Surgical Endoscopy

, Volume 25, Issue 7, pp 2168–2174

Laparoscopic cholecystectomy poses physical injury risk to surgeons: analysis of hand technique and standing position

  • Yassar Youssef
  • Gyusung Lee
  • Carlos Godinez
  • Erica Sutton
  • Rosemary V. Klein
  • Ivan M. George
  • F. Jacob Seagull
  • Adrian Park



This study compares surgical techniques and surgeon’s standing position during laparoscopic cholecystectomy (LC), investigating each with respect to surgeons’ learning, performance, and ergonomics. Little homogeneity exists in LC performance and training. Variations in standing position (side-standing technique vs. between-standing technique) and hand technique (one-handed vs. two-handed) exist.


Thirty-two LC procedures performed on a virtual reality simulator were video-recorded and analyzed. Each subject performed four different procedures: one-handed/side-standing, one-handed/between-standing, two-handed/side-standing, and two-handed/between-standing. Physical ergonomics were evaluated using Rapid Upper Limb Assessment (RULA). Mental workload assessment was acquired with the National Aeronautics and Space Administration-Task Load Index (NASA-TLX). Virtual reality (VR) simulator-generated performance evaluation and a subjective survey were analyzed.


RULA scores were consistently lower (indicating better ergonomics) for the between-standing technique and higher (indicating worse ergonomics) for the side-standing technique, regardless of whether one- or two-handed. Anatomical scores overall showed side-standing to have a detrimental effect on the upper arms and trunk. The NASA-TLX showed significant association between the side-standing position and high physical demand, effort, and frustration (p < 0.05). The two-handed technique in the side-standing position required more effort than the one-handed (p < 0.05). No difference in operative time or complication rate was demonstrated among the four procedures. The two-handed/between-standing method was chosen as the best procedure to teach and standardize.


Laparoscopic cholecystectomy poses a risk of physical injury to the surgeon. As LC is currently commonly performed in the United States, the left side-standing position may lead to increased physical demand and effort, resulting in ergonomically unsound conditions for the surgeon. Though further investigations should be conducted, adopting the between-standing position deserves serious consideration as it may be the best short-term ergonomic alternative.


Laparoscopic cholecystectomy Training Endoscopy Surgical standing position Technique Ergonomics RULA 


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Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Yassar Youssef
    • 1
  • Gyusung Lee
    • 1
  • Carlos Godinez
    • 1
  • Erica Sutton
    • 1
  • Rosemary V. Klein
    • 1
  • Ivan M. George
    • 1
  • F. Jacob Seagull
    • 1
  • Adrian Park
    • 1
  1. 1.Division of General SurgeryUniversity of Maryland Medical CenterBaltimoreUSA

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