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Physical and psychological impact of surgery on the operating surgeon
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  1. Anumithra Amirthanayagam1,
  2. Seth O'Neill1,
  3. Charles Goss2 and
  4. Esther L Moss1,3,4
  1. 1 College of Life Sciences, University of Leicester, Leicester, UK
  2. 2 Department of Occupational Health, University Hospitals of Leicester NHS Trust, Leicester, UK
  3. 3 Department of Gynaecological Oncology, University of Leicester, Leicester, UK
  4. 4 Gynaecological Oncology, University Hospitals of Leicester NHS Trust, Leicester, UK
  1. Correspondence to Dr Esther L Moss, College of Life Sciences, University of Leicester, Leicester, LE1 7RH, UK; em321{at}le.ac.uk

Abstract

The impact of surgery on the surgeon’s well-being encompasses both physical and psychological aspects. Physically, surgeons are at risk of work-related musculoskeletal symptoms due to the nature of their work, and this risk can be impacted by theater environment, equipment design, and workload. Many symptoms will be self-limiting, but work related musculoskeletal symptoms can lead to the development of an injury, which can have far reaching effects, including the need for medical or surgical treatment, time away from work, or a change in clinical duties. Additionally, surgery can place a significant cognitive workload on the lead operator and this can be exacerbated, or alleviated, by the surgical environment, experience of the assistance, surgical modality, and case complexity. Measuring and quantifying the impact of surgery on the surgeon is a challenging undertaking. Tools such as motion capture, physiological markers, including heart rate variability and salivary cortisol, and questionnaires can provide insights into understanding the overall impact of surgery on the surgeon. A holistic approach that incorporates injury prevention strategies, communication, and support, is vital in assessing and mitigating risk factors. Injury prevention assessment tools and interventions that can be used within the busy surgical environment are needed, alongside increased ergonomic awareness. Addressing the impact of surgery on the surgeon is a multifaceted challenge, and long term positive changes can only be sustained with the support of the whole surgical team and healthcare organizations by developing and maintaining a supportive working environment.

  • Surgery

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Introduction

Gynecological oncologists undertake complex and radical surgery on an often high risk, highly comorbid patient population, which can be both physically and psychologically demanding. Surgeons are not machines, and performing surgery can impact the operating surgeon in many different ways, including potentially contributing to the high burnout rates reported in doctors within the obstetrics and gynecology specialty.1 In aiming to understand these impacts, it is important to recognize that surgeons do not work in isolation but can be influenced by numerous intrinsic and extrinsic factors within their work and social environments. Any or all of these factors could have an impact on their physical and psychological well-being and, as a consequence their surgical performance.2

The most widely recognized physical impact on the operating surgeon is the development of work-related musculoskeletal symptoms. This can be related to numerous factors associated with the practical aspect of performing surgery, and reportedly is increasing in prevalence due to the wide scale uptake of minimally invasive surgery over the past two decades. Psychological impacts of performing surgery are more difficult to define since the term often refers to the mental or emotional state of a person. However, within the surgical setting, this term typically includes cognitive workload, which is defined as involving conscious intellectual activity, such as thinking, reasoning, or remembering.3 4 The introduction of new technology or surgical procedures, coupled with dynamic changes within the theater environment, including changing between surgical modalities during the course of an operating session, can increase cognitive workload,5 6 and can be exacerbated by factors such as team communication and theater environment. It has been shown that ‘cognitive failure’ and ‘frustration’, along with ‘subjective workload in areas of performance’, should be considered as determinant variables in predicting patient safety/outcomes.7 The Safer Surgery Checklist created by Dr Atul Gawande8 9 (inspired by the Boeing checklist from the 1930s) is a prime example of creating a standardized environment with a view to increasing patient safety by reducing human error and avoiding cognitive overload through precise communication and strict adherence to protocols. Introduction of the checklist has been associated with a significant reduction in deaths within the first 30 days of surgery and perioperative complications, and has been shown to have an impact in many countries and healthcare environments.9

