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the residency program [ 59 ]. Evidence suggests that trainee and surgeon perfor-
mance improves when optimizing posture [ 102 ], monitor position [ 46 , 98 , 121 –
123 ], and table height [ 97 , 132 ]. Surgical warm-up [ 99 , 146 – 150 ] and intraoperative
breaks [ 56 , 154 , 155 ] have similar benefits.
Ergonomic education may be as simple as providing in-person feedback in the
operating room. Franasiak and colleagues found that, following in-person ergo-
nomic training in robotic surgery, 88% changed their practice and 74% noted
reduced muscular strain. All these surgeons found in-person education helpful and
felt formal ergonomic training should be required for robotics [ 20 ]. In-person ergo-
nomic education should encompass walking the resident through proper operating
room setup. This includes placing the top of the monitor at eye level and directly in
front of the surgeons [ 91 , 119 , 122 , 123 ], placing the foot pedal directly in front of
the working foot [ 133 ], and adjusting the operating surface to pubic height for lapa-
roscopic cases [ 130 , 131 ] and to elbow height for open cases while taking into
account the height of the resident [ 129 ]. Staff surgeons may also implement intra-
operative breaks allowing all members of the surgical team to reap the benefits.
Given that the ACMGE requires all surgery programs to have access to a simula-
tion lab, ergonomic training may take place in a simulated setting [ 58 ]. Xiao et al.
found that a series of exercises simulating various table and monitor heights and
ideal ergonomic setup helped surgeons understand human factors in the operating
room [ 99 ]. Residents may practice operating with correct posture in the simulation
lab without concern for distraction from the operative case. We have found that a
short course of didactic instruction, self-assessment of postures from their own sur-
gical videos, and simulation lab practice are effective in raising awareness of ergo-
nomics among both residents and attending surgeons. This is best followed up with
in-person intraoperative coaching to help with implementation. Residents can also
use simulators to warm-up prior beginning the operative day. Ergonomists are avail-
able at some institutions and can work directly with staff surgeons and residents,
especially in the office environment.
Finally, attending surgeons have the opportunity to help change some negative
aspects of surgical culture. Surgical culture not only tends to deny the presence and
negative impact of musculoskeletal discomfort but is also resistant to changes in
surgical practice. Surgeon educators play a key role in demonstrating to residents
how competent leaders facilitate changes in practice, set up ergonomically friendly
operating rooms, demonstrate proper instrument use, maintain correct postures, and
incorporate breaks and warm-ups into their routines. Understanding the impact of
ergonomics on intraoperative performance will lead to innovative research and
intervention strategies for prevention of musculoskeletal injury to improve the per-
formance and well-being of the next generation of surgeons.
Acknowledgments This material is the result of work supported with resources and use of facili-
ties at the Minneapolis VA Health Care System.
Disclaimer The contents of this publication do not represent the views of the US Department of
Veterans Affairs or the US government.
C. Ronstrom et al.