Several studies have suggested that certain surgeon characteristics are associated with an increased risk of developing morbidity due to performing laparoscopic procedures. Franasiak et al. observed that those at the greatest risk were surgeons of younger age, shorter time in practice, smaller glove size, and shorter stature [7]. It has been reported that laparoscopic surgeons early in their education use 130–138 % greater force and torque when performing laparoscopic surgery compared to their more experienced counterparts [8]. It is rationalized that as a surgeon gains more experience, hand-eye coordination is increased, as does efficiency in handling endoscopic instruments [8].

Similarly, it has been reported that finger numbness and eyestrain are less common in experienced surgeons. Hemal et al. showed that 13 and 16 % of surgeons with greater than 2 years of experience reported finger numbness and eyestrain, respectively, compared to 31 and 40 % of surgeons with less than 2 years of experience [9]. The authors suggested that surgeons first starting out in their career may not have received proper ergonomic training during their surgical education and that over time, they learned through experience to adjust their technique to decrease symptoms [9].

In contrast, Park et al. report that the single most predictive risk factors for the development of laparoscopic surgery-related symptoms were in those surgeons with the highest laparoscopic case volumes. The surgeon’s age or years of laparoscopic experience did not seem to have a significance of an impact [6]. The available evidence, although somewhat conflicting, shows that there are main factors that can be targeted in hopes of decreasing the risk of laparoscopy-induced injuries for surgeons.

Current laparoscopic instruments were adopted from those used in procedures minimally related to their current use. EMG studies demonstrated that the use of laparoscopic instruments can increase muscular work of the forearm and thenar compartment by a factor of 2–5 compared to using a standard hemostat [4]. Further studies indicated that when using laparoscopic instruments, EMG percentages exceeded accepted threshold limits, suggesting that the muscles were working in excess of their ability to avoid fatigue [10]. Nonergonomic instruments can promote many uncomfortable movements and maneuvers. For example, the wrists can be forced into a flexed position with ulnar deviation (Fig. 2.1a, b) [11]. This movement moves the surgeon out of the neutral position and can cause compression of the median nerve.

Nerve compression is a major concern for laparoscopic surgeons. The development of neuropraxia has been commonly attributed to performing laparoscopic procedures. Prolonged pressure of the radial digital nerve of the thumb and the palmar branch of the median nerve is a relatively common cause of digital neuropraxia [12]. In a survey of 50 laparoscopic surgeons, 40 % had experienced neuropraxia with symptoms lasting a median of 9 h and occurring a median of 4.5 different times [13]. There was a direct correlation between the frequency and total number of cases performed annually [13]. It is theorized that in an effort to perform precise movements and reduce tremor, surgeons will maintain an excessively forceful grip of the instrument compressing digital nerves [13].

These major drawbacks of the laparoscopic instruments can be attributed to their present design. Instrument shape poses a major problem for surgeons. The style of the most commonly used laparoscopic instruments possesses a scissor style with a pistol grip which requires thumb manipulation [14]. Furthermore, in the same study, Van Veelen et al. defined the ergonomic requirements for laparoscopic instruments and noted that the design of that most common style only met three out of the eight ergonomic requirements that they defined [14]. It has been observed that the scissor-handle type of laparoscopic instruments is associated with excessive wrist excursions during high-precision tasks and the cylindrical-handle type is associated with excessive wrist excursions during global tasks [15]. Moreover, laparoscopic instruments often possess narrow contact surfaces that are not ideal for accommodating the surgeons’ hands and fingers [11]. This puts pressure on small areas of the fingers that can eventually lead to numbness during the case.

The force required during the use of laparoscopic instruments is another major problem. When using the laparoscopic instrument, force must be applied, extending down the length of the instrument to the tip. This correlates with a force requirement of 4–6 times that of open surgery instruments [2]. This creates a problem for surgeons with busy caseloads as high forces must be maintained consistently during surgery, which can quickly result in fatigue. Force creation has been found to be a significant problem for surgeons with relatively small hands. Those with a glove size of 6.5 or smaller have been observed to experience significantly more difficulty with the use of laparoscopic instruments [16]. This is troubling as 36 % of the study group had a glove size of 6.5 or less [16]. Glove size ranges from 5.5 to 9 at increments of 0.5, yet there exists only one size of laparoscopic instrument [6]. Surgeons could potentially benefit from having the option of choosing from a collection of differently sized laparoscopic instruments.