Annals of Surgery Journal Club

Interactive resource for surgery residents and surgeons to discuss and critically evaluate articles published in Annals of Surgery selected by a monthly guest expert who will review an article each month, offer questions and respond to reader's comments.

Saturday, February 2, 2013

February Journal Club
Moderator: Dr. Caprice Greenberg
Article: Do Micropauses Prevent Surgeon's Fatigue and Loss of Accuracy Associated With Prolonged Surgery? An Experimental Prospective Study. Dorion, Dominique; Darveau, Simon: Annals of Surgery. 257(2):256-259, February 2013.
Summary: Micropauses or a formal 20-second break every 20-minutes of work are commonly used in other work environments to optimize performance and combat fatigue.   In an innovative study, Dorion and Darvaeu enrolled 16 surgeons, including both staff and residents, to investigate the effectiveness of micropauses in the operating room.  Each surgeon was asked to participate in three sessions under different conditions – once after a common operation of at least 2 hours, once after the same procedure with the introduction of micropauses, and once before any surgery to serve as a control.   Both subjective and objective data were collected immediately following the operation.  Measures included the level of discomfort experienced in different body parts measured on a visual analog scale, strength as measured by the ability to hold a 2.5kg weight with the dominant hand in 90 degree flexion, and accuracy as measured by the ability to trace a shape with scissors. 

Micropauses were associated with decreased levels of discomfort in the neck, back, shoulders, wrists, elbows, and eyes, but not in the lower extremities.   Following  a 2 hour operation, the amount of time that surgeons were able to hold a weight decreased by 33% and this effect was completely attenuated by the addition of micropauses.  Similarly, accuracy was compromised post-operatively with an average of 7 times as many errors.  Micropauses again significantly attenuated this effect.   

Surgeons have traditionally viewed themselves as infallible.  A BMJ article reported that 70% of surgeons agreed that “even when fatigued, I perform effectively during critical times” compared to 47% of anesthesiologists and only 26% of pilots.  There has however been a major shift in surgical culture over the last few years as evidenced by the growing number of studies documenting the rates of burn-out and fatigue within our profession.  Whether due to the work hour restrictions for residents, a change in the demographics of practicing surgeons, or simply a by-product of modern society, surgeons are willing to pay more attention to our own basic human needs and limitations.  This study provides objective evidence to support the deleterious impact of long-hours in the operating room and evaluates a simple intervention to combat the high rates of chronic neck and back pain, including significant long-term disability, previously documented in surgery.   Hopefully more collaborative work engaging human factors engineers and other experts in areas such as ergonomics will follow.


1.       What are the advantages and disadvantages of the crossover design utilized in this study?

2.       Which results of the study are most compelling?  The documentation of the degradation of performance or the effectiveness of the intervention?  Why?

3.       Do you believe that ergonomics is an important issue in the operating room?  Are there currently any strategies that you employ to combat the impact of fatigue?

Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers.