https://orcid.org/0009-0007-1588-9366
Figures
Abstract
Purpose
Technological advancements have expanded options available for minimally invasive surgery, particularly laparoscopic surgery (LS) and robot-assisted laparoscopic surgery (RALS). However, these developments raise important questions about their impact on surgeon performance and well-being. This scoping review aimed to systematically map the current literature on the use of electromyography (EMG) to assess muscle activation in surgeons performing LS and RALS.
Methods
This study was a scoping review of the literature and did not require ethical approval. This review was conducted following the Joanna Briggs Institute (JBI) guidelines and the PRISMA-ScR checklist. A comprehensive search was performed across multiple databases including MEDLINE, Scopus, PubMed, EMBASE, and others. Studies were screened and selected using the Population, Concept, and Context (PCC) framework. Data were charted using a custom extraction form and analysed descriptively. Studies were included if they took place in a surgical setting (including simulated environments) involving laparoscopic abdominal surgery and used EMG to measure electrical activity, ergonomics, or muscular stress of a muscle group.
Results
Ninety-four unique studies published between 1997 and 2025 were included. Most studies focussed on LS (n = 62), with fewer investigating RALS (n = 5), comparing LS and RALS directly (n = 12) or isolated laparoscopic task settings (n = 15). EMG was primarily used to assess muscle activation in the deltoids, trapezius, and forearm muscles. Studies employed various methodologies, including root mean squared (RMS) amplitude and median frequency analysis, and often integrated EMG with other tools such as EEG, kinematic analysis, and questionnaires. Within the subset of comparative studies between RALS and LS, findings consistently suggested lower muscle activation in RALS compared to LS, particularly in the upper body musculature. However, this should be interpreted cautiously because the comparative evidence base is relatively small and heterogeneous.
Conclusions
EMG is a well-established and versatile tool for evaluating the ergonomic demands of minimally invasive surgery. While the broader literature maps the muscular demands of LS, a specific trend within comparative studies suggests RALS may reduce electrical activity compared to LS, especially in the shoulders and upper back. However, methodological variability and limited longitudinal data highlight the need for standardised protocols and further research. Future studies should explore long-term musculoskeletal outcomes and integrate EMG into surgical training to enhance ergonomic awareness. A future meta-analysis may be feasible, but only for carefully defined subgroups with comparable EMG protocols, task types, muscle groups, normalization procedures, and outcome measures.
Citation: Davitt M, Gaffney CJ, Subar D, Hayes LD (2026) Electromyography in abdominal laparoscopic and robot-assisted laparoscopic surgery: A scoping review. PLoS One 21(8): e0354158. https://doi.org/10.1371/journal.pone.0354158
Editor: Denis Alves Coelho, Jonkoping University, SWEDEN
Received: January 14, 2026; Accepted: July 3, 2026; Published: August 3, 2026
Copyright: © 2026 Davitt et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: This study is a scoping review that utilised and synthesised data that has previously been published in the public domain. All data that supports the findings can be found within either the referenced material, within the review itself or the supplementary search strategy document. No primary or new data was generated during the process of writing this review by any author. The inclusion criteria and search strategy is detailed within the methods section, and the review details are available to view on PROSPERO: (Study ID: CRD420251023254; https://www.crd.york.ac.uk/PROSPERO/view/CRD420251023254).
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Abdominal minimally invasive surgery (MIS), including both laparoscopic surgery (LS) and robot-assisted laparoscopic surgery (RALS), has transformed the surgical field, allowing for minimally invasive alternatives to the traditional use of open surgical techniques. Research has suggested that LS often reduces post-operative hospital stays, recovery times, improves cosmetic outcomes, and shortens surgery length compared to traditional surgery, although reports vary between populations and procedures [1]. However, LS introduces ergonomic challenges, including prolonged improper static postures and constrained instrument manipulation, which contribute to significant musculoskeletal strain in surgeons [2]. This causes both acute and chronic musculoskeletal disorders and fatigue, leading to reduced length of surgeon careers, increase work absence, general reductions in well-being, and potential reductions in quality of patient care.
