sensors

Article
Comparative Study of Ergonomics in Conventional and
Robotic-Assisted Laparoscopic Surgery
Manuel J. Pérez-Salazar 1 , Daniel Caballero 1 , Juan A. Sánchez-Margallo 1, * and Francisco M. Sánchez-Margallo 2

1 Bioengineering and Health Technologies Unit, Jesús Usón Minimally Invasive Surgery Centre,
ES-10004 Cáceres, Spain; [email protected] (M.J.P.-S.); [email protected] (D.C.)
2 Scientific Direction, Jesús Usón Minimally Invasive Surgery Centre, ES-10004 Cáceres, Spain;
[email protected]
* Correspondence: [email protected]

Abstract: BACKGROUND: This study aims to implement a set of wearable technologies to record
and analyze the surgeon’s physiological and ergonomic parameters during the performance of con-
ventional and robotic-assisted laparoscopic surgery, comparing the ergonomics and stress levels of
surgeons during surgical procedures. METHODS: This study was organized in two different settings:
simulator tasks and experimental model surgical procedures. The participating surgeons performed
the tasks and surgical procedures in both laparoscopic and robotic-assisted surgery in a randomized
fashion. Different wearable technologies were used to record the surgeons’ posture, muscle activity,
electrodermal activity and electrocardiography signal during the surgical practice. RESULTS: The
simulator study involved six surgeons: three experienced (>100 laparoscopic procedures performed;
36.33 ± 13.65 years old) and three novices (<100 laparoscopic procedures; 29.33 ± 8.39 years old).
Three surgeons of different surgical specialties with experience in laparoscopic surgery (>100 laparo-
scopic procedures performed; 37.00 ± 5.29 years old), but without experience in surgical robotics,
participated in the experimental model study. The participating surgeons showed an increased level
of stress during the robotic-assisted surgical procedures. Overall, improved surgeon posture was ob-
tained during robotic-assisted surgery, with a reduction in localized muscle fatigue. CONCLUSIONS:
A set of wearable technologies was implemented to measure and analyze surgeon physiological
Citation: Pérez-Salazar, M.J.; and ergonomic parameters. Robotic-assisted procedures showed better ergonomic outcomes for the
Caballero, D.; Sánchez-Margallo, J.A.; surgeon compared to conventional laparoscopic surgery. Ergonomic analysis allows us to optimize
Sánchez-Margallo, F.M. Comparative surgeon performance and improve surgical training.
Study of Ergonomics in Conventional
and Robotic-Assisted Laparoscopic Keywords: minimally invasive surgery; urology; gynecology; general surgery; simulation setting;
Surgery. Sensors 2024, 24, 3840.
wearable device; motion analysis; stress level; localized muscle fatigue; muscle activity
https://doi.org/10.3390/s24123840

Academic Editors: Bashir Morshed

and Klaus Moessner
1. Introduction
Received: 17 April 2024
Revised: 15 May 2024 Laparoscopic surgery is a surgical technique with well-known benefits for the patient
Accepted: 11 June 2024 compared to traditional open techniques, such as the reduction of tissue trauma, post-
Published: 14 June 2024 operative pain, or hospital stay, among others. However, it is a technique with a steep
learning curve, and it is physically and mentally demanding for the surgeon. As a result,
the onset of musculoskeletal problems in surgeons is common, mainly due to the ergonomic
deficiencies of the equipment and the surgical work environment [1].
Copyright: © 2024 by the authors. The advantages of surgical robotics include tools to improve the surgical precision, a
Licensee MDPI, Basel, Switzerland. better visual perception of the surgical field thanks to three-dimensional imaging, and a
This article is an open access article
more comfortable posture for the main surgeon at the console, who can operate in a seated
distributed under the terms and
position. However, there is still scarce scientific evidence that surgical robotics significantly
conditions of the Creative Commons
improves surgeon ergonomics over conventional laparoscopic surgery [2].
Attribution (CC BY) license (https://
On the other hand, the technical difficulty of laparoscopic surgery, whether robotic-
creativecommons.org/licenses/by/
assisted or not, together with the complexity of certain surgical procedures, leads to a
4.0/).

Sensors 2024, 24, 3840. https://doi.org/10.3390/s24123840 https://www.mdpi.com/journal/sensors

Sensors 2024, 24, x FOR PEER REVIEW 2 of 28

Sensors 2024, 24, 3840 2 of 26

On the other hand, the technical difficulty of laparoscopic surgery, whether robotic-
assisted or not, together with the complexity of certain surgical procedures, leads to a
considerable increase in the surgeon’s stress levels. This can negatively affect the quality
considerable
of the surgery increase
and the inpatient’s
the surgeon’s stress
surgical levels. [3].
outcome ThisBeing
can negatively affect high-stress
able to predict the quality
of the surgery and the patient’s surgical outcome [3]. Being able
situations for the surgeon during surgery would allow measures to be taken to reduce to predict high-stress
situations for the surgeon during surgery would allow measures to be taken to reduce their
their impact on the quality of care.
impact on the quality of care.
There are traditional methods to assess the workload, both mental and physical, of
There are traditional methods to assess the workload, both mental and physical,
surgeons during their surgical activity, such as the subjective SURG-TLX scale [4]. How-
of surgeons during their surgical activity, such as the subjective SURG-TLX scale [4].
ever, the evolution in wearable technology allows us to have sensors of reduced size,
However, the evolution in wearable technology allows us to have sensors of reduced size,
which facilitate the recording and analysis of physiological and ergonomic parameters of
which facilitate the recording and analysis of physiological and ergonomic parameters
the surgeon, without interrupting their surgical performance. Some of these objective
of the surgeon, without interrupting their surgical performance. Some of these objective
parameters are the surgeon’s posture by means of body motion techniques, force/torque
parameters are the surgeon’s posture by means of body motion techniques, force/torque
analysis [5], muscle activity by analyzing the electromyographic (EMG) signal [6,7], and
analysis [5], muscle activity by analyzing the electromyographic (EMG) signal [6,7], and
the level of stress by examining the electrocardiogram (ECG) or the electrodermal activi-
the level of stress by examining the electrocardiogram (ECG) or the electrodermal activity
ty (EDA) signals [8,9].
(EDA) signals [8,9].
Recording data
Recording dataononthethesurgeon’s
surgeon’sergonomics
ergonomics and
and surgical
surgical performance
performance using
using wear-
wearable
able technology
technology can be can be a powerful
a powerful tool fortool for monitoring
monitoring the surgeon’s
the surgeon’s health conditions
health conditions during
during surgery, as well as the quality of care provided to the
surgery, as well as the quality of care provided to the patient. Similarly, these patient. Similarly, these
technolog-
technological innovations can offer robust solutions for the analysis
ical innovations can offer robust solutions for the analysis and comparison of objectiveand comparison of
objective physiological and ergonomic parameters
physiological and ergonomic parameters during surgery. during surgery.
Therefore, the
Therefore, the aim
aimofofthis
thisstudy
studyisistoto implement
implement a set
a set of wearable
of wearable technologies
technologies for
for the
the recording
recording and analysis
and analysis of theofsurgeon’s
the surgeon’s physiological
physiological and ergonomic
and ergonomic parameters
parameters during
during surgical
surgical performance
performance in laparoscopic
in laparoscopic and robotic-assisted
and robotic-assisted surgery.surgery. Moreover,
Moreover, dif-
different
ferent ergonomic and stress factors of surgeons during conventional and
ergonomic and stress factors of surgeons during conventional and robotic-assisted laparo- robotic-assisted
laparoscopic
scopic practicepractice will be compared
will be compared to better to betterthe
identify identify the improvements
improvements and defi-
and deficiencies that
ciencies that the use of surgical robotics entails
the use of surgical robotics entails in surgical practice. in surgical practice.

2. Materials and Methods

The studies
studieswere
werecarried
carriedout using
out standard
using standardequipment for conventional
equipment laparoscopic
for conventional laparo-
surgery and robotic-assisted surgery.surgery.
Specifically, an Olympus TM Visera Visera
III (Tokyo, Japan)
scopic surgery and robotic-assisted Specifically, an Olympus TM III (Tokyo,
tower TM robotic
Japan)was
towerused
wasduring laparoscopic
used during activities
laparoscopic and theand
activities Versius
the Versius platform
TM robotic (CMR
platform
Surgical; Cambridge,
(CMR Surgical; UK) forUK)
Cambridge, the for
robotic-assisted surgicalsurgical
the robotic-assisted activities (Figure(Figure
activities 1). 1).

Figure 1.
Figure 1. Versius TM Robotic Platform: instrument beside units (left) and surgeon console (right).
VersiusTM Robotic Platform: instrument beside units (left) and surgeon console (right).

