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Surgical Ergonomics

Work-related musculoskeletal symptoms are common among surgeons, although prevalence varies by specialty, procedure, and how symptoms are measured. Urology combines open, laparoscopic, robotic, microscopic, and endoscopic work, each with different ergonomic demands.[1][18] Surgical ergonomics is the fit between the surgeon's posture, the operating-room setup and the instruments. Setup and work practices are modifiable contributors to work-related musculoskeletal disorders (WMSDs), and long reconstructive cases add sustained load.

See also: Incisions & Closure, Robotic Platforms.

Scope of the Problem​

Prevalence among surgeons​

In a systematic review and meta-analysis of surgeons and interventionalists, reported career prevalence of specific diagnoses was approximately 17% for cervical spine degeneration, approximately 18% for rotator-cuff pathology, approximately 19% for lumbar spine degeneration, and approximately 9% for carpal tunnel syndrome.[6] Neck, back, and shoulders are commonly affected sites across specialties.[4][5]

In that review, 12% of respondents with a work-related musculoskeletal disorder reported work leave, restriction, modification, or retirement; denominators and definitions differed among contributing studies.[6] In one included survey of 103 injured surgeons, 19% reported their injury to the institution.[6] Limited formal ergonomics training has also been reported.[4] These findings identify reporting and education gaps without establishing a uniform risk for every surgeon.

Prevalence among urologists​

In a survey of 285 responding urologists, 245 (86%) reported a musculoskeletal complaint in the preceding 12 months; 177 (62% of all respondents) considered their complaints work-related.[7] Endourology (OR 3.06; 95% CI 1.37–6.80) and laparoscopy (OR 1.70; 95% CI 1.27–2.28) were associated with chronic complaints in this survey.[7] In a 2025 ergonomics education pilot, 38 participants completed a baseline survey; 55% reported physical pain in the operating room and 42% reported pain during an endoscopic case in the preceding month.[16] One-third of surveyed urologists described their ergonomics knowledge as minimal and 8% as nonexistent.[7]

Risk factors and disparities​

The core risk factors are static non-neutral posture, repetitive motion, prolonged procedural duration, suboptimal table and monitor height, and poor instrument design.[1] Female surgeons report higher rates of occupational injury and discomfort with instrument use, and instrument and console geometry designed around male hand size and stature is a proposed contributor.[2] Trainees report higher pain levels than attendings, which has been linked to workload and the absence of ergonomic teaching.[1]

Core Ergonomic Principles​

The central concept is neutral positioning: keeping the spine, shoulders, elbows, and wrists within a biomechanical window that minimizes static muscle loading and joint stress.[2][3][8]

RegionTarget neutral position
NeckMinimal flexion/extension; avoid rotation and lateral bending
ShouldersRelaxed, minimal abduction (ideally <30°)
Elbows90–120° of flexion
WristsNeutral (avoid sustained ulnar/radial deviation)
BackUpright, lumbar lordosis preserved
FeetFlat, weight distributed; step stool as needed

Operating-room setup checklist

  • Table height. For open surgery, at or slightly below the surgeon's elbow; for laparoscopy, low enough that elbows can sit at 90–120° with relaxed shoulders
  • Monitor placement. Approximately 80–120 cm from the laparoscopic surgeon, slightly below eye level, and aligned with the operative field to limit neck rotation.[18]
  • Foot pedals. Directly in front of the surgeon to avoid hip rotation and asymmetric loading
  • Instruments and trays. Within easy arm reach (<60 cm) to avoid repeated trunk flexion and shoulder reaching
  • Loupes and headlights. Fitted with enough declination angle that the neck does not need to flex more than ~15° to see the field
  • Anti-fatigue mats and step stools. Accommodate height differences across the surgical team and reduce lower-extremity strain
  • Lighting. Sufficient overhead illumination so that the surgeon does not unconsciously lean in

Modality-Specific Considerations​

Open surgery​

Open cases combine prolonged standing, static posture, manual retraction, and forceful movements. The highest-load positions are sustained neck flexion (loupes, deep pelvis), shoulder abduction (retraction), and static lumbar extension (long standing cases).[9] For the reconstructive urologist, deep-pelvic work (posterior urethroplasty, VVF and RUF repair, complex fistula reconstruction, radical perineal reconstruction) is the dominant ergonomic stressor.

