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Unfortunately, these aprons weigh an average of 10 pounds and lead to increased
muscle strain of the trunk, most notably the trapezius and pectoral muscles [ 140 ,
141 ]. Back pain is reported in over half of interventional cardiologists and vascular
surgeons who routinely use lead aprons [ 48 , 142 ]. It is important to have an appro-
priately fitted radioprotective apron, not only for comfort of fit but also to avoid the
extra weight from an apron that is too large. Ideal lead aprons are two pieces
because the weight on the lower section is distributed on the pelvis rather than
entirely on the shoulders [ 143 ].
Surgical Warm-Up
Warm-up exercises are a standard activity for professional sports players, musi-
cians, and singers. Physical warm-up decreases injury in other professions by
increasing flexibility, circulation, and muscle temperature [ 144 , 145 ]. Many sur-
geons perform “mental warm-up” exercises by reviewing imaging and discussing
the surgical approach prior to cases. However, physical warm-up exercises have not
been widely adopted by surgeons. Although surgical skill warm-up has not yet been
proven to decrease the risk of musculoskeletal discomfort in surgeons, many other
important benefits have been noted. In 2012, Lee et al. studied the effect of a 20-min
warm-up 1 h prior to laparoscopic renal surgery as compared to no warm-up. The
warm-up involved completing an electrocautery skill task on a simulator and 15 min
of laparoscopic suturing and knot tying in a pelvic box trainer. Following the warm-
up, video analysis of operative technique showed an improvement in hand move-
ment smoothness, tool movement smoothness, and posture stability. Pupillary eye
tracking showed an increase in attention, and mental workload was significantly
decreased as analyzed by electroencephalogram [ 146 ]. Chen et al. performed a sim-
ilar study and found that a brief (<15 min) warm-up on a low-fidelity laparoscopic
trainer immediately prior to laparoscopic surgery improved the intraoperative per-
formance of the resident irrespective of resident level of training or case complexity
[ 147 ]. Similar results have been shown using a robotic simulator for warm-up prior
to robotic-assisted surgery [ 99 , 148 – 150 ].
Intraoperative Breaks
Many high-risk professions have mandated breaks, including airplane pilots,
nuclear power plant employees, and air-traffic control workers to mitigate fatigue,
improve employee health, and enhance safety [ 151 – 153 ]. Studies of intraopera-
tive breaks during MIS and open surgery have varied in break timing and duration
and range from 20s breaks every 20min to 5min breaks every 40 min [ 56 , 154 ,
155 ]. More frequent short breaks are superior to fewer long breaks in reducing
muscular fatigue [ 112 ]. Intraoperative breaks have been shown to decrease sali-
vary cortisol, suggesting that breaks decrease stress [ 56 ]. They also have been
shown to almost entirely prevent the effects of musculoskeletal discomfort,
C. Ronstrom et al.