The studies were organized in two different setups: simulatorsimulator studies

studies and
and experi-
experi-
mental model studies. All participating surgeons received training sessions in the use of
the robotic platform, which included at least two consecutive days practicing with tasks
similar to
to the
the protocol
protocolused
usedduring
duringthe
thestudy.
study.The
Theobjective
objectiveofof
the training
the sessions
training was
sessions to
was
learn thethe
to learn basic aspects
basic of the
aspects use use
of the of the
of platform, the handling
the platform, of theofcontrols,
the handling and its
the controls, main
and its
functionalities to be able
main functionalities to betoable
perform safe surgeries.
to perform safe surgeries.
To ensure the same ergonomic conditions for all surgeons, in the case of laparoscopic
practice, the height of the operating table was adjusted according to the surgeon’s height,
and the monitor was placed in front of the surgeon and at eye level. In the case of robotic-
Sensors 2024, 24, 3840 3 of 26

assisted practice, the surgeon adjusted the height of the screen and console according to
the height of his/her eyes and forearms.

2.1. Evaluation in a Simulation Setting

Surgeons with different levels of experience in laparoscopic surgery and no experience
in surgical robotics participated in this study. All participating surgeons in this study
performed a set of tasks using both conventional laparoscopic surgery and the surgical
robotics platform.
Peg transfer. Eye–hand coordination task consisting of transferring rubber pieces in
the form of elongated toroids from one pole to another by passing the piece from one hand
to the other. Two fenestrated forceps were used for the dominant and non-dominant hands.
A repetition was considered when the surgeon moves all three pieces to the three target
poles, and the entire task consisted of two repetitions. A time limit of ten minutes was set
for this task.
Labyrinth. In this task, participants were asked to pass a needle through a circuit
of rings, with different orientations and heights. The needle must be inserted with the
dominant hand and withdrawn on the other side with the non-dominant hand. A needle
holder is used in the dominant hand and a Maryland dissector in the other hand. The
resolution of the entire circuit is considered as a repetition. A time limit of ten minutes is
set for this task.
Suture. For this task, participants were asked to make a stitch in an organic tissue (ex
vivo pig stomach). The suture consisted of needle passage, a double knot, and two single
knots in opposite directions. A needle holder is used in each hand. A time limit of ten
minutes was established for suturing.

2.2. Evaluation in Experimental Model

The surgeons performed a set of surgical procedures according to their surgical spe-
cialty both by conventional laparoscopy and with the robotic platform. A total nephrectomy
in porcine model was performed for the urology specialty, a gastrotomy in porcine model
for the general surgery specialty, and an ovariectomy in a sheep model for the gynecology
specialty. All experimental protocols were approved by the corresponding local Animal Ex-
perimentation Committee (References: EXP-20230325, EXP-20230320, and EXP-20230313).

2.3. Subjective Evaluation

At the beginning and at the end of each surgical task/procedure, participants were
asked to complete a SURG-TLX survey [4]. This questionnaire allows the evaluation of the
surgeon’s mental and physical workload before and during the performance of the surgical
activities. Among the aspects to be evaluated are mental, physical, and temporal demands,
level of perceived stress, distraction, and level of complexity of the task performed.

2.4. Data Recording

2.4.1. Physiological Data
Wearable devices (EcgMove 4 and EdaMove 4 activity sensors; Movisens GmbH,
Karlsruhe, Germany) were used to record the electrocardiogram (ECG) and electrodermal
activity (EDA), respectively, of the participating surgeons. The data recorded from the
EDA and ECG sensors were in microsiemens and heart rate, with an output rate of 32 Hz
and 1024 Hz, respectively. DataAnalyzer software from Movisens GmbH was used for
date analysis.
The EDA sensor was attached to the front of the right ankle of each participant by
means of a band (Figure 2) and the ECG sensor was attached on the chest, under the left
pectoral, for each participant.
Sensors 2024, 24, x FOR PEER REVIEW 4 of 28

The EDA sensor was attached to the front of the right ankle of each participant by
Sensors 2024, 24, 3840 4 ofleft
26
means of a band (Figure 2) and the ECG sensor was attached on the chest, under the
pectoral, for each participant.

Figure 2. EdaMove 4 activity sensor placed on the surgeon’s ankle.

2.4.2. Kinematic Data

The Xsens motion analysis system (Movella Inc.; Henderson, NV, USA) was used to
capture the movement of the study participants (Figure 3). This system uses 17 inertial
sensors to record the movements of the subject’s body segments in real time, with an
update rate up to 60 Hz per sensor.
In addition, the wireless EMG TRIGNO™ Avanti system from DELSYS was used to
record the muscle activity by means of electromyographic (EMG) signals (Figure 3). This
Figure
system2.2.has
Figure EdaMove
up to 4416
EdaMove activity
sensors
activity sensor placed
withplaced
sensor on the
the surgeon’s
a sampling
on surgeon’s ankle.
rate of 1024 Hz. A trigger system was used
ankle.
for recording synchronization between the Xsens and Delsys systems. The EMG signal
2.4.2.
2.4.2. Kinematic
Kinematic Data
Datagroups was recorded bilaterally: upper trapezius, middle trapezius,
of following muscle
The Xsens
Xsens motion
Thespinae,
erector motion analysis system
analysis triceps
brachioradialis, (Movella
systembrachii,
(Movella Inc.;
Inc.; Henderson,
vastus Henderson,
lateralis, and NV,
NV, USA)
USA) was
was used
gastrocnemius used to
to
medi-
capture
alis. Thethe
capture the
EMG movement
movement
sensors wereof
of the study
theplaced
studyonparticipants
participants
each muscle (Figure
(Figure 3).
3). This
according This system
system
to the uses
uses 17
SENIAM 17 inertial
inertial
guidelines
sensors
sensors totorecord
[10]. Prior to thethe
record movements
the movements
placement of of the subject’s
of sensor,
each body
the subject’s
the segments
body
skin in realin
segments
was cleaned time,
byrealwith an
time,
gently update
with
rubbing anit
rate
updateup
with 70% to
rate60 Hz per sensor.
up to 60 alcohol.
isopropyl Hz per sensor.
In addition, the wireless EMG TRIGNO™ Avanti system from DELSYS was used to
record the muscle activity by means of electromyographic (EMG) signals (Figure 3). This
system has up to 16 sensors with a sampling rate of 1024 Hz. A trigger system was used
for recording synchronization between the Xsens and Delsys systems. The EMG signal
of following muscle groups was recorded bilaterally: upper trapezius, middle trapezius,
erector spinae, brachioradialis, triceps brachii, vastus lateralis, and gastrocnemius medi-
alis. The EMG sensors were placed on each muscle according to the SENIAM guidelines
[10]. Prior to the placement of each sensor, the skin was cleaned by gently rubbing it
with 70% isopropyl alcohol.

Figure3.3.Example
Figure Exampleof
oflocation
locationof
ofEMG
EMGsensors
sensors(left)
(left)and
andinertial
inertialsensors
sensorsfor
formotion
motionanalysis
analysis(right).
(right).
In addition, the wireless EMG TRIGNO™ Avanti system from DELSYS was used to
recordRaw the EMG
muscle signals were
activity by processed using a band-pass filter
means of electromyographic (EMG) of signals
20–300 (Figure
Hz. The3). filtered
This
EMG was then smoothed using an algorithm with a moving window
system has up to 16 sensors with a sampling rate of 1024 Hz. A trigger system was used of 125 ms and cal-
culated as root mean square (RMS). To normalize the results for
for recording synchronization between the Xsens and Delsys systems. The EMG signal each subject, the EMG
values
of were muscle
following presented as percentage
groups of maximum
was recorded voluntary
bilaterally: contraction
upper trapezius, (%MVC).
middle MVC
trapezius,
erector spinae, brachioradialis, triceps brachii, vastus lateralis, and gastrocnemius medialis.
The EMG sensors were placed on each muscle according to the SENIAM guidelines [10].
Prior
Figureto3.the placement
Example of each
of location sensor,
of EMG the skin
sensors (left)was
and cleaned by gently
inertial sensors rubbing
for motion it with 70%
analysis
(right).
isopropyl alcohol.
Raw EMG signals were processed using a band-pass filter of 20–300 Hz. The filtered
EMGRaw wasEMG then signals
smoothed wereusing
processed using a band-pass
an algorithm filter ofwindow
with a moving 20–300 Hz. Thems
of 125 filtered
and
EMG was as
calculated then smoothed
root mean squareusing(RMS).
an algorithm with athe
To normalize moving
resultswindow
for eachofsubject,
125 mstheand EMGcal-
culatedwere
values as root mean square
presented (RMS). of
as percentage Tomaximum
normalizevoluntary
the resultscontraction
for each subject,
(%MVC). the MVC
EMG
values
was were presented
performed separately as for
percentage of maximum
each muscle group just voluntary
before eachcontraction (%MVC).
test by asking MVC
each subject
to perform specific contractions against a fixed resistance.
Sensors 2024, 24, 3840 5 of 26

2.5. Data Analysis

2.5.1. Stress
Mean EDA and ECG sensor values were obtained for each surgeon and for each task
or surgical procedure analyzed. The correlation between the parameters reported by the
surgeons for the workload levels (SURG-TLX) and the values recorded by the EDA and
ECG sensors was also computed.