Additionally, there is a need for greater awareness of the exacerbating and mitigating factors that can impact on surgeons’ health in order for high risk behaviors to be modified, thereby reducing the likelihood of long term negative sequelae and injuries. This will also support the development of targeted interventions to support and optimize operating surgeons’ performance while protecting their physical and psychological health, and importantly the potential impact on patient outcomes and the effect of pain on motor control and skill acquisition.10

Physical Impact

The prevalence of work-related musculoskeletal symptoms reported by surgeons is very high, with more than 80% of respondents in many studies.11 The high prevalence of work-related musculoskeletal symptoms raises the possibility of recruitment bias with subjective survey studies, with surgeons experiencing symptoms being more likely to reply, especially because only a proportion (<30%) have reportedly acted on symptoms and sought treatment.12 Another explanation could be symptom self-management, particularly with surgeons for whom taking time away from performing surgery would be disruptive for the clinical service or their careers. What can be concluded from the currently available data is that work-related musculoskeletal symptoms are not isolated to a few individuals, but can impact a high proportion of the surgical workforce at different times during their careers.

Performing surgery appears to be an exacerbating factor for work-related musculoskeletal symptoms as a result of physical requirements placed on the operating surgeon, and is comparable with industrial workers.13 Many symptoms will be self-limiting, but work-related musculoskeletal symptoms can lead to the development of an injury which can have far reaching effects. For the individual, this may result in medical or surgical interventions, pain management, a change in clinical duties, or ultimately a reduction in career longevity and potential loss of earnings. In terms of the surgical workforce, it means loss of expertise for an extended period of time, thereby adding to the workload of other team members. However, the impact on patients also needs to be considered, because almost a third of surgeons (30%) reported taking their own work-related musculoskeletal symptoms into consideration when advising on surgical modality.11 Such decisions could have significant implications for patients, particularly if the open route is preferred to minimally invasive surgery, given the higher associated rates of postoperative morbidity and longer recovery,14 but also for other members of the surgical team, healthcare environment, and economy.15

Work-Related Musculoskeletal Symptoms

Numerous variables, including surgeon, patient, and infrastructural factors can increase the risk or exacerbate work-related musculoskeletal symptoms, and awareness of these could help surgeons identify their personal risk and take mitigating steps.

Surgeon Anthropometry

Surgeons do not come in a standard size and the impact of anthropometry, the study of the human body and physical ability16 17 on surgeon kinematics, in only now beginning to be realized. Work-related musculoskeletal symptoms typically result from excessive strain on particular muscle groups or joints, due to repetition of movements or non-neutral positioning. The most commonly reported sites of work-related musculoskeletal symptoms are the upper and lower back, neck, and shoulders,16 18 and have been linked to surgeon height, sex, and surgical modality. In particular, surgeon height is inversely associated with upper limb work-related musculoskeletal symptoms,19 20 with arm span and elbow height also appearing to have an association. Female surgeons are also reported to be at greater risk, most likely due to their typically smaller physical builds.20–22

Surgical Modality

Open surgery has been superseded in many situations by minimally invasive surgery due to improved patient outcomes, including lower rates of intraoperative complications and shorter recovery periods. Open surgery is still the preferred route for some indications, most notably cytoreductive surgical cases, which can be many hours in duration. The reported patterns of work-related musculoskeletal symptoms appear to differ by surgical modality, with minimally invasive surgery being particularly cited as a greater risk factor compared with open surgery (Figure 1). A meta-analysis by Stucky et al, reported that leg pain, stiffness, and numbness had an odds ratio of >25 for minimally invasive surgery compared with open surgery, and that the neck, back, and shoulder are common sites of symptoms.11 Other injuries, such as lumbar spine conditions (19%), injury to the rotator cuff (18%), degenerative cervical (17%), and carpal tunnel syndrome (9%) are also reported.23

