Surgeons are known to be a unique group of healthcare professionals that are at a higher risk for the development of a range of work related musculoskeletal (MSK) pains and injuries. MSK disorders are typically defined as musculoskeletal complaints, symptoms, or pain that reflect a number of conditions, such as neck pain, back pain, shoulder pain, pain of limbs, carpal tunnel syndrome, myofacial dysfunction syndrome, atypical facial pain, and so forth [1]. These could range from mild, infrequent symptoms, to severe and debilitating ones [2], interfering with surgeons daily activities.

As the popularity of bariatric surgery increases [3], efforts into improving its patient safety and decreasing its invasiveness have also been on the rise. However, with this shift towards minimal invasiveness, surgeon ergonomic constraints have been imposed, with recent reports showing a 73–88% prevalence of physical complaints in surgeons performing laparoscopic surgeries [4,5,6]. And while newer techniques in minimally invasive surgeries, such as natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS) have greater benefits for the patient [7, 8], they have been shown to increase the physical workload for the surgeon [9,10,11]. On the other hand, the recent emergence of robotic surgery may provide the surgeon with ergonomic benefits; allowing the surgeon to operate from a seated position, with more degrees of freedom for instrumental movement and 3 dimensional vision [12, 13].

The physical posture, therefore, of a bariatric surgeon while providing care to their patient should ideally be that all muscles are in a relaxed, well-balanced, and neutral position. Postures outside of this neutral position for a prolonged period, such as those experienced during surgery, are likely what cause the musculoskeletal discomfort experienced by this population of physicians [14].

We, therefore, conducted a study to explore the prevalence of MSK pain and injuries in bariatric surgeons from around the world, investigating possible factors contributing to these injuries.

Methods

Survey

We developed an online, web-based survey adapted from the previously validated Nordic Musculoskeletal Questionnaire [15] using an online survey generator. We have attached a sample of the questionnaire in Fig. 1. The survey was then sent out to bariatric surgeons around the world through multiple social media platforms. Participants were queried about professional background and demographics, primary practice setting, and various issues related to bariatric surgeries and MSK injuries. Demographics collected included gender, age, height, weight, years practicing, average hours in the operating room per week, glove size, and most commonly employed operating position.

Fig. 1
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Sample of the survey

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The sections of the survey included: demographics, physician visits, bariatric surgery background data, bariatric procedures, revisional bariatric procedures, and discomfort and procedure duration. The symptom portion of the questionnaire inquired about the nine different anatomic regions used in the NMQ: neck, shoulders, elbows, wrists/hands, upper back, lower back, hips/thighs, knees, and ankles/feet. The survey skipped to the next section if a respondent indicated no pain experienced in any body region. If they answered positively, however, further questions followed. These included questions about interference with work, difficulties, and characterization of the difficulty (pain, stiffness, weakness, paresthesia, or other), severity (scale of 0–10), whether the symptoms stopped the surgeon from operating, and whether the surgeon attributed their symptoms to their work.

Statistical analysis

The study was conducted anonymously between May 2017 and August 2017, receiving responses from 113 bariatric surgeons from around the world. Descriptive statistics were analyzed using SPSS software version 22. The significance of the difference between the two values was analyzed using a two-tailed unpaired Student’s t test. Significant levels were assessed at p-value < 0.05. %.

Results

A total of 113 bariatric surgeons from 34 countries around the world completed the survey during the period of data collection, with the majority (15.9%) being from Kuwait. Of the respondents, 94.7% were men, with an average age of 45.2 years. The rest of the demographics are summarized in Table 1. Details on respondents’ health status are reported in Table 2.

Table 1 Demographics
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Table 2 Physician visits
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Table 3 summarizes the experiences of the surgeons in open versus laparoscopic versus robotic surgery. It was seen that 98.2% of surgeons reported performing sleeve gastrectomy, and 88% reported performing gastric bypasses, with 65.7% performing the surgery in the French position (Tables 4, 5).

Table 3 Background data
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Table 4 Bariatric procedures
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Table 5 Revisional bariatric procedures
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66% of participants reported that they have experienced some level of discomfort/pain attributed to surgical reasons, causing the case load to decrease in 27.2% of the surgeons (Table 6). It was seen that the back was the most affected area in those performing open surgery, while shoulders and back were equally as affected in those performing laparoscopic, and the neck for those performing robotic (Fig. 2), with 29.4% of the surgeons reporting that this pain has affected their task accuracy/surgical performance. As demonstrated by Fig. 3, the nature of the discomfort experienced was shown to be mostly pain for open and laparoscopic surgery, but of the fatigue nature for robotic surgery (Fig. 4). Figure 5 illustrates the difference between genders when it came to assessing the location of pain according to the type of surgery. A higher percentage of females than males reported pain in the neck, back and shoulder area when performing laparoscopic procedures. Supine positioning of patients evoked more discomfort in the wrists, while the French position caused more discomfort in the back region. An interesting observation was seen when correlating amount of physical exercise per week with pain/discomfort during surgery. It was seen that a higher percentage of surgeons that did not exercise experienced more issues in the neck and back region, while those that exercised more than 3 h a week experienced issues in their shoulders and wrists in both open and laparoscopic approaches.

