Abstract
Background
Surgeons are actively seeking ways to enhance operating room ergonomics. A comprehensive report on surgeon job-related disease and injuries could raise awareness, encourage workplace improvements, and emphasize the importance of ergonomic practices such as body posture awareness, appropriate operating room setup, and exercise to lessen discomfort and improve general health.
Purpose
To address the ergonomic challenges that surgeons in Jordan face during their work and to investigate how demographic variables may impact a surgeon’s ability to perform open and laparoscopic procedures proficiently.
Methods
This cross-sectional observational study investigated the ergonomics of surgical practice and evaluated the impact of demographic factors on the proficiency of surgeons performing both open and laparoscopic procedures. Using a self-administered questionnaire, data were gathered from 150 Jordanian doctors who had completed more than six months of surgical training and were employed by the government, the military, or the private sector.
Results
In this study involving 150 surgeons in Jordan, demographic characteristics were assessed, revealing that male respondents, particularly from the military sector, had higher mean scores in both laparoscopic and open surgical approaches. Multiple linear regression analysis identified private institutions and military affiliation as significant positive predictors for achieving high scores in laparoscopic procedures, while exclusive military affiliation emerged as the sole significant predictor for open procedures.
Conclusion
The study highlights surgical ergonomics’ role in reducing pain and improving outcomes. Prioritizing appropriate ergonomic training, encouraging discomfort reporting, and raising awareness of official recommendations are critical for the longevity of surgeons’ careers, well-being, and, ultimately, better patient outcomes.
Keywords: Surgical ergonomics, Surgeon health, Laparoscopic surgery, Open surgery, Demographic factors, Jordanian surgeons, Occupational injuries
Introduction
Many surgeons have suffered from work-related injuries such as carpal tunnel syndrome, lumbar disc herniation, or cervical spinal stenosis [1–5]. Surgeons who sustain these injuries may have to have surgery themselves, take time off, or perhaps retire sooner than expected [1, 5]. In addition to potentially restricting overall work effectiveness, chronic pain, numbness, and exhaustion can also arise over years of manual labor rather than from a specific injury [6].
While this issue was mainly neglected in the past, surgeons are now actively looking for ways to enhance the ergonomics of operating rooms. However, surgical ergonomics research and development lag significantly compared to other industrial domains [6]. Consequently, a thorough report on the diseases and injuries suffered by surgeons on the job could raise awareness of ergonomic problems in the operating room and draw attention to any possible impact, thus encouraging improvements in the workplace [6].
Enhancing surgical ergonomics might lessen discomfort and lessen unfavorable effects. This includes being conscious of one’s body posture and appropriately setting up the operating area. Additional tactics include warming up before the initial surgery and pausing during the procedure as arranged. Surgeons can lessen pain outside the operating room by making their workspace more ergonomic and frequently exercising and stretching to stay in excellent health [7]. Ergonomic principles should be taught to residents by surgeon educators, who should also demonstrate how they should be used in the operating room [7].
We performed this cross-sectional observational study to determine which type of surgery—open or laparoscopic—is better for surgical ergonomics.
Materials and methods
Study design and objectives
This was a cross-sectional observational study. The objective is to shed light on the ergonomic aspects of surgical practice and comprehend how demographic variables affect a surgeon’s proficiency in open and laparoscopic procedures.
Data collection instrument
The study used a self-administered questionnaire to collect data from surgeons working in Jordan. The survey data were electronically gathered via Google Forms and was entered into an Excel spreadsheet.
The questionnaire was adapted from and informed by previously validated instruments used in ergonomic assessments in surgical settings, including those reported by Plerhoples et al. (2012), Sari et al. (2010), and Gabrielson et al. (2021) [8–10]. The full questionnaire is provided in the supplementary materials.
Study population and sampling
After consulting the Jordan Medical Association, the study targeted 150 physicians with surgical training exceeding 6 months, residing in Jordan, and currently working in either the Ministry of Health, the military, or the private sector. The sample was obtained by querying the Jordanian Medical Association for a representative sample, and the request was aimed to ensure that the sample was representative of the larger population of physicians meeting the inclusion criteria.
