World Journal of Surgery

, 35:1961

First online:

Open Access This content is freely available online to anyone, anywhere at any time.

Development and Validation of a Surgical Workload Measure: The Surgery Task Load Index (SURG-TLX)

  • Mark R. WilsonAffiliated withInstitute of Human Performance, University of Hong KongSchool of Sport and Health Sciences, University of Exeter Email author 
  • , Jamie M. PooltonAffiliated withInstitute of Human Performance, University of Hong KongDepartment of Surgery, University of Hong Kong
  • , Neha MalhotraAffiliated withInstitute of Human Performance, University of Hong Kong
  • , Karen NgoAffiliated withInstitute of Human Performance, University of Hong Kong
  • , Elizabeth BrightAffiliated withDepartment of Urology, Royal Devon and Exeter Hospital, Royal Devon and Exeter NHS Foundation Trust
  • , Rich S. W. MastersAffiliated withInstitute of Human Performance, University of Hong Kong



The purpose of the present study was to develop and validate a multidimensional, surgery-specific workload measure (the SURG-TLX), and to determine its utility in providing diagnostic information about the impact of various sources of stress on the perceived demands of trained surgical operators. As a wide range of stressors have been identified for surgeons in the operating room, the current approach of considering stress as a unidimensional construct may not only limit the degree to which underlying mechanisms may be understood but also the degree to which training interventions may be successfully matched to particular sources of stress.


The dimensions of the SURG-TLX were based on two current multidimensional workload measures and developed via focus group discussion. The six dimensions were defined as mental demands, physical demands, temporal demands, task complexity, situational stress, and distractions. Thirty novices were trained on the Fundamentals of Laparoscopic Surgery (FLS) peg transfer task and then completed the task under various conditions designed to manipulate the degree and source of stress experienced: task novelty, physical fatigue, time pressure, evaluation apprehension, multitasking, and distraction.


The results were supportive of the discriminant sensitivity of the SURG-TLX to different sources of stress. The sub-factors loaded on the relevant stressors as hypothesized, although the evaluation pressure manipulation was not strong enough to cause a significant rise in situational stress.


The present study provides support for the validity of the SURG-TLX instrument and also highlights the importance of considering how different stressors may load surgeons. Implications for categorizing the difficulty of certain procedures, the implementation of new technology in the operating room (man–machine interface issues), and the targeting of stress training strategies to the sources of demand are discussed. Modifications to the scale to enhance clinical utility are also suggested.