2.5.2. Motion Analysis

Flexion/extension of the neck, shoulder, elbow, wrist, back, and knee, as well as
abduction/adduction of the shoulder, was analyzed for representative joints in the analysis
of the surgeon’s posture in robotic-assisted surgical practice [1]. Average values for the
degrees of each analyzed joint were obtained and compared between study groups.
In addition, the surgeon’s body posture was assessed considering the rapid upper
limb assessment (RULA) method [11]. RULA gives a score of the posture of the upper and
lower limb joints, as well as an overall score of the subject’s posture, establishing a certain
level of risk of developing musculoskeletal disorders.
Other techniques that can be used to provide a body posture score include the rapid
entire body assessment (REBA) method [12] or the Ovako working analysis system (OWAS)
method [13]. However, the RULA method is optimal for upper-body-intensive tasks such
as surgical practice. The REBA method is less detailed in the evaluation of specific pos-
tures, as it is mainly recommended for tasks that require rapid changes in body posture,
mostly produced by instability and heavy weights. The OWAS method is an observational
method that classifies combinations of body postures and is often used as a first approxi-
mation but is often complemented by another method (such as RULA or REBA) for a more
complete evaluation.

2.5.3. Localized Muscle Fatigue

For the study of localized muscle fatigue, the evolution of the amplitude and median
frequency of the muscle activity was analyzed for each task and surgical procedure. Mus-
cular fatigue was quantified using the joint analysis of spectrum and amplitude (JASA)
method [14].

2.6. Statistical Analysis

Jamovi (Jamovi Project, 2024, Version 2.5) and R (R Foundation for Statistical Com-
puting, Vienna, Austria; Version 4.3.1) software platforms were used for data and statisti-
cal analysis.

3. Results
3.1. Evaluation in a Simulation Setting
Six surgeons participated in the study in the simulated setting: three experts
(>100 laparoscopic procedures performed; 1.80 ± 0.10 m tall and 36.33 ± 13.65 years
old) and three novices (<100 laparoscopic procedures performed; 1.82 ± 0.05 meters
tall and 29.33 ± 8.39 years old) in laparoscopic surgery, both with no experience in
robotic surgery.
The results of the simulator tasks focus mainly on the suturing task, as it is considered
the most complete and technically demanding, although the other simulation tasks are also
taken into account.

3.1.1. Stress
Surgeons, both novice and experienced in laparoscopic surgery, report a lower physical
demand in the performance of the training tasks using robotic-assisted surgery compared
to the conventional laparoscopic technique (Figure 4). Surgeons with experience in la-
paroscopic surgery reported higher levels of stress in the performance of the tasks using
conventional laparoscopic surgery.
 3.1.1. Stress
Surgeons, both novice and experienced in laparoscopic surgery, report a lower
physical demand in the performance of the training tasks using robotic-assisted surgery
compared to the conventional laparoscopic technique (Figure 4). Surgeons with experi-
Sensors 2024, 24, 3840
ence in laparoscopic surgery reported higher levels of stress in the performance of6 of
the26
tasks using conventional laparoscopic surgery.

Comparison
Figure4.4.Comparison
Figure of of SURG-TLX
SURG-TLX parameters
parameters (mental
(mental demand,
demand, temporal
temporal demand,
demand, physical
physical de-
demand,
mand, stress,
stress, tasktask complexity,
complexity, andand distractions),
distractions), and and
EDAEDA and ECG
and ECG signal
signal results
results during
during simu-
simulator
lator tasks using conventional (CONV) and robotic-assisted (ROBOT) laparoscopy for novice and
experienced laparoscopic surgeons. * p < 0.05.

A strong positive correlation was observed between the level of stress and the level of
complexity of the tasks, as well as between the reported mental demand and the level of
distractions, in the group of novice surgeons.
Sensors 2024, 24, 3840 7 of 26

3.1.2. Motion Analysis

The results showed statistically significant differences (p < 0.05) in conventional and
Sensors 2024, 24, x FOR PEER REVIEWrobotic-assisted
laparoscopic suturing, for both the experienced and novice8surgeons,
of 28

regarding the joint postures analyzed (Figures 5 and 6).

Comparative
Figure5.5.Comparative
Figure range
range of motion
of motion of the
of the neck,
neck, back,
back, shoulder,
shoulder, elbow,
elbow, wrist,wrist, and knees
and knees duringduring
laparoscopic(CONV)
laparoscopic (CONV)andandrobotic-assisted
robotic-assisted(ROBOT)
(ROBOT)suture
sutureon
onsimulator.
simulator.Group
Groupofofnovice
novicesur-
surgeons
in laparoscopic
geons surgery.
in laparoscopic surgery.
Sensors
Sensors 2024,
2024, 24,
24, x3840
FOR PEER REVIEW 9 of 28
8 of 26

Figure
Figure 6.
6. Comparative
Comparative range
range of
of motion
motion of
of the
the neck,
neck, back,
back, shoulder,
shoulder, elbow,
elbow, wrist,
wrist, and
and knees
knees during
during
laparoscopic
laparoscopic (CONV)
(CONV) and
and robotic-assisted
robotic-assisted (ROBOT)
(ROBOT) suture
suture on simulator. Group
Group ofof experienced
experienced
surgeons
surgeons in
in laparoscopic
laparoscopic surgery.
surgery.
Sensors 2024, 24, 3840 9 of 26

The RULA during the suturing task shows a higher RULA score in the use of the
laparoscopic technique compared to the robotic-assisted one (Table 1). The overall score
with the laparoscopic technique suggests changes in the surgeon’s posture.

Table 1. Comparison of RULA score during conventional laparoscopic (CONV) and robotic-assisted
(ROB) suturing on simulator for novice and experienced laparoscopic surgeons.

Experience Technique Value

Upper limbs Novices CONV 4.333 ± 0.577
ROB 3.500 ± 0.707
Experienced CONV 4.000 ± 1.414
ROB 3.000 ± 0.000
Body and lower limbs Novices CONV 7.000 ± 0.000
ROB 5.500 ± 2.121
Experienced CONV 6.000 ± 1.414
ROB 5.000 ± 1.414
Global score Novices CONV 6.333 ± 0.577
ROB 4.000 ± 1.414
Experienced CONV 5.500 ± 2.121
ROB 5.000 ± 2.828

3.1.3. Muscle Activity

In general, experienced surgeons had less muscle activity in the right-sided muscles
(Figure 7, upper graph). In laparoscopic surgery, they required greater muscle activity of
the middle trapezius and triceps brachii on the right side than with robotic-assisted surgery.
Robotic-assisted surgery required greater muscle activity for the brachioradialis and upper
trapezius bilaterally, left middle trapezius, and right vastus lateralis.
For novice surgeons (Figure 7, bottom graph), robotic-assisted surgery required greater
muscle activity for the upper trapezius and vastus lateralis on the right side and the
gastrocnemius medialis on the left side. Laparoscopic surgery required greater muscle
activity of the erector spinae and middle trapezius bilaterally, the right triceps brachii and
gastrocnemius medialis, and the left upper trapezius and vastus lateralis. All muscles
bilaterally showed statistically significant differences between laparoscopic and robotic-
assisted surgery (p < 0.001).
For the remaining simulator tasks, labyrinth and peg transfer, the results obtained
resembled those of the suturing task. Thus, these results also recorded higher muscle
activity on the left side.

3.1.4. Localized Muscle Fatigue

Analysis of localized muscle fatigue during the simulator suturing task showed a
trend of higher muscle fatigue and lower force use for laparoscopic surgery compared to
robotic-assisted surgery for the expert surgeons (Figure 8, upper graph). These results
were similar to those obtained for the labyrinth and peg transfer tasks, highlighting that
for peg transfer robotic-assisted surgery shows a high degree of muscle fatigue recovery
and lower muscle fatigue. The mean values obtained for the percentage of force increase
were 4.31 ± 2.35 in the case of the conventional laparoscopic surgery and 0.98 ± 0.76 for
the robotic-assisted laparoscopic surgery. In the case of the percentage of muscle fatigue,
the values obtained were 11.44 ± 8.27 and 2.11 ± 1.37, respectively, for the conventional
and robotic-assisted laparoscopic surgery. For the percentage of muscle fatigue recovery,
for conventional laparoscopic surgery the mean value was 2.12 ± 0.31 and for the robotic-
assisted laparoscopic surgery the value was 5.70 ± 2.75. For the percentage of force
decrement, for the conventional laparoscopic surgery the value obtained was 3.92 ± 2.85
and for the robotic-assisted laparoscopic surgery the value was 1.28 ± 0.81.
 Sensors2024,
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28

Figure7.7.Comparison
Figure Comparisonofofmuscle
muscleactivity (%MVC)
activity (%MVC) of of
experienced (upper
experienced image)
(upper image)andand
novice (bottom
novice (bot-
image) surgeons during performance of simulator suturing task using conventional (red)
tom image) surgeons during performance of simulator suturing task using conventional (red) and robotic-
and
robotic-assisted
assisted (blue) laparoscopic
(blue) laparoscopic surgery
surgery for for the following
the following muscles: muscles: Brachioradialis
Brachioradialis (BRACH), (BRACH),
Erector
Erector(ER_SPIN),
spinae spinae (ER_SPIN), Gastrocnemius
Gastrocnemius medialismedialis (GAS_MED),
(GAS_MED), Middle trapezius
Middle trapezius (MID_TRAP),
(MID_TRAP), Triceps
Triceps brachii (TRI_BRA), Upper trapezius (UP_TRAP), and Vastus lateralis
brachii (TRI_BRA), Upper trapezius (UP_TRAP), and Vastus lateralis (VAS_LAT). (VAS_LAT).

