Ergonomic challenges and barriers of robotic surgery—a review

Introduction

Improved performance, efficiency and user well-being are important advantages of robotic surgery (RS). Despite overcoming many ergonomic challenges of open and laparoscopic surgery, new challenges have been created. The assessment of the ergonomic benefits and detriments of RS can be considered in relation to the domains of posture, organization, and cognition. Despite the many reported benefits relating to improved posture, manipulation and visualisation, there are some unique challenges of RS in these areas which need to be overcome to enhance surgeon performance (1,2). These ergonomic benefits can additionally be enhanced by simple surgeon adjustments and interventions (3). There is a paucity of studies that have reported on the negative ergonomic effects of RS and this is the first review to address the ergonomic challenges and barriers. In a survey of 432 robotic surgeons, 56% reported physical symptoms such as finger and neck pain, and eye fatigue (4). The known ergonomic challenges of RS include fatigue due to longer operating time, lack of haptic feedback, and workflow disruptions related to surgeon separation. These barriers need to be compensated for to improve surgeon well-being. RS can have both beneficial and detrimental effects on the cognitive load of the surgeon. The objective of the review is to present the ergonomic challenges and barriers of RS, as well as practical solutions to overcome them (Table 1).

Methods

A literature search was conducted in February 2025, using PubMed. All English language studies published from inception to February 2025 were considered and no restriction was imposed regarding study design. To find relevant publications, the keywords “barriers”, “challenges”, “ergonomics”, and “robotic surgery” were used. Other keywords used were extracted from previous review articles on ergonomics and RS. These keywords are used as subheadings in the discussion. In addition, a hand search of references cited in the studies and reviews was conducted to ensure literature saturation. Original articles published in peer-reviewed journals were considered.

Posture

The high prevalence of musculoskeletal pain among surgeons can impact surgeons’ comfort, efficiency and career longevity negatively. RS may be less physically demanding because of the surgeon’s seated position and ability to rest the shoulders but may result in a more static posture. Several studies have reported the greatest muscle strain to occur in the shoulders during laparoscopic surgery, in the forearms during RS, and in the neck during both procedures (5-9). The head-down and downgaze positioning of RS can on the one hand result in harmful neck flexion but on the other hand help reduce tear film evaporation as a result of smaller ocular surface exposure and allow a more intuitive line of sight operating (10-11).

Resting of the forearms on the robotic console bar results in less deltoid and biceps activation (12). Sub-optimal upper limb ergonomic positioning during RS occurs when the shoulders are held in an abducted position (13). Judicious use of the clutch system can return the upper limbs to a more ergonomic position with the elbows flexed at 90 degrees, resting comfortably on the console bar and tucked in adjacent to the body (14-16). The surgeon can consciously use the clutch more frequently if aware of situations when shoulder abduction occurs during RS. Certain manoeuvres, such as dissecting in the peripheral working space on the robotic screen and the use of certain instruments, such as the robotic stapler or needle-holder, worsen shoulder postural ergonomics (17). Research has demonstrated ergonomic deficits in the current close console set-up for very short and very tall surgeons due to the limited height range of the robotic console bar (10). This ergonomic challenge is abolished with open robotic console systems, where surgeons can stand up during surgery.

Ergonomic interventions that are effective in reducing upper limb pain during RS include the use of forearm compression sleeves, prevention from strengthening exercises, rest breaks with targeted stretching, ergonomics education, and use of pressure sensors to provide feedback on armrest load (15,16,18-21). Rest breaks with targeted stretching and use of compression sleeves during RS are facilitated by the freedom to move around without restrictions imposed by the need to maintain sterility. Intraoperative microbreaks can interrupt prolonged periods of static posture and low-level intensity muscle activity (22-23). Optimal ergonomic adjustment of the robotic console steps have been recommended, namely: adjusting the chair height to match the popliteal height, moving the chair as close to the armrest as possible, sitting upright and lowering the console to a level where viewing through the binoculars is comfortable, holding the loop controllers with arms by the sides, raising the armrest up to the forearm, and adjusting the pedal position to keep the knees at right angles (24).

