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Received: 1 June 2018 | Accepted: 17 July 2018

DOI: 10.1002/jso.25197

REVIEW ARTICLE

Ergonomics in microsurgery

Chrisovalantis Lakhiani MD1 | Sean M. Fisher MD2 |

David E. Janhofer BS1 | David H. Song MD, MBA1

1
Department of Plastic Surgery, MedStar
Georgetown University Hospital, Abstract
Washington, DC There is a growing body of evidence to suggest that surgeon posture while operating
2
Section of Plastic and Reconstructive
contributes to cervical musculoskeletal strain, discomfort, and chronic pain.
Surgery, University of Washington Medicine,
Seattle, Washington, DC Microsurgeons may be particularly susceptible to this risk due to persistent neck
flexion, long periods of static posture, and the use of heavy, high‐power loupe
Correspondence
David H. Song, MD, MBA, Department of magnification. Several techniques are thus presented that may help in obviating the
Plastic Surgery, MedStar Plastic &
cervicospinal repercussions of performing microsurgery.
Reconstructive Surgery, Georgetown
University Hospital School of Medicine,
Washington, DC. KEYWORDS
Email: David.H.Song@MedStar.net ergonomic, microsurgery, neck pain, posture, reconstructive surgery

1 | BACKGROUND compared with the general surgical population due to repeated

The merits of ergonomic principles are well recognized and heavily
applied in industry, military, and any other fields where sustained
physical performance and productivity are intertwined.1-4 Such
industries have enacted policies and best‐practice standards in an
effort to maximize human capital through the reduction of work‐
related injuries, performance errors, and otherwise lost productivity.
In surgery, work‐related musculoskeletal pain or discomfort can
affect not only the comfort of the surgeon, but also their ability to
complete a surgical operation safely. While population studies
estimate that musculoskeletal disorders (MSDs) affect between
20% and 30% of the general population, certain groups within
5-9
healthcare have been found to far exceed these statistics. Among
surveyed laparoscopic, ophthalmic, and general surgeons, the
reported prevalence of musculoskeletal symptoms in the neck and
shoulders is as high as 87%.10-15 Due to the impending shortage in
the surgical workforce and the extensive time invested in surgical
training, reduced career longevity due to musculoskeletal symptoms
can be construed as a form of healthcare expenditure waste that
diminishes our ability to serve the public need.16
A recent survey of plastic surgeons in the United States, Canada,
and Norway demonstrated a high rate of musculoskeletal symptoms,
with nearly two‐third of respondents reporting neck discomfort related
to their occupation.17 Plastic surgeons were found to be at high risk for
17
work‐related musculoskeletal injuries across the body. Surgeons who
perform microvascular surgery may be at additional risk for MSDs
840 | © 2018 Wiley Periodicals, Inc. wileyonlinelibrary.com/journal/jso
exposure to risk factors associated with MSDs. These include static
and awkward positioning, repetitive motions, hyperflexion of the
cervical spine, and limited recovery time.18-22 Degenerative effects
are compounded by the microvascular surgeonʼs use of loupe
magnification, the operating microscope, and headlamps, each of which
causes further atlantoaxial strain. Musculoskeletal symptoms associated
with operating can manifest in a variety of ways, with the most
frequently affected regions being the neck, shoulders, and lumbar
spine.23,24 Cervicospinal injuries pose a particular threat to micro-
surgical career longevity due to the possibility of progression to
degenerative disc disease with associated cervical radiculopathy. To
date, however, there are limited data describing the frequency or
etiology of cervicospinal injuries in microvascular surgeons.10 The goal
of this review is to evaluate the contributors to cervicospinal injuries
among microvascular surgeons, as well as to summarize the current
literature of surgical ergonomics and propose strategies for injury
mitigation.
2 | C E RV IC A L S P I N E B I O M E C H A N IC S
The cervical spine comprises four distinct sections that contribute to
the kinematics of the neck. The first is the cradle, comprised of the
atlas, occiput, and the corresponding atlanto‐occipital joint, which
permits finite flexion and extension between the head and neck.
Inferior to the cradle lays the axis, which permits axial rotation of the
J Surg Oncol. 2018;118:840-844.