Inclusion criteria
Physicians with surgical training exceeding 6 months.
Currently working in the Jordanian Ministry of Health, the military, or the private sector.
Proficiency in laparoscopic or open surgery.
Exclusion criteria
Physicians do not meet the inclusion criteria for surgical training duration or employment setting.
Physicians are involved exclusively in robotic or endoscopic surgery.
Ethical consideration
These measures included protecting doctors’ identities by ensuring anonymity for physicians, not using pictures of patients, getting informed consent, and permitting voluntary involvement.
Statistical analysis
Statistical Package for Social Sciences (SPSS) version 26 was used for statistical analysis. Descriptive analysis displayed categorical variables as percentages and frequencies while presenting numerical variables as a mean and standard deviation to evaluate the data quantitatively. Normality was tested using the Shapiro–Wilk test. Independent t-tests and ANOVA were conducted to assess potential differences in means among variables. Multiple linear regression was used to investigate potential predictors for having higher scores in laparoscopic and open approaches. In the laparoscopic model, the correlation coefficient (R) was 0.304, suggesting a weak positive correlation between the independent variables and the total score. The coefficient of determination R2 was calculated at 0.093, indicating that the included independent variables can explain approximately 9.3% of the variance total score. The adjusted R2 was notably lower at 0.020, reflecting a minimal improvement in explanatory power.
Additionally, the Durbin-Watson statistic yielded a value of 1.709, implying the potential presence of positive autocorrelation in the residuals. In the open approach model, R was 0.281, and R2 was 0.079, suggesting that the included predictors can explain approximately 7.9% of the variability in the total score. The adjusted R2 is relatively low at 0.005, indicating a limited improvement in explanatory power. Additionally, the Durbin-Watson statistic is 1.585, suggesting a potential presence of positive autocorrelation in the residuals. A p-value of less than 0.05 was considered statistically significant.
Questionnaire pilot assessment
A pilot assessment was carried out to evaluate a questionnaire’s readability, comprehensibility, and content reliability. This study included 24 participants, and the overall Cronbach’s Alpha coefficient was 0.930. Specifically, the laparoscopic scale demonstrated a coefficient of 0.860, while the open procedure subscale showed a coefficient of 0.887.
Results
Demographic characteristics
One hundred and fifty respondents filled in the questionnaire. The male respondents numbered 104 (69.3%). The mean age of the male respondents was 33.65 ± 6.72 (± SD). Many lived in the central area, accounting for 127 (84.7%). Eighty-five were married (56.7%) and had a monthly income of less than 1000 JDs (56.7%). Sixty-seven had less than five years of work experience (44.7%). Eighty-six were general surgeons (57.3%), while the rest comprised 64 (42.7%) general surgery residents. Fifty-six respondents were working in either public (37.3%) or private (37.3%) sectors, while the remaining respondents were in the military (25.4%). Table 1 shows the demographic characteristics of the included participants.
Table 1.
Demographic characteristics. (n = 150)
| Item | Frequency (%) |
|---|---|
| Age in years (mean ± SD) | 33.65 ± 6.72 |
| Gender | |
| Male | 104 (69.3) |
| Female | 46 (30.7) |
| Residency | |
| North | 16 (10.7) |
| Central | 127 (84.7) |
| South | 7 (4.6) |
| Social status | |
| Single | 65 (43.3) |
| Married | 85 (56.7) |
| Monthly income | |
| Less than 1000 JDs | 85 (56.7) |
| More than 1000 JDs | 65 (43.3) |
| Years of experience | |
| Less than 5 years of experience | 67 (44.7) |
| More than 5 and less than 10 years | 55 (36.7) |
| More than 10 years of experience | 28 (18.6) |
| Specialty | |
| Residents | 64 (42.7) |
| General surgeons | 86 (57.3) |
| Work field | |
| Public | 56 (37.3) |
| Private | 56 (37.3) |
| Military | 38 (25.4) |
JDs Jordanian dinar, SD standard deviation
Laparoscopic and open approach
In evaluating laparoscopic approaches, the mean score was 27.40 (6.84 ± SD), ranging from 11 to 46. Independent t-tests and ANOVA were conducted to explore potential differences in mean scores, revealing that respondents in the military field had the highest mean score (p-value = 0.003). Similarly, the open approach’s mean score was 27.97 (6.83 ± SD), ranging from 10 to 48. Independent t-tests and ANOVA revealed that respondents in the military field also demonstrated the highest mean score (p-value = 0.031). Table 2 further delineates the correlation between demographic characteristics and mean laparoscopic and open procedures scores.