Figure 1

Distribution of surgeons’ subjective reported physical impact of surgery on the surgeon by surgical modality. The images represent data from the meta-analysis by Stucky et al.11

The rise in the prevalence of work-related musculoskeletal symptoms has coincided with the increase in conventional laparoscopic surgical procedures, and many surgeons attribute their work-related musculoskeletal symptoms or injuries to performing laparoscopic surgery. The validation of miniaturized wearable motion sensor systems has enabled surgeon ergonomics and kinematics to be measured, including in the live surgical setting.24 This has given new insights into economy of motion, but also movement control, through calculation of parameters such as jerk (measure of motor control),25 angular speed (measure of change of orientation of object with time), and cumulative displacement (total change in body segments from original position).26 Holding non-neutral postures for prolonged periods of time can lead to musculoskeletal injuries. Consideration should be given to laparoscopic surgery port placement, particularly in patients with a high body mass index, because this can result in the need to hold high risk postures (eg, rapid entire body assessment scores are significantly higher for contralateral compared with ipsilateral port placement).16

Robotic-assisted surgery has been proposed as a more favorable alternative to laparoscopic surgery with regard to the potential of work-related musculoskeletal symptoms,27 28 but it is not without ergonomic issues, reported to be associated with the console design.29 The most widely used platform (DaVinci) has a fixed posture console and has been designed for an operator height of 155–200 cm,30 and this may explain why the most common work-related musculoskeletal symptoms associated with robotic-assisted surgery are related to the operator’s neck and wrists.31 Another factor that needs to be considered is the type of chair used by the operator while sitting at the console.32 New and emerging robotic platforms have tried to build on operating surgeons’ experience and feedback, and alter the design of consoles, incorporating more open structures, but only time will tell whether particular work-related musculoskeletal symptoms are associated with these designs.

Theater Environment

An evaluation of ergonomics in surgery recognized that instrument design and theater setup, including the operating table and vision monitors, and the length and handles of instruments, are often cited as reasons for the higher rates of work-related musculoskeletal symptoms seen in laparoscopic surgery.33 Operating table height is recognized as a common exacerbating factor for work-related musculoskeletal symptoms due to equipment limitations and the need for compromise within the surgical team. The table height should be 20–30% lower than elbow height to maintain neutral postures while performing a surgical procedure,34 but when calculating this height, the patient’s abdominal depth, which may be increased with insufflation, also needs to be considered. The availability of operating tables that have the capability to achieve low level settings is limited in many hospitals,34 and consequentially, the average table height (720 mm) and patient abdominal depth (285–430 mm) means that many surgeons will not be able to work in an optimal ergonomic setup.16 35

It is important not to focus only on the lead operating surgeon when considering theater set up and dynamics, but instead to take a holistic view to include all of the surgical staff. It is likely that the lead surgeon and surgical assistants will have different anthropometric measurements, and large differences in heights in particular can be challenging to reconcile when it comes to operating table height. This can result in one person, often the trainee, either standing on a step or bending over the table, and adopting non-optimal ergonomic positions, thereby potentially increasing their work-related musculoskeletal symptoms risk.

Standard Size Equipment

The ability to adapt theater environments to suit the operating surgeon is often limited, or not possible, due to a pre-existing set-up or equipment designed with a one-size-fits-all approach.36 Hand size and the issue of standard surgical instruments, typically designed for male surgeons, is now attracting interest by surgical specialties and manufacturers, partly due to the rising number of females operating surgeons within the surgical workforce. Surgeons with a glove size of <7 reportedly have a lower grip strength than those with a glove size >7 (231 vs 397 Newtons (N)), and women have a lower baseline grip strength compared with their male counterparts (288 vs 451 N).37 As a result, glove size and ergonomic workload appear to be inversely correlated with lower grip strength, resulting in greater workload (p<0.01).37 Stress impact on grip can result in episodes of neuropraxia, fatigue, and pressure issues,38 and female surgeons, due to their typically smaller hand/glove size, are at increased risk of injury.39 Minimally invasive surgery instruments have been reported as being more difficult to use by surgeons with smaller hands. For example, a reduction in grip strength with the LigaSure (p=0.02) and HALO PKS devices (p<0.01)37 and, in particular, index finger length, has the greatest impact on pressure (p<0.001) and fatigue (p<0.001).36 These findings are not surprising given the instrument mechanics and the need to use the activation buttons or rotate the device repeatedly during a surgical procedure. Collaboration between operating surgeons and engineers could help address the identified issues with anthropometry and surgical instrument design.40

