405specifically decreased strength and precision of movement [ 154 ]. Significant
improvement in upper extremity discomfort is due to less time spent in static posi-
tions. Eye fatigue scores improve by 50% when incorporating intraoperative
breaks into laparoscopic surgery [ 155 ]. Short, regular breaks do not significantly
prolong the operation duration [ 56 , 155 ].
Recent studies advocate for stretching during 90 s of intraoperative breaks every
20–40 min during laparoscopic and open surgery [ 56 , 156 ]. Stretching increases
circulation and eases muscle fatigue [ 157 ]. Park et al. studied intraoperative stretches
performed while maintaining sterility. Stretches included neck flexion and exten-
sion, backward shoulder rolls with chest stretch, upper back and hand stretch, low
back flexion and extension with gluteus maximus squeeze, and forefoot and heel
lifts for lower extremity and ankle stretches. They found significant improvement in
neck, shoulder, hand, and lower back pain when compared to control. Surgeons
reported perceived improvements in physical performance and mental focus, and
87% of the surgeons enrolled in the study planned to continue intraoperative stretch-
ing breaks even after the study concluded [ 56 ]. Anecdotally, we have used this tech-
nique during long microsurgery cases, noting decreased pain and stiffness, not only
in surgeons and assistants but also in circulating nurses who spend long periods of
time at the computer.
A potential drawback of this intervention is that breaks create interruptions. This
can decrease compliance by surgeons who do not want to pause the procedure [ 154 ].
However, during a typical procedure without planned intraoperative breaks, work-
flow is interrupted on average 4 min per hour due to personnel- or equipment-related
events [ 158 ]. During a study of intraoperative breaks by Dorion and colleagues, it
was subjectively noted that nursing staff will frequently use the timed breaks to take
care of many of these other potential disruptions [ 154 ].
Prevention of Injury Outside of the Operating Room
Although the operating room is where the majority of ergonomic interventions are
implemented, there are factors outside the operating room which can contribute to
musculoskeletal pain. These factors may be addressed using proper office ergonom-
ics and by maintaining good health through routine exercise and stretching.
Proper Office Ergonomics
Whether it be reviewing charts and films or writing patient notes, a surgeon spends
significant time in front of a computer. The ergonomic considerations for computer
monitor use share similarities with MIS monitors. However, computer viewing
tends to be more near-vision reading work. For this reason, the center of the com-
puter screen should be lowered even more than the MIS monitor as the downward
gaze increases the ability of the eye to accommodate and converge by 25–30%.
Ideal positioning of the computer screen is with the center 20–50° below the eye
22 Surgical Ergonomics