Laparoscopic surgery​

Laparoscopy imposes monitor-driven neck posture, sustained arm elevation, and static grip force on some instrument handles. Surveys have reported musculoskeletal symptoms in roughly 70–90% of regularly operating laparoscopic surgeons, but design and response biases limit generalization.[10][11] Prolonged reconstructive cases such as laparoscopic pyeloplasty, ureteral reimplantation, and sacrocolpopexy warrant particular attention to fixed posture.

Robotic-assisted surgery​

Depending on the platform, a closed robotic console can support seated operation with forearm and head support; open consoles offer different viewing and posture options.[28] In a paired cross-sectional study of 12 experienced surgeons performing hysterectomy, median neck-muscle activity was 7.4% versus 5.3% of maximal EMG activity during laparoscopic versus robotic surgery (p<0.05); lower-back activity was higher with robotic surgery.[10] A multicenter gynecologic trial found lower perceived physical workload with robotic surgery; it did not measure EMG or later injury.[12] A 2026 urology-specific review of 22 studies also found lower physical task demand with robotic surgery, while neck and back symptoms and prolonged non-neutral positions persisted.[28] In a survey, neuromusculoskeletal disorders were reported by 1 of 14 predominantly robotic surgeons (approximately 7%) versus approximately 60–67% in other modality groups.[14]

Static neck posture at the console, prolonged low-back isometric loading, and eye strain are under-recognized.[11][13] The bedside assistant inherits many of the laparoscopic ergonomic liabilities (static standing, awkward reach between arms, suboptimal monitor placement) and is often forgotten in console-centric ergonomic discussions.

Endoscopic work​

Cystoscopy, ureteroscopy, and percutaneous endoscopic work (as performed in reconstructive practice for fistula inspection, graft or flap surveillance, neo-urethral evaluation) generate distinctive ergonomic stress: sustained asymmetric stance, wrist deviation on rigid and flexible scopes, and, during fluoroscopic cases, the cumulative musculoskeletal load of lead aprons. Endourology had the largest modality-specific association with chronic musculoskeletal complaints in one urologist survey.[7]

Microsurgery​

Microsurgical work (vasoepididymostomy, microsurgical testicular sperm extraction, microsurgical subinguinal varicocelectomy, microvascular free-flap work for phalloplasty or complex perineal reconstruction) magnifies every open-surgery ergonomic risk: the field is small, the magnification is high, and any postural drift is rapidly felt. Microscope ergonomics (ocular height, tilt, binocular angulation) must be set before scrubbing, not after.

Urology-Specific Recommendations​

Endoscopic cases​

  • Adjust the cystoscopy tower and monitor to eye level before starting
  • Use an adjustable-height procedure chair where the case allows
  • Position foot pedals directly in front of the surgeon, not to the side
  • Take microbreaks during long ureteroscopic or percutaneous work
  • Consider lighter flexible scopes and ergonomic handle grips
  • For lead-apron fluoroscopic cases, use two-piece aprons and offload onto support stands between runs

Laparoscopy​

  • Plan trocar placement to minimize extreme instrument angulation
  • Adjust table height so elbows sit at 90–120° with relaxed shoulders
  • Place monitors about 80–120 cm from the surgeon and slightly below eye level.[18]
  • Use articulating instruments for deep pelvic work to reduce wrist deviation
  • Schedule microbreaks during long reconstructive cases