Patient Factors

Increasing duration and complexity of surgical procedures is associated with greater operating surgeon workload and, as a result, an increased theoretical risk of work-related musculoskeletal symptoms. The exacerbating factor reported to have the greatest impact on surgeon work-related musculoskeletal symptoms appears to be patient body mass index, and the combination of a high volume workload and a high body mass index patient population increases the risk of injury exponentially.20 The rapid uptake of minimally invasive surgery is predominantly influenced by improved patient outcomes.41 It has been established that performing laparoscopic surgical procedures on high body mass index patient models has a significant impact on surgeons’ movements and muscle workload, specifically jerkiness and angular speed of the movements.26 This can lead to worsening of upper body positioning and non-neutral postures, as determined by the LUBA ergonomic framework, even in experienced surgeons.25

Patient body mass index is frequently cited as an exacerbating factor for work-related musculoskeletal symptoms, and gynecological oncologists are likely to be particularly affected due to the etiological association between obesity and endometrial cancer, and minimally invasive surgery being the preferred surgical route. Surgeon experience has been shown to impact kinematics, possibly due to learned adaptation and behavioral change. The difference between experienced and novice surgeons is particularly marked at lower levels of simulated obesity,26 and raises the need to train future surgeons for technical performance but also to protect against injuries, in a similar manner to elite athlete training.

Injury Prevention

Prevention is always better than a cure, and resolving work-related musculoskeletal symptoms is often challenging. Currently, there are no evidenced based approaches that have been shown to prevent work-related musculoskeletal symptoms in surgeons, but regimens using strengthening exercises, ergonomic training, and behavior change are reported to have benefits for both prevention and rehabilitation of work-related musculoskeletal symptoms in other settings.42–44 Using expertise and evidence from sporting domains, it is highly likely that developing a greater understanding of the biomechanical stresses (forces applied to tissue) and strains (tissue deformation) experienced by surgeons during surgery could lead to interventions designed to either reduce these stresses and strains,45 46 or increase the robustness of underlying tissue.47 Interventions that succeed in improving load tolerance and/or reducing load are likely to reduce the burden of work-related musculoskeletal symptoms.48

Primary prevention should involve strengthening exercises targeting the neck, upper limbs, and lower back, and be completed regularly enough to achieve adaptation and therefore improved load tolerance. The mechanism for improved tolerance is through mechanotransduction and tissue adaptation.49 In addition, individualized ergonomic assessment and advice, specifically focusing on problem areas and an individual’s biomechanics, would achieve a reduction in positions and postures associated with high stress/strain on specific body parts. The combination of increased load tolerance and a reduction in load allows individuals to work within the safe zone, thereby reducing injury risk.50

The approach used for primary prevention has also been shown to be suitable for rehabilitation from work-related musculoskeletal symptoms.42 51 Success is related to individualized rehabilitation from experts, tailoring the dosage of interventions to their patients, and understanding of the physical demands of surgery.52 Potential adaptions in practice could also include warm-up exercises before surgery, microbreaks, postural change (sitting-to-standing), and ergonomic training programs.31 53 However, validated tools to measure the efficacy of such interventions, alongside measures of tissue stress/strain (eg, motion capture and kinematics), also need to be explored and validated.53

Psychological Impact

A relationship between performance and stimulation was described many years ago, known as Yerkes–Dodson law.54 In keeping with this law, there is an association between surgical performance and surgeon response to simulation or stress, with a certain level of simulation resulting in a eustress response: greater concentration, technical functioning, and consequentially better patient outcomes.55 Too much stimulation, however, can have the opposite effect, leading to a distress response, negatively impacting technical performance through an impact on physical, emotional, behavioral, and cognitive responses2 (Figure 2).