3.1.4.For
Localized Muscle Fatigue
novice surgeons (Figure 8, bottom graph), the simulator suturing task showed
markedly greater
Analysis muscle fatigue
of localized musclefor laparoscopic
fatigue during thesurgery compared
simulator to robotic-assisted
suturing task showed a
surgery.
trend of higher muscle fatigue and lower force use for laparoscopic surgerya compared
However, for the labyrinth task, robotic-assisted surgery showed high degree to
of muscle fatigue recovery and a lower degree of force use compared
robotic-assisted surgery for the expert surgeons (Figure 8, upper graph). These results to laparoscopic
surgery. Robotic-assisted
were similar surgery
to those obtained forwas
themore balanced
labyrinth and in
pegterms of muscle
transfer tasks, fatigue and force
highlighting that
use than laparoscopic surgery for both experienced and novice surgeons.
for peg transfer robotic-assisted surgery shows a high degree of muscle fatigue recovery The mean values
obtained
and lower formuscle
the percentage
fatigue. ofTheforce
meanincrease
valueswere 3.66 ±for
obtained 2.41 inpercentage
the the case of the conventional
of force increase
laparoscopic surgery and 3.01 ± 1.80 for the robotic-assisted laparoscopic
were 4.31 ± 2.35 in the case of the conventional laparoscopic surgery and 0.98 ± 0.76 for surgery. In
the case of the percentage of muscle fatigue, the values obtained were 4.36
the robotic-assisted laparoscopic surgery. In the case of the percentage of muscle fatigue, ± 3.08 and
0.31 ± 0.23, obtained
the values respectively,
werefor11.44
the conventional
± 8.27 and 2.11 and± robotic-assisted
1.37, respectively,laparoscopic surgeries.
for the conventional
For the percentage of muscle fatigue recovery, for conventional laparoscopic
and robotic-assisted laparoscopic surgery. For the percentage of muscle fatigue recovery, surgery the
mean value was 2.60 ± 1.71 and for the robotic-assisted laparoscopic surgery
for conventional laparoscopic surgery the mean value was 2.12 ± 0.31 and for the robotic- the value
was 3.97 ± 0.41. For the percentage of force decrement, for the conventional laparoscopic
assisted laparoscopic surgery the value was 5.70 ± 2.75. For the percentage of force dec-
 mean values obtained for the percentage of force increase were 3.66 ± 2.41 in the case of
the conventional laparoscopic surgery and 3.01 ± 1.80 for the robotic-assisted laparo-
scopic surgery. In the case of the percentage of muscle fatigue, the values obtained were
4.36 ± 3.08 and 0.31 ± 0.23, respectively, for the conventional and robotic-assisted laparo-
Sensors 2024, 24, 3840 scopic surgeries. For the percentage of muscle fatigue recovery, for conventional laparo-
11 of 26
scopic surgery the mean value was 2.60 ± 1.71 and for the robotic-assisted laparoscopic
surgery the value was 3.97 ± 0.41. For the percentage of force decrement, for the conven-
the value
tional obtained was
laparoscopic the4.35
value± 1.83 and for
obtained wasthe4.35
robotic-assisted
± 1.83 and forlaparoscopic the valuelapa-
the robotic-assisted was
2.29 ± 1.36.
roscopic the value was 2.29 ± 1.36.

Figure 8. Comparison of fatigue and muscle strength increase/decrease for experienced (upper
graph) and novice (bottom graph) surgeons between simulator suturing task in laparoscopic (red)
and robotic-assisted (blue) surgeries.

In the case of robotic-assisted surgery, localized muscle fatigue during the simulator
suturing task was similar for expert and novice surgeons (Figure 9, upper graph). However,
expert surgeons used more force than novices. Consequently, the mean values obtained
for the percentage of force increase were 2.83 ± 1.79 in the case of the expert surgeon and
1.80 ± 0.37 for the novice surgeons. In the case of the percentage of muscle fatigue, the
values obtained were 2.40 ± 1.23 and 0.86 ± 0.60, respectively, for the expert and novice
surgeons. For the percentage of muscle fatigue recovery, for novice surgeons the mean
value was 1.06 ± 0.06 and for the expert surgeons the value was 0.64 ± 0.08. For the
percentage of force decrement, for the expert surgeons the value obtained was 1.27 ± 0.88
and for the novice surgeons the value was 0.88 ± 0.61. In the case of laparoscopic surgery,
localized muscle fatigue during the simulator suturing task showed a trend of higher
muscle fatigue and lower use of force for expert surgeons compared to novices (Figure 9,
bottom graph). Of note was the muscle fatigue of the novice surgeons and the near-zero use
 and novice surgeons. For the percentage of muscle fatigue recovery, for novice surgeons
the mean value was 1.06 ± 0.06 and for the expert surgeons the value was 0.64 ± 0.08. For
the percentage of force decrement, for the expert surgeons the value obtained was 1.27 ±
0.88 and for the novice surgeons the value was 0.88 ± 0.61. In the case of laparoscopic
Sensors 2024, 24, 3840 surgery, localized muscle fatigue during the simulator suturing task showed a trend of
12 of 26
higher muscle fatigue and lower use of force for expert surgeons compared to novices
(Figure 9, bottom graph). Of note was the muscle fatigue of the novice surgeons and the
near-zero
of force by use of forcesurgeons.
the expert by the expert
On thesurgeons.
other hand, Onexpert
the other hand,were
surgeons expertmoresurgeons
balancedwerein
more balanced in terms of muscle fatigue and use of force than novice
terms of muscle fatigue and use of force than novice surgeons. The mean values obtained surgeons. The
mean
for thevalues obtained
percentage for the
of force percentage
increase were of force
4.31 increase
± 3.35 in thewere
case4.31 ± 3.35
of the in the
expert case of
surgeons
the expert
and 3.17 ±surgeons andnovice
2.48 for the 3.17 ± surgeons.
2.48 for theInnovice
the case surgeons. In the caseof
of the percentage ofmuscle
the percentage
fatigue,
of muscle
the values fatigue,
obtained the values
were 11.45obtained
± 9.29 were 11.45±±1.97,
and 4.46 9.29 respectively,
and 4.46 ± 1.97,for respectively,
the expert and for
the expert
novice and novice
surgeons. surgeons.
For the percentageFor the percentage
of muscle of muscle
fatigue fatigue
recovery, recovery,
for novice for novice
surgeons the
surgeons
mean valuethewas
mean
5.70value was
± 2.70 and5.70
for±the
2.70 and for
expert the expert
surgeons surgeons
the value was the
3.78value
± 1.55.wasFor
3.78
the±
1.55. For the percentage of force decrement, for the expert surgeons the
percentage of force decrement, for the expert surgeons the value obtained was 6.06 ± 2.13 value obtained
was for
and 6.06the
± 2.13 andsurgeons
novice for the novice surgeons
the value was 1.28the±value
0.71. was
These 1.28 ± 0.71.
results These
were results
similar were
to those
similar tofor
obtained those
the obtained
labyrinthforandthe labyrinth
transfer pegand transfer peg tasks.
tasks.

Sensors 2024, 24, x FOR PEER REVIEW 14 of 28

Figure9.9.Comparison
Figure Comparisonof offatigue
fatigueand
andforce
forceincreasing/decreasing
increasing/decreasing when
whenperforming
performingsuturing
suturingtask
taskin
in
robotic-assisted (upper graph) and laparoscopic surgeries (bottom graph) between expert surgeons
robotic-assisted (upper graph) and laparoscopic surgeries (bottom graph) between expert sur-
geonsand
(blue) (blue) and surgeons
novice novice surgeons
(red). (red).

3.2. Evaluation in Experimental Model

3.2. Evaluation in Experimental Model
Three surgeons experienced in laparoscopic surgery (>100 laparoscopic procedures
Three surgeons experienced in laparoscopic surgery (>100 laparoscopic procedures
performed; 1.77 ± 0.07 m tall and 37.00 ± 5.29 years old) and novices in robotic surgery
performed; 1.77 ± 0.07 m tall and 37.00 ± 5.29 years old) and novices in robotic surgery
participated in the study with experimental models. Each surgeon performed the surgical
participated in the study with experimental models. Each surgeon performed the surgi-
procedures according to his/her specialty: urology, gynecology, or general surgery.
cal procedures according to his/her specialty: urology, gynecology, or general surgery.

