Surg Endosc and Other Interventional Techniques

DOI 10.1007/s00464-016-5076-6

Comparison of fatigue accumulated during and after prolonged

robotic and laparoscopic surgical methods: a cross-sectional study
Manuel González-Sánchez1 • Ivan González-Poveda2 • Santiago Mera-Velasco2 •

Antonio I. Cuesta-Vargas3,4

Received: 16 February 2016 / Accepted: 22 June 2016

Ó Springer Science+Business Media New York 2016

Abstract surgeon) was measured three times, totalling 12 measured

Background The aim of the present study was to analyse surgery interventions. The minimal duration of surgery was
the fatigue experienced by surgeons during and after per- 180 min.
forming robotic and laparoscopic surgery and to analyse Results Pre- and post-surgery, all questionnaires showed
muscle function, self-perceived fatigue and postural that the magnitude of change was higher for the chief
balance. surgeon compared with the assistant surgeon, with differ-
Methods Cross-sectional study considering two surgical ences of between 10 % POMS and 16.25 % VAS (robotic
protocols (laparoscopic and robotic) with two different protocol) and between 3.1 % POMS and 12.5 % VAS
roles (chief and assistant surgeon). Fatigue was recorded in (laparoscopic protocol). In the inter-profile comparison, the
two ways: pre- and post-surgery using questionnaires chief surgeon (robotic protocol) showed a lower balance
[Profile of Mood States (POMS), Quick Questionnaire capacity during the SLBT after surgery. During the inter-
Piper Fatigue Scale and Visual Analogue Scale (VAS)- vention, the kinematic variables showed significant dif-
related fatigue] and parametrising functional tests [hand- ferences between the chief and assistant surgeon in the
grip and single-leg balance test (SLBT)] and during the robotic protocol, but not in the laparoscopic protocol.
intervention by measuring the muscle activation of eight Regarding muscle activation, there was not enough muscle
different muscles via surface electromyography and kine- activity to generate fatigue.
matic measurement (using inertial sensors). Each surgery Conclusion Prolonged surgery increased fatigue in the
profile intervention (robotic/laparoscopy–chief/assistant surgeon; however, the magnitude of fatigue differed
between surgical profiles. The surgeon who experienced
the greatest fatigue was the chief surgeon in the robotic
protocol.

& Antonio I. Cuesta-Vargas

Keywords Surface EMG
Kinematic measurement

[email protected] Handgrip
Balance
Profile of Mood States
Quick
Questionnaire Piper Fatigue Scale
1
Health Sciences Faculty, Department of Health Science,
University of Jaén, Campus de las Lagunillas SN. Ed. B3 –
Despacho 412, 23071 Jaén, Spain Minimally invasive surgery offers a number of advantages
2
to the patient, which has encouraged its widespread use
Surgeon into Servicio de Cirugı́a General de Carlos Haya
SAS (Sistema Andaluz de Salud), Malaga, Spain
despite the complex technical difficulties involved [1]. In
3
addition to these technical difficulties, it has been observed
Departamento de psiquiatria y fisioterapia, Instituto de
Investigación Biomédica de Málaga (IBIMA), Universidad
that surgeons operating regularly have adverse symp-
de Málaga, Arquitecto Francisco Peñalosa s/n. (ampliación tomatologies due to ergonomic requirements [1]. Among
Campus Teatinos), 29071 Malaga, Spain the most common causes of reduced ergonomics during
4
School of Clinical Sciences, Queensland University, laparoscopy are excessive strain on the neck, held
Brisbane, Australia

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abduction of the shoulder, prolonged standing with little Materials and methods
change of position and excessive flexing of the hand [2, 3].
This accumulation of malposition negatively affects the Design
postural health of surgeons who perform laparoscopy and
causes the appearance of paraesthesia and pain in the hand, This was a cross-sectional study in which muscle fatigue
wrist, arm, shoulder and neck [2–4]. and postural balance before, during and after two surgical
The execution of surgery in a sitting position, which techniques (laparoscopy and robotic) were recorded in a
offers minimal resistance to the movement of the surgeon during surgery. Measurements were taken during
instruments, or three-dimensional visualisation through a digestive surgery with a previously estimated duration of
console [5], enables the use of robotic surgery and 180 min.
reduces physiological stress for surgeons while main-
taining the benefits of minimally invasive laparoscopic Settings
surgery [6, 7]. However, the lack of ergonomics could
cause the early onset of fatigue. Muscle fatigue could Measurements were taken in two public hospitals in
occur during or after any gesture or task that reduces the Malaga between March 2014 and June 2015.
maximum capacity to generate power or force [8],
defined as a state that temporarily limits the ability to Participants
perform a task or job precisely because of the same task
or job [9]. In addition, when the postural muscles that The subject analysed in this study was a general and
control balance are fatigued, they may alter their func- digestive surgeon with over 15 years of experience in
tion, negatively conditioning balance and postural sta- regularly performing laparoscopic and robotic surgery.
bility [10–12]. Some studies analysed the effects of
fatigue on the static balance of the individual and con- Ethical considerations
cluded that there was a direct correlation between pos-
tural muscle fatigue and the static balance of the person The study was conducted according to ethical principles of
[13, 14]. Other studies suggested movement as a strategy the Declaration of Helsinki. Ethical approval was received
to slow the onset of fatigue, especially when space for from a local ethics committee.
work was reduced [15, 16]. The principles of confidentiality and autonomy were
The detection and classification of neuromuscular fati- upheld through informed consent and the segregation of
gue have contributed significantly to information regarding data to ensure anonymity at all times. The data were pro-
human–computer interactions, sports injuries, performance cessed and guarded with respect for the privacy of the
and ergonomics [17]. subject and the current data protection legislation (Law
Surface electromyography (sEMG) is frequently used to 15/1999) on the protection of personal data.
analyse muscle function during the execution of a partic-
ular task by a particular muscle and facilitates the analysis Instruments for measuring fatigue
of the responses given by a muscle during the execution of
a particular gesture [18]. In addition, inertial sensors have Surgeons’ Patient-Reported Outcome Measures (PROMS)
frequently been used to analyse the postural balance of
individuals [19]. To analyse self-perceived fatigue, the Profile of Mood
A recent study considered the fatigue accumulated by States (POMS) [21] and the Quick Questionnaire Piper
surgeons when performing an intervention by comparing Fatigue Scale (QPFS) [22] were used. The POMS com-
muscle function and postural stability before and after prises 65 items [item scale 0 (Not at all)–4 (Extremely)],
robotic and laparoscopic surgery [20]. However, no studies with scores grouped into seven subscales: Anger–Hostility
have compared the onset of fatigue in the surgeon during (11 items), Depression–Dejection (14 items), Fatigue–In-
robotic and laparoscopic surgery. ertia (8 items) Vigour–Activity (6 items), Friendliness (6
The aim of this study was to analyse the fatigue expe- items), Tension–Anxiety (3 items) and Confusion (3 items)
rienced by a surgeon during and after surgery by compar- [23]. The Vigour subscale had an inverse relationship with
ing robotic and laparoscopic surgery and analysing muscle the other subscales [24]. This questionnaire presented a
function, self-perceived fatigue and postural balance. It reliability (Cronbach’s alpha) ranging between 0.77 and
was hypothesised that there would be significant differ- 0.92 [21]. The QPFS is a questionnaire with 15 items
ences during and after surgery between the two method- [response scale 0 (best situation)–10 (worst situation)]
ologies analysed. based on the Piper Fatigue Scale-Revised and has