LAKHIANI ET AL.
atlas and the cranium. The third section, the root, comprises the C2
to C3 junction and is typically regarded as the beginning of the non‐
atlantoaxial cervical spine. The column (C3‐C7) represents the final
unit, which allows for further flexion, extension, lateral flexion, and
axial rotation.25
Given the possibility for triplanar deviation from neutral
positioning, 12 distinct movements exist for each functional unit of
21,26
the cervical spine at any given moment. Accurate measurements
of cervical strain are thus difficult to quantify in isolated vectors of
1
force. However, several studies have utilized both cadaveric and
experimental models to demonstrate the substantial loads placed on
a variety of cervical structures during the physiologic range of
motion.27-29
Notably, these experiments have demonstrated a substantial
increase in the force that is imparted on cervical structures with
increasing degrees of neck flexion. With the head positioned 30°
anteriorly beyond a neutral position, there is a fourfold increase in
the weight observed by the cervical spine.30 Clinically, this degree of
flexion translates to a relative risk of greater than 2.0 for the
development of neck pain.31 Though this finding oversimplifies the
complex kinematics at work by neglecting lateral flexion and rotation,
it underscores the considerable increase in force experienced by the
cervical spine when the cranium is held in a flexed posture.
3 | POSTU RE
There is now considerable clinical evidence that identifies static
flexed posture of the neck and shoulders as a risk factor for the
development of MSDs of the neck and upper extremities.32-34 Such
injuries are frequently observed in industries in which a static
downward gaze predominates the working environment, as this gaze
leads to a sustained forward head posture (FHP). 35,36
FHP entails
flexion of the lower cervical spine with associated scapular
protraction, and while it is difficult to establish a causal relationship,
many individuals suffering neck‐related MSDs exhibit such postural
abnormalities.37,38 If left unopposed over long periods of time, this
maladapted posture imparts an increased compressive load on
surrounding tissues, which has the potential to adversely affect
various soft tissue components, bony structures, and neural
elements.39-41 A study of microsurgeon movement determined the
surgeon remained primarily static (0.3 ± 0.4 movements per minute)
while using the microscope compared with at rest (5.5 ± 6.1 move-
ments per minute).7 In another study of otolaryngologists performing
microsurgery, rapid upper limb assessment revealed scores indicating
poor posture and increased risk for neck injury, with neck flexion
beyond 10° associated with increased joint load musculoskeletal
symptoms.42,43
Literature from related fields has shown similar deleterious
effects of sustained FHP. In the field of oculoplastic surgery (OPS),
nearly 60% of surgeons report neck pain associated with surgery and
44
42% have modified OR practices due to symptoms. Loupes and
headlamps are frequently used in the field of OPS and are believed to
10969098, 2018, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jso.25197 by University Of Sydney, Wiley Online Library on [21/01/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
| 841
contribute to musculoskeletal symptoms, as their weight has
considerable effect on user posture.45 This sentiment has been
reflected by a recent field study measuring postural data in various
operative procedures. In over 50 hours of recorded operative time,
surgeons spent 85% of their time in a nonneutral posture with at
least 15° of cervical flexion, while 25% of the operative time was
spent in an extreme posture with at least 45° of flexion.46,47 In
addition, participants were found to have spent equal amounts of
time with added lateral flexion and rotation ranging from 15° to 45°,
thus increasing the overall strain placed on cervical structures.46,47
In the field of otolaryngology, Babar‐Craig et al48 reported a 72%
prevalence of back and neck pain among surgeons in the UK. The
authors noted that otology demonstrated the highest prevalence of
these symptoms and attributed these findings to the frequency of the
microscope use. Orthopedic surgeons have also been found to have
high reported rates of neck and upper extremity symptoms, with the
prevalence of subjective neck and shoulder pain reported as 59% and
34%, respectively.49 The overwhelming majority of orthopedic
surgeons included in the study (84%) felt that the nature of their
work contributed to their symptoms.49 Similarly, high rates of neck
pain and discomfort have been reported in the context of thoracic
surgery and urology.50,51
4 | MUSCULAR FATIGUE
Muscular fatigue is a natural occurrence while operating and likely
significantly contributes to musculoskeletal pain among surgeons.