3.2.1. Stress
Surgeons presented higher levels of electrodermal activity during robotic-assisted
procedures. Similarly, the reported levels of stress, mental demand, and task complexity
Sensors 2024, 24, 3840 13 of 26

3.2.1. Stress
Surgeons presented higher levels of electrodermal activity during robotic-assisted
procedures. Similarly, the reported levels of stress, mental demand, and task complexity
were higher in surgical robotics compared to the conventional laparoscopic technique.
However, the reported physical demand was higher in the case of laparoscopic procedures.
Although remarkable, no statistically significant differences were shown in these results.
A positive correlation has been observed between the temporal demand of the surgi-
cal procedure and the physical demand (0.868 Spearman’s rho; p < 0.05) and complexity
(0.893 Spearman’s rho; p < 0.02) reported by surgeons, as well as between the subjec-
tive stress during surgical interventions and distraction perceived (0.890 Spearman’s rho;
p < 0.02).

3.2.2. Motion Analysis

The results showed statistically significant differences (p < 0.05) in conventional and
robotic-assisted laparoscopic procedures for the joint postures analyzed, except for the
shoulder during the ovariectomy (Figures 10–12).
Analyzing the ergonomic risk level of the surgeon’s posture, the surgeon’s posture
presents a low level of ergonomic risk during the performance of total nephrectomy,
both by conventional laparoscopic and robotic-assisted surgeries (Table 2). In the case of
gastrotomy, it presents a medium level of risk for both techniques, so it is recommended to
improve the surgeon’s posture as soon as possible. Finally, the ergonomic risk level of the
surgeon’s posture was medium for ovariectomy performed by conventional laparoscopic
surgery, however, it obtained a high risk level during robotic-assisted ovariectomy, so it is
recommended that the surgeon’s posture be improved immediately.

Table 2. Comparison of RULA score during different surgical procedures performed by conventional
laparoscopy (CONV) and robotic-assisted surgery (ROB).

Procedure Technique Value

Upper limbs Gastrotomy CONV 3
ROB 3
Total nephrectomy CONV 3
ROB 3
Ovariectomy CONV 3
ROB 4
Body and low limbs Gastrotomy CONV 7
ROB 7
Total nephrectomy CONV 3
ROB 3
Ovariectomy CONV 7
ROB 7
Global score Gastrotomy CONV 6
ROB 6
Total nephrectomy CONV 4
ROB 4
Ovariectomy CONV 6
ROB 7
Sensors 2024,
Sensors 24,24,
2024, x FOR
3840 PEER REVIEW 15 of 28
14 of 26

Figure 10.
Figure Comparative range
10. Comparative rangeofofmotion
motion ofof
thethe
neck, back,
neck, shoulder,
back, elbow,
shoulder, wrist,wrist,
elbow, and knees duringdur-
and knees
conventional (CONV) and robotic-assisted (ROBOT) laparoscopic gastrotomy.
ing conventional (CONV) and robotic-assisted (ROBOT) laparoscopic gastrotomy.
Sensors 2024, 24, x FOR PEER REVIEW 16 of 28
Sensors 2024, 24, 3840 15 of 26

Figure 11.
Figure 11.Comparative
Comparativerange
range
of of motion
motion of the
of the neck,
neck, back,back, shoulder,
shoulder, elbow,
elbow, wrist, wrist, and during
and knees knees dur-
ing conventional
conventional (CONV)
(CONV) and robotic-assisted
and robotic-assisted (ROBOT) (ROBOT) laparoscopic
laparoscopic total nephrectomy.
total nephrectomy.
Sensors 2024, 24, x FOR PEER REVIEW 17 of 28
Sensors 2024, 24, 3840 16 of 26

Figure12.
Figure 12.Comparative
Comparativerange
range
of of motion
motion of the
of the neck,
neck, back,back, shoulder,
shoulder, elbow,elbow,
wrist, wrist, andduring
and knees knees dur-
ing conventional (CONV) and robotic-assisted (ROBOT) laparoscopic total ovariectomy.
conventional (CONV) and robotic-assisted (ROBOT) laparoscopic total ovariectomy.

Analyzing the ergonomic risk level of the surgeon’s posture, the surgeon’s posture
presents a low level of ergonomic risk during the performance of total nephrectomy,
both by conventional laparoscopic and robotic-assisted surgeries (Table 2). In the case of
 Sensors 2024, 24, 3840 17 of 26

3.2.3. Muscle Activity

In general, the muscles on the right side recorded lower muscle activity during gastro-
tomy (Figure 13). Robotic-assisted surgeries required greater muscle activity for the right
vastus lateralis. The laparoscopic procedure required higher muscle activity for the gas-
trocnemius medialis and middle trapezius bilaterally, the right brachioradialis and upper
24, x FOR PEER REVIEW 19 ofbilater-
trapezius superiorly, and the left triceps brachii and vastus lateralis. All muscles 28
ally showed statistically significant differences between laparoscopic and robotic-assisted
surgeries (p < 0.001).

Figure 13. Comparison of muscle activity (%MVC) during the performance of a gastrotomy by
Figure 13. Comparison of muscle activity (%MVC) during the performance of a gastrotomy by
conventional (red) and robotic-assisted (blue) laparoscopic surgeries for the following muscles:
conventional (red) and robotic-assisted (blue) laparoscopic surgeries for the following muscles:
Brachioradialis (BRACH), Erector spinae (ER_SPIN), Gastrocnemius medialis (GAS_MED), Middle
Brachioradialis (BRACH), Erector spinae
trapezius (MID_TRAP), Triceps(ER_SPIN), Gastrocnemius
brachii (TRI_BRA), medialis
Upper trapezius (GAS_MED),
(UP_TRAP), and VastusMid-
lateralis
dle trapezius (MID_TRAP),
(VAS_LAT). Triceps brachii (TRI_BRA), Upper trapezius (UP_TRAP), and Vastus
lateralis (VAS_LAT).
During the performance of total nephrectomy, muscle activity was generally more
balanced between the
During the performance right and
of total left sides compared
nephrectomy, muscle to other surgical
activity wasprocedures
generally(Figure
more 14).
In this surgical procedure, robotic-assisted surgery required greater muscle activity of the
balanced between the right and left sides compared to other surgical procedures (Figure
left brachioradialis and of the middle trapezius, triceps brachii, and vastus lateralis on
14). In this surgical procedure, robotic-assisted surgery required greater muscle activity
the right side. Surgeries with conventional laparoscopic technique led to greater muscle
of the left brachioradialis
loading of theand of spinae
erector the middle trapezius, triceps
and gastrocnemius medialisbrachii, andmiddle
bilaterally, vastus lat-
trapezius,
eralis on the right side.
triceps Surgeries
brachii, with
and vastus conventional
lateralis on the left laparoscopic technique
side. All bilateral led tostatistically
muscles showed great-
er muscle loading of the
significant erector spinae
differences betweenand gastrocnemius
laparoscopic medialis bilaterally,
and robotic-assisted surgeries (p <middle
0.001).
With respect to ovariectomy, in general, the muscles on the
trapezius, triceps brachii, and vastus lateralis on the left side. All bilateral musclesright side recorded slightly
higher muscle activity than the muscles on the left side (Figure 15). Conventional laparo-
showed statistically significant differences between laparoscopic and robotic-assisted
scopic surgery required greater activity of the gastrocnemius medialis and vastus lateralis
surgeries (p < 0.001).
on the right side. Robotic-assisted surgery required greater muscle activity for the right
erector spinae and the middle and upper trapezius, triceps brachii, and vastus lateralis
on the left side. All bilateral muscles showed statistically significant differences between
laparoscopic and robotic-assisted surgeries (p < 0.001).
 eralis on the right side. Surgeries with conventional laparoscopic technique led to great
er muscle loading of the erector spinae and gastrocnemius medialis bilaterally, middle
trapezius, triceps brachii, and vastus lateralis on the left side. All bilateral muscle
showed statistically significant differences between laparoscopic and robotic-assisted
Sensors 2024, 24, 3840 18 of 26
surgeries (p < 0.001).

Sensors 2024, 24, x FOR PEER REVIEW 20 of 2

Brachioradialis (BRACH), Erector spinae (ER_SPIN), Gastrocnemius medialis (GAS_MED), Mid

dle trapezius (MID_TRAP), Triceps brachii (TRI_BRA), Upper trapezius (UP_TRAP), and Vastu
lateralis (VAS_LAT).

With respect to ovariectomy, in general, the muscles on the right side recorde
slightly higher muscle activity than the muscles on the left side (Figure 15). Convention
al laparoscopic surgery required greater activity of the gastrocnemius medialis an
vastus lateralis
Figure on theofright
14. Comparison side.
muscle Robotic-assisted
activity (%MVC) during the surgery required
performance greater
of a total muscle activ
nephrectomy
Figure 14. Comparison of muscle activity (%MVC) during the performance of a total nephrectomy
ty for the right erector
by conventional (red) and spinae and the
robotic-assisted middle
(blue) and upper
laparoscopic surgeriestrapezius, triceps
for the following brachii, an
muscles:
by conventional (red) and robotic-assisted (blue) laparoscopic surgeries for the following muscles
Brachioradialis (BRACH), Erector spinae (ER_SPIN), Gastrocnemius medialis (GAS_MED),
vastus lateralis on the left side. All bilateral muscles showed statistically significant di Middle
trapezius
ferences (MID_TRAP),
between Triceps brachii
laparoscopic and(TRI_BRA), Upper trapezius
robotic-assisted (UP_TRAP),
surgeries (p < and Vastus lateralis
0.001).
(VAS_LAT).