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advantages such as brevity and the ease of interpretation of palpated. In addition, to minimise the electromyographic
results (the results are accumulated in one dimension) [22]. limitations (impedance of the skin), the skin was shaved
It had a reliability score of 0.947 and a validity of 0.743 and cleaned with alcohol, as recommended by SENIAM.
[22]. Finally, the Visual Analogue Scale (VAS)-related Electromyographic data collection was conducted using
fatigue was used. The surgeon was asked: What is your the software Megawin 3.0.1 (Mega Electronics Ltd, Kuo-
level of fatigue after performing surgery? Self-adminis- pio, Finland). In addition, to remove high-frequency noise,
tered questionnaires were completed before and after a high-pass corner filter (20 Hz) was used. The maximum
surgery. voluntary contraction (MVC) of each muscle was obtained
according to previously used protocols [28]. Each maximal
Objective Clinical Outcome Measure (OCOM) activation test was performed three times (maximum con-
traction for 5 s with 30 s of rest between contractions),
Surface EMG using, as a reference for normalisation, the maximum
activation value registered.
The electromyography Biomonitor ME6000 (Mega Elec- The electromyographic recording was performed during
tronics Ltd.) was used to record muscle activation. The the development of the surgical interventions.
sampling frequency was 2000 Hz. On the dominant side,
the following eight muscles were analysed: tibialis anterior, Inertial sensors
medial gastrocnemius, vastus medialis, biceps muscle
femoris, abdominal transverse, erector spinae, medial del- An inertial sensor with a sampling frequency of 180 Hz
toids and trapezius muscle (Fig. 1). For each muscle, three (InertiaCube3TM of InterSense Inc. (Bedford, Mas-
electrodes were used [Al/AgCl (2.5 cm2)] with a 1-cm gap sachusetts, USA) was used to collect the surgeon’s kine-
between the three. The electrodes were positioned fol- matic variables during surgery. After cleaning the skin, the
lowing the recommendations of the European project inertial sensors were fixed to the skin with tape and rein-
‘‘Surface Electromyography for the Non-Invasive Assess- forced with a rubber band. The inertial sensor was placed
ment of Muscles’’ (SENIAM) [25, 26] and the elec- on the back at the T7 level. Before placing the inertial
tromyography manufacturer (Mega Electronics Ltd) [27]. sensors, they were calibrated positioning the coordinates’
Before positioning each electrode, each muscle was centre at the down left corner.

Fig. 1 Positioning scheme of the electrodes according to the analysed muscle. Images taken from the programMegaWin 3.0.1 (Mega Electronics
Ltd, Kuopio, Finland)

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The inertial sensors created a kinematic record during Scale (QPFS) was also used, resulting in a variable
the single-leg balance test (SLBT) balancing test and dur- obtained from the sum of the 15 items of the questionnaire;
ing the course of surgery. the VAS recorded visual analogue scale-related fatigue.
The OCOM included the handgrip test [maximum and
Functional tests maximum peak handgrip strength (average of three
attempts)] and the SLBT, which measured the time until
The participant performed the SLBT, which was intended the first attempt at maintaining balance or when the hands
to measure static balance. In this test, the participant had to were separated from the hips. The SLBT had a ceiling of
stand on one leg with the other leg in suspension, and the 30 s. Kinematic variables recorded during the SLBT and
hip in a neutral position with the knee flexed to 90° with during surgery included (for all axes): mean displacement,
his/her hands on the hips. The test was completed when the mean velocity and time. Electromyography variables were
participant removed the hands from the hips or when the recorded during surgery in all above-mentioned muscles
suspended leg touched the ground. If this did not occur, the and included median muscle activation frequency (average
test ended after the participant had remained static for 30 s. muscle activation recorded throughout surgery, where
The test was performed in four different settings: supported mean values presented normalised frequencies) and median
by dominant and non-dominant legs and with eyes open muscle activation slope (MDFslope), where the initial and
and closed. In addition, this test was monitored kinemati- final values of muscle activation were used in a linear
cally using the inertial sensors positioned on the back at the regression in which the slope of the linear regression was
T7 level. the fatigue level. Kinematic variables included mean
Finally, the hydraulic JamarÒ handgrip dynamometer angular displacement (average angular displacement in the
(Sammons Preston Rolyan, Chicago, IL) was used three three axes recorded during surgery) and average speed (the
times to perform the maximal handgrip test on both hands average speed of displacement during the operation).
(dominant and non-dominant) for 5 s each, with a break of
60 s between repetitions. Statistical analysis
The two functional tests were performed before and
after each surgery. A descriptive analysis of the anthropometric variables was
performed. For each of the four intervention profiles
Surgical protocols (robotic/laparoscopy–chief/assistant surgeon), along with
the outcome variables, a descriptive study of those that
Two surgical protocols, laparoscopic and robotic surgery were measured during surgery was performed. In addition
using the Da VinciÒ Surgical System (Intuitive Surgical— to the outcome variables measured before and after sur-
Sunnyvale, CA), were performed in the present study. gery, based on the distribution of the sample (calculated
During the two protocols, the surgeon performed two dis- through the KS test), a pre- and post-intervention com-
tinct roles: chief surgeon, ordered to perform surgery and parison was made using Student’s t test for parametric
make decisions during the operation, and assistant surgeon, variables and Wilcoxon’s test for nonparametric variables.
responsible for assisting the chief surgeon during surgery. In addition, an ‘‘inter-profile’’ comparison comparing all
The chief surgeon was placed in the control device during outcome variables between the four intervention profiles
the intervention involving robotics, while, in laparoscopic was performed. A one-way ANOVA for each of the pre-
surgery, the surgeon was responsible for performing sur- intervention and post-intervention variables was per-
gery. The assistant surgeon was responsible for modifying formed. The level of significance was established as
the various arms of the surgical robot in the robotic inter- p B 0.05. For statistical analysis, The Statistical Package
vention, whereas in laparoscopic surgery, the assistant for Social Sciences (SPSS) was used (version 21.0 for
surgeon was responsible for holding the camera for the Windows, Chicago, IL).
chief surgeon.