Progressive surgeon hand, arm, back, and leg muscle fatigue has been
demonstrated via intraoperative electromyographical testing.52 In
another study, surgeons were found to experience a 33% reduction
in isometric contractile arm strength after 2 hours of operating.53
Slack et al54,55 found the brachioradialis muscle to be the first arm
muscle to show evidence of fatigue with prolonged operative time,
and in a separate study demonstrated a notable increase in surgeon
hand tremor of 6.67% per hour of operating time. In addition to
prolonged operative time, mental stressors while operating have
been shown to contribute to physical fatigue and worsen hand
tremor.56 Though not specifically measured in studies, similar
muscular fatigue is likely manifested in neck extensor muscles over
time, further contributing to neck flexion, FHP, and associated
cervicospinal strain.
5 | EFFECTS OF LOUPES, HEADLAMPS,
AND THE OPERATIN G M IC ROSC OPE
The use of loupe magnification has been shown to increase the mean
cervical load by 40% at all postures and across all cervical levels.46,47
This poses a significant threat to cervical health; indeed, more than
80% of surgeons who routinely use loupe magnification report
neck symptoms.47 While their use is necessary in the practice of
microsurgery, diligent selection of appropriate lenses and frames may

842 | LAKHIANI
help to minimize prolonged neck hyperflexion. Important factors to
consider are the loupe magnification, frame weight, declination angle,
and working distance of the lens.
When selecting loupes, one must consider the magnification
needed for the operation, as increasing levels of magnification
significantly increase the weight of the device. In all cases, carbon
fiber and stainless steel frames can be used to help reduce device
weight. Front‐mounted loupes pose a significant disadvantage
compared with through‐the‐lens mounted loupes with regard to
cervical strain; front mounting moves the center of gravity of the
device forward, increasing cervical muscle strain as the neck
extensors work harder to hold the added weight during flexed
posture. The declination angle and working distance of the lens do
not directly influence axial load or cervical strain, but contribute to
the overall line of sight of the surgeon and thus play a critical role in
maintaining appropriate posture.18 Loupes that have an improper
working distance for the required task and/or a declination angle less
than 25° predispose surgeons to postures that may result in neck
18
strain.
Although nearly 70% of plastic surgeons endorse using head-
lamps, they should be used judiciously.44 Sahni et al18 demonstrated
that spinal surgeons who frequently used both headlamps and loupes
reported an increase in the frequency and severity of neck
symptoms. This is the result of the additional moment arm that is
imparted on cervical structures while wearing a headlamp. The added
weight yields concomitant increases in cervical loads at all angles,
18
which may hasten degeneration over time. Furthermore, any
discrepancy between the focal length of loupes and that of the
headlamp provide greater opportunity for the surgeon to assume
45
threatening postures. Therefore, the surgeon must be diligent in
their selection and judicious in their use to avoid protracted exposure
to harmful postures.
While most microvascular anastomoses may be performed with
either loupes or the microscope, use of the latter still predominates
the field.57 In addition, operations requiring high magnification (eg,
lymphatic surgery or digital replantation) necessitate use of the
microscope. Previous studies have observed that use of the operating
microscope constrains the surgeonʼs eye location, reduces comfort,
and may force awkward surgeon positioning.7,58 While adjustable
microscopes may afford the surgeon a neck posture in neutral
position in ideal circumstances, a constrained operating environment
or inappropriate positioning may force the surgeon or assistant into a
flexed or laterally deviated neck position. In one study of
microsurgery trainees, the neck was observed to be flexed greater
than the recommended 10°, 88% of the time while using the
7
operating microscope.
6 | PREVENTATIVE AND CO RRECT IVE
MEASURES
Prevention of cervical MSDs and muscular fatigue begins in
the preoperative arena. Appropriate planning, coordination of
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ET AL.
supplies, and assignment of clear team roles and responsibilities
are paramount for reducing operative time and, therefore, total
cervicospinal strain. Intraoperative breaks are also useful for
musculoskeletal rest and regeneration. Breaks need not be long to
have powerful effects. Dorion and Darveau tested surgeon
accuracy in tracing a star with a Metzenbaum scissor after a
2‐hour‐long operation and found that surgeons who implemented
short, 20‐second microbreaks to rest muscles every 20 minutes
during the operation made sevenfold less errors than surgeons
who did not implement breaks.53 Hallbeck et al59 demonstrated
that stretching and short exercises performed during intraopera-
tive breaks led to self‐reported improvements in surgeon focus,
physical performance, and musculoskeletal wellness. Park et al60
found similar effects of intraoperative breaks on both mental and
physical well‐being and proposed routine intraoperative breaking
as a useful strategy for reducing surgeon physical discomfort and
fatigue.