Figure 15. Comparison of muscle activity (%MVC) during the performance of an ovariectomy
Figure 15. Comparison
by conventional of robotic-assisted
(red) and muscle activity (%MVC)
(blue) during
laparoscopic the performance
surgeries of anmuscles:
for the following ovariectomy b
conventional
Brachioradialis (BRACH), Erector spinae (ER_SPIN), Gastrocnemius medialis (GAS_MED), Middle muscle
(red) and robotic-assisted (blue) laparoscopic surgeries for the following
Brachioradialis (BRACH),
trapezius (MID_TRAP), Erector
Triceps spinae
brachii (ER_SPIN),
(TRI_BRA), Gastrocnemius
Upper trapezius (UP_TRAP), medialis (GAS_MED),
and Vastus lateralis Mid
dle(VAS_LAT).
trapezius (MID_TRAP), Triceps brachii (TRI_BRA), Upper trapezius (UP_TRAP), and Vastu
lateralis (VAS_LAT).

3.2.4. Localized Muscle Fatigue

The analysis of localized muscle fatigue during different surgical procedure
showed lower muscle fatigue and higher force use in laparoscopic procedures compare
to robotic-assisted ones (Figure 16). However, robotic-assisted procedures reported mor
balanced muscle fatigue and force use than laparoscopic ones. Considering surgical spe
Sensors 2024, 24, 3840 19 of 26

3.2.4. Localized Muscle Fatigue

The analysis of localized muscle fatigue during different surgical procedures showed
lower muscle fatigue and higher force use in laparoscopic procedures compared to robotic-
assisted ones (Figure 16). However, robotic-assisted procedures reported more balanced
muscle fatigue and force use than laparoscopic ones. Considering surgical specialties,
the results for ovariectomy were very scattered, occupying the extremes for localized
muscle fatigue and force use for both surgical techniques. Consequently, the mean values
obtained for the percentage of force increase were 6.47 ± 5.85 in the case of the conventional
laparoscopic surgery and 4.10 ± 2.89 for the robotic-assisted laparoscopic surgery. In
the case of the percentage of muscle fatigue, the values obtained were 7.99 ± 6.75 and
1.04 ± 0.97, respectively, for the conventional and robotic-assisted laparoscopic surgeries.
For the percentage of muscle fatigue recovery, for conventional laparoscopic surgery the
mean value was 2.45 ± 0.53 and for the robotic-assisted laparoscopic surgery the value was
9.52 ± 0.81. For the percentage of force decrement, for the conventional laparoscopic surgery
the value obtained was 5.62 ± 3.06 and for the robotic-assisted laparoscopic surgery the
value was 2.26 ± 1.71. For total nephrectomy and gastrotomy, the results are more balanced
and
Sensors 2024, 24, follow
x FOR a general trend. In this case, procedures by conventional laparoscopy required21 of 28
PEER REVIEW
high force use and lower localized muscle fatigue. In this way, for total nephrectomy, the
mean values obtained for the percentage of force increase were 1.70 ± 1.52 in the case of
the conventionalfatigue.
laparoscopic surgery
In this way, for total 0.17 ± 0.06 for
and nephrectomy, thethe
meanrobotic-assisted
values obtainedlaparoscopic
for the percentage
of force
surgery. In the case of theincrease
percentagewere of1.70 ± 1.52fatigue,
muscle in the case of the conventional
the values obtained were laparoscopic
0.45 ± 0.36 surgery
and 0.17 ± 0.06for
and 0.19 ± 0.08, respectively, forthe
the conventional
robotic-assistedand laparoscopic surgery.laparoscopic
robotic-assisted In the case of the percentage
surgery.
For the percentage of muscle
of muscle fatigue, the values
fatigue obtained
recovery, were 0.45 ± 0.36laparoscopic
for conventional and 0.19 ± 0.08, respectively,
surgery the for
the conventional and robotic-assisted laparoscopic surgery. For the percentage of muscle
mean value was 0.72 ± 0.56 and for the robotic-assisted laparoscopic surgery the value
fatigue recovery, for conventional laparoscopic surgery the mean value was 0.72 ± 0.56
was 1.20 ± 0.81. andForforthethe
percentage of force
robotic-assisted decrement,
laparoscopic for the
surgery theconventional
value was 1.20laparoscopic
± 0.81. For the per-
surgery the valuecentage
obtained was 0.62 ± 0.48 and for the robotic-assisted
of force decrement, for the conventional laparoscopic laparoscopic surgery
surgery the value obtained
the value was 0.55 ± 0.22. For the gastrotomy, the mean values obtained for the
was 0.62 ± 0.48 and for the robotic-assisted laparoscopic surgery the value was 0.55 ± percentage
of force increase 0.22.
wereFor the±gastrotomy,
1.13 0.71 in thethe case of the
mean conventional
values obtained for laparoscopic
the percentagesurgery and
of force increase
0.88 ± 0.61 for thewererobotic-assisted
1.13 ± 0.71 in thelaparoscopic surgery. Inlaparoscopic
case of the conventional the case ofsurgery
the percentage
and 0.88 ±of 0.61 for
muscle fatigue, thethe robotic-assisted
values obtained laparoscopic
were 3.23surgery. In the0.42
± 1.91 and case±of0.19,
the percentage
respectively,of muscle
for thefatigue,
the values obtained were 3.23 ± 1.91 and 0.42 ± 0.19,
conventional and robotic-assisted laparoscopic surgeries. For the percentage of muscle respectively, for the conventional
fatigue recovery,and robotic-assisted laparoscopic surgeries. For the percentage of muscle fatigue recov-
for conventional laparoscopic surgery the mean value was 0.05 ± 0.03 and
ery, for conventional laparoscopic surgery the mean value was 0.05 ± 0.03 and for the ro-
for the robotic-assisted laparoscopic surgery the value was 0.39 ± 0.08. For the percentage
botic-assisted laparoscopic surgery the value was 0.39 ± 0.08. For the percentage of force
of force decrement, for the
decrement, forconventional
the conventional laparoscopic
laparoscopicsurgery
surgery thethevalue
value obtained
obtained was was
2.89 ± 1.52
2.89 ± 1.52 and forand for the robotic-assisted laparoscopic surgery the value was 0.65 ± 0.44. 0.44.
the robotic-assisted laparoscopic surgery the value was 0.65 ±

Figure 16. Comparison of fatigue

Figure 16. and of
Comparison increase/decrease in force exerted
fatigue and increase/decrease in forceby surgeons
exerted during during
by surgeons the the
performance of surgical procedures (circle: ovariectomy; triangle: total nephrectomy; square: gastro- gas-
performance of surgical procedures (circle: ovariectomy; triangle: total nephrectomy; square:
trotomy) using conventional (red) and robotic-assisted (blue) laparoscopic surgeries.
tomy) using conventional (red) and robotic-assisted (blue) laparoscopic surgeries.
4. Discussion
With the introduction of new robotic systems, many of the ergonomic challenges
faced in open and laparoscopic surgery have been overcome, while new ones have been
created. Among these, we will highlight the new designs of robotic instrument controls,
the use of foot pedals, and the various types of screens (closed, open, and semi-open).
Sensors 2024, 24, 3840 20 of 26