Robotic console​

  • Reset all console parameters (seat height, armrest, interpupillary distance, viewer angle) at the start of every case; do not inherit the prior surgeon's settings
  • Adjust the seat and pedals to keep the feet supported and avoid sustained or excessive ankle dorsiflexion during pedal use.[28]
  • Armrests should support the forearms without shoulder elevation
  • Use clutching frequently to return the wrists to neutral
  • Plan safe opportunities to change posture or pause during long cases; the 20–40-minute stretch interval was studied mainly outside robotic console work
  • For the bedside assistant: anti-fatigue mat, dedicated assistant monitor at eye level, and pre-planned trocar choreography

Open reconstructive surgery​

  • Set table height for the specific field; deep pelvic work is lower than the surgeon's elbow
  • Verify loupe declination before scrubbing
  • Use self-retaining retractors (Bookwalter, Omni, Turner-Warwick, Balfour variants) where appropriate to reduce sustained manual retraction
  • When standing operators differ in height, adjust the table for the taller operator as the procedure allows; shorter operators may use a step stool.[29]
  • Consider anti-fatigue mats and, where appropriate, compression stockings for prolonged standing; no threshold duration has been established

Seated perineal work (graft quilting). For a seated approach to perineal urethroplasty and graft quilting, one described setup positions the lithotomy table around umbilicus level so the seated surgeon's elbows stay near a relaxed 60–110°, with the patient about an arm's length away and slight Trendelenburg used to bring the perineum into view; a right-handed surgeon can lean the torso back and rotate the shoulders (left forward, right back) to change the working angle without moving the head, with the assistant positioned to the surgeon's right (torso turned about 45° to the patient) and the instrument nurse to the left.[26]

Evidence-Based Mitigation Strategies​

Intraoperative interventions​

Targeted stretching micro breaks (TSMBs)​

Targeted stretching microbreaks are a studied intraoperative ergonomic intervention. The multicenter cohort by Park et al. (2017, Ann Surg) included 66 participating surgeons and operating-room staff across four centers and 341 procedures. It used 1.5–2-minute guided stretching breaks every 20–40 minutes targeting hands / wrists, forearms, shoulders, neck, and lower back, performed at the sterile field without regowning.[19]

  • Significantly improved post-procedure pain scores in the neck, lower back, shoulders, upper back, wrists and hands, knees, and ankles.
  • No statistically significant operative-duration difference was detected between microbreak and comparison procedures.
  • No statistically significant difference in reported benefit was detected between laparoscopic and open procedures.
  • 57% of surgeons perceived improved physical performance; 38% improved mental focus.[19]
  • 87% planned to continue TSMBs beyond the study.[19]

The 2023 ASGE guideline suggests microbreaks and scheduled macrobreaks for GI endoscopists .[27] Its panel cautioned that the supporting surgical cases were generally longer than GI endoscopy.[27] It cites a small web-app-prompted stretch pilot over 12 surgical days: end-of-day surveys reported less pain or discomfort on 100% of surgical days, better physical performance and lower fatigue on 91.7%, and better mental focus on 83.3%.[25]

The 2025 Kjærgaard et al. systematic review and meta-analysis found reduced pain with active microbreaks in pooled standardized estimates (effect sizes −0.24 to −0.62 across body regions). Passive microbreak findings were described narratively rather than pooled; overall evidence certainty was very low to low by GRADE.[21]

Practical implementation:

  • Stretches performed at the sterile field with hands above waist level, with no regowning required.
  • Circulating nurse or timer app (e.g., phone, OR display) to prompt breaks.
  • Protocol is adaptable to open, laparoscopic, and robotic cases.
  • Mayo Clinic printable guides are available as the reference protocol.

