stress among experienced and inexperienced surgeons during laparoscopic cholecystectomy

PURPOSE

Surgical procedures are mentally and physically demanding, and stress during surgery may compromise patient safety. We investigated the impact of surgical experience on surgeons' stress levels and how perioperative sleep quality may influence surgical performance.

METHODS

Eight experienced and 8 inexperienced surgeons each performed 1 laparoscopic cholecystectomy. Questionnaires measuring perioperative mental and physical strain using validated visual analog scale and Borg scales were completed. Preoperative and postoperative sleep quality of the surgeon was registered and correlated to perioperative strain parameters.

RESULTS

Preoperative to postoperative frustration among experienced surgeons was significantly reduced and this was not found in the inexperienced surgeons (visual analog scale: preoperative 13 (2-65) mm, postoperative 4 (0-51) mm vs. preoperative 5(0-10) mm, postoperative 5(1-46) mm; P=0.04). Physical strain was significantly induced in both groups in the upper extremities. Preoperative and postoperative sleep quality was significantly correlated to postoperative mental strain parameters.

CONCLUSIONS

Perioperative frustration levels were different among inexperienced and experienced surgeons. Perioperative sleep quality may influence postoperative mental strain and should be considered in studies examining surgeons' stress.