Table 2.
The correlation between demographic characteristics and mean scores in laparoscopic and open procedures
| Item | Laparoscopic approach | Open approach | ||
|---|---|---|---|---|
| Mean ± SD | P – value | Mean ± SD | P – value | |
| Gender A | 0.578 | 0.786 | ||
| Male | 27.19 ± 6.78 | 27.87 ± 7.11 | ||
| Female | 27.87 ± 7.02 | 28.20 ± 6.21 | ||
| Residency B | 0.266 | 0.545 | ||
| North | 25.19 ± 6.03 | 26.19 ± 5.49 | ||
| Central | 27.79 ± 6.84 | 28.17 ± 6.88 | ||
| South | 25.43 ± 8.28 | 28.43 ± 8.90 | ||
| Social status A | 0.666 | 0.057 | ||
| Single | 27.12 ± 6.53 | 26.75 ± 6.66 | ||
| Married | 27.61 ± 7.10 | 28.89 ± 6.84 | ||
| Monthly income A | 0.107 | 0.147 | ||
| Less than 1000 JDs | 26.61 ± 6.63 | 27.26 ± 6.82 | ||
| More than 1000 JDs | 28.43 ± 7.02 | 28.89 ± 6.77 | ||
| Years of experience B | 0.693 | 0.315 | ||
| Less than 5 years of experience | 26.87 ± 7.42 | 27.10 ± 8.00 | ||
| More than 5 and less than 10 years | 27.85 ± 6.38 | 28.33 ± 5.37 | ||
| More than 10 years of experience | 27.79 ± 6.40 | 29.32 ± 6.28 | ||
| Specialty A | 0.341 | 0.177 | ||
| Residents | 26.78 ± 7.45 | 27.09 ± 8.01 | ||
| General surgeons | 27.86 ± 6.35 | 28.62 ± 5.75 | ||
| Work field B | 0.003 | 0.031 | ||
| Public | 24.98 ± 6.56 | 26.29 ± 7.08 | ||
| Private | 28.88 ± 5.77 | 28.27 ± 5.64 | ||
| Military | 28.79 ± 7.79 | 30.00 ± 7.56 | ||
A: independent t – test, B: ANOVA
JDs Jordanian dinar, SD standard deviation
Multiple linear regression analysis was employed to investigate potential predictor factors for achieving high laparoscopic and open procedures scores. Respondents from private institutions (OR = 3.509; p = 0.019; 95% CI: 0.575–6.442) or the military (OR = 3.595; p = 0.021; 95% CI: 0.548–6.643) were identified as significantly positive predictors in the laparoscopic approach. In open procedures, being exclusively from the military emerged as the only significant positive predictor (OR = 3.839; p = 0.014; 95% CI: 0.775–6.903). Table 3 illustrates the results of the multiple linear regression for laparoscopic and open procedures.
Table 3.