Table 6 MSK injuries attributed to bariatric surgical procedures
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Fig. 2
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Percentage of surgeons that had experienced abnormal amounts of pain or discomfort by area

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Fig. 3
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Nature of the pain/discomfort experienced by surgical approach

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Fig. 4
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Pain or discomfort experienced according to gender

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Fig. 5
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Pain or discomfort experienced according to weekly hours of exercise

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Only 36.9% of the respondents who had experienced pain/discomfort due to surgical reasons had some form of imaging done to diagnose the problem (Table 6) and 57.7% sought medical treatment for their MSK problem, of which 6.35% had to undergo surgery for their issue, and 55.6% of those felt that the treatment resolved their problem.

Discussion

Work-related MSK injuries are one of the most important occupational health issues among health care workers, and with the high physical demands of surgeons’ daily activities, high rates of MSK injuries have been reported, specifically between the orthopedic surgery group [16,17,18]. This has been hypothesized to be due to the fact that a static posture needs to be maintained for long periods of time while using precision hand and wrist movements during surgical procedures [14]; in a systemic review conducted, Alleblas et al. [19] was able to show that the prevalence of MSK complaints was 74% among surgeons. This number is comparable to our percentage of bariatric surgeons that had reported the existence of some form of MSK problem that they would attribute to their work. However, there are currently no studies that look specifically into the prevalence and cause of MSK injuries and pain the bariatric surgery group.

A possible angle to consider is that, while the prevalence of bariatric surgery is on the rise [3], the shift towards the laparoscopic approach has become more prominent, with 68.5% of our study population having over 10 years of experience in laparoscopic bariatric surgery as of 2017. This has been hypothesized to be due to the fact that laparoscopic bariatric surgeries are the preferred approach from the patients’ perspective, as well as the most recommended approach by guidelines, given the lower complication rates and improved aesthetics over the open approach [20,21,22]. However, this comes with its own consequences given a different form of physical demand and physical workload for the surgeon, taking little consideration of ergonomics. As shown by our study, 58.4% of bariatric surgeons complained of pain in their shoulders, as well as in the back region and 40.59% reported having pain in their wrists and fingers while performing laparoscopic bariatric surgeries. These numbers were shown to be notably higher than those for the open approach, with 15.2 and 20.7% reporting pain in their wrists and fingers, respectively. This observation is understandable given the equipment and surgical techniques employed in laparoscopic bariatric surgeries.

One reported benefit from the introduction of robotic surgery in bariatrics is the superior ergonomics that it is known to offer. However, from our study population, it was shown that 69.2% of the surgeons complained of having had some form of pain or discomfort in the neck that they attributed to performing bariatric surgery using the robotic approach. This can be explained given the position in which robotic surgery is performed. This has also been shown to be the case in several previous studies conducted [4, 23,24,25], but at a much lower average prevalence of 35% than in our study population.

An interesting observation noted was the difference in results when comparing genders. On average, female surgeons are known to have smaller hands and glove sizes, and therefore, the “one size fits all” of the laparoscopic equipment handles may be a cause of discomfort [4, 9]. However, according to our results, male participants tended to exhibit more pain during laparoscopic bariatric procedures in their wrists and fingers compared to the female ones (17.6% and 18.0% vs. 11.8% and 5.9% respectively), but vice versa when it came to neck and shoulder complaints (15.8% and 23.9% vs. 23.5% and 35.3%). This finding could be influenced by the anatomical muscular differences between the sexes, as well as the differences between working life and private circumstances [26].

Physical complains may be thought of as “part of the job”, however, when such complaints appear to influence the quality of surgical care, it becomes a matter of concern. As was shown by our study, 27.2% of the surgeons felt like the pain they had experienced had caused them to decrease their caseload, with 29.4% of the surgeons reporting that this pain has affected their task accuracy/surgical performance. Multiple previous studies illustrated the same finding, with surgeons believing that their surgical performance was negatively affected by their own injury or pain [27,28,29]. This observation is of concern and raises the question as to what should be done to decrease these modifiable factors.

The limitations of our study include the use of self-reported measure to assess the degree of pain, as well as recall bias, as the disorders were surgeon-reported injuries. However, while subjective reports are not alone diagnostic of musculoskeletal pathology, subjective complaints remain the most common manifestation of musculoskeletal occupational injury.

Conclusion

MSK injuries and pain are a common occurrence among the population of bariatric surgeons, and has the ability to hinder performance at work, decreasing case loads and performance. Therefore, it is of importance to investigate ways in which to improve ergonomics for these surgeons as to improve quality of life. From our results, we could see that the French position was a cause of back pain, while lack of exercise was correlated to neck and back issues.