Physical fitness and exercise have been promoted as ways to
obviate cervicospinal and lower back strain. Both targeted and
general fitness prevent and ameliorate neck injuries by improving
posture and reducing reported symptoms.36,46 Furthermore, FHP
can be corrected by stretching foreshortened trapezius, sternoclei-
domastoid, and levator scapulae muscles and by strengthening the
deep cervical flexors.61 While alterations in posture may translate
to an overall improvement in spinal health over time, both targeted
and general fitness should also be emphasized for symptomatic
management. Regular exercise directly reduces MSD symptoms in
surgeons, with studies supporting the performance of exercise of
>5 hours/week and/or >3 days/week.62 Targeted exercises that
focus on concentric and eccentric contractions with slow lifting
velocity (eg, front shoulder raises, lateral shoulder raises, dumbbell
flies, and shoulder shrugs) have also been shown to reduce neck and
shoulder pain.63
Technological advancements in loupe and microscope tech-
nology may also serve to ameliorate MSDs of the neck and upper
extremities in surgeons. One such technology is the development
of deflection prismatic lenses. These lenses are equipped with a
built‐in declination angle that permits the viewing field to reside
at a fixed angle 5° below a true horizontal line of site. These
lenses clinically reduce neck and shoulder pain by minimizing the
degree of neck flexion required to visualize the viewing field.64
Similarly, the development of stereoscopic video displays may
serve to eliminate the duration of forward head posturing during
microsurgery through the use of a three‐dimensional (3‐D) video
screen and lightweight lenses. In a recent study by Yu et al7
examining the postural changes in microsurgical trainees on
traditional stereoscopic microscopes versus 3‐D video display, the
authors observed that neck angles were a mean 9° to 13° more
neutral, and that the time trainees spent in neck extension was
significantly higher (30% vs 17%). An additional merit of
stereoscopic 3‐D video microscopy is that of enhanced team
engagement in the operation, as the display makes the micro-
scopic field visible to all in the operating room.

LAKHIANI ET AL.
7 | S UMMAR Y
Deteriorating cervicospinal health poses a major threat to the
current surgical community, as a majority of surgeons report some
degree of neck pain and associated MSD. In microsurgery, this risk is
particularly threatening due to the use of high‐power loupe
magnification, the operating microscope, long case duration, and
frequent prolonged awkward neck and body positioning. Awareness
of such health risks may allow microsurgeons to better maintain
ergonomic technique, when possible. The implementation of short
intraoperative breaks and moderate regular exercise, as well as the
judicious use of heavy surgical head gear and new technologies, may
help to ameliorate some of the more untoward aspects of
microsurgical care and afford greater career longevity.
CO NFLICTS OF INTE RES T
The authors declare that they have no conflicts of interest.
OR CID
David H. Song http://orcid.org/0000-0002-8448-0296
REFERENC ES
1. Berguer R. Surgery and ergonomics. Arch Surg. 1999;134:1011‐1016.
2. Chavalitsakulchai P, Ohkubo T, Shahnavaz H. A model of ergonomics
intervention in industry: case study in Japan. J Hum Ergol.
1994;23:7‐26.
3. Svensson E, Angelborg‐Thanderz M, Sjöberg L. Mission challenge,
mental workload, and performance in military aviation. Aviat Space
Environ Med. 1993;64:985‐991.
4. Annett J. The learning of motor skills: sports science and ergonomics
perspectives. Ergonomics. 1994;37:5‐16.
5. Punnett L, Wegman DH. Work‐related musculoskeletal disorders: the
epidemiologic evidence and the debate. J Electromyogr Kinesiol.
2004;14:13‐23.
6. Ibrahim NI, Mohanadas D. Prevalence of musculoskeletal disorders
among staffs in specialized healthcare centre. Work. 2012;41:
2452‐2460.
7. Yu D, Green C, Kasten SJ, Sackllah ME, Armstrong TJ. Effect of
alternative video displays on postures, perceived effort, and
performance during microsurgery skill tasks. Appl Ergon. 2016;
53:281‐289.