Other intraoperative interventions​

  • Position alternation. When feasible, shift between sitting and standing during staged reconstructive cases.
  • Streamlined instrument passing to reduce repetitive reach.
  • Adequate tie length. Short ties drive awkward wrist and shoulder posture.
  • Scheduled handoff points. In very long cases, alternating surgeon participation can permit periodic rest breaks when the operative step allows.[30]

Equipment and technology​

  • Ergonomic chairs with adjustable height, lumbar support, and armrests for seated cases
  • Height-adjustable tables that reach both low (open pelvic) and high (bariatric robotic) extremes
  • Lighter-weight instruments with neutral-grip handles
  • Anti-fatigue mats
  • Graduated compression stockings

Exercise-based prevention​

The Giagio et al. 2019 multicenter RCT (Ann Surg) cluster-randomized 141 surgeons by surgical division (65 program, 76 control) to a preventive program combining OR ergonomic principles with physical exercises supervised by a physical therapist or to usual practice. At six months, the study reported:[20]

  • Low back pain in 50.0% of the program group versus 66.2% of controls (p = 0.04).[20]
  • Analgesic consumption in 15.5% of the program group versus 30.9% of controls at six months (p = 0.03).[20]
  • Improved general-health quality of life at both 3 and 6 months (p = 0.04).
  • Physical activity was the only modifiable independent factor associated with WMSDs in the study’s baseline analysis (OR 2.44).[20]

Resistance training is a plausible component of prevention.[22] A surgeon-focused commentary proposes moderate-intensity sessions of about 20 minutes twice weekly, drawing on evidence from other populations.[22] Rathee et al. (2025) studied self-administered strengthening exercises combined with intraoperative targeted stretch microbreaks in four surgeons performing thyroidectomy and mastectomy. EMG showed less muscle fatigue and postural strain, but the subjective workload score did not change. Rathee et al. studied short-term EMG outcomes; long-term injury prevention was unmeasured.[23]

Active microbreak studies report short-term pain outcomes, whereas resistance training is a proposed adjunct whose effect on long-term injury in surgeons remains untested.[21][22]

Education​

The Comprehensive Operating Room Ergonomics (CORE) program is an occupational-therapy-based intervention addressing biomechanical, psychophysical and psychosocial risks. In a pilot of six laparoscopic surgeons, RULA ergonomic risk scores fell after the intervention (p = 0.03).[15] A urology-specific pilot combined didactic training with real-time physical-therapist feedback during endoscopic cases and improved ergonomic knowledge among participating urologists.[16] Reviews from adjacent specialties (minimally invasive gynecologic surgery, orthopedics) describe the same approach: short structured didactics plus intraoperative feedback.[17]

Gleave et al. (2025) proposed a comprehensive residency curriculum integrating education, microbreaks, ergonomic adjustment, and physical fitness. Their narrative review cites a prior combined-program experience in which 85% of residents reported reduced discomfort and 93% expected better OR performance; these were self-reports, not measured long-term performance.[24]

Behavioral​

  • Regular off-the-clock exercise and stretching, particularly posterior-chain and rotator-cuff strengthening
  • Ambidexterity training
  • Conscious posture self-monitoring: a verbal check-in every 20 minutes during a long case
  • Institutional wellness and load-management programs

System-Level Change​

Surgeon WMSDs are attributed largely to operating-room design and workload.[1] Institutional measures include:

  • Ergonomics integrated into surgical training curricula (residency and fellowship)
  • Ergonomic assessment part of the evaluation process for new instruments, platforms, and workflows
  • Anonymous WMSD needs assessments to target wellness programs
  • Protected time and institutional policies supporting microbreaks
  • Funding for ergonomic innovation and for urology-specific research
  • Formal collaboration with occupational therapists and ergonomists

Reconstructive urologists and urogynecologists operate for long hours over decades, so the ergonomic environment bears directly on career-length operative capacity.

References​

1. Stewart A, Brown K, Booth K, Wu DH. "Musculoskeletal Disorders in Surgeons: A Systematic Review on Prevalence, Risk Factors, and Mitigation Strategies." The American Surgeon. 2026. doi:10.1177/00031348261436809

2. Valtanen RS, van Niekerk M, Chu CR. "Ergonomics in the Operating Room: Recommendations for Orthopaedic Surgeons." J Am Acad Orthop Surg. 2025;33(10):e531-e540. doi:10.5435/JAAOS-D-24-01206

3. Barrios EL, Polcz VE, Hensley SE, et al. "A Narrative Review of Ergonomic Problems, Principles, and Potential Solutions in Surgical Operations." Surgery. 2023;174(2):214-221. doi:10.1016/j.surg.2023.04.003

4. Aaron KA, Vaughan J, Gupta R, et al. "The Risk of Ergonomic Injury Across Surgical Specialties." PLoS One. 2021;16(2):e0244868. doi:10.1371/journal.pone.0244868

5. Vasireddi N, Vasireddi N, Shah AK, et al. "High Prevalence of Work-Related Musculoskeletal Disorders and Limited Evidence-Based Ergonomics in Orthopaedic Surgery: A Systematic Review." Clin Orthop Relat Res. 2024;482(4):659-671. doi:10.1097/CORR.0000000000002904

6. Epstein S, Sparer EH, Tran BN, et al. "Prevalence of Work-Related Musculoskeletal Disorders Among Surgeons and Interventionalists: A Systematic Review and Meta-analysis." JAMA Surg. 2018;153(2):e174947. doi:10.1001/jamasurg.2017.4947

7. Tjiam IM, Goossens RH, Schout BM, et al. "Ergonomics in Endourology and Laparoscopy: An Overview of Musculoskeletal Problems in Urology." J Endourol. 2014;28(5):605-11. doi:10.1089/end.2013.0654

8. Tetteh E, Wang T, Kim JY, et al. "Optimizing Ergonomics During Open, Laparoscopic, and Robotic-Assisted Surgery: A Review of Surgical Ergonomics Literature and Development of Educational Illustrations." Am J Surg. 2024;235:115551. doi:10.1016/j.amjsurg.2023.11.005

9. Haddad A, Lendoire M, Ito K, et al. "Ergonomic Considerations in Open Liver Surgery." J Gastrointest Surg. 2025. doi:10.1016/j.gassur.2025.102241

10. Dalsgaard T, Jensen MD, Hartwell D, et al. "Robotic Surgery Is Less Physically Demanding Than Laparoscopic Surgery: Paired Cross Sectional Study." Ann Surg. 2020;271(1):106-113. doi:10.1097/SLA.0000000000002845

11. Monfared S, Athanasiadis DI, Umana L, et al. "A Comparison of Laparoscopic and Robotic Ergonomic Risk." Surg Endosc. 2022;36(11):8397-8402. doi:10.1007/s00464-022-09105-0

12. Hotton J, Bogart E, Le Deley MC, et al. "Ergonomic Assessment of the Surgeon's Physical Workload During Robot-Assisted Versus Standard Laparoscopy in a French Multicenter Randomized Trial (ROBOGYN-1004 Trial)." Ann Surg Oncol. 2023;30(2):916-923. doi:10.1245/s10434-022-12548-3

13. Krämer B, Neis F, Reisenauer C, et al. "Save Our Surgeons (SOS) — An Explorative Comparison of Surgeons' Muscular and Cardiovascular Demands, Posture, Perceived Workload and Discomfort During Robotic vs. Laparoscopic Surgery." Arch Gynecol Obstet. 2023;307(3):849-862. doi:10.1007/s00404-022-06841-5

14. Norasi H, Hallbeck MS, Elli EF, et al. "Impact of Preferred Surgical Modality on Surgeon Wellness: A Survey of Workload, Physical Pain/Discomfort, and Neuromusculoskeletal Disorders." Surg Endosc. 2023;37(12):9244-9254. doi:10.1007/s00464-023-10485-0

15. Hess P, Athanasiadis D, Lee NK, et al. "Preventing Surgeon Work-Related Musculoskeletal Disorders: A Pilot Study of the Comprehensive Operating Room Ergonomics (CORE) Program." Am J Occup Ther. 2024;78(5):7805205090. doi:10.5014/ajot.2024.050395

16. Davis MF, Marantidis J, Rahematpura S, Sussman RD. "Incorporating Intra-Operative Education Into Ergonomics Training for Endourology Cases: A Pilot Study." Urology. 2025;204:23-29. doi:10.1016/j.urology.2025.04.039