Variables Results

Before beginning the study, the surgeon’s anthropometric Descriptive results

data were collected. Outcomes were recorded using the
Surgeons’ Patient-Reported Outcome Measures (PROMS) The digestive surgeon was 44 years old, 1.87 cm tall and
and the Profile of Mood States (POMS); the main result weighed 92 kg with a BMI of 27.45 kg/m2. The total
(the POMS value) and seven sub-scales were calculated number of intervention measures was 12 (three for each of
based on the number of items. The Quick Piper Fatigue the surgical protocols). There were no significant

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differences in the duration of the surgical procedures per- measured during the SLBT in both the chief and assistant
formed, with an average of 218.46 (±14.55) min. Figure 2 surgeon profiles (Table 2).
shows the MVC of each muscle recorded during Daniels’
test. To normalise the electromyographic measures, the Intra-profile differences after different surgical protocols
maximal muscle activation recorded during Daniels’s test
was used. There were no significant differences between Comparison of the variables of the chief surgeon during
surgeon profiles in this study. robotic and laparoscopic surgery revealed that the magni-
tude of the change experienced by Surgeons’ PROMS
Variables measured pre- and post-surgical variables after the robotic protocol with respect to the
intervention laparoscopy protocol was significantly higher for all Sur-
geons’ PROMS except POMSConfusion and QPFS. In addi-
Intra-profile differences tion, during the SLBT, the results showed that there was
higher functional fatigue in the chief surgeon during
Table 1 shows pre- and post-intervention results and the robotic surgery. Table 1 shows that there was a signifi-
differences between each of the variables during robotic cantly greater change in 15 of the kinematic variables
interventions. The results showed significant changes following robotic surgery (Table 1), whereas only five of
between pre- and post-surgery intervention in all Surgeons’ the kinematic variables showed a significantly greater
PROMS variables analysed. However, the magnitude of change following laparoscopic surgery (Table 2). Mean-
change was much larger for the chief surgeon compared to while, the change in the SLBT runtime with the eyes open
the assistant surgeon, with a difference equal to or greater and the dominant leg was significantly higher in the robotic
than 10 % (10 % POMS; 11.7 % QPFS; 16.25 % VAS) in surgery protocol. With closed eyes and the non-dominant
the two robotic surgery profiles. Significant changes were leg, the change in the SLBT runtime was significantly
also observed in the pre- and post-intervention OCOM higher in the laparoscopy surgery protocol. There were no
variables. In the inter-profile comparison, the tests showed significant differences in SLBT runtime between the non-
that the chief surgeon had a lower balance capacity, dominant leg with eyes closed and the eyes open with
showing a significantly greater magnitude of change in all dominant leg scenario.
kinematic variables recorded during the SLBT in different When comparing the changes in the assistant surgeon
conditions (Table 1), with the exception of some speed after the robotic and laparoscopy surgery protocol, there
measurements. were significantly higher changes in six Surgeons’ PROMS
Similarly, when comparing the change in intra-profiles (POMSIndex, POMSFatigue, POMSVigour, POMSFriendliness,
that occurred during laparoscopic intervention, significant POMSAnxiety, and QPFS) after the laparoscopy surgery
differences were observed in all Surgeons’ PROMS and protocol, while in two Surgeons’ PROMS, the changes
OCOM variables, with the exception of velocities were significantly higher after the robotic surgery protocol

Fig. 2 MVC of each muscle

analysed during the surgical
intervention

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Table 1 Change in fatigue,

Robotic Laparoscopic Dif profile post-inter.
‘‘intra-profile’’ (main surgeon
and assistant surgeon) and Pre Post Dif. Pre Post Dif.
‘‘inter-profile,’’ the surgeon
after surgical interventions with PRO
chief surgeon surgery protocol POMS
POMS Index 7.00 40.50 33.50*** 4.50 26.00 21.50*** 12.00***
Anger 0.50 6.50 6.00** 0.00 2.50 2.50*** 3.5***
Depression 0.00 1.50 1.50* 0.00 1.00 1.00** 0.5**
Fatigue 0.50 3.00 2.50* 0.50 2.50 2.00** 0.5**
Vigor 2.50 12.00 9.50*** 1.50 7.50 6.00** 3.5*
Friendliness 2.50 11.50 9.00*** 1.50 8.00 6.50*** 2.5**
Anxiety 0.50 3.50 3.00*** 1.00 2.50 1.50* 1.5***
Confusion 0.50 2.50 2.00** 0.00 2.00 2.00** 0
QPFS 16.00 68.00 52.00*** 15.50 68.50 53.00** -1
VAS 21.80 72.60 50.80*** 20.90 64.00 43.10** 7.7***
Functional test
Handgrip (kg)
Maximum left 39.50 35.00 -4.50*** 39.00 30.50 8.50*** 4.5**
Maximum right 40.50 36.50 -4.00*** 42.00 32.50 9.50*** 5.5***
Single-leg balance test
Dominant leg
Opened eyes
Time (seg) 30.00 16.25 -14.75*** 30.00 19.34 -11.75*** 3.0**
Displacement (°)
Flex/Ext 2.24 21.09 18.85*** 4.84 23.92 19.08** -0.23
Incl. L/R 9.58 24.55 14.97*** 9.49 21.26 11.77** 3.2***
Rot L/R 9.87 35.24 25.37*** 9.86 28.67 18.81* 6.56**
Velocity (°/s)
Flex/Ext 40.67 46.18 5.51* 41.62 43.23 1.61 3.9**
Incl. L/R 23.75 30.48 6.73* 23.67 25.00 1.33 5.4***
Rot L/R 51.29 58.04 6.75** 52.49 56.44 3.95 2.8*
Closed eyes
Time (seg) 30.00 9.28 -20.72*** 30.00 10.57 -19.43*** 1.29
Displacement (°)
Flex/Ext 9.51 48.48 38.97*** 9.29 48.97 39.68*** -0.71
Incl. L/R 14.01 53.09 39.08*** 14.50 44.54 30.04*** 9.04**
Rot L/R 15.29 57.73 42.44*** 15.68 46.89 31.21*** 11.23***
Velocity (°/s)
Flex/Ext 42.09 46.15 4.06* 42.66 42.28 -0.38 4.44***
Incl. L/R 29.67 30.79 1.12 29.63 32.81 3.18* -2.06*
Rot L/R 56.38 55.07 -1.31 57.45 57.12 -0.33 -0.98
Non-dominant leg
Opened eyes
Time (seg) 30.00 16.47 -13.53*** 30.00 16.34 -13.66*** -0.13
Displacement (°)
Flex/Ext 5.84 24.87 19.03*** 6.06 20.12 14.06** 4.97***
Incl. L/R 11.94 26.53 14.59*** 11.78 22.45 10.67* 3.92**
Rot L/R. 12.33 40.21 27.88*** 12.65 33.21 20.56*** 7.32***
Velocity (°/s)
Flex/Ext 35.68 43. 58 7.90** 35.31 44.78 9.47** -1.57*
Incl. L/R 36.39 44.32 7.93* 37.23 31.74 -5.49* 2.44**

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Table 1 continued
Robotic Laparoscopic Dif profile post-inter.
Pre Post Dif. Pre Post Dif.