Manipulation

RS manipulation ergonomics is enhanced by seven degrees of freedom instrument tip movement, scaling function, fulcrum effect elimination, and ability to control multiple instruments (25). Despite enhanced dexterity supported by the robotic system, detrimental manipulation ergonomics can occur due to a lack of haptic feedback and clashing of the robotic arms. These two factors will be addressed in later sections. Even the potential manipulation ergonomic benefits of RS are not without challenges. Firstly, there is an initial learning curve to attain mastery of the loop controllers to manipulate the flexible instrument tips (26). Simulation training and increasing robotic operating experience facilitate the improvement of manipulation accuracy and speed. Another challenge of RS is temporary neuropraxia of the fingers caused by prolonged pinching of the thumb and index finger placed inside the loop controllers (27). The robotic surgeon can place their thumbs and fingers outside the loops to facilitate relaxation of the finger pulps. Thirdly, the trade-off for improved precision associated with scaling of movement is increased operating time and associated fatigue. Paradoxically, experienced laparoscopic surgeons who are mentally and subconsciously acclimatised to the visualisation-proprioception disconnect between the screen view and the hand position may need to retrain their brain/eye/hand co-ordination to allow for the elimination of the fulcrum effect (28). Finally, control of three instruments and the camera allows the surgeon to operate with more independence but this may be associated with increased cognitive load.

Visualisation

The visualisation ergonomic benefits of RS are due to improved exposure, three-dimensional vision, stable control of the camera and screen located at the line of sight (29). The advantage of three-dimensional vision may be negated in some surgeons who have reduced or no stereopsis (30). Stereoacuity declines with age and may be related to insufficient correction of refractive error (31,32). Correction of refractive error is a simple intervention that can improve three-dimensional vision, especially in older surgeons. Detrimental visualisation ergonomics with RS can occur because of visual fatigue and mismatch between visual and other sensory input. This can be overcome with simple interventions, increasing RS experience, and brain sensory system adaptation. The two main causes of visual fatigue during RS are dry eyes and accommodative stress. Use of lubricating eye drops, screen breaks (utilising the 20:20:20 rule of 20-second break every 20 minutes to view a distant object at 20 feet), blink efficiency training (to induce motor memory with repeated complete blink practice sessions), and correction of refractive error are simple non-invasive interventions which can reduce visual fatigue (33). Visual-perception mismatch can occur during RS because the use of the clutch can lead to a brain sensory misalignment of surgeon’s hand and instrument tip positions. An initial simulation RS study involving novice surgeons found that visual-perception mismatch impaired performance (34). However, a subsequent real-life study involving an experienced surgeon found that visual-perception mismatch was well compensated for during RS (35).

Fatigue

Physical and mental fatigue from prolonged operating time are potential ergonomic detriment of RS. Robotic colorectal surgery has been demonstrated to take longer than laparoscopic colorectal surgery. Two meta-analyses reported increased mean operating times of 56 minutes and 38 minutes with robotic compared to laparoscopic colorectal surgery (36,37). This finding may be partly related to the fact that most series reported on case series when mainly hybrid procedures were performed, as demonstrated by a low total robotic console time to total operation time ratio (38). Other factors such as surgeon experience, case complexity, and surgery team familiarity also impact operation duration (39).

Prolonged operating time has been associated with muscle and visual fatigue, resulting in impaired precision as well as digital eye strain symptoms (29,40,41). Deterioration in performance and symptoms of mental exhaustion, irritability and impaired surgical judgement can develop after two to four hours of operating time (42,43). A meta-analysis and other studies have demonstrated cognitive performance to be more impaired than psychomotor skills with fatigue, and therefore, more emphasis should be placed on preventing cognitive errors when surgeons are tired (44,45).

There are several interventions with varying outcomes that may help reduce fatigue and improve concentration. These interventions include avoidance of sleep deprivation, scheduled and unscheduled intraoperative rest breaks, scheduling RS cases to commence in the morning, caffeine use, meditation, mindfulness intervention and intermittent stretching exercises (44,46-49).

Lack of haptic feedback

One of the main ergonomic disadvantages of the robotic system is loss of force and tactile feedback, which can result in inaccurate application of force. To compensate for the lack of haptic feedback, experienced robotic surgeons use tissue deformation cues from restoration of three-dimensional (3D) vision (50). Another technique to compensate for the lack of haptic feedback is the creation of a safe surgical operating zone with virtual boundaries (51). Simulation studies have reported reduced grasping forces, enhanced precision, and improved performance with the addition of haptic feedback during RS (52-54). Recognising the importance of haptic feedback, the newer robotic systems, such as Senhance and the updated Intuitive da Vinci 5 surgical system, do offer force feedback via sensors near the instrument tips.