The introduction of RALS has offered a new paradigm for minimally invasive surgery, with these systems offering surgeons advancements in precision and visualisation whilst potentially mitigating the limitations of surgical ergonomics faced by manual LS [3–5]). There is a debate regarding the extent to which RALS has improved minimally invasive surgery compared to LS. In particular, the area of musculoskeletal demand is an active field of research with a recent review by Shugaba et al. [3] aiming to answer whether all minimally invasive surgery should be robotic- this scoping review takes a distinct approach.
Instead of focusing solely on comparative outcomes of LS and RALS, this review aims to systematically map the current available literature that uses electromyography (EMG) to evaluate muscular activation of surgeons during these procedures collectively and individually. This is because EMG provides valuable insight into factors that affect coordination, fatigue, and the surgical biomechanical demands previously described. This scoping review seeks to identify and describe how EMG is being used across the entire field of minimally invasive surgery. For example, which muscle groups are more commonly assessed, methodologies used, the reported patterns and lengths of EMG data collection, and ultimately identify what the current gaps are within the literature. Considering the exploratory nature of this review, which differs from a more focussed approach of a systematic review, a broader research question was utilised to broaden the scope of the search, making a scoping review methodology appropriate [6]. A systematic review with meta‑analysis would require methodologically similar studies and a narrowly focussed question, conditions not yet met within the overall EMG literature.
While a comprehensive review of the effects of EMG during RALS and LS is an essential tool to guide patient care, it remains uncertain as to whether the available literature is sufficient to conduct quantitative pooling of data (i.e., a meta-analysis). Therefore, undertaking a traditional systematic review and meta-analysis, with a tightly focussed research question would be premature [7]. Consequently, we elected to undertake a scoping review. This approach retains the systematic approach to literature searching but aims to map out the current state of the research [7]. Using the JBI scoping review guidelines [8], a scoping review aims to use a broad set of search terms and include a wide range of study designs and methods (in contrast to a systematic review [8]). This approach has the benefit of clarifying key concepts, surveying current data collection approaches, and identifying critical knowledge gaps.
Objectives
We aimed to provide an overview of existing literature concerning EMG in MIS. Our three specific objectives of this scoping review were to (1) conduct a systematic search of the published literature concerning EMG during LS and RALS, (2) map characteristics and methodologies used across these surgical modalities, and (3) provide recommendations for the advancement of the research area. This review will complement the current work of meta-analyses in this field by offering a unique insight into research concerning the biomechanical aspects of surgical performance, EMG.
Review questions
Primary review question:
- What is the current evidence regarding EMG of surgeons performing LS and RALS settings?
Secondary Review Questions:
- Are there any identifiable trends in EMG research over time regarding LS and RALS settings (this aims to characterise the maturity and evolution of the evidence base over the 28-year period)?
- Are different methodologies utilised during EMG studies (e.g., variations in intervention, electrode placement, outcome measures)?
Methods
The methodology for this scoping review was completed using the Joanna Briggs Institute (JBI) scoping review guidelines [8] and was reported according to the PRISMA-ScR checklist [9] (S1 File). The protocol of the review, outlining the objectives was registered with PROSPERO before searches were made (Study ID: CRD420251023254. Available at: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251023254). This review was registered as a systematic review due to the lack of option to register as a scoping review. Aside from this, the review followed the details of the registered protocol.
Inclusion/exclusion criteria
As advised for scoping reviews, the inclusion criteria were developed using the Population, Concept and Context (PCC) framework [8]. Studies were included if they investigated any surgical setting involving laparoscopic abdominal surgeons and used EMG to measure electrical activity, ergonomic workload, or muscular stress in any muscle group. Eligible sources encompassed clinical trial protocols, and peer-reviewed research, quantitative, qualitative, or mixed-methods. A dedicated search of grey literature was not performed. This was due to initial pilot searches revealing a high volume of irrelevant records that lacked EMG metrics and did not meet the inclusion criteria of the review. Conference papers and conference abstracts were also not included. Broad inclusion was essential to capture EMG research trends and identify application gaps, particularly given the limited frequency of follow-up studies in this clinical field due to access challenges. Key exclusion criteria consisted of: meta-analyses or literature reviews or studies focusing on non-abdominal/non-minimally invasive surgery. During the screening process, “wrong study design” was defined as any non-empirical or secondary research, such as commentaries, editorials, or conference abstracts without full-text availability. “Wrong outcome” primarily referred to studies where EMG was used for anything other than assessing surgeon workload. This includes measuring patient muscle responses.