Rot L/R 52.60 56.37 3.77 53.59 59.62 6.03** -2.26**

Closed eyes
Time (seg) 26.45 4.84 -21.61*** 25.97 6.77 -19.20*** -2.41*
Displacement (°)
Flex/Ext 14.32 59.24 44.92*** 13.87 49.09 35.22*** 9.7**
Incl. L/R 19.21 63.44 44.23*** 19.68 53.70 34.02** 10.21***
Rot L/R 20.74 63.18 42.44*** 21.48 52.44 30.96*** 11.48***
Velocity (°/s)
Flex/Ext 43.55 44.87 1.32 45.06 42.17 -2.89* -4.21**
Incl. L/R 27.55 34.15 6.60** 28.41 40.29 11.88** -5.28***
Rot L/R 58.24 60.44 2.20 60.27 63.28 3.01** -0.81
Pre pre-intervention, Post post-intervention, Dif difference, Dif Profile Post-Inter differences between both
surgeon profiles (chief and assistant surgeon), PRO Patient-Reported Outcome, QPFS Quick Piper Fatigue
Scale, POMS Profile Mood States, VAS Visual Analogue Scale, Flex/Ext flexion–extension, Incl. L/R left–
right inclination, Rot L/R left–right rotation
Significance (p): * B0.05; ** B0.005; *** B0.001

(POMSConfusion and VAS). There were no significant dif- significant differences of 26 % (POMS), 14.50 (QPFS) and
ferences in POMSAnger and POMSDepression between the 16.25 % (VAS) (Table 3). As regards the OCOM vari-
two protocols (Table 2). Nevertheless, in the assistant ables, the handgrip was significantly weaker in the chief
surgeon, the changes observed in functional tests after the than in the assistant surgeon profile after both protocols,
laparoscopy surgery protocol were not significant for grip but the changes were higher after laparoscopy [4.00 kg
strength in either hand, compared with robotic surgery (right hand) and 5.50 kg (left hand)] (Table 4), compared
protocol. Finally, in the SLBT, significant differences in with the robotic surgery protocol (0.50 kg—both hands).
the changes produced were observed in only 5 of the 24 Nevertheless, the behaviour of the SLBT kinematic vari-
kinematic variables recorded after the laparoscopy protocol ables measured after both protocols differed between roles.
(Table 2), with the highest difference identified (10.51°) in Significant differences were observed between the chief
the left/right lateral inclination measured during SLBT and assistant surgeon in 25 of the 28 kinematic variables
with the eyes closed. The change in the SLBT runtime with measured after the robotic surgery protocol (Table 3).
the dominant leg was significantly higher after the After the laparoscopy surgery protocol, a significant dif-
laparoscopy surgery protocol; no significant differences ference was observed between the two profiles in 9 of the
were observed between protocols in terms of the SLBT 28 variables analysed.
runtime with the non-dominant leg.

Inter-profile differences after the same protocol Variables measured during surgery

Comparison of the inter-profile differences in variables Tables 5 and 6 show the kinematic variables recorded
measured pre- and post-laparoscopic intervention revealed during surgical interventions in terms of surgeon profile
significant differences in all Surgeons’ PROMS and (assistant and chief) per protocol (robotic and laparoscopy).
OCOM variables after laparoscopic surgery, with the Table 5 shows that there were significant differences in the
exception of velocities measured during the SLBT in both kinematic variables between surgeon profiles during the
the chief and assistant surgeon profiles (Table 4). In the robotic protocol, whereas there were no significant differ-
post-intervention inter-profile comparison, there were sig- ences in the laparoscopy protocol. Similarly, there were
nificant differences in all three Surgeons’ PROMS vari- significant differences in kinematic variables of the chief
ables measured (POMS 3.1 %; QPFS 8 %; 12.5 % VAS) surgeon between the two protocols (Table 6). However,
after laparoscopic surgery protocol, although the magni- there were no significant differences between protocols in
tude of the inter-profile difference was lower than in the terms of the kinematic records of the assistant surgeon
post-robotic surgery protocol (Table 4), which showed (Table 6).

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Table 2 Change in fatigue,

Robotic Laparoscopic Dif profile post-inter.
‘‘intra-profile’’ (main surgeon
and assistant surgeon) and Pre Post Dif. Pre Post Dif.
‘‘inter-profile,’’ the surgeon
after surgical interventions with PRO
assistant surgeon surgery POMS
protocol
POMS Index 6.00 13.50 7.50*** 3.50 17.00 13.50*** -6***
Anger 0.00 2.00 2.00** 0.50 2.50 2.00** 0
Depression 0.00 0.00 0.00** 0.00 0.50 0.50* -0.5
Fatigue 0.00 1.00 1.00* 0.00 1.50 1.50* -0.5*
Vigor 2.50 4.50 2.00** 1.50 5.50 4.00** -2**
Friendliness 2.50 5.00 2.50** 1.50 5.50 4.00** -1.5**
Anxiety 0.50 1.00 0.50* 0.00 1.50 1.50* -1**
Confusion 0.50 1.00 0.50* 0.00 0.00 0.00** 0.5*
QPFS 16.00 53.50 37.50*** 16.50 57.50 41.00*** -3.5***
VAS 20.35 54.90 34.55*** 21.20 51.80 30.60** 3.95***
Functional test
Handgrip (kg)
Maximum left 39.50 35.50 4.00** 39.50 35.00 4.50** -0.5
Maximum right 41.50 38.00 3.50** 41.50 37.50 4.00*** -0.5
Single-leg balance test
Dominant leg
Opened eyes
Time (seg) 30.00 23.49 -7.11*** 30.00 21.93 -8.07*** 0.96**
Displacement (°)
Flex/Ext 2.28 17.24 14.96*** 3.08 17.33 14.25*** 0.71
Incl. L/R 9.68 20.11 10.43*** 9.68 20.29 10.61*** -0.18
Rot L/R. 9.67 29.35 19.68*** 9.67 29.37 19.70** -0.02
Velocity (°/s)
Flex/Ext 41.89 44.47 2.58 41.89 43.45 1.56 1.02
Incl. L/R 23.51 25.15 1.64 23.51 25.23 1.72 -0.08
Rot L/R 55.57 57.80 2.23 55.57 56.47 0.90 1.33
Closed eyes
Time (seg) 30.00 12.87 -16.53*** 30.00 11.69 -18.31*** 1.78*
Displacement (°)
Flex/Ext 9.41 38.18 28.77*** 9.41 39.10 29.69*** -0.92
Incl. L/R 14.43 54.03 39.60*** 14.43 43.52 29.09** 10.51***
Rot L/R 15.35 47.36 32.01*** 15.35 46.18 30.83** 1.18
Velocity (°/s)
Flex/Ext 42.26 43.88 1.62 42.26 43.30 1.04 0.58
Incl. L/R 28.56 31.67 3.11* 30.56 31.71 1.15 1.96*
Rot L/R 54.97 56.75 1.78 54.97 55.69 0.72 1.06
Non-dominant leg
Opened eyes
Time (seg) 30.00 20.55 -9.14*** 30.00 19.86 -10.14*** 1
Displacement (°)
Flex/Ext 5.83 21.89 16.06*** 5.83 20.15 14.32** 1.74*
Incl. L/R 11.65 21.74 10.09*** 11.65 22.03 10.38*** -0.29
Rot L/R 12.30 32.92 20.62*** 12.30 32.09 19.79** 0.83
Velocity (°/s)
Flex/Ext 39.74 42.75 3.01 39.74 43.19 3.45** -0.44
Incl. L/R 26.38 32.91 6.53* 26.38 32.17 5.79** 0.74