Multiple linear regression for laparoscopic and open procedures
| Laparoscopic approach | Open approach | |||||||
|---|---|---|---|---|---|---|---|---|
| 95% CI | 95% CI | |||||||
| Item | OR | Lower Bound | Upper Bound | P – value | OR | Lower Bound | Upper Bound | P – value |
| Age in years | 0.061 | − 0.281 | 0.402 | 0.726 | − 0.043 | − 0.386 | 0.300 | 0.805 |
| Gender | ||||||||
| Male | 0.086 | − 2.474 | 2.647 | 0.947 | − 0.156 | − 2.731 | 2.419 | 0.905 |
| Female A | . | . | . | . | . | . | . | . |
| Residency | ||||||||
| North | − 0.632 | − 6.969 | 5.705 | 0.844 | 1.626 | − 4.7746 | 7.998 | 0.615 |
| Central | 0.426 | − 3.605 | 4.456 | 0.844 | 0.389 | − 3.664 | 4.441 | 0.850 |
| South A | . | . | . | . | . | . | . | . |
| Social status | ||||||||
| Single | − 0.145 | − 3.023 | 2.732 | 0.921 | 2.182 | − 0.711 | 5.075 | 0.138 |
| Married A | . | . | . | . | . | . | . | . |
| Monthly income | ||||||||
| Less than 1000 JDs | 1.860 | − 1.633 | 5.353 | 0.294 | 0.175 | − 3.337 | 3.687 | 0.921 |
| More than 1000 JDs A | . | . | . | . | . | . | . | . |
| Years of experience | ||||||||
| Less than 5 years of experience A | . | . | . | . | . | . | . | . |
| More than 5 and less than 10 years | − 0.296 | 0.888 | − 4.447 | 3.855 | − 0.128 | − 4.303 | 4.046 | 0.952 |
| More than 10 years of experience | − 1.384 | 0.503 | − 5.460 | 2.691 | 1.087 | − 3.012 | 5.185 | 0.601 |
| Specialty | ||||||||
| Residents | − 0.489 | − 4.725 | 3.746 | 0.820 | − 0.028 | − 4.288 | 4.231 | 0.990 |
| General surgeons A | . | . | . | . | . | . | . | . |
| Work field | ||||||||
| Private | 3.509 | 0.575 | 6.442 | 0.019 | 2.316 | − 0.634 | 5.266 | 0.123 |
| Military | 3.595 | 0.548 | 6.643 | 0.021 | 3.839 | 0.775 | 6.903 | 0.014 |
| Public A | . | . | . | . | ||||
A = The reference category
Discussion
Understanding the challenges facing surgeons regarding the ergonomics of the operating room is vital to developing accommodations in the work environment and changing surgery protocols to reduce work-related injuries and improve surgical performance. This study aimed to explore the effects of demographic variables on ergonomic accommodations and training in two surgical approaches (laparoscopic and open).
The participating doctors answered ten questions about each surgical approach, rating aspects of the operating room environment (such as lighting, noise control, seating arrangements, and ergonomic tools/equipment) and ergonomic training workshops, surgeon feedback/input, and institution protocols. They gave their answers as a number score for each question; strongly disagree = 1, disagree = 2, somehow agree = 3, agree = 4, strongly agree = 5. The total score was calculated out of 50.
After analyzing our data, we found no significant difference in the mean laparoscopic versus open surgery scores. However, when reviewing the literature, the consensus seems to be that surgeons performing minimally invasive surgery tend to experience more physical symptoms or discomfort than those performing open procedures [6, 8–11]. This further emphasizes the need for better ergonomic adaptations for laparoscopic surgeries, even more so than for open surgeries. In Jordan, the factors we have studied like lighting, seating arrangements… etc. are generally the same or very similar in both surgical approaches, as the operating rooms are not designated a single type of procedure. Recommendations would include tailoring operating room environments to the types of procedures most preformed in them and providing special training for surgeons preforming laparoscopic procedures.
When we delved deeper into some of the demographic factors possibly affecting the mean scores, we found that in both laparoscopic and open surgeries, respondents in the military gave higher scores. Being a respondent from the military was identified as a significantly positive predictor in both laparoscopic and open procedures, while being from private institutions was identified as a significantly positive predictor in the laparoscopic approach. Military hospitals and private institutes are often held to high quality and patient care standards. This includes adhering to ergonomic guidelines and best practices in surgery to ensure optimal patient outcomes and minimize the risk of complications.