Search strategy
Initially the search was made in Medical Literature Analysis and Retrieval System Online (MEDLINE) and Academic Search Ultimate. The full search strategy was then developed using titles and abstracts to identify key words that would be needed to create an all-encompassing search within the titles and abstracts of the texts. The search strategy was then used and adapted to each database including Web of Science, Scopus, PubMed, MEDLINE, ERIC, EMBASE, AMED and Academic search ultimate. Each individual search line was then peer-reviewed by the chief investigator LH and a research librarian, which was then altered based on feedback. Language restrictions were set to exclude any literature not in English. The final searches were conducted on Web of Science (Clarivate), Scopus (Elsevier), PubMed, MEDLINE (Ovid), ERIC (EBSCO), EMBASE (Ovid), AMED (EBSCO), and Academic Search Ultimate (EBSCO). Sources that were included were hand-searched for other articles that may be eligible in the review. The final searches were conducted in March 2025 and coverage of the search included sources from any date until the search date. To improve transparency and reproducibility, the MEDLINE search strategy was structured by grouping key concepts and combining them using Boolean operators. Specifically, electromyography related terms and laparoscopic or minimally invasive surgery terms were searched as separate concept blocks joined using AND. The full search strategy that includes the search string for each included database can be found in S2 File. The full MEDLINE (Ovid) search strategy was as follows:
(exp
Electromyography/
OR (Electromyograp* OR EMG).ti,ab.
)
AND
(
exp Laparoscopy/
OR exp Hand-Assisted Laparoscopy/
OR exp Laparoscopes/
OR exp Cholecystectomy, Laparoscopic/
OR (
Laparoscop*
OR endoscop*
OR (
(minimally-invasive OR keyhole OR video-assisted OR “video assisted” OR “belly button”)
adj3 (surg* OR procedure* OR intervention* OR operation*)
)
).ti,ab.
)
The term “robotic” and related terms were not included in the final search strategy following a sensitivity analysis. Specifically, additional searches incorporating robotic-related keywords were conducted; however, these did not identify any additional eligible records beyond those retrieved by the final search strategy. These terms were therefore excluded to avoid redundancy without compromising the completeness of the search.
Study selection
All selected studies were uploaded to Rayyan (Qatar Computing Research Institute, Doha, Qatar) where they were stored and then duplicates removed initially by Rayyan’s duplication detection algorithm which was used to highlight potential duplicates and then the primary reviewer (MD) manually deleted manuscripts that were correctly identified as duplicates. Articles with the same outcomes such as the preprint and peer-reviewed versions were also consolidated using this process. The titles and abstracts of each article were then screened by the primary reviewer (MD) and then reviewed by a second independent reviewer (LH). Any differences in opinion about source inclusion were resolved in discussion (with CG). Full text screening against the inclusion and exclusion criteria then commenced after uploading the articles to Rayyan with the same independent review process taking place and any conflicts being resolved. Eighteen papers were excluded due to the full texts being unavailable, but an effort was made to locate all full texts with authors being contacted and requests for access being sent. All publications were included after this step.
Data charting
Studies selected for analysis in this review were charted using a custom form which was created for this review. The custom data extraction form was created in accordance with JBI guidelines [8]. When multiple sources of the same research were found, the research was condensed into one source material to reduce the chances of double counting. Study characteristic data extracted into table format included: Author name, surgical modality, location, design, aims and summary of results. This table was created using guidance from the Template for Intervention Description and Replication (TIDieR) [10] and is shown below. Data are presented in diagrams and tables, supported by text summaries that highlight significance and relevance of each section.