4. Discussion
With the introduction of new robotic systems, many of the ergonomic challenges faced
in open and laparoscopic surgery have been overcome, while new ones have been created.
Among these, we will highlight the new designs of robotic instrument controls, the use
of foot pedals, and the various types of screens (closed, open, and semi-open). Surveys
reported that 56.1% of regularly practicing robotic surgeons continue to experience related
physical symptoms or discomfort, mainly neck stiffness and finger and eye fatigue [15].
Analyzing surgeon stress levels during laparoscopic and robotic-assisted surgeries is
a critical task since surgeon stress can directly affect surgeon performance and decision-
making ability during surgery. High levels of stress can lead to errors, lengthen operative
time, and compromise patient safety [16,17]. In addition, stress affects fine motor skills
and precision, which are critical in minimally invasive procedures. Stressed surgeons may
have difficulty with delicate movements, which can impact surgical outcomes. In addition,
prolonged stress can lead to burnout and negatively influence the longevity of a surgeon’s
career. Therefore, managing surgeon stress levels helps to improve surgical outcomes,
patient safety, and the overall well-being of the surgical team.
A study with the Senhance robotic surgical system (Asensus Surgical, Durham, NC,
USA) analyzed the results of the SURG-TLX survey of six centers, covering several disci-
plines and surgical procedures, both by laparoscopic and robotic-assisted surgeries [16].
Their results showed significantly lower overall workload levels for robotic surgeons com-
pared to laparoscopic surgeons. In general, a higher mental workload was observed in
robotic-assisted surgery, but lower physical demands and less distraction. In our study,
surgeons also reported a lower physical demand during surgical robotics in both evaluation
settings, with a significant difference in the simulation setting. It was observed that this
physical demand was strongly influenced by tasks and procedures requiring high temporal
demand during surgical procedures and high complexity for simulator tasks. In general,
subjective stress was higher for experts than for novice surgeons, being significantly cor-
related with heart rate (ECG) in laparoscopic tasks. However, in robotic-assisted surgical
procedures the level of stress was highly correlated with complexity, mental demand, and
electrodermal activity (EDA).
In the case of objective analysis, a study by Sujka et al. demonstrated that robotic
surgery could lead to a lower increase in salivary alpha-amylase and cortisol in the surgeon
compared with laparoscopic surgery, suggesting a reduction in physiologic stress [17]. For
this study, saliva was collected using a passive drool collection system at the beginning,
middle, and end of each case; amylase and cortisol were measured by ELISA. In the present
study, EDA and ECG were recorded, seeking to achieve physiological data for stress. EDA
was higher during laparoscopic procedures, being significant for novice surgeons, while
ECG showed a higher level for experts, correlated with their subjective stress. During the
surgical procedures the objective and subjective stresses were similar, showing higher EDA
during the robotic-assisted surgery. This may be due to the lack of experience with this
technique considering that all surgeons had experience in laparoscopic surgery but not in
robotic-assisted surgery.
Surgeons experienced increased complexity during conventional laparoscopic inter-
ventions, as well as their physical demand or even the objective stress of EDA. This may be
because the robotic surgical platform provides easier rotation of surgical instruments, as
well as a clutching mechanism that allows them to adapt the position of the instruments
during the surgical activity, which improves their ergonomic conditions and enables them
to reach remote areas with less effort.
The final objective of every task, the safety of the patient, is tightly related to the
complexity and temporary demand experienced by surgeons. Attending to the results from
the experimental model, surgeons felt greater subjective stress, task complexity, and mental
demand, as well as objective stress from EDA, during the least experienced methodology,
resulting in an increase in failure. Similarly, during the simulator model, complexity of the
task and errors were also highly correlated with stress.
Sensors 2024, 24, 3840 21 of 26

Surgeon’s motion analysis plays a crucial role in ergonomic analysis within the context
of surgery. Ergonomic guidelines for robotic surgery can be significantly improved by
considering motion analysis. Understanding how surgeons move during procedures
allows for better arrangement of operating rooms and leads to a reduction in mental and
physical stress.
The methods for analyzing the surgeon’s posture have evolved dramatically, from
methods based on photogrammetry [18], through infrared camera systems in combination
with retro-reflective markers [19], which are very limited by occlusions and therefore not
suitable for loaded environments such as an operating room. Another study made use of
the Xbox Connect camera [20]. This is a video-game-oriented camera that allows measuring
the positions of the surgeon’s head, shoulders, mid-spine, hips, and knees using Kinetisense
software. However, the system’s accuracy and problems with occlusions do not make
it a suitable solution for clinical settings. As a technological evolution, we have inertial
sensors, which allow us to record the surgeon’s posture accurately and without limitations
of occlusions of the environment. Therefore, this type of system, such as the one used in
this study, would certainly be the most appropriate for postural ergonomics analysis in
surgical environments.
Within laparoscopic tasks, it is interesting to mention laparoscopic suturing. Dur-
ing conventional laparoscopic surgery, which includes limited degrees of freedom or a
two-dimensional view, novice surgeons experience limitations in the learning curve of
intracorporeal suturing, whereas robotic-assisted surgery offers benefits in suturing perfor-
mance and decreases workflow [21].
It should be noted that, in general, the use of the robotic platform leads to greater
flexion of the back compared to the conventional laparoscopic technique. However, the
flexion is usually less than 15 degrees and therefore not highly ergonomically detrimen-
tal [1]. This slight flexion is related to the fact that during robotic-assisted procedures the
surgeon remains seated.
During the evaluation of the shoulder posture, we can observe some remarkable
behaviors in terms of its abduction/adduction. When surgeons perform tasks with con-
ventional laparoscopy, they must maintain a slight abduction due to the height restrictions
of the operating table. However, the robotic platform offers the possibility to clutch the
instruments in search of a more ergonomic posture, which leads them to perform the most
complex movements with the dominant hand.
Considering that back flexion/extension refers to the lumbar region, the height of
the console screen would primarily affect neck posture. The height of the console and the
armrests of the robotic platform are synchronized, both adjusting to the elbows so that at
rest they should describe 90 degrees. When the surgeon makes this adjustment, the lumbar
region is usually adequately positioned in the back of the chair, as we can see in the graphs
showing the posture during robot-assisted surgery, with the elbows close to 90º and the
back slightly flexed. In conventional laparoscopy, the height of the operating table in an
excessively low position can cause the surgeon’s back to bend excessively in order to reach
the target anatomical areas.
Analyzing knee flexion/extension in robotic-assisted procedures, some values outside
the expected range have been observed for the left knee. It appears that surgeons tend to
extend the leg for long periods while sitting to seek rest. This is also a common behavior
during driving, mainly dominated by the use of the right foot. On the other hand, some
graphs show some negative values (outliers) in knee flexion/extension, which is considered
an inconsistent value. This may be due to the calculation performed by the Xsens motion
analysis system software. Usually, the posture is calculated considering the relationship
between sensors placed on different joint segments (in this case tibia and femur). Perhaps
the out-of-range value occurs when the surgeon lifts the knee sufficiently while seated, and
therefore the software detects the tibia sensor above the femur sensor. This type of situation
needs to be addressed in subsequent studies.
Sensors 2024, 24, 3840 22 of 26

Similar to other studies [20], the RULA values obtained for the surgeon’s posture
during robotic practice indicate a medium ergonomic risk. However, the level of ergonomic
risk of the surgeon’s posture during robotic-assisted laparoscopic ovariectomy was consid-
ered high, which leads to the recommendation that the surgeon should improve his posture
as soon as possible. This result is related to a worse ergonomically inadequate upper limb
position during surgery. In the case of the simulator tasks, novice surgeons showed a
significant improvement in the ergonomics of their posture during robotic-assisted surgery
compared to conventional laparoscopic surgery.
One of the advantages of robot-assisted surgery compared to conventional laparo-
scopic surgery is the adjustment possibilities offered by the platform with respect to the
surgeon’s physical characteristics, allowing the height and proximity of the monitor to be
adapted, as well as the height of the controls and the armrests. This favors surgeons to
have more ergonomically adequate postures during the surgical practice, mainly of the
back and neck.
Not only is it important to analyze the posture of the main surgeon, but the rest of
the surgical team also plays a critical role in the safety and quality of patient care. In fact,
studies show that the main surgeon’s posture at the console of the robotic platform is more
ergonomic than that of the assistant at the patient’s bedside [22]. However, as we have seen
in the results of this and other studies, the console can also limit posture, increasing static
workload that could be associated with musculoskeletal symptoms.
The introduction of robotics into surgical practice requires knowledge and analysis of
the surgeon’s muscle activity to ensure proper ergonomics, as well as to guarantee opti-
mal use of robotic instruments, which translates into precise movements during surgery.
A study comparing robotic-assisted laparoscopic surgery and conventional laparoscopic
surgery found differences in muscle activation patterns [23]. In general, robotic-assisted
surgery requires lower levels of muscle activation in the neck and shoulder region. In the
present study, significantly higher muscle activation values were obtained in the middle
trapezius during robotic-assisted surgery, both in the simulator studies and in the perfor-
mance of gastrotomy. Similar results regarding elevated muscle activity in the neck muscles
in laparoscopic surgery were also presented by Dalsgaard et al. during a comparative
study on hysterectomy [24]. In addition, results have shown that when performing more
complex and longer surgical procedures, such as gastrotomy, nephrectomy, or ovariectomy,
a significant increase in muscle loading on the gastrocnemius medialis is shown during
laparoscopic practice compared to robotic-assisted surgery. This may be due to the fact that
the surgeon is standing during the surgical activity.
Evidence has been obtained indicating that forearm muscles show a high strain during
robotic-assisted surgery, especially those controlling ulnar deviation movements [23]. This
result is in line with the present study, which showed a higher muscle activation in the
brachioradialis compared to the conventional laparoscopic technique, mainly in the group
of surgeons with experience in laparoscopic surgery. This may be related to the use of the
handles and other controls. It is worth noting that the VersiusTM robotic platform does
not have pedals, so all controls are integrated into the handles (e.g., clutch), substantially
increasing their use compared to other platforms such as da VinciTM (Intuitive Surgical;
Sunnyvale, CA, USA) that do have pedals for camera control and active instruments.
Another study in colorectal surgery demonstrated prolonged periods of low-intensity
muscle activity in the shoulders during laparoscopic surgery and in the forearms for
robotic-assisted surgery [25]. RULA analysis indicated a greater need for a change in
working posture during laparoscopic compared to robotic surgery.
On the other hand, muscle workload analysis helps to optimize the surgeon’s posture
and minimize fatigue. Prolonged surgical procedures, such as laparoscopic and robotic
surgeries, can lead to significant muscle fatigue in surgeons [26]. This affects cognitive
function, decision making, and overall performance during surgery. By understanding mus-
cle fatigue, ergonomic improvements can be made to surgical techniques and equipment
design, and strategies can be implemented to mitigate its impact on surgeon well-being
Sensors 2024, 24, 3840 23 of 26

