Minimal access surgery (MAS)-related surgeon morbidity syndromes



The benefits of minimal access surgery (MAS) in terms of accelerated recovery, reduced period of short-term disability, and patient outcome account for the widespread use of the laparoscopic approach by the majority of general surgeons. In adopting this approach with its current limitations and poor ergonomics, surgeons have been known to sustain surgery-related injuries encompassed by a spectrum best described as MAS-related surgeon morbidity syndromes, some of which are currently overlooked and poorly researched. Equivalent morbidities including the overuse syndrome (from overuse of certain muscle groups during long operations) have been documented in open surgery but are nowadays rare occurrences. As more advanced MAS operations are performed with long execution times, new patterns of neuromusculoskeletal injuries are being recognized. The surgical fatigue syndrome has also been described, though its complex nature is not fully understood. Virtually little is known on other long-term adverse effects on the surgeon following many years of operating from images displayed on a television monitor or LCD screen, and these include deterioration of visual acuity and function of the ocular muscles responsible for fixation–refixation of the eyeballs. The limited reported literature on the MAS-related surgeon morbidity syndromes identifies certain risk factors for these injuries pertaining to central and peripheral domains. Only improved knowledge of the etiology and underlying ergonomic factors based on investigative studies followed by improved instrumentation and operating room (OR) ergonomics will provide near- and long-term solutions.

Key words

MAS-related surgeon morbidity syndromes Overuse and fatigue syndromes Neuromuscular and hand injuries Visual acuity problems, prevention 


