Evolution of ergonomics in thoracic surgery: a comparative analysis of the surgeon’s physical and cognitive load during VATS and RATS
Authors:
L. Tulinský
Authors‘ workplace:
Chirurgická klinika LF OU a FN OstravaKatedra chirurgických studií, LF OU, Ostrava
Published in:
Rozhl. Chir., 2026, roč. 105, č. 8, s. 391-396.
Category:
Review
doi:
https://doi.org/10.48095/ccrvch2026391
Overview
Introduction: Minimizing patient trauma in thoracic surgery introduces hidden ergonomic and cognitive burdens for the surgeon. This review aims to comparatively analyze these loads during the transition from thoracoscopy (video-assisted thoracoscopic surgery – VATS) to robotic-assisted surgery (robotic-assisted thoracic surgery – RATS).
Methods: A literature review was conducted focusing on objective (surface electromyography, RULA kinematic analysis, eye blink rate) and subjective (NASA--TLX) ergonomic assessments in multi-port VATS, uniportal VATS (uVATS), and RATS during pulmonary resections.
Results: Conventional VATS is associated with extreme static ischemia of the axial skeleton. Transitioning to uVATS improves the viewing axis, but increases frustration due to instrument clashing. RATS eliminates postural strain (significantly improved RULA scores); however, the lack of haptic feedback and spatial isolation lead to a measurable increase in cognitive load and psychological stress. Newer approaches (uRATS, bi-RATS) represent an effort to compromise between invasiveness and ergonomics. Clinically, RATS is associated with higher postoperative patient pain; however, improved ergonomics and tremor elimination demonstrably correlate with a higher quality of lymphadenectomy and oncological radicality.
Conclusion: Robotic surgery shifts the surgeon‘s burden from the physical to the cognitive domain. Understanding this paradigm is crucial for preventing musculoskeletal disorders, optimizing training, and ensuring maximum oncological safety for the patient.
Keywords:
Ergonomics – video-assisted thoracoscopic surgery – thoracic surgery – robotic surgical procedures – cognitive load
Sources
1. Bendixen M, Jørgensen OD, Kronborg C et al. Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: a randomised controlled trial. Lancet Oncol 2016; 17 (6): 836–844. doi: 10.1016/S1470-2045 (16) 00173-X.
2. Yoon SH, Jung MC, Park SY. Evaluation of surgeon‘s muscle fatigue during thoracoscopic pulmonary lobectomy using interoperative surface electromyography. J Thorac Dis 2016; 8 (6): 1162–1169. doi: 10.21037/jtd.2016.04.16.
3. Mathey-Andrews CA, Venkateswaran S, McCarthy ML et al. A national survey of occupational musculoskeletal injuries in cardiothoracic surgeons. J Thorac Cardiovasc Surg 2024; 168 (2): 617.e3–625.e3. doi: 10.1016/j.jtcvs.2023.08.038.
4. Epstein S, Sparer RV, Tran BN et al. Prevalence of work-related musculoskeletal disorders among surgeons and interventionalists: a systematic review and meta-analysis. JAMA Surg 2018; 153 (2): e174947. doi: 10.1001/jamasurg.2017.4947.
5. Veronesi G, Novellis P, Voulaz E et al. Robot-assisted surgery for lung cancer: state of the art and perspectives. Lung Cancer 2016; 101 : 28–34. doi: 10.1016/j.lungcan.2016.09.004.
6. Mazzella A, Casiraghi M, Galetta D et al. How much stress does a surgeon endure? The effects of the robotic approach on the autonomic nervous system of a surgeon in the modern era of thoracic surgery. Cancers (Basel) 2023; 15 (4): 1207. doi: 10.3390/cancers15041207.
7. Janda V. Svalové dysbalance a jejich vliv na posturální stabilitu. Rehabil Fyz Lek 2000; 7 (2): 45–49.
8. Bertolaccini L, Viti A, Terzi A. Ergon-trial: ergonomic evaluation of single--port access versus three-port access video-assisted thoracic surgery. Surg Endosc 2015; 29 (10): 2934–2940. doi: 10.1007/s00464-014-4024-6.
9. Hart SG, Staveland LE. Development of NASA-TLX (Task Load Index): results of empirical and theoretical research. Adv Psychol 1988; 52 : 139–183. doi: 10.1016/S0166-4115 (08) 62386-9.