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Table 2 continued
Robotic Laparoscopic Dif profile post-inter.
Pre Post Dif. Pre Post Dif.

Rot L/R 56.55 59.21 2.66 56.55 58.12 1.57 1.09

Closed eyes
Time (seg) 26.60 7.71 -18.89*** 24.61 7.17 -17.44** -1.45
Displacement (°)
Flex/Ext 14.83 46.48 31.65*** 14.83 47.98 33.15*** -1.5*
Incl. L/R 19.36 54.01 34.65*** 19.36 52.71 33.35*** 1.3
Rot L/R 22.16 54.36 32.20*** 22.16 52.50 30.34*** 1.86**
Velocity (°/s)
Flex/Ext 40.50 45.04 4.54* 40.50 43.53 3.03** 1.51*
Incl. L/R 29.48 40.55 11.07** 29.48 39.32 9.84** 1.23
Rot L/R 56.19 63.24 7.05* 56.19 61.11 4.92** 2.13**
Pre pre-intervention, Post post-intervention, Dif difference, Dif Profile Post-Inter differences between both
surgeon profiles (chief and assistant surgeon), PRO Patient-Reported Outcome, QPFS Quick Piper Fatigue
Scale, POMS Profile Mood States; VAS Visual Analogue Scale, Flex/Ext flexion–extension, Incl L/R left–
right inclination, Rot L/R left–right rotation
Significance (p): * B0.05; ** B0.005; *** B0.001

Figure 3 presents the mean activation values of each of during surgery (Tables 3, 4). Based on these results, the
the eight muscles analysed for the surgeon profile and aim of the study was achieved and the hypothesis was
during either robotic or laparoscopic protocols. It is confirmed.
apparent that median frequency muscle activation only
exceeded 25 % MVC (27.33 % MVC) in the erector spi- Pre- and post-intervention variables
nae, while the MDF from other muscles ranged from
9.87 % MVC (biceps femoralis–chief surgeon–robotic Intra-profile comparison
protocol) to 19.40 % MVC (trapecious–chief surgeon–
robotic protocol). When we analysed the results of the Surgeons’ PROMS
Finally, Table 7 presents the MDFslope I, presented in and functional test pre- and post-intervention, we observed
absolute (Hz/min) and relative values (%/min). Figure 4 significant differences in all outcome variables (Tables 1,
shows a graphic example of the calculation of the MDFs- 2); however, the changes differed depending on the surgi-
lope. Both Fig. 4 and Table 7 shows that there was no cal profile and intervention. Thus, the Surgeons’ PROMS
clearly defined trend in the positive and negative MDFs- variables experienced a greater change in the chief surgeon
lope values, or within the muscle in different situations profile (POMS 8.27–12.88 %; QPFS 28.67–36.67 %; VAS
(within the same surgeon profile and surgical intervention). 50.80–53.00 %) compared to the assistant surgeon profile
(POMS 2.88–5.19 %; QPFS 25–27.33 %; VAS
30.60–34.55 %) (Tables 1, 2). These differences in the
Discussion subjective aspect of fatigue may be attributed to the deci-
sion-making process and the execution of the technique
The aim of this study was to analyse the onset and evo- during surgery, which were two aspects that increased
lution of fatigue experienced by a surgeon (chief and fatigue [29, 30].
assistant) before, during and after surgical interventions After performing the surgery, significant changes (from
using robotic (Da VinciÒ) and laparoscopic surgery pro- pre- to post-intervention) were observed in all OCOM
tocols. The results showed that there were significant dif- variables. In the handgrip test, the chief surgeon experi-
ferences in all outcome variables analysed before and after enced a greater change following laparoscopy (right
surgery; however, the magnitude of the differences was 9.50 kg and left 8.50 kg) with respect to the other sce-
different depending on the profile and the surgical proce- narios, in which the strength decreased by 3.5–4.5 kg
dure performed (Tables 1, 2). In this sense, there were (Tables 1, 2). This difference could be due to the fact that
significant differences in the kinematic variables recorded during robotic surgery, the surgeon experienced little or no