Critical appraisal of individual sources of evidence
In accordance with the PRISMA-ScR guidelines and the JBI manual for scoping reviews, a formal critical appraisal or risk-of-bias assessment of the included sources was not performed [8]. The rationale was based on the exploratory nature of the objectives of this review, aiming to map methodologies and identify gaps within the field rather than to assess the quality of the research or provide any clinical recommendations. This approach allowed the review to be more inclusive of a wide variety of studies that add to the overall assessment of technical and methodological trends that may otherwise have been omitted in a synthesis focused solely on the quality of research.
Results
Study characteristics
1,216 studies were identified during the initial search. Following deduplication in Rayyan, 857 titles and abstracts were screened against the inclusion criteria. When testing for eligibility, a total of 116 studies were assessed; 94 unique studies were included [11–102]. This is demonstrated below in Fig 1.
The analysed 94 studies were categorised as being conducted in a manual LS (n = 62) setting, standalone RALS setting (n = 5), comparative RALS vs LS setting (n = 12) or isolated laparoscopic tasks setting (n = 15). Full descriptions of each study are shown in Table 1 and distribution of task are shown in Table 2.
Of these studies, different muscle groups were investigated in different quantities per study. This means the total tally of muscle groups investigated exceeds the total number of studies: deltoids (n = 51), forearm (n = 48), trapezius (upper back) (n = 46), biceps brachii (n = 38), triceps brachii (n = 21), hand/wrist (n = 17), erector spinae/lower back (n = 14), neck (n = 14), gastrocnemius (n = 3), quadriceps (n = 2), abdominals (n = 2), pectoralis major (n = 2), hamstrings (n = 1), tibialis anterior (n = 1), hip flexors (n = 1). These studies spanned in time of publishing from 1997 until 2025 (up to the search date). The frequency of reported muscle groups is presented in Fig 2. below.
This figure reflects the distribution of research focus rather than comparative muscle activation between LS and RALS. Modality-specific findings are reported in the Results text.
LS findings
Studies using EMG during LS contributed the most research papers analysed (n = 62) and were observational than interventional. As shown in Fig 3. below, research since 1997 has been developing an understanding of the ergonomic and physical demands that this type of surgery places on the surgeons. This long-standing investigation was foundational in establishing EMG as a method of quantifying various outcomes of ergonomic demand. For example, research by Berguer et al. [19,21,23] used EMG to quantify “physical effort” of surgeons during LS, identifying awkward working angles and body positions which increased muscular demand. This research interest within the field has developed over time, eventually investigating the result of the greater levels of muscular demand (musculoskeletal complaints of surgeons) and using EMG to not just identify the levels of muscular demand, but identify ways in which it can be alleviated in terms of altering technique or introducing new tools [12,14].
RALS and comparative LS and RALS findings
While EMG in LS has dominated the literature, the growing use of RALS has led to its inclusion in EMG-based studies. The first investigation of EMG during RALS was conducted by Judkins et al. [40]. Since then, only five studies have focussed exclusively on EMG in RALS, as shown in Fig 3. This limited number may reflect a tendency for RALS research to focus on comparisons with LS rather than standalone characterisation. Consequently, more studies (n = 12) have directly compared EMG data between LS and RALS. Research by Chandra et al. [27] and Monfared et al. [61] demonstrated lower EMG activity in RALS, particularly in the trapezius and deltoid muscles. These comparisons are essential to support anecdotal claims that RALS reduces the physical demands placed on surgeons.
Task-based vs full surgical settings findings
The data also revealed differences between studies that used EMG in simulated or task-based settings versus full surgical procedures. Protocols varied widely, with some studies conducted in laboratory environments and others in clinical settings. This allowed for greater control over variables, such as task duration, complexity, and instrument type, that are difficult to manipulate in observational studies of live surgery, which is the predominant design in LS and RALS research. For example, Berguer et al. [20] compared muscular demand during LS tasks versus open surgery tasks, while Huang et al. [38] examined EMG across different training environments. These studies offer valuable insights into specific aspects of LS, including the impact of instruments, training conditions, and techniques. However, the ecological validity of such findings may be limited, as surgeons rarely perform isolated tasks in clinical practice. Therefore, introducing new tools or techniques into practice requires a larger body of evidence. One such study is Nishimoto et al. [63], which investigated the use of a knee rest to reduce muscular strain during surgery.