8. Gupta BD, Agarwal S, Gupta B, et al. Effect of deep cervical flexor
training vs. conventional isometric training on forward head posture,
pain, neck disability index in dentists suffering from chronic neck
pain. J Clin Diagn Res. 2013;7(10):2261‐2264.
9. Auerbach JD, Weidner ZD, Milby AH, Diab M, Lonner BS.
Musculoskeletal disorders among spine surgeons: results of a survey
of the Scoliosis Research Society membership. . Spine. 2011;36(26):
E1715‐E1721.
10. Capone AC, Parikh PM, Gatti ME, Davidson BJ, Davison SP.
Occupational injury in plastic surgeons. Plast Reconstr Surg.
2010;125(5):1555‐1561.
11. Davis WT, Fletcher SA, Guillamondegui OD. Musculoskeletal occupa-
tional injury among surgeons: effects for patients, providers, and
institutions. J Surg Res. 2014;189(2):207‐212.
10969098, 2018, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jso.25197 by University Of Sydney, Wiley Online Library on [21/01/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
| 843
12. Park A, Lee G, Seagull FJ, Meenaghan N, Dexter D. Patients benefit
while surgeons suffer: an impending epidemic. J Am Coll Surg.
2010;210(3):306‐313.
13. Sivak‐Callcott JA, Diaz SR, Ducatman AM, Rosen CL, Nimbarte AD,
Sedgeman JA. A survey study of occupational pain and injury in
ophthalmic plastic surgeons. Ophthalmic Plast Reconstr Surg. 2011;
27(1):28‐32.
14. Szeto GPY, Ho P, Ting ACW, Poon JTC, Cheng SWK, Tsang RCC.
Work‐related musculoskeletal symptoms in surgeons. J Occup Rehabil.
2009;19(2):175‐184.
15. Wauben LSGL, Van Veelen MA, Gossot D, Goossens RHM.
Application of ergonomic guidelines during minimally invasive
surgery: a questionnaire survey of 284 surgeons. Surg Endosc.
2006;20(8):1268‐1274.
16. Williams TE, Jr, Satiani B, Thomas A, Ellison EC. The impending
shortage and the estimated cost of training the future surgical
workforce. Ann Surg. 2009;250(4):590‐597.
17. Khansa I, Khansa L, Westvik TS, Ahmad J, Lista F, Janis JE.
Work‐related musculoskeletal injuries in plastic surgeons in the
United States, Canada, and Norway. Plast Reconstr Surg. 2018;
141(1):165e‐175e.
18. Sahni D, James K, Hipp J, et al. Is there an Increased incidence of
cervical degenerative disease in surgeons who use loupes and a
headlight? J Spine. 2015;04(5):256. https://doi.org/10.4172/2165‐
7939.1000256
19. Rubin DI. Epidemiology and risk factors for spine pain. Neurol Clin.
2007;25(2):353‐371.
20. Ruitenburg MM, Frings‐Dresen MHW, Sluiter JK. Physical job
demands and related health complaints among surgeons. Int Arch
Occup Environ Health. 2013;86(3):271‐279.
21. Sivak‐Callcott JA, Mancinelli CA, Nimbarte AD. Cervical occupational
hazards in ophthalmic plastic surgery. Curr Opin Ophthalmol. 2015;
26(5):392‐398.
22. Larsson B, Søgaard K, Rosendal L. Work related neck–shoulder pain:
a review on magnitude, risk factors, biochemical characteristics,
clinical picture and preventive interventions. Best Pract Res Clin
Rheumatol. 2007;21(3):447‐463.
23. Esmaeilzadeh S, Ozcan E, Capan N. Effects of ergonomic intervention
on work‐related upper extremity musculoskeletal disorders among
computer workers: a randomized controlled trial. Int Arch Occup
Environ Health. 2014;87(1):73‐83.
24. Soueid A, Oudit D, Thiagarajah S, Laitung G. The pain of surgery: pain
experienced by surgeons while operating. Int J Surg. 2010;
8(2):118‐120.
25. Bogduk N, Mercer S. Biomechanics of the cervical spine. I: Normal
kinematics. Clin Biomech. 2000;15(9):633‐648.
26. Iorio JA, Jakoi AM, Singla A. Biomechanics of degenerative spinal
disorders. Asian Spine J. 2016;10(2):377‐384.