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Table 3 Change in fatigue,

Chief surgeon Assistant surgeon Dif profile post-inter.
‘‘intra-profile’’ (main surgeon
and assistant surgeon) and Pre Post Dif. Pre Post Dif.
‘‘inter-profile,’’ the surgeon
after surgical interventions with PRO
robotic surgery protocol POMS
POMS Index 7.00 40.50 33.50*** 6.00 13.50 7.50*** -26.00***
Anger 0.50 6.50 6.00** 0.00 2.00 2.00** -4.00**
Depression 0.00 1.50 1.50* 0.00 0.00 0.00** -1.50**
Fatigue 0.50 3.00 2.50* 0.00 1.00 1.00* -1.50***
Vigor 2.50 12.00 9.50*** 2.50 4.50 2.00** -7.50**
Friendliness 2.50 11.50 9.00*** 2.50 5.00 2.50** -6.50**
Anxiety 0.50 3.50 3.00*** 0.50 1.00 0.50* -2.50**
Confusion 0.50 2.50 2.00** 0.50 1.00 0.50* -1.50*
QPFS 16.00 68.00 52.00*** 16.00 53.50 37.50*** -14.50**
VAS 21.80 72.60 50.80*** 20.35 54.90 34.55*** -16.25***
Functional test
Handgrip (kg)
Maximum left 39.50 35.00 -4.50*** 39.50 35.50 4.00** -0.50**
Maximum right 40.50 36.50 -4.00*** 41.50 38.00 3.50** -0.50**
Single-leg balance test
Dominant leg
Opened eyes
Time (seg) 30.00 16.25 -14.75*** 30.00 23.49 -7.11*** 7.64***
Displacement (°)
Flex/Ext 2.24 21.09 18.85*** 2.28 17.24 14.96*** -3.89*
Incl. L/R 9.58 24.55 14.97*** 9.68 20.11 10.43*** -4.54**
Rot L/R 9.87 35.24 25.37*** 9.67 29.35 19.68*** -5.69**
Velocity (°/s)
Flex/Ext 40.67 46.18 5.51* 41.89 44.47 2.58 -2.93*
Incl. L/R 23.75 30.48 6.73* 23.51 25.15 1.64 -5.09**
Rot L/R 51.29 58.04 6.75** 55.57 57.80 2.23 -4.52*
Closed eyes
Time (seg) 30.00 9.28 -20.72*** 30.00 12.87 -16.53*** 4.19**
Displacement (°)
Flex/Ext 9.51 48.48 38.97*** 9.41 38.18 28.77*** -10.20***
Incl. L/R 14.01 53.09 39.08*** 14.43 54.03 39.60*** 0.52
Rot L/R 15.29 57.73 42.44*** 15.35 47.36 32.01*** -10.43**
Velocity (°/s)
Flex/Ext 42.09 46.15 4.06* 42.26 43.88 1.62 -2.44*
Incl. L/R 29.67 30.79 1.12 28.56 31.67 3.11* 2.99*
Rot L/R 56.38 55.07 -1.31 54.97 56.75 1.78 3.09**
Non-dominant leg
Opened eyes
Time (seg) 30.00 16.47 -13.53*** 30.00 20.55 -9.14*** 4.39***
Displacement (°)
Flex/Ext 5.84 24.87 19.03*** 5.83 21.89 16.06*** -2.97*
Incl. L/R 11.94 26.53 14.59*** 11.65 21.74 10.09*** -4.50*
Rot L/R 12.33 40.21 27.88*** 12.30 32.92 20.62*** -7.26*
Velocity (°/s)
Flex/Ext 35.68 43. 58 7.90** 39.74 42.75 3.01 -4.89*
Incl. L/R 36.39 44.32 7.93* 26.38 32.91 6.53* 1.40

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Table 3 continued
Chief surgeon Assistant surgeon Dif profile post-inter.
Pre Post Dif. Pre Post Dif.

Rot L/R 52.60 56.37 3.77 56.55 59.21 2.66 -1.11

Closed eyes
Time (seg) 26.45 4.84 -21.61*** 26.60 7.71 -18.89*** 2.72*
Displacement (°)
Flex/Ext 14.32 59.24 44.92*** 14.83 46.48 31.65*** -13.27***
Incl. L/R 19.21 63.44 44.23*** 19.36 54.01 34.65*** -9.58**
Rot L/R 20.74 63.18 42.44*** 22.16 54.36 32.20*** -10.24***
Velocity (°/s)
Flex/Ext 43.55 44.87 1.32 40.50 45.04 4.54* 3.22*
Incl. L/R 27.55 34.15 6.60** 29.48 40.55 11.07** 4.47*
Rot L/R 58.24 60.44 2.20 56.19 63.24 7.05* 4.85*
Pre pre-intervention, Post post-intervention, Dif difference, Dif Profile Post-Inter differences between both
surgeon profiles (chief and assistant surgeon), PRO Patient-Reported Outcome, QPFS Quick Piper Fatigue
Scale, POMS Profile Mood States, VAS Visual Analogue Scale, Flex/Ext flexion–extension, Incl L/R left–
right inclination, Rot L/R left–right rotation
Significance (p): * B0.05; ** B0.005; *** B0.001

resistance to the use of the instruments. This feature is one significant differences in most of the Surgeons’ PROMS
of the great advantages of robotic surgery compared to variables. These results indicate that fatigue perceived by
laparoscopy [5]. the surgeon after the robotic surgery protocol was signifi-
On the other hand, when analysing the results of the cantly higher compared to the laparoscopy surgery protocol
SLBT in tests with the dominant leg with the eyes open and (Table 1). The VAS variable deserves special attention
closed, the changes experienced by the chief surgeon in the because it was a question that the surgeon could interpret in
robotic condition were greater than those experienced in a more open way, integrating concepts and feelings that
the other scenarios. Differences were also significant when perhaps were not included in the POMS and QPFS vari-
comparing the data for the assistant following the robotic ables. The difference in the change experienced by the
and the laparoscopic protocols (Tables 5, 6, 7). Both the chief surgeon after the robotic surgery protocol was 7.5 %.
results of the handgrip and the SLBT were contrary to Likewise, the change in the 15 kinematic variables recor-
those found in a previous study [20] in which, after com- ded during SLBT during the four conditions was signifi-
paring the fatigue of surgeons in robotic and laparoscopy cantly higher after the robotic protocol than after the
protocols, the authors found no significant differences laparoscopy protocol (Table 1). During the robotic surgery
between the two protocols. The differences between studies protocol, the chief surgeon must maintain the same position
may reflect differences in the duration of surgery. In the throughout surgery and cannot modify his position freely.
present study, the mean duration of surgery was 218.46 This could increase the physical fatigue and worsen the
(±14.55) min, while the surgeries analysed in the previ- mental fatigue experienced by the chief surgeon because of
ously mentioned study [20] had a duration of 89 and the constant decisions made during surgery, which would
114 min for the laparoscopic and robotic protocols, explain the difference in fatigue perceived after laparo-
respectively. This increased operating time coupled with scopy and robotic surgery.
the reduction in ergonomics identified elsewhere [5] as one Regarding the change in mental fatigue perceived by the
of the principle issues in robotic surgery might explain the assistant surgeon, there were significant differences in 6 of
differences in the SLBT results observed in the present the 10 Surgeons’ PROMS variables analysed. One reason
study. for this could be that during robotic surgery, the main
function of the assistant surgeon is to exchange the ‘‘arms’’
Inter-profile comparison of the robotic system according to the needs of the chief
surgeon, while during laparoscopy, the assistant surgeon
Comparison of the differences between the chief surgeon must concentrate on giving the chief surgeon the best
after laparoscopy and robotic surgery protocol revealed image through the camera that he holds. These differences