  1. 1.
    Ankrum DR (1996) Viewing distance at computer workstations. Workplace Ergon 2: 10–13Google Scholar
  2. 2.
    Ballantyne GH (2002) Robotic surgery, telerobotic surgery, telepresence, and telementoring. Surg Endosc 16: 1389–1402PubMedCrossRefGoogle Scholar
  3. 3.
    Berguer R, Forkey DL, Smith WD (1999) Ergonomic problems associated with laparoscopic surgery. Surg Endosc 13: 466–468PubMedCrossRefGoogle Scholar
  4. 4.
    Berguer R, Gerber S, Kilpatrick G, Beckley D (1998) An ergonomic comparison of in-line vs. pistol-grip handle configuration in a laparoscopic grasper. Surg Endosc 12: 805–808PubMedCrossRefGoogle Scholar
  5. 5.
    Berguer R, Gerber S, Kilpatrick G, Remler M, Beckley D (1999) A comparison of forearm and thumb muscle electromyographic responses to the use of laparoscopic instruments with either a finger grasp or a palm grasp. Ergonomics 42(12): 1634–1645PubMedCrossRefGoogle Scholar
  6. 6.
    Berguer R, Hrelijac A. (2004) The relationship between hand size and difficulty using surgical instruments: a survey of 726 laparoscopic surgeons. Surg Endosc. 18: 508–512PubMedCrossRefGoogle Scholar
  7. 7.
    Berguer R, Smith WD, Chung YH (2001) Performing laparoscopic surgery is significantly more stressful for the surgeon than open surgery. Surg Endosc 15: 1204–1207PubMedCrossRefGoogle Scholar
  8. 8.
    Berguer R (1998) Surgical technology and the ergonomics of laparoscopic instruments. Surg Endosc 12: 458–462PubMedCrossRefGoogle Scholar
  9. 9.
    Blackwell J, Kornatz K, Heath E (1999) Effect of grip span on the maximal grip force and fatigue of flexor digitorum superficialis. Appl Ergon 30: 401–405PubMedCrossRefGoogle Scholar
  10. 10.
    Buess GF, Schurr MO, Fischer SC (2000) Robotics and allied technologies in endoscopic surgery. Ann Surg 135: 229–235Google Scholar
  11. 11.
    Crothers IR, Gallager AG, McClure N, James DTD, McGuigan J (1999) Experienced laparoscopic surgeons are automated to the fulcrum effect: an ergonomic demonstration. Endoscopy 31(5): 365–369PubMedCrossRefGoogle Scholar
  12. 12.
    Cuschieri A (1995) Whither minimal access surgery: tribulations and expectations. Am J Surg 1: 9–19Google Scholar
  13. 13.
    Dennison AR, Britton BJ (1984) Penetrating anorectal injury. Dis Colon Rectum 27: 64Google Scholar
  14. 14.
    Emam TA, Frank TG, Hanna GB, Cuschieri A (2001) Influence of handle design on the surgeon’s upper limb movements, muscle recruitment, and fatigue during endoscopic suturing. Surg Endosc 15: 667–672PubMedCrossRefGoogle Scholar
  15. 15.
    Emam TA, Hanna GB, Kimber C, Dunkley P, Cuschieri A, (2000) Effect of intracorporeal-extracorporeal instrument length ratio on endoscopic task performance and surgeon movements. Arch Surg 135: 62–65PubMedCrossRefGoogle Scholar
  16. 16.
    Fuller G, Manford M (2000) Common peripheral nerve lesions (chapter 5), In: Fuller G, Manford M (eds), Neurology: an illustrated colour text. Churchill Livingstone, London, pp 106–107Google Scholar
  17. 17.
    Gagner M, Begin E, Hurteau R, Pomp A (1994) Robotic interactive laparoscopic cholecystectomy (letter). Lancet 343: 596–597PubMedCrossRefGoogle Scholar
  18. 18.
    Gallagher AG, McClure N, McGuigan, Ritchie K, Sheehy NP (1998) An ergonomic analysis of the fulcrum effect in the acquisition of endoscopic skills. Endoscopy 30(7): 617–620PubMedCrossRefGoogle Scholar
  19. 19.
    Gibson WC (1979) Bethune’s China. Forty years on. JAMA 242(19): 2091–2092PubMedCrossRefGoogle Scholar
  20. 20.
    Gordon DJ, Wilkinson P (1991) Prolonged use of a surgical retractor causing neuropathy in an assistant. J R Coll Surg Edinb 36: 132PubMedGoogle Scholar
  21. 21.
    Grandjean E, Hunting W, Piderman (1983) VDT workstation design: preferred settings and their effects. Human Factors 25: 161–175PubMedGoogle Scholar
  22. 22.
    Standring S (editor in chief) (2005) Grays anatomy: the anatomical basis of clinical practice, 39th ed. Elsevier Churchill Livingstone, EdinburghGoogle Scholar
  23. 23.
    Hanly EJ, Talamini MA (2004) Robotic abdominal surgery. Am J Surg 188: 19S–26SPubMedCrossRefGoogle Scholar
  24. 24.
    Hanna GB, Shimi SM, Cuschieri A (1997) Optimal port locations for endoscopic intracorporeal knotting. Surg Endosc 11: 397–401PubMedCrossRefGoogle Scholar
  25. 25.
    Hanna GB, Shimi SM, Cuschieri A (1998) Task performance in endoscopic surgery is influenced by location of the image display. Ann Surg 227(4): 481–484PubMedCrossRefGoogle Scholar
  26. 26.
    Hedge A, Sims WR, Becker FD (1995) Effects of lens-indirect and parabolic lighting on the satisfaction, visual health, and productivity of office workers. Ergonomics 38: 260–280PubMedGoogle Scholar
  27. 27.
    Hill SG, Kroemer KHE (1986) Preferred declination of the line of sight. Human Factors 28: 27–134Google Scholar
  28. 28.
    Hopkins A (1993) Common neurological syndromes (chapter 6), In: A. Hopkins (ed), Clinical neurology: a modern approach. Oxford Medical Publication, OxfordGoogle Scholar
  29. 29.
    Horgan LF, O’riordan DC, Doctor N (1997) Neuropraxia following laparoscopic procedures: an occupational injury. Min Invas Ther Allied Technol 6: 33–35CrossRefGoogle Scholar
  30. 30.
    Jaschinski-Kruza W (1988) Visual strain during VDU work: the effect of viewing distance and dark focus. Ergonomics 31: 1449–1465PubMedGoogle Scholar
  31. 31.
    Jaschinski-Kruza W (1990) On the preferred viewing distances to screen and document at VDU workplaces. Ergonomics 33: 1055–1063Google Scholar
  32. 32.