Objectively measuring surgeon stress is challenging, partly because responses vary between individuals, with many surgeons internalizing responses, but also the situation being measured has to be realistic in order to elicit a genuine response. Simulation training is useful in preparing clinicians for complex and emergency events, but knowing that it is an artificial situation will not create the same dynamic or response as a real world event. Stress is a multifactorial and multidimensional concept that is impacted by environment. For example, the theater environment is reported to be associated with greater levels of stress compared with clinic or ward settings.56 As with the physical impact of surgery on the operating surgeon, contributing factors can include surgeon experience, modality, setting, and patient aspects, but measuring and quantifying the psychological or stress impact is challenging.

Figure 2

Relationship between cognitive workload and response of the cardiac afferent autonomic system to stress, based on Yerkes–Dodson law 54 and the Eustress curve.55 LF/HF, low frequency/high frequency; RMSSD, root mean square of successive differences.

Measuring Physical Markers of ‘Stress’

Because stress is impacted by numerous intrinsic and extrinsic physical and psychological factors, measuring stress in the live surgical setting can be apt but also difficult, because the focus always has to remain on the patient, with measurement tools as unobtrusive as possible. Numerous tests, including skin conductance, thermal activity, salivary cortisol, α-amylase, secretory immunoglobulin A, and chromogranin A, have been investigated as potential biomarkers of stress. However, measures that have been trialed most frequently in the live surgical setting are heart rate and heart rate variability based tests, salivary cortisol, and the state–trait anxiety inventory (STAI).57

Heart Rate

Heart rate is regulated by the autonomic nervous system and is predominantly influenced by the physical workload of larger muscle compartments,58 59 as well as extrinsic factors such as environmental temperature.58 60 Heart rate has been shown to detect an acute stress response in the surgical setting and can differentiate between high and low case complexity.61 62 Heart rate is a highly sensitive marker of stress and is relatively easy to record during live surgery.

Heart Rate Variability

Heart rate variability measures the net effect on the cardiac afferent autonomic system, which includes the impact of psychological workload.60 Derivatives of heart rate variability that give additional information are: the root mean square of successive differences between normal heart beats, a marker of the activation of the parasympathetic system,63–65 and frequency domain methods (low frequency, high frequency), with the low frequency/high frequency ratio66 being a reflection of the net effect on the autonomic nervous system (Figure 3). Heart rate variability has been used to identify the varying levels of stress experienced by an operating surgeon while performing surgery and/or supervising trainees at different time points in an index procedure.67 It has also been used in studies evaluating the impact of cognitive workload between open and laparoscopic surgery, in which a link between laparoscopic surgery and increased cognitive strain was reported.68

Figure 3

Two key heart rate variability measures that have been used in studies as a measure of cognitive workload: root mean square of successive differences (RMSSD) and low frequency/high frequency ratio (LF/HF).76 90

Salivary Cortisol

Cortisol is a result of the activation of the hypothalamus–pituitary–adrenal axis, and levels rise within 5 min of the stress stimulus, reaching a peak level after 30–40 min. Salivary cortisol concentrations mirror plasma concentrations,69 and as a result have been used as a method for monitoring stress in several studies.70 71 Within the hypothalamus–pituitary–adrenal axis, each component (hippocampus, hypothalamus, pituitary, and adrenal glands) has its own set of receptors, proteins, and mechanisms of action that can influence salivary cortisol levels.71 Thus it is not feasible to completely mitigate the confounding bias, and therefore a clear correlation between salivary samples and acute stress levels can prove difficult to establish.71