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Table 4 Change in fatigue,

Chief surgeon Assistant surgeon Dif profile post-inter.
‘‘intra-profile’’ (main surgeon
and assistant surgeon) and Pre Post Dif. Pre Post Dif.
‘‘inter-profile,’’ the surgeon
after surgical interventions with PRO
LAPAROSCOPY surgery POMS
protocol
POMS Index 4.50 26.00 21.50*** 3.50 17.00 13.50*** 8.00**
Anger 0.00 2.50 2.50*** 0.50 2.50 2.00** 0.50
Depression 0.00 1.00 1.00** 0.00 0.50 0.50* 0.50
Fatigue 0.50 2.50 2.00** 0.00 1.50 1.50* 0.50
Vigor 1.50 7.50 6.00** 1.50 5.50 4.00** 2.00*
Friendliness 1.50 8.00 6.50*** 1.50 5.50 4.00** 2.50**
Anxiety 1.00 2.50 1.50* 0.00 1.50 1.50* 0.00
Confusion 0.00 2.00 2.00** 0.00 0.00 0.00** 2.00*
QPFS 15.50 68.50 53.00** 16.50 57.50 41.00*** 12.00**
VAS 20.90 64.00 43.10** 21.20 51.80 30.60** 12.50**
Functional test
Handgrip (kg)
Maximum Left 39.00 30.50 8.50*** 39.50 35.00 4.50** 4.00***
Maximum Right 42.00 32.50 9.50*** 41.50 37.50 4.00*** 5.50***
Single-leg balance test
Dominant leg
Opened Eyes
Time (seg) 30.00 19.34 -11.75*** 30.00 21.93 -8.07*** 3.68**
Displacement (°)
Flex/Ext 4.84 23.92 19.08** 3.08 17.33 14.25*** -4.83*
Incl. L/R 9.49 21.26 11.77** 9.68 20.29 10.61*** -1.16
Rot L/R 9.86 28.67 18.81* 9.67 29.37 19.70** 0.89
Velocity (°/s)
Flex/Ext 41.62 43.23 1.61 41.89 43.45 1.56 -0.05
Incl. L/R 23.67 25.00 1.33 23.51 25.23 1.72 0.39
Rot L/R 52.49 56.44 3.95 55.57 56.47 0.90 -3.05*
Closed eyes
Time (seg) 30.00 10.57 -19.43*** 30.00 11.69 -18.31*** 1.12
Displacement (°)
Flex/Ext 9.29 48.97 39.68*** 9.41 39.10 29.69*** 10.01***
Incl. L/R 14.50 44.54 30.04*** 14.43 43.52 29.09** -0.95
Rot L/R 15.68 46.89 31.21*** 15.35 46.18 30.83** -0.38
Velocity (°/s)
Flex/Ext 42.66 42.28 -0.38 42.26 43.30 1.04 1.42
Incl. L/R 29.63 32.81 3.18* 30.56 31.71 1.15 -2.03
Rot L/R 57.45 57.12 -0.33 54.97 55.69 0.72 1.05
Non-dominant leg
Opened eyes
Time (seg) 30.00 16.34 -13.66*** 30.00 19.86 -10.14*** 3.52*
Displacement (°)
Flex/Ext 6.06 20.12 14.06** 5.83 20.15 14.32** 0.26
Incl. L/R 11.78 22.45 10.67* 11.65 22.03 10.38*** -0.29
Rot L/R 12.65 33.21 20.56*** 12.30 32.09 19.79** -0.77
Velocity (°/s)
Flex/Ext 35.31 44.78 9.47** 39.74 43.19 3.45** -6.02**
Incl. L/R 37.23 31.74 -5.49* 26.38 32.17 5.79** 11.28*

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Table 4 continued
Chief surgeon Assistant surgeon Dif profile post-inter.
Pre Post Dif. Pre Post Dif.

Rot L/R 53.59 59.62 6.03** 56.55 58.12 1.57 -4.46*

Closed eyes
Time (seg) 25.97 6.77 -19.20*** 24.61 7.17 -17.44** 1.76
Displacement (°)
Flex/Ext 13.87 49.09 35.22*** 14.83 47.98 33.15*** -2.07
Incl. L/R 19.68 53.70 34.02** 19.36 52.71 33.35*** -0.67
Rot L/R. 21.48 52.44 30.96*** 22.16 52.50 30.34*** -0.62
Velocity (°/s)
Flex/Ext 45.06 42.17 -2.89* 40.50 43.53 3.03** 5.92*
Incl. L/R 28.41 40.29 11.88** 29.48 39.32 9.84** -2.04
Rot L/R 60.27 63.28 3.01** 56.19 61.11 4.92** 1.91
Pre pre-intervention, Post post-intervention, Dif difference, Dif Profile Post-Inter differences between both
surgeon profiles (chief and assistant surgeon), PRO Patient-Reported Outcome, QPFS Quick Piper Fatigue
Scale, POMS Profile Mood States, VAS Visual Analogue Scale, Flex/Ext flexion–extension, Incl L/R left–
right inclination, Rot L/R left–right rotation
Significance (p): * B0.05; ** B0.005; *** B0.001

Table 5 Median values of muscle activation frequency slope for each of the eight muscles analysed for both profiles surgeon (and assistant
chief) and the two protocols of surgery (robotic–laparoscopy)
Robotic Laparoscopy
Chief surgeon Assistant surgeon Chief surgeon Assistant surgeon
Hz/min %/min Hz/min %/min Hz/min %/min Hz/min %/min

Trapecius 1.7554 0.0029 -6.4463 -0.0093 -2.5318 -0.0042 5.9103 0.0111

Medial deltoids -1.4917 -0.0025 6.4848 0.0094 -1.9382 -0.0032 -5.5662 -0.0105
Erector spinae 3.7758 0.0063 2.0991 0.0035 -6.4352 -0.0107 -3.2844 -0.0054
Transverse abdominal -1.2337 -0.0020 5.1128 -0.0074 1.5192 0.0025 4.6192 0.0087
Biceps femoris 1.6331 0.0027 7.0995 0.0103 -2.1219 -0.0035 -3.0469 -0.0058
Vastus medialis -1.9218 -0.0032 7.4441 0.0108 2.5947 0.0043 3.5090 0.0061
Medial gastrocnemius 1.4889 0.0025 6.4250 0.0093 -1.9710 -0.0033 5.6186 0.0106
Tibialis anterior -1.5606 -0.0026 -5.6117 -0.0081 -2.2045 -0.0037 5.2974 0.0100

in changes in Surgeons’ PROMS variables were not on the records collected during surgery, the chief surgeon
reflected in the variables of the functional tests: No sig- demonstrated significantly lower mobility in the robotic
nificant differences were observed in the handgrip test, protocol than in the other scenarios (Tables 3, 5), while no
while in the balance tests, significant differences were only significant differences were observed among the other
observed in 9 of the 28 variables analysed (Table 2). One profiles (Tables 4, 5). The increased fatigue caused by the
possible explanation for these more equal results (espe- lack of mobility may be one reason why the lack of
cially in functional variables) could be found in the higher ergonomics had been identified as a problem in robotic
mobility that the assistant surgeon had relative to the chief surgery. Previous studies have shown that maintaining the
surgeon during both protocols. same non-ergonomic posture causes (in the short term) the
early onset of fatigue and (in the long term) the develop-
Variables measured during surgery ment of musculoskeletal problems, a high percentage of
which are debilitating [31].
In the present study, we considered a surgeon’s mobility On the contrary, none of the muscles studied during
and his muscle activity during surgical interventions. Based surgery exceeded an activation of 25 % MVC, except for