27. Yoganandan N, Kumaresan S, Pintar FA. Biomechanics of the cervical
spine Part 2. Cervical spine soft tissue responses and biomechanical
modeling. Clin Biomech. 2001;16(1):1‐27.
28. Goel VK, Clausen JD. Prediction of load sharing among spinal
components of a C5‐C6 motion segment using the finite element
approach. Spine. 1998;23(6):684‐691.
29. Teo EC, Ng HW. Evaluation of the role of ligaments, facets and disc
nucleus in lower cervical spine under compression and sagittal moments
using finite element method. Med Eng Phys. 2001;23(3):155‐164.
30. Hansraj KK. Assessment of stresses in the cervical spine caused by
posture and position of the head. Surg Technol Int. 2014;25:
277‐279.
31. Lindegård A, Gustafsson M, Hansson GÅ. Effects of prismatic glasses
including optometric correction on head and neck kinematics,
perceived exertion and comfort during dental work in the oral
cavity—a randomized controlled intervention. Appl Ergon. 2012;
43(1):246‐253.

844 | LAKHIANI
32. Aaras A, Fostervold KI, Ro O, Thoresen M, Larsen S. Postural load
during VDU work: a comparison between various work postures.
Ergonomics. 1997;40(11):1255‐1268.
33. Schüldt K, Ekholm J, Harms‐Ringdahl K, Németh G, Arborelius UP.
Effects of changes in sitting work posture on static neck and shoulder
muscle activity. Ergonomics. 1986;29(12):1525‐1537.
34. Winkel J, Westgaard R. Occupational and individual risk factors for
shoulder‐neck complaints: Part II—the scientific basis (literature
review) for the guide. Int J Ind Ergon. 1992;10:85‐104.
35. Szeto GPY, Straker L, Raine S. A field comparison of neck and
shoulder postures in symptomatic and asymptomatic office workers.
Appl Ergon. 2002;33(1):75‐84.
36. Ruivo RM, Carita AI, Pezarat‐Correia P. The effects of training and
detraining after an 8 month resistance and stretching training
program on forward head and protracted shoulder postures in
adolescents: randomised controlled study. Man Ther. 2016;21:76‐82.
37. Braun BL, Amundson LR. Quantitative assessment of head and
shoulder posture. Arch Phys Med Rehabil. 1989;70(4):322‐329.
38. Hanten WP, Lucio RM, Russell JL, Brunt D. Assessment of total head
excursion and resting head posture. Arch Phys Med Rehabil. 1991;72
(11):877‐880.
39. Moustafa IM, Diab AA. The effect of adding forward head posture
corrective exercises in the management of lumbosacral radiculo-
pathy: a randomized controlled study. J Manipulative Physiol Ther.
2015;38(3):167‐178.
40. Harrison DE, Cailliet R, Harrison DD, Troyanovich SJ, Harrison SO. A
review of biomechanics of the central nervous system—Part II: spinal
cord strains from postural loads. J Manipulative Physiol Ther. 1999;
22(5):322‐332.
41. Ferrara LA. The biomechanics of cervical spondylosis. Adv Orthop.
2012;2012:493605. https://doi.org/10.1155/2012/493605.
42. McAtamney L, Nigel Corlett E. RULA: a survey method for the
investigation of work‐related upper limb disorders. Appl Ergon.
1993;24(2):91‐99.
43. Statham MM, Sukits AL, Redfern MS, Smith LJ, Sok JC, Rosen CA.
Ergonomic analysis of microlaryngoscopy. Laryngoscope. 2010;
120(2):297‐305.
44. Sivak‐Callcott JA, Diaz SR, Ducatman AM, et al. A survey study of
occupational pain and injury in ophthalmic plastic surgeons.
Ophthalmic Plast Reconstr Surg. 2011;27(1):28‐32.
45. Rohrich RJ. Why I hate the headlight and other ways to protect your
cervical spine. Plast Reconstr Surg. 2001;107(4):1037‐1038.
46. Nimbarte AD, Sivak‐Callcott JA, Zreiqat M, Chapman M. Neck
postures and cervical spine loading among microsurgeons operating
with loupes and headlamp. IIE Trans Occup Ergon Hum Factors. 2013;
1(4):215‐223.