State–Trait Anxiety Inventory

Trials of the state–trait anxiety inventory in numerous and various contexts have demonstrated that it can capture both the state of anxiety and degree of trait to develop anxiety.72 The state–trait anxiety inventory allows overall impact to be measured and accounts for the positive influence of training and coping mechanisms on increasing the stress threshold. A shortened six item version has been validated, facilitating data capture in the surgical environment, and has been shown to measure relative changes in mental state over relatively short periods of time.73–75

Stress Measurement ‘Tools’

Although physiological measures can give a measure of stress, it is important that they are not used in isolation because any results need to be interpreted individually and within the context of a given situation. It is therefore advisable to combine objective measures with a subjective measure, collecting information on the operating surgeon’s perception of a situation.60 For example, combining heart rate variability and the state–trait anxiety inventory has been shown to differentiate high and low stress surgical procedures, with a correlation between perceived and objective stress (r=0.766).76

Researchers have explored taking this work further by combining multiple measures to create stress measurement tools. One of the most widely tested to date is the Imperial Stress Assessment Tool (ISAT) which uses salivary cortisol, heart rate, and the state–trait anxiety inventory to record intraoperative stress levels.75 However, adding factors together is complex and does not necessarily increase sensitivity, as seen with the Imperial Stress Assessment Tool, where heart rate and salivary cortisol alone had higher sensitivity levels (91% and 70%, respectively). Analysis of the construct validity of these markers showed 70% concordance between subjective (state–trait anxiety inventory) and objective measures, together and individually (80% for cortisol and 84% for heart rate).75

The NASA Task Load Index (NASA TLX)77 is used in human factors research and has recently been applied to surgical workload in surgeons with the development of the Surgery Task Load Index (SURG TLX).78 SURG-TLX aims to subjectively evaluate the ‘mental, physical, and temporal demands’ as well as ‘task complexity, situational stress, and distractions’ as six different domains.78 Providing an assessment of the overall impact of surgery on the operating surgeon is challenging, but this tool considers the mechanisms by which different sources of stress can impact on the surgeon.

The ISSUE (impact of minimally invasive surgery on surgeon health) study intends to build on previously reported work incorporating physical measures (heart rate and heart rate variability) with psychological (state–trait anxiety inventory) and surgeon kinematics.79 Including a measure that can quantify the range of movements required to perform a procedure is challenging in the live surgical setting and requires unobtrusive measuring equipment and expert analytical pipelines. The aim of ISSUE is to develop and validate the S-impact score, which can be used to assess the impact on the operating surgeon of performing surgical cases of different complexity and modality (open, laparoscopic, and robotic-assisted).

Communication

Other factors that need to be considered are team dynamics. These are particularly important with robotic-assisted surgery due to the theater layout and the relative isolation of the console surgeon from the bedside assistants. The concept of surgeon–team separation describes the communication hurdles that influence situational awareness and decision making,80 and highlights the need for non-verbal/verbal communication within teams. Such factors need to be taken into account when considering the operating surgeon’s cognitive workload and the need to lead the theater team while maintaining a high technical performance. Analysis of teamwork and efficiency using the anticipation of steps as the marker of choice showed anticipation and active engagement led to reduced operative times, and greater team familiarity resulted in lower rates of inconveniences.81 Improved training, retention of experienced staff, and team consistency/familiarity could be used to reduce communication issues.80

Stress in Context

Qualitative research, using interviews or focus groups, has been used in studies to uncover associations and motivations that may not be apparent from other data collection tools, such as questionnaires. Wetzel’s study from 2006 interviewed 10 consultants and six trainee surgeons to explore stressful stimuli and potential mitigating factors.2 It identified key themes of early recognition of risks, stop and stand back, control of self, and control of the situation. The collective learning that can come from capturing lived experiences is immense, but requires surgeons to be willing to discuss challenges and potential sources of stress.