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Table 6 Record kinematic

Chief surgeon Assistant surgeon
variables made during surgery
and differences between the two Robotic Lapar. Dif. Robotic Lapar. Dif.
protocols of intervention
(robotic or laparoscopy) profile Displacement (°)
for the same surgeon (chief or Flexion/extension 8.72 41.09 32.37*** 38.33 39.84 1.51
assistant surgeon)
(±19.30) (±8.66) (±6.35) (±6.77)
Left/right inclination 14.59 38.48 23.89*** 43.37 41.90 -1.47
(±34.80) (±7.39) (±5.73) (±6.09)
Left/right rotation 9.65 43.48 33.83*** 40.39 41.31 0.92
(±23.76) (±6.97) (±7.02) (±6.73)
Velocity (°/s)
Flexion/extension 2.37 19.76 17.39*** 19.27 18.91 -0.36
(±46.91) (±10.03) (±8.22) (±8.44)
Left/right Inclination 4.29 18.43 14.14*** 17.27 16.55 -0.72
(±39.57) (±8.59) (±10.66) (±9.88)
Left/right Rotation 2.69 17.68 14.99*** 17.08 18.49 1.41
(±37.33) (±9.17) (±9.09) (±10.38)
Lapar laparoscopy; Dif difference
Significance (p): * B0.05; ** B0.005; *** B0.001

Fig. 3 Mean frequency muscle activation recorded during the surgical intervention for each muscle analysed

the erector spinae, in which the activation reached an profiles and protocols, the results of the test indicated lower
average of 27.33 % MVC (chief surgeon–robotic protocol) post-intervention fatigue in the chief surgeon–robotic pro-
(Fig. 3). Thus, muscle activation did not reach the mini- tocol. These results may be attributed to the position of the
mum level of activation to cause muscle fatigue [32]. This chief surgeon during the robotic protocol, as he was seated
trend was further confirmed by the MDFslope, which lay with minimal capacity for movement. Thus, one could
between -0.0107 %/min (erector spinae–chief surgeon– argue that muscle activity was required to maintain the
laparoscopy) and 0.0111 %/min (trapezius–assistant sur- position for a long time, while in the other three profiles,
geon–laparoscopy). The rate of change in the MDFslope the surgeon had a greater range of motion. Previous studies
was minimal and, in many muscles, was not negative. have shown that muscle contractions during dynamic
Thus, although muscle activity was comparable between activity promote activation recovery of individual muscle

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Table 7 Median values of muscle activation frequency slope for each of the eight muscles analysed for both profiles surgeon (and assistant
chief) and the two protocols of surgery (robotic–laparoscopy)
Robotic Laparoscopy
Chief surgeon Assistant surgeon Chief surgeon Assistant surgeon
Hz/min %/min Hz/min %/min Hz/min %/min Hz/min %/min

Trapecius 1.7554 0.0029 -6.4463 -0.0093 -2.5318 -0.0042 5.9103 0.0111

Medial deltoids -1.4917 -0.0025 6.4848 0.0094 -1.9382 -0.0032 -5.5662 -0.0105
Erector spinae 3.7758 0.0063 2.0991 0.0035 -6.4352 -0.0107 -3.2844 -0.0054
Transverse abdominal -1.2337 -0.0020 5.1128 -0.0074 1.5192 0.0025 4.6192 0.0087
Biceps femoris 1.6331 0.0027 7.0995 0.0103 -2.1219 -0.0035 -3.0469 -0.0058
Vastus medialis -1.9218 -0.0032 7.4441 0.0108 2.5947 0.0043 3.5090 0.0061
Medial gastrocnemius 1.4889 0.0025 6.4250 0.0093 -1.9710 -0.0033 5.6186 0.0106
Tibialis anterior -1.5606 -0.0026 -5.6117 -0.0081 -2.2045 -0.0037 5.2974 0.0100

Fig. 4 % MVC muscle activation (erector spinae) for two surgeon profiles (chief and assistant surgeon) and for two intervention protocols (Da
Vinci and Laparoscopy) with the fatigue tendency (dashed line)

fibres, causing a better distribution of the stimulus along fatigue during surgery, such as, for example, improved
the entire muscle [33]. Conversely, maintaining the same physical condition.
position during surgery caused increased fatigue as well as
reduced motor control post-intervention [34]. In fact, one Limits and strengths
study suggested the need for micropauses (every 30 min) in
prolonged surgical interventions, which would help to To our knowledge, this is the first study to analyse the
decrease fatigue and its deleterious effects [35]. mobility and muscular activity of a surgeon performing
long-duration surgery (more than 2 h). It is also the first to
Implication of the research compare the results depending on the surgeon profile (as-
sistant and chief surgeon) and intervention protocol (la-
According to the results of this study, fatigue related to the paroscopic and robotic). However, this study also has some
development of robot–surgeon interaction can influence the limitations. For example, the study was conducted on the
results of surgery. Thus, both the most experienced sur- same surgeon (over 15 years of experience in general
geons and medical residents who join the different hospital surgery and surgery on the digestive tract) in the two
services should plan strategies to avoid or limit the onset of analysed profiles (chief and assistant) for the two protocols

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balance in healthy subjects. Isokinet Exerc Sci 14:301–306
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Conclusion (2004) Performance on the balance error scoring system
decreases after fatigue. J Athl Train 39:156–161
13. Riemann BL, Guskiewicz KM (2000) Contribution of the
The main conclusion that can be reached after analysing peripheral somatosensory system to balance and postural equili-
the results of the present study is that long-duration surgery birum. In: Lephart SM, Fu FH (eds) Proprioception and neuro-
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handgrip strength and motor control. However, the mag- gue on indices of balance. J Sport Rehabil 13:312–322
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Disclosure All authors, Manuel González-Sánchez, Ivan González- induced fatigue on postural balance: a comparison of treadmill
Poveda, Santiago Mera-Velasco and Antonio I. Cuesta-Vargas, versus cycle fatiguing protocols. Eur J Appl Physiol
declare that they have no conflicts of interest or financial ties to 113(5):1303–1309. doi:10.1007/s00421-012-2553-z
disclose. 20. Butler KA, Kapetanakis VE, Smith BE, Sanjak M, Verheijde JL,
Chang YH, Magtibay PM, Magrina JF (2013) Surgeon fatigue
and postural stability: is robotic better than laparoscopic surgery?
J Laparoendosc Adv Surg Tech A 23(4):343–346. doi:10.1089/
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