In contrast, other factors like age, gender, marital status, residency/work location, monthly income, years of experience, and being a general surgeon or a surgery resident had no significant effect on the scores.
Agreeing with our results, Sari et al. and Park et al. found no statistically significant difference between males and females in experiencing physical complaints [9, 12]. Other studies [8, 13–15] found that females are more likely to experience discomfort, pain, and work-related injuries. This can probably be explained by the fact that most surgeons are male, meaning most surgical equipment, operating room setup, and surgical procedures were designed to suit their needs. This indicates the need to reconsider the design of laparoscopic instrument handles and adjust table height, among other improvements, to accommodate better the exigencies of being a female surgeon [16]. Our study did not directly measure pain/discomfort levels; instead, it had the surgeons rate factors of OR environment and ergonomic training, which can arguably be generalized to both genders since there is no gender-based separation in training or workplace in most hospitals in Jordan.
When it came to age, three studies [8, 9, 14] found no correlation with experiencing symptoms. On the other hand, some studies [12, 13] reported that older surgeons experienced fewer symptoms than younger ones. It is worth considering, nonetheless, that an older age does not necessarily mean more surgeries are performed. Thus, a more accurate measure would be experience, which may be measured using several different metrics such as the total number of procedures, years in practice, or annual case volume [10]. Still, more experienced surgeons reported less musculoskeletal pain or injury [10]. This finding can have two possible explanations. One is that as surgeons gain more work experience, they also learn what positions and ergonomic habits cause and avoid the most pain. The other is the “healthy worker effect” as described by Gabrielson et al., in which a healthier group of research participants is left as injured surgeons are more likely to retire from the field [10].
Also, in concordance with our results, Sari et al. found no statistically significant differences between specialist surgeons and trainees [12]. Dianat et al. found no effect of marital status, among other demographics, on reported musculoskeletal symptoms during or after surgery [14].
Strengths and limitations
Some limitations may be due to selection bias resulting from its restricted focus on subjects from Jordan. Excluding robotic or endoscopic procedures may limit a thorough investigation of surgical methods. The study’s narrow focus on laparoscopic and open operations and its geographic exclusivity to Jordan make it challenging to interpret and apply to other contexts. Furthermore, time restrictions and the use of a questionnaire as the only method for data collection point to certain drawbacks that should be considered for a comprehensive comprehension of the study’s findings. Also, the multiple linear regression model may have limited explanatory capability, and further investigation into the significance of individual predictors and potential autocorrelation issues are recommended for model enhancement.
Conclusion
In conclusion, this study highlighted the different factors that may affect surgical ergonomics in two surgical approaches: open and laparoscopic. While we found no difference between open and laparoscopic procedures, factors such as working in military hospitals or private institutes emerged as positive predictors for better ergonomic accommodations. There is a pressing need to train surgeons in proper ergonomic techniques, encourage reporting pain or discomfort, and heighten awareness of official ergonomic guidelines. This will reflect positively on surgeons’ well-being and increase career longevity and sustainability. Not to mention better surgical performance, therefore, better patient outcomes.
Author contributions
MYS: conceptualization and methodology. MYS, JFA, AH, BQ, SQ, MA, BA, MA, and MAN: investigation and data curation. IS and MAzid: formal analysis. MYS, JFA, and IS: Writing - Original Draft. MAJ, IS, and MA: Supervision. IS: Project administration. MAzid, IS, and MAJ: Writing - Review & Editing. All authors read and approved the final content.
Funding
This study was not funded.
Data availability
No datasets were generated or analysed during the current study.
Declarations
Statement of ethics
The article describes a cross-sectional study. The Ethics Committee at Al-Basheer Hospital waived ethical approval.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Ibrahim Serag, Email: Hemaserag89@gmail.com.
Mohamed Abouzid, Email: Mmahmoud@ump.edu.pl.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
No datasets were generated or analysed during the current study.