    Jaschinski-Kruza W (1991) Eyestrain in VDU users: viewing distance and the resting position of ocular muscles. Human Factors 33: 69–83PubMedGoogle Scholar
  33. 33.
    Kano N, Yamakawa T, Ishikawa Y, Miyagima N, Ohtaki S, Kasugai H (1995) Prevention of laparoscopic surgeon’s thumb. Surg Endosc 9: 738–739PubMedGoogle Scholar
  34. 34.
    Kano N, Yamakawa T, Kasugai H, (1993) Laproscopic surgeon’s thumb. Arch Surg 128: 1172PubMedGoogle Scholar
  35. 35.
    Kennedy A, Baccino T (1995) The effects of screen refresh rate on editing operations using a computer mouse pointing device. Q J Exp Psychol 48A(1): 55–71Google Scholar
  36. 36.
    Kennedy A, Murray WS (1996) Eye movement control during the inspection of words under conditions of pulsating illumination. Eur J Cogn Psychol 8(4): 381–403Google Scholar
  37. 37.
    Lawther RE, Kirk GR, Regan MC (2002) Laparoscopic procedures are associated with a significant risk of digital nerve injury for general surgeons. Ann R Coll Surg Engl 84: 443–444PubMedGoogle Scholar
  38. 38.
    Lee WJ, Chae YS (2001) Superficial nerve damage of thumb of laparoscopic surgeon. Surg Laparosc Endosc Percutan Tech 11(3): 207–208PubMedCrossRefGoogle Scholar
  39. 39.
    Li R, Jenssen J, Hill J, Bowersox JC (2000) Quantitative evaluation of surgical task performance by remote-access endoscopic telemanipulation. Surg Endosc (2000) 14: 431–435CrossRefGoogle Scholar
  40. 40.
    Majeed AW, Jacob G, Reed MWR, Johnson AG (1993) Laparoscopist’s thumb: an occupational hazard. Arch Surg 128: 357PubMedGoogle Scholar
  41. 41.
    Hanly EJ, Talamini MA (2004) Robotic abdominal surgery. Am J Surg (sppl) 19S–26SGoogle Scholar
  42. 42.
    Owens DA, Wolf-Kelly K (1987) Near work, visual fatigue, and variations of occulomotor tones. Invest Opthalmol Visual Sci 28: 743–749Google Scholar
  43. 43.
    Owens DA (1984) The resting state of the eyes. Am Scientist 72: 378–387Google Scholar
  44. 44.
    Parr J (1976) An introduction to ophthalmology. University of Utago Press, Dunedin, New Zealand, pp 62–64, 97–99Google Scholar
  45. 45.
    Patkin M, Isabel L (1995) Ergonomics, engineering and surgery of endosurgical dissection. J R Coll Surg Edinb 40: 120–132PubMedGoogle Scholar
  46. 46.
    Pearse MF (1991) Surgeon and their injuries. Injury 22(3): 253–255PubMedCrossRefGoogle Scholar
  47. 47.
    Quick NE, Gilette JC, Shapiro, Adrales GL, Gerlach D, Park AE (2003) The effect of using laparoscopic instruments on muscle activation patterns during minimally invasive training procedures. Surg Endosc 17: 462–465PubMedCrossRefGoogle Scholar
  48. 48.
    Ripple P (1952) Variation of accomodation in vertical directions of gaze. Am J Ophthalmol 35: 1630–1634PubMedGoogle Scholar
  49. 49.
    Sackier JM, Berci G (1992) A laparoscopic hazard for the surgeon. Br J Surg 79(7): 713PubMedGoogle Scholar
  50. 50.
    Scurr MO, Buess G, Neisius B, Voges U (2000) Robotics and telemanipulation technologies for endoscopic surgery. A review of the ARTEMIS project. Advanced Robotic Telemanipulator for Minimally Invasive Surgery. Surg Endosc 14: 375–381CrossRefGoogle Scholar
  51. 51.
    Tyrell R, Leibowitz H (1990) The relation of vergence effort to reports of visual fatigue following prolonged near work. Human Factors 32: 341–357Google Scholar
  52. 52.
    Uhrich ML, Underwood RA, Standeven JW, Soper NJ, Engsberg JR (2002) Assessment of fatigue, monitor placement, and surgical experience during simulated laparoscopic surgery. Surg Endosc 16: 635–639PubMedCrossRefGoogle Scholar
  53. 53.
    Van der Zee DC, Bax NMA (1995) Digital nerve compression due to laparoscopic surgery. Surg Endosc 9: 740PubMedGoogle Scholar
  54. 54.
    Veltman JA, Gaillard AW (1998) Physiological workload reactions to increasing levels of task difficulty. Ergonomics 41: 656–669PubMedCrossRefGoogle Scholar
  55. 55.
    Vereczkei A, Bubb H, Feussner H (2003) Laparoscopic surgery and ergonomics. Surg Endosc 17: 1680–1682CrossRefGoogle Scholar
  56. 56.
    Verma GR (2004) Pressure sore and digital neuropraxia of the thumb in laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech 14(3): 178–179PubMedCrossRefGoogle Scholar
  57. 57.
    Walt AJ (1983) The world’s best-known surgeon. Surgery 97(4): 582–590Google Scholar
  58. 58.
    Wilkinson IMS (1999) Nerve root, nerve plexus and peripheral nerve lesions (chapter 9), In: Essential neurology, 3rd ed. Wilkinson IMS (ed), Blackwell Science, LondonGoogle Scholar
  59. 59.
    Williams B (1974) Some surgeons and their hand injuries. Practitioner 213: 717–719PubMedGoogle Scholar
  60. 60.
    Wolf JS, Marcovich R, Gill IS, Sung GT, Kavoussi LR, Clayman RV, Mcdougall EM, Shalhav A, Dunn MD, Afane JS, Moore RG, Parra RO, Winfield HN, Sosa RE, Chen RN, Moran ME, Nakada SY, Hamilton BD, Albala DM, Koleski F, Das S, Adams JB, Polascik TJ (2000). Survey of neuromuscular injuries to the patient and surgeon during urologic laparoscopic surgery. Urology 55(6): 831–836PubMedCrossRefGoogle Scholar
  61. 61.
    Wyssoki WM, Moesta KT, Schlag PM (2003) Surgery, surgical education and surgical procedures in the digital era. Med Sci Monit 9(3): RA69–RA75Google Scholar
  62. 62.
    Zuidema GD, Sloan H (2001) Alfred Blalokck, Norman Bethune, and the Bethune murals. Surgery 130(5): 866–881PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, Inc. 2005

Authors and Affiliations

  1. 1.Cuschieri Skills Centre, Ninewells Hospital and Medical SchoolUniversity of DundeeDundee
  2. 2.Scuola SuperioreS’Anna di Studi UniversitariPisaItaly

Personalised recommendations