10. Yao J, Chang Z, Zhu L et al. Uniportal versus multiportal thoracoscopic lobectomy: ergonomic evaluation and perioperative outcomes from a randomized and controlled trial. Medicine (Baltimore) 2020; 99 (42): e22719. doi: 10.1097/MD.0000000000022719.
11. Elkhouly AG, Santhirakumaran G, Shanahan B et al. Objective assessment of ergonomics and performance of thoracic surgeons during real-life anatomical robotic pulmonary resections. Interdiscip Cardiovasc Thorac Surg 2025; 40 (8): ivaf180. doi: 10.1093/icvts/ivaf180.
12. Tulinský L, Jarošová N, Adamica Det al. Robotická vs. uniportální lobektomie: prospektivní analýza pooperační bolesti, potřeby analgezie a individuálních rizikových faktorů. Rozhl Chir 2025; 104 (12): 533–542. doi: 10.48095/ccrvch2025533.
13. Tulinský L, Jarošová N, Adamica D et al. Pain and recovery after robotic vs. uniportal lobectomy for lung cancer: a comparative analysis. Surg Endosc 2025; 39 (11): 7181–7190. doi: 10.1007/s00464-025-12083-8.
14. Gonzalez-Rivas D, Bosinceanu LM, Manolache V et al. Uniportal fully robotic--assisted major pulmonary resections. Ann Cardiothorac Surg 2023; 12 (1): 52–61. doi: 10.21037/acs-2022-urats-29.
15. Nachira D, Kuzmych K, Congedo MT et al. Biportal-RATS vs. uniportal-VATS for lung resections: a propensity score--matched analysis from early experience. J Clin Med 2025; 14 (24): 8715. doi: 10.3390/jcm14248715.
16. Adamica D, Tulinský L, Hrubovčák J et al. Roboticky asistovaná torakoskopie vs. videoasistovaná torakoskopie v otázce radikality mediastinální lymfadenektomie. Rozhl Chir 2025; 104 (12): 526–532. doi: 10.48095/ccrvch2025526.
17. Adamica D, Tulinský L, Bujok P et al. Radicality of mediastinal lymphadenectomy in anatomic lung resection for lung cancer: a comparative analysis of uniportal video-assisted thoracoscopic and robotic-assisted thoracoscopic approaches. Surg Endosc 2026; 40 (4): 2938–2946. doi: 10.1007/s00464-026-12572-4.
18. Novellis P, Maisonneuve P, Dieci E et al. Quality of life, postoperative pain, and lymph node dissection in a robotic approach compared to VATS and OPEN for early stage lung cancer. J Clin Med 2021; 10 (8): 1687. doi: 10.3390/jcm10081687.
19. Toker A, Özyurtkan MO, Demirhan Ö et al. Lymph node dissection in surgery for lung cancer: comparison of open vs. video--assisted vs. robotic-assisted approaches. Ann Thorac Cardiovasc Surg 2016; 22 (5): 284–290. doi: 10.5761/atcs.oa.16-00087.
20. Cerfolio RJ, Ghanim A, Dylewski M et al. The long-term survival of robotic lobectomy for non-small cell lung cancer: a multi-institutional study. J Thorac Cardiovasc Surg 2018; 155 (2): 778–786. doi: 10.1016/j.jtcvs.2017.09.016.
21. Jin R, Zhang Z, Zheng Y et al. Health--related quality of life following robotic--assisted or video-assisted lobectomy in patients with non-small cell lung cancer: results from the RVlob randomized clinical trial. Chest 2023; 163 (6): 1576–1588. doi: 10.1016/j.chest.2022.12.037.
Labels
Surgery Orthopaedics Trauma surgeryArticle was published in
Perspectives in Surgery
2026 Issue 8
- Metamizole at a Glance and in Practice – Effective Non-Opioid Analgesic for All Ages
- Safety and Tolerance of Metamizole in Postoperative Analgesia in Children
- Metamizole in perioperative treatment in children under 14 years – results of a questionnaire survey from practice
- Obstacle Called Vasospasm: Which Solution Is Most Effective in Microsurgery and How to Pharmacologically Assist It?
Most read in this issue
- Současné výzvy dětské chirurgie: období mezi demografií, centralizací, regulací a rodiči
- Mondor’s disease as the initial presentation of breast cancer
- VIII. děčínské chirurgické dny
- 10. plzeňské dny HPB a mamární chirurgie