EMG methodology
Although all studies utilised EMG, its role varied depending on the study aims. The following sections outline the most common applications. The most frequently used method for quantifying muscular activation was root mean squared (RMS) amplitude [103]. RMS translates the EMG signal into a measurable amplitude that correlates with the electrical activity generated by motor nerves. It is typically normalised using maximal voluntary contraction (%MVC), which represents the maximum force a muscle can produce when flexed. This allows for comparison of average amplitude over time. For example, Kong et al. [46] used RMS to compare muscle activation between three-dimensional and two-dimensional surgical systems, finding lower RMS values in the former. Similarly, Matern et al. [58] investigated different laparoscopic tool handles and found one design produced significantly higher muscular activity (60% RMSmax) compared to others (25% and 30%).
EMG is also used to assess muscular fatigue, defined as a reduction in the muscle’s mechanical ability to generate force [104,105]. This is commonly measured using median frequency, which decreases over time as fatigue sets in [106]. Studies have used this metric to examine how various factors influence fatigue rates. For instance, Alhusuny et al. [13] observed declining median frequency in the erector spinae and anterior deltoids during complex tasks, while Asadi et al. [16] identified muscle groups more susceptible to fatigue during LS. Both RMS and median frequency provide precise, quantitative insights that move beyond general observations and allow ergonomic effects to be rigorously assessed.
Scope of EMG application and broader physiological assessment
In addition to its primary use in assessing surgeon ergonomics, EMG has also served as a complementary tool in broader physiological analyses. In these cases, researchers often incorporate additional data collection methods to build a more comprehensive understanding of how specific techniques, tools, surgical procedures, or tasks affect the surgeon. These approaches are outlined below.
A variety of supporting questionnaires were used frequently to assess comorbidities, perceptions of physical and cognitive load, and physical symptoms that may be correlated with EMG. These questionnaires were an important tool in the research of Dalager et al. [30] and Shugaba et al. [84] where questionnaires were used to gain insight into surgeons’ perceptions about physical wellbeing before quantitative analysis took place. Liang et al. [51] used self-report questionnaires in the form of the NASA Task Load Index. This can be used to assess self-perceptions across multiple scales such as temporal stress, physical demand, cognitive demand, performance, effort and frustration [107]. In this study no difference was found in any of the six reported self-perception scales for surgeons when operating on patients with obesity (BMI > 30 kg/m2). Questionnaires in research by Kraemer et al. [47] were also used to assess the surgeons’ perceptions of tools with rotatable handles vs non-rotatable handles. They reported that there was no preference from the surgeons between the two types of handles. This allowed the objective EMG data to be complimented with context about the surgeons’ perceptions.
A small proportion of the identified literature choose to utilise methods of analysing cognitive demand using objective measures by using an electroencephalogram (EEG) which is a non-invasive method of measuring electrical activity in the brain [108]. Within the research, multiple studies including Asadi et al. [16] and Shugaba et al. [84] have used EEG as a method of assessing cognitive demands alongside muscular demands using EMG in both LS and RALS. This distinction is critical as it suggests that while RALS may alleviate physical strain, it may simultaneously increase mental workload. The use of EEG alongside EMG is important to contribute to a holistic picture of the effect that RALS has on the surgeon. Just focussing on muscular demand ignores the potential for other factors, such as cognitive demand. This hinders the potential benefits of clinical applications that solve issues within the surgical profession due to reductionist results.
