Ergonomics of minimally invasive surgery: an analysis of muscle effort and fatigue in the operating room between laparoscopic and robotic surgery



Our aim was to determine how objectively-measured and self-reported muscle effort and fatigue of the upper-limb differ between surgeons performing laparoscopic (LAP) and robotic-assisted (ROBOT) surgeries.


Surgeons performing LAP or ROBOT procedures at a single-institution were enrolled. Objective muscle activation and self-reported fatigue were evaluated, and comparisons were made between approaches. Muscle activation of the upper trapezius (UT), anterior deltoid (AD), flexor carpi radialis (FCR), and extensor digitorum (ED) were recorded during the surgical procedure using Trigno wireless surface electromyography (EMG). The maximal voluntary contraction (MVC) was obtained to normalize root-mean-square muscle activation as %MVCRMS. The median frequency (MDF) was calculated to assess muscle fatigue. Each surgeon also completed the validated Piper Fatigue Scale-12 (PFH-12) before and after the procedure for self-perceived fatigue assessment. Statistical analysis was done using SAS/STAT software, with α = 0.05.


28 surgeries were recorded (LAP: N = 18, ROBOT: N = 10). EMG analysis revealed the ROBOT group had a higher muscle activation than LAP for UT (37.7 vs. 25.5, p = 0.003), AD (8.9 vs. 6.3, p = 0.027), and FCR (14.4 vs. 10.9, p = 0.019). Conversely, LAP required more effort for the ED, represented by a significantly lower MDF compared to the ROBOT group (91.2 ± 1.5 Hz vs. 102.8 ± 1.5 Hz, p < 0.001). Survey analysis revealed no differences in self-reported fatigue before and after the surgery between approaches, p = 0.869.


Our analysis revealed surgeons show similar fatigue levels performing the first case of the day using either robotic or LAP surgery. Surgeons performing LAP surgery had more fatigue in the forearm, robotic surgery required more shoulder and neck use, but neither was superior. Neither technique produced significant overall fatigue on survey. Long-term selective use of these different muscles could be correlated with different patterns of injury. Future studies are needed to fully understand long-term implications of prolonged surgery on occupational injury.

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Funding for this study was provided by the SAGES Robotic Surgery Research Grant and Center for Advanced Surgical Technology at the University of Nebraska Medical Center.

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Correspondence to Dmitry Oleynikov.

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Dmitry Oleynikov is the shareholder of Virtual Incision Corporation. Priscila Rodrigues Armijo, Chun-Kai Huang, Robin High, Melissa Leon and Ka-Chun Siu have no conflicts of interest or financial ties to disclose.

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Armijo, P.R., Huang, CK., High, R. et al. Ergonomics of minimally invasive surgery: an analysis of muscle effort and fatigue in the operating room between laparoscopic and robotic surgery. Surg Endosc 33, 2323–2331 (2019).

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  • Ergonomics
  • Robotic surgery
  • Electromyography
  • Minimally invasive surgery