47. Nimbarte AD, Zreiqat M, Chapman M, Sivak‐Callcott JA, Physical risk
factors for neck pain among oculoplastic surgeons. In: Proc IIE Annu
Conf Expo; May 19‐23, 2012; Orlando, FL
48. Babar‐Craig H, Banfield G, Knight J. Prevalence of back and neck pain
amongst ENT consultants: national survey. J Laryngol Otol. 2003;
117(12):979‐982.
49. Knudsen ML, Ludewig PM, Braman JP. Musculoskeletal pain in
resident orthopaedic surgeons: Results of a novel survey. Iowa Orthop
J. 2014;34:190‐196.
10969098, 2018, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jso.25197 by University Of Sydney, Wiley Online Library on [21/01/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ET AL.
50. Welcker K, Kesieme EB, Internullo E, Kranenburg van Koppen LJC.
Ergonomics in thoracoscopic surgery: results of a survey among thoracic
surgeons. Interact Cardiovasc Thorac Surg. 2012;15(2):197‐200.
51. Wolf JS, Jr, Marcovich R, Gill IS, et al. Survey of neuromuscular
injuries to the patient and surgeon during urologic laparoscopic
surgery. Urology. 2000;55(6):831‐836.
52. Yoon SH, Jung MC, Park SY. Evaluation of surgeonʼs muscle fatigue
during thoracoscopic pulmonary lobectomy using interoperative
surface electromyography. J Thorac Dis. 2016;8(6):1162‐1169.
53. Dorion D, Darveau S. Do micropauses prevent surgeonʼs fatigue and
loss of accuracy associated with prolonged surgery? An experimental
prospective study. Ann Surg. 2013;257(2):256‐259.
54. Slack PS, Coulson CJ, Ma X, Pracy P, Parmar S, Webster K. The effect
of operating time on surgeonʼs hand tremor. Eur Arch Otorhinolar-
yngol. 2009;266(1):137‐141.
55. Slack P, Coulson C, Ma X, Webster K, Proops D. The effect of
operating time on surgeonsʼ muscular fatigue. Ann R Coll Surg Engl.
2008;90(8):651‐657.
56. Growdon W, Ghika J, Henderson J, et al. Effects of proximal and
distal musclesʼ groups contraction and mental stress on the
amplitude and frequency of physiological finger tremor. An accel-
erometric study. Electromyogr Clin Neurophysiol. 2000;40(5):295‐303.
57. Jarrett PM. Intraoperative magnification: who uses it? Microsurgery.
2004;24(6):420‐422.
58. Franken RJPM, Gupta SC, Banis JC, et al. Microsurgery without a
microscope: laboratory evaluation of a three‐dimensional on‐screen
microsurgery system. Microsurgery. 1995;16(11):746‐751.
59. Hallbeck MS, Lowndes BR, Bingener J, et al. The impact of
intraoperative microbreaks with exercises on surgeons: a multi‐
center cohort study. Appl Ergon. 2017;60:334‐341.
60. Park AE, Zahiri HR, Hallbeck MS, et al. Intraoperative "Micro Breaks"
with targeted stretching enhance surgeon physical function and mental
focus: a multicenter cohort study. Ann Surg. 2017;265(2):340‐346.
61. Lynch SS, Thigpen CA, Mihalik JP, Prentice WE, Padua D. The effects
of an exercise intervention on forward head and rounded shoulder
postures in elite swimmers. Br J Sports Med. 2010;44:376‐381.
62. Kitzmann AS, Fethke NB, Baratz KH, Zimmerman MB, Hackbarth DJ,
Gehrs KM. A survey study of musculoskeletal disorders among
eyecare physicians compared with family medicine physicians.
Ophthalmology. 2012;119(2):213‐220.
63. Zebis MK, Andersen LL, Pedersen MT, et al. Implementation of neck/
shoulder exercises for pain relief among industrial workers: a
randomized controlled trial. BMC Musculoskelet Disord. 2011;12:205.
64. Lindegård A, Nordander C, Jacobsson H, Arvidsson I. Opting to wear
prismatic spectacles was associated with reduced neck pain in dental
personnel: a longitudinal cohort study. BMC Musculoskelet Disord.
2016;17:347.
How to cite this article: Lakhiani C, Fisher SM, Janhofer DE,
Song DH. Ergonomics in microsurgery. J Surg Oncol. 2018;118:
840‐844. https://doi.org/10.1002/jso.25197