and surgical outcomes [27]. The results of the present study explore a comparison between
conventional and robotic-assisted laparoscopic surgeries from the perspective of localized
muscle fatigue and muscle activity.
Joint EMG spectrum and amplitude analysis (JASA) graphs have been widely applied
in the scientific literature for the analysis of muscle fatigue [28,29]. This method relates the
electrical activity and median frequency of the EMG spectrum, obtaining in a schematic
representation of the relationship between localized muscle fatigue and force use [30].
In previous studies, trapezius muscle fatigue during laparoscopic surgeries has been
studied, as the trapezius is shown to be vulnerable to localized muscle fatigue, being
the main muscle affected in the process of musculoskeletal tension [31,32]. This fact is
being corrected with robotic surgery as the movement of the main dominant muscles for
laparoscopic surgery has been seen to be reduced, supporting the advantages of robotic
surgery [33]. In addition, these results show less localized muscle fatigue and greater use
of force with robotic surgery than with conventional laparoscopic surgery. In the present
study, the results showed great similarity to those obtained by novice surgeons. However,
in the case of expert surgeons, force use and localized muscle fatigue were reduced for
conventional laparoscopic surgery but high force use and slightly higher localized muscle
fatigue were seen for robotic-assisted surgery. This fact could be related to the high degree of
experience in performing conventional laparoscopic surgeries in contrast to robotic-assisted
surgeries [34].
The results obtained during simulator tasks for expert and novice surgeons are in align-
ment with those obtained by Wee et al. [35], who demonstrated that from an ergonomic
point of view robotic surgery is superior to conventional laparoscopic surgery. There-
fore, future robotic surgeons should receive formal and thorough training for adequate
familiarization [34].
Muscle activity is closely related to muscle fatigue, and prolonged muscle activity of
small, single muscle fibers can cause degenerative muscle changes even with very low levels
of muscle activity. For this reason, ergonomic positioning is very important for laparoscopic
surgical activities [36]. The muscles analyzed in this study have been extensively evaluated
in other works for laparoscopic and robotic surgeries, the main muscles being the upper
and middle trapezius, triceps brachii, and brachioradialis [37]. Overall, for both types of
surgeons, expert and novice, conventional laparoscopic surgery required greater muscle
activity for the middle trapezius and right-sided triceps brachii. Robotic-assisted surgery
required greater muscle activity for the vastus lateralis on the left side.
From the results of the present study, it stands out that muscle activity on the right side
is lower than muscle activity on the left side. This fact could be related to the dominant side
of the surgeons, showing less effort using the dominant side than the non-dominant side.
Consistent with this fact, muscle activity on the dominant side also appears to increase
slightly over time compared with the non-dominant side, suggesting that the dominant
side may be more susceptible to slowly developing future musculoskeletal disorders [38].
Considering the surgeons’ experience, expert surgeons required greater muscle activity
in robotic-assisted surgery than in conventional laparoscopic surgery. However, novice
surgeons required greater muscle activity in conventional laparoscopic surgery than in
robotic-assisted surgery. This could be related to the fact that expert surgeons have a
high degree of experience in performing conventional laparoscopic surgeries in contrast
to robotic-assisted surgeries [34] and yet novice surgeons have more developed skills
necessary for robotic-assisted surgery and hand–eye coordination skills. Moreover, all
muscles bilaterally show statistically significant differences between laparoscopic and
robotic-assisted surgeries. This fact demonstrates the different use of muscles between
laparoscopic and robotic-assisted surgeries for both types of surgeons, experts and novices.
Among the limitations of this study is the small number of participants. It is necessary
to continue working in this line of research, increasing the number of studies to obtain more
conclusive and representative results. On the other hand, due to the limitations due to the
number of EMG sensors to be used simultaneously, there are still important muscle groups
Sensors 2024, 24, 3840 24 of 26

related to laparoscopic surgery, such as the deltoids or the biceps brachii, that should be
evaluated in future studies to obtain more comprehensive results. Finally, it would be
necessary to study the correlation over time between the activity of the muscle groups and
the joint angles to analyze whether a posture maintained over time may be related to the
appearance of localized muscle fatigue or another musculoskeletal disorder.

5. Conclusions
In this study, a set of wearable technologies and devices have been implemented and
developed to record and analyze physiological and ergonomic parameters of surgeons
during surgical performance in conventional and robotic-assisted laparoscopic surgery.
Robotic-assisted laparoscopic surgery showed better performance and better ergonomic
outcomes for surgeons than conventional laparoscopic surgery. Regarding physiological
parameters, the objective stress experienced during conventional laparoscopic procedures
was higher for both physiological recordings (EDA and ECG), related to the subjective
questionnaire for stress (SURG-TLX), and for mental and physiological demand, allowing
robotic-assisted laparoscopic surgery to present lower stress levels. In addition, surgeon
motion analysis in robotic-assisted laparoscopic surgery contributes to better outcomes,
reduced fatigue, and improved safety and health than conventional laparoscopic surgery,
both for surgeons and patients. Regarding ergonomic parameters, postural habits and
motor control are different among surgeons, which affects muscle activation patterns.
Understanding muscle activity during robotic-assisted laparoscopic surgery ensures pre-
cise movements, minimizes fatigue, and contributes to improved patient outcomes and
surgeon health.
Future studies focusing on the robotic work environment, both the lead surgeon and
the rest of the surgical team, should be strengthened. It would be convenient to extend the
studies on complex surgical procedures to obtain more conclusive results regarding the
ergonomic and stress of surgeons in situations close to reality and for different surgical
disciplines. Similarly, new cognitive analysis methods such as eye tracking or electroen-
cephalography (EEG) should be studied and compared with the ergonomic and physiolog-
ical results obtained by using the methodology proposed in this work. Finally, it would
be interesting to compare different robotic platforms for laparoscopic surgery and with
different configurations with respect to the controls, the type of vision system, or the use of
foot pedals and how they affect the surgeon’s ergonomics during surgical performance.
Ergonomic analysis allows us to study individual variations in the different ergonomic
parameters to improve surgical training and guidelines. Considering the rapid expansion
of robotic-assisted surgical procedures in clinical practice, the analysis and improvement
of the ergonomic conditions of surgeons and the surgical team are essential to provide
optimal working conditions, ensuring the well-being of the surgical team and thus the
quality of patient care. Training of the surgical team in optimizing ergonomic settings may
be necessary to maximize ergonomic benefits in surgical robotics.

Author Contributions: Conceptualization, M.J.P.-S., D.C., J.A.S.-M., F.M.S.-M.; Data curation, M.J.P.-S.,
D.C., J.A.S.-M.; Formal analysis, M.J.P.-S., D.C., J.A.S.-M., F.M.S.-M.; Funding acquisition, J.A.S.-M.,
F.M.S.-M.; Investigation, M.J.P.-S., D.C., J.A.S.-M., F.M.S.-M.; Methodology, M.J.P.-S., D.C., J.A.S.-M.,
F.M.S.-M.; Project administration, M.J.P.-S., D.C., J.A.S.-M., F.M.S.-M.; Resources, M.J.P.-S., D.C.,
J.A.S.-M., F.M.S.-M.; Software, M.J.P.-S., D.C., J.A.S.-M.; Supervision, J.A.S.-M., F.M.S.-M.; Validation,
M.J.P.-S., D.C., J.A.S.-M., F.M.S.-M.; Visualization, M.J.P.-S., D.C., J.A.S.-M.; Writing—original draft,
M.J.P.-S., D.C., J.A.S.-M.; Writing—review & editing, M.J.P.-S., D.C., J.A.S.-M., F.M.S.-M. All authors
have read and agreed to the published version of the manuscript.
Funding: This work has been partially funded by the Regional Government of Extremadura, the
Spanish Ministry of Science, Innovation and Universities, the European Social Fund, the European
Regional Development Fund and European Union NextGenerationEU funds (grant numbers PD18077,
TA18023, and GR21201), the Recovery, Transformation and Resilience Plan (PRTR-C17.I1), and the
Extremadura ERDF Operational Program 2021–2027.
Sensors 2024, 24, 3840 25 of 26

Institutional Review Board Statement: The animal study protocols were approved by the Insti-
tutional Review Board of the Directorate General of Agriculture and Livestock of the Regional
Government of Extremadura (References: EXP-20230325, EXP-20230320, and EXP-20230313).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Data available on request due to restrictions e.g. privacy or ethical.
Conflicts of Interest: The authors declare no conflict of interest.

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