Robot arm clashes

One challenge that is unique to RS is robot arm collision, which can restrict movement, impair control of instruments, and cause trauma to the bedside assistant or patient. Robot arm clashes can be reduced by wider spacing of ports, use of targeting at the beginning of the case to align the arms towards the target, ensuring even spacing of the robotic arms, aligning the vertical ports perpendicular to the main target site and use of the patient clearance buttons which can drop the posterior elbows of the robot arms (55,56). With multi-quadrant surgery, re-docking of the robot with the closed console systems is sometimes required to reduce robotic arm clashes and facilitate dissection. Arm collisions can be more easily avoided with robotic systems that use individual patient carts for each arm than with a single integrated patient cart.

Workflow disruptions

Surgeon separation from other team members and the patient is the main contributor of workflow disruptions during RS (57). Workflow disruptors are unexpected deviations from the natural progression of surgery and have been attributed to difficulties of communication, coordination, surgeon factors, training, situation awareness, instrument changes and spatial configuration (58). The review article reported a lack of research into the implementation and outcome evaluation of interventions in RS, even though the causes of flow disruptors have been well described (58). The possible organizational interventions include enhancement of communication (such as use of precise language, noise-cancelling headsets, or open robotic console system), team briefing or checklist use to improve coordination, leadership training, enhancement of teamwork and collaborative team situation awareness, and change of spatial configuration to improve movement efficiency (59,60). Another method to categorize interventions that overcome workflow disruptions is the resilience supports (61). These responses to unexpected event adaptations may be related to the team, task, tools, technology, organisation, and environment (62).

Cognition

Cognitive ergonomics encapsulates the mental resources (working memory, sensory motor response and perception) required to complete a task (63). The impact of RS on cognition is complex but likely to be overall beneficial (64). Improvement of RS physical ergonomics facilitates the delegation of less cognitive resources to physical tasks. However, fatigue, multi-tasking and the lack of haptic feedback may have a detrimental effect on cognitive load (65). Similarly, organisational ergonomic issues related to workflow disruptions from team separation and reduced situation awareness may increase cognitive load. Improved communication, anticipation by team members, and shared situation awareness/mental models are some organisational interventions which can help reduce surgeon cognitive load (66,67).

Cognitive training can facilitate automatic performance of tasks by reducing working memory with the use of repetition and the automation of constructed schemas (68,69). Cognitive training can improve skills such as memory, attention and problem-solving. Cognitive training techniques include mentorship, cognitive simulation training, mental rehearsal, technical practice, video review and cognitive task analysis (CTA). Mentorship allows real-time assessment and feedback. Mentorship can be facilitated by the dual console robotic system design because the mentor can assist and take over certain parts of the surgery for demonstration purposes (70). Mentoring during RS can develop not only the motor technical skills but also the cognitive skills (71). Mental rehearsal involving motor imagery without execution has been shown to be an effective intervention to improve technical robotic skills (72). CTA based training involves expert review and analysis of the cognitive processes involved in each key operation step (73). The structured CTA training framework can involve the analysis of the sequence of tasks, explanation of the rationale behind important decision points, provision of technical tips for key steps, as well as implementation of strategies to avoid potential pitfalls and manage complications.

Bedside assistant

Despite ergonomic benefits of RS for the bedside assistant, such as the ability to sit down during much of the operation and avoidance of prolonged static posture holding the laparoscope and instrument with outstretched arms, there are ergonomic detriments which include impairment of effective communication and collision with the robotic arms (74,75). Being aware of certain predictable situations when collisions between robotic and bedside assistant arms occur can allow the operating surgeon to consciously avoid them (74). Judicious positioning of ports, previous surgeon bedside assistant experience, anticipatory communication, and moving the robotic arms more slowly to adjust for the scaling component of the fulcrum effect are interventions that can prevent bedside assistant injury.

Conclusions

This review has demonstrated that there are ergonomic challenges to overcome with RS, despite the overall ergonomic benefits. Previous review articles on this topic reported mainly on the organizational ergonomic detriments. The strength of this review is that it has also reported on the potential physical and cognitive ergonomic detriments of RS. The main limitation of the review article is that some of the described interventions are based on simulation studies involving novice surgeons and, therefore not generalizable to real-life surgery and experienced surgeons. Some of the interventional studies involved surgeons performing non-RS, computer screen users, or sportspeople.

The availability of haptic feedback in the newer versions of the robotic console system may allow research into the impact of its introduction in real-life surgery. There is great potential for future interventional research assessing the impact on surgeon well-being and patient outcome during non-simulated RS. Some of the detrimental ergonomic effects of RS can be overcome with non-invasive interventions and by gaining more experience operating with the robotic system.

Acknowledgments

None.

Footnote

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-25-10/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-25-10/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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