Recognizing when either ourselves or co-workers are moving along the stress curve from eustress to distress is important because operating surgeons have a higher rate of burnout compared with the general population.82 The need to support surgeons who are experiencing or at risk of burnout is now being discussed more openly and will hopefully lead to the acceptance of support networks, as well as interventions to reduce the risks and associated consequences.83 Again, this requires individuals to be open to discussing challenges and experiences, which many may be reluctant to do because this may be perceived as exposing weaknesses.

Seeking Help

Doctors may face barriers or be reluctant to access healthcare for work-related musculoskeletal symptoms or other conditions related to their work. Kay et al described numerous factors, including embarrassment, worries about confidentiality, cost, time pressures, desire to self-manage, and more.84 Additionally, surgeons may have concerns about the impact of any sick leave on their patients, earnings, medical licensing, and career ambitions, and may not wish to be perceived as those who challenge embedded processes and cultures. However, if symptoms develop, surgeons should be assessed by a medical practitioner who is familiar with general occupational health principles (ie, who is aware of the importance of the biopsychosocial approach and the demands of the work undertaken) as well as musculoskeletal conditions.85–87 Determining the correct medical diagnosis is important to guide management, along with the reassurance provided by exclusion of any serious or specific pathology. The treatment of symptoms necessitates a holistic approach through the engagement of occupational health professionals, musculoskeletal specialists, rehabilitation and physical therapy experts.87

Apart from supporting the health of the individual worker, occupational health and safety professionals can also engage with their employer and visit the workplace to assess and advise on adjustments to working practices, processes, and rehabilitation in work. The UK Health and Safety Executive recommends that employers take a proactive position to detect any emerging trends of musculoskeletal symptoms in workers. In the US, the National Institute for Occupational Safety and Health Musculoskeletal Health Program aims to reduce the burden of work-related musculoskeletal symptoms through a focused program of research and prevention that protects workers from work-related musculoskeletal symptoms, as well as help management mitigate related risks and liabilities, and practitioners to improve the efficacy of workplace interventions.88 Specific legislation will vary by country,89 and there is the need to prospectively collect data on the number of surgeons who are experiencing work-related musculoskeletal symptoms in order to determine the magnitude of the issue and ensure availability of support.

Moving Forward

It is clear from the evidence that has been generated to date that more work is needed to identify modifiable factors that can reduce the risks to surgeons’ health, and as a result improve patients’ surgical outcomes. Work is also needed to review the design of essential equipment, such as handheld devices, because a one-size-fits-all approach is impacting a large number of surgeons, particularly those with smaller hand/glove sizes. Employers should aim to provide an environment that enables surgeons to maintain physical and psychological health. Working with institution representatives to improve the ergonomics and theater workflows, as well as having a no blame culture and supporting staff who are experiencing challenges, will also encourage a positive working environment. Research is also needed to support the surgeon in looking after their own health, including physical training programs to strengthen at risk muscle groups and to protect against injury, and ergonomics training programs for surgeons in training, to teach good practice early on in their surgical careers.

Future proofing the surgical workforce against injuries, physical or psychological, is of vital importance and without such developments not only will surgeons suffer the consequences but patient outcomes will also be impacted, due to the potential for greater surgical complications. A culture that promotes the safety and well-being of all surgical personnel, that encourages open communication about ergonomic issues, and identifies potential areas of improvements will ultimately significantly improve both patient and surgeon outcomes.

Ethics statements

Patient consent for publication

Ethics approval

Not applicable.

Acknowledgments

We thank Louise Fairgrieve for her support in creating the figures for this article.

References

Footnotes

  • Twitter @DrEstherMoss1

  • Contributors All authors contributed to the first draft of the manuscript. All authors reviewed and approved the final version.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors. The research was carried out at the National Institute for Health and Care Research (NIHR) Leicester Biomedical Research Centre (BRC).

  • Competing interests ELM has received research grants from Intuitive Surgical to undertake the ISSUE study, and grants for unrelated research from the British Gynaecological Cancer Society and Hope Against Cancer. AA has been funded by Intuitive Surgical to undertake the ISSUE study.

  • Provenance and peer review Commissioned; internally peer reviewed.