Impact of the Single Incision Laparoscopic Cholecystectomy (SILC) Versus 4-port Laparoscopic Cholecystectomy On Surgeon Stress and Workload: A Randomized Controlled Trial.

Amro M Abdelrahman, MBBS1, Denny Yu, PhD1, Bethany Lowndes2, Susan Hallbeck, PhD3, Bingener Juliane, MD4. 1Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic., 2Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic., 3Department of surgery, 4Division of subspecialty general surgery, Department of Surgery, Mayo Clinic.


The goal of this study was to compare surgeon stress and workload between single incision laparoscopic cholecystectomy (SILC) and 4-port laparoscopic cholecystectomy during an ongoing randomized trial. Despite patient satisfaction and preference, SILC may expose surgeons to an excessively high workload and stress that may impact surgeon health and performance.


During a double-blind randomized controlled trial comparing patient outcomes for single port versus 4-port cholecystectomy (NCT0148943), heart rate monitoring and salivary cortisol levels were used to measure surgeon stress and workload. Continuous heart rate data was collected using a portable heart rate monitor attached to the surgeon’s chest with wireless data capture. Heart rate was sampled at three points in the operation: prior to the start (baseline), after clipping the cystic duct, and immediately after the procedure. Average heart rate, maximum heart rate, and mean change between the three distinct points within each procedure were analyzed. Salivary cortisol levels were sampled from the surgeon before the random assignment of the surgical procedure, during the surgery after the cystic duct was clipped, and after the procedure ended. The salivary specimens were placed on dry ice, stored at -80oF and assayed using ELISA (Salimetrics Inc.). To account for cortisol diurnal rhythm changes, only-first cases of the day were included in the cortisol analysis. After each procedure, the surgeon completed the SURG-TLX questionnaire, which is a validated workload assessment adapted from the National Aeronautics and Space Administration-Task load index (NASA-TLX). Student t-tests, Wilcoxon rank sum test, and Kruskal-wallis non-parametric ANOVAS on the dependent variables by the technique (single-port vs 4-port) were performed in intention to treat analysis with α=0.05.


Twenty three SILC and twenty five 4-port laparoscopic cholecystectomies were included in the study. No significant differences were observed in the patient demographics and procedure time (Table 1). SILC had significantly higher post-surgery maximum heart rates than 4-port (p<0.01). SILC also had significantly higher mean change in the maximum heart rate during and before each procedure (p<0.05), and after and before each procedure (p<0.01). Furthermore, inter-quartile range of the average heart rates ranged between the 85 and 99 beats/minute, and mean change in the average heart rate during and before each procedure was significantly higher in SILC than 4-port (p<0.01). Salivary cortisol level was significantly higher during SILC than 4-port (0.23 ug/dl SILC, 0.16 ug/dl 4-port, p<0.01), and the significance remained consistent for first cases only analysis. Using a 20 points visual analogue scales in SURG-TLX, higher physical demands were reported for SILC than 4-port (8.05/20 SILC, 7.50/20 4-port, p<0.05).


Objective stress measures of heart rate and salivary cortisol, and subjective physical workload on SURG-TLX were higher during SILC, indicating that SILC may be more stressful and physically demanding to the surgeon than the 4-port. Surgeon stress and workload may impact patients’ outcomes, thus ergonomic improvement on SILC is necessary.image

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