17. Lin E, Young R, Shields J, Smith K, Chao L. "Growing Pains: Strategies for Improving Ergonomics in Minimally Invasive Gynecologic Surgery." Curr Opin Obstet Gynecol. 2023;35(4):361-367. doi:10.1097/GCO.0000000000000875

18. Gabrielson AT, Clifton MM, Pavlovich CP, et al. "Surgical Ergonomics for Urologists: A Practical Guide." Nat Rev Urol. 2021;18(3):160-169. doi:10.1038/s41585-020-00414-4

19. Park AE, Zahiri HR, Hallbeck MS, et al. "Intraoperative 'Micro Breaks' with Targeted Stretching Enhance Surgeon Physical Function and Mental Focus: A Multicenter Cohort Study." Ann Surg. 2017;265(2):340-346. doi:10.1097/SLA.0000000000001665

20. Giagio S, Volpe G, Pillastrini P, et al. "A Preventive Program for Work-Related Musculoskeletal Disorders Among Surgeons: Outcomes of a Randomized Controlled Clinical Trial." Ann Surg. 2019;270(6):969-975. doi:10.1097/SLA.0000000000003199

21. Kjærgaard C, Jahn A, Nielsen TK, et al. "Physical Activity Interventions and Musculoskeletal Health in Surgeons: A Systematic Review and Meta-Analysis." Occup Environ Med. 2025;82(9):451-458. doi:10.1136/oemed-2025-110237

22. Vijay A, Brennan PA, Fagbohun M, Oeppen RS, Parry D. "Could Resistance Training Prevent or Improve Work-Related Musculoskeletal Disorders Among Surgeons?" Ann R Coll Surg Engl. 2025;107(7):453-456. doi:10.1308/rcsann.2024.0089

23. Rathee HK, Joy J, Anil AK, et al. "Structured Muscle-Strengthening Exercise Program and Intraoperative Targeted Stretch Micro-Breaks: A Work in Cohesion to Improve Surgeon Ergonomics During Open Thyroidectomy and Modified Radical Mastectomy." Am J Surg. 2025;247:116517. doi:10.1016/j.amjsurg.2025.116517

24. Gleave A, Shah A, Giff A, et al. "Promoting Longevity in Surgical Careers: A Narrative Review and Fitness Program to Reduce Occupational Pain." J Surg Educ. 2025;82(7):103512. doi:10.1016/j.jsurg.2025.103512

25. Pawa S, Kwon RS, Fishman DS, et al. "American Society for Gastrointestinal Endoscopy Guideline on the Role of Ergonomics for Prevention of Endoscopy-Related Injury: Methodology and Review of Evidence." Gastrointest Endosc. 2023;98(4):492-512.e1. doi:10.1016/j.gie.2023.05.055

26. Joshi PM, Navarro J, Aubé-Peterkin M. Ergonomics of Urethroplasty. In: Joshi PM, Aubé-Peterkin M, Kulkarni SB, Datar G, eds. Surgical Atlas of Urethroplasty. Springer; 2024:3–9. doi:10.1007/978-981-97-5196-9_1

27. Pawa S, Kwon RS, Fishman DS, et al. "American Society for Gastrointestinal Endoscopy guideline on the role of ergonomics for prevention of endoscopy-related injury: summary and recommendations." Gastrointest Endosc. 2023;98(4):482-491. doi:10.1016/j.gie.2023.05.056

28. Cook B, Vasdev N, Luk A, Dasgupta P. "Redefining surgical ergonomics: a systematic review of ergonomic outcomes in robotic urological surgery." J Robot Surg. 2026;20(1):107. doi:10.1007/s11701-025-03057-y

29. American College of Surgeons. Surgical Ergonomics Recommendations. 2023. Full recommendations

30. Schlussel AT, Maykel JA. "Ergonomics and Musculoskeletal Health of the Surgeon." Clin Colon Rectal Surg. 2019;32(6):424–434. doi:10.1055/s-0039-1693026