Several studies also complemented the use of EMG with kinematic analysis of surgeons’ limbs. The use of accelerometery, posture and joint angle analysis provided a multi-faceted analysis of the physical demands faced by surgeons. This works in partnership with the use of EMG as it provides external quantification of the biomechanical movements and positions of the surgeons, whilst EMG gives an internal insight on the production of these movements. Within this research, kinematic analysis was most commonly assessed in the upper limbs with varying applications. Chandra et al. [27] used accelerometers on the hand and forearm to calculate joint angle of the wrist and elbow when completing repetitive tasks and see whether this influenced wrist tremors. This study found that as the surgeons became more “fatigued” (measured using EMG mean frequency) the tremors at the wrist increased. Perez-Duarte et al. [69] also investigated the movement of the right hand and wrist angles using the Cyber Glove motion capture data glove (CyberGlove Systems, San José, CA, USA). This used wrist angle to calculate risk scores comparing LS and single site laparoendoscopy using a modified Rapid Upper Limb Assessment (also used in research by Tieken et al. [92]) that assessed risk of injury [109]. It was found that there was a lower risk of injury in single site laparoendoscopy compared to LS. However, the EMG data showed that activity was lower in the trapezius and forearm extensor muscles during LS compared to single site laparoendoscopy. The varied integration of kinematic analyses adds value to quantitative EMG data by providing methodological triangulation through observable meaning within biomechanical landmarks. This added context improves validity of EMG as a tool, strengthening the clinical application of the results by providing interpretation of the surgeons’ biomechanical interaction with the environment.
Muscle groups assessed
While this research used EMG to investigate the muscular demands of a large proportion of the body, some muscle groups were researched more heavily demonstrated by Fig 2. This section dissects the findings from the muscles that were most frequently investigated: the deltoids, trapezius, forearm, biceps and triceps muscles. The following section synthesises findings across the entire body of included EMG research, irrespective of surgical modality, to describe which muscle groups have been most frequently investigated. Where modality-specific differences between LS and RALS have been identified, these are explicitly stated.
The deltoids and trapezius muscles
When referring to the deltoid muscles, there are three main muscles: the anterior deltoid, lateral deltoid and posterior deltoid [110]. Similarly, when referring to the trapezius, there are three sections: the upper, middle and lower [111]. Both muscle groups have an important role to play in many functions surrounding the neck and shoulders that surround stability and movement of the joints. In the research, 51 studies chose to investigate the deltoids and 46 chose to investigate the trapezius (and upper back). This is not surprising as within the previous literature surrounding the musculoskeletal discomfort for surgeons, which is a common rationale for research in this field, many studies have pointed to shoulder and neck pain as a serious issue for surgeon wellbeing, time off sick, length of career and even surgical performance [112–114]. Research by Shugaba et al., Hubert et al. [39] and Zihni et al. [102] all found that there was lower muscular demand in the deltoids and trapezius during RALS compared to LS. In the LS only literature, factors that affect the workload of these muscles with research by Steinhilber et al. [87] and Matern et al were also investigated [59] higher surgical table height and “awkward” head and neck positions increased activation in the trapezius and deltoids.
The forearm muscles
The forearm muscles are vastly responsible for fine motor skills required to perform movement and instrument manipulation at the wrist during laparoscopic surgery [115]. Of the 48 studies that investigated the forearm muscles within this field (refer to Fig 3), many studies investigated the effect of differing designs in surgical instruments with varying results. Shimomura et al. [83] found that a re-designed, trial dissector handles reduced muscular activation in the forearm compared to a conventional dissector handle. Contrasting research is also prevalent. Sancibrian et al. [75] that found that there was no difference in muscle activation between a “new ergonomic surgical handle” and a traditional surgical tool handle. Although both studies show contrasting results about the effect that surgical tools have on muscle activation, they both act as evidence that the focus of this field is to mitigate hand and forearm strain in surgeons.
Other research that investigated the forearms investigated the muscular demands of completing different tasks with varying complexity. Perez-Duarte et al. [70] found that a higher degree of muscle activation was required to complete tasks such as suturing but Quick et al. [71] found that the greatest level of activation in the forearms was during cable-tying exercises. Further investigations showed that using an endoscope produced peak forces that were greater than the recommended levels of activation [79]. Whichever aspect of LS was investigated, the forearm muscles were subjected to high levels of muscle activation during activities that required precise and complex movements, showing that EMG is a trusted method of measuring lower levels of muscle activation caused by fine movements.
The biceps and triceps muscles
The biceps and triceps muscle groups are responsible for flexion and extension at the elbow joint [116] and play a crucial role in the stability or the arm when manoeuvring instruments into the most optimal position. Research within this field has focussed on the effects that sustained flexion, or extension under load or tension may have on the levels of muscular activation in these muscles. This is supported by research that suggests that the level of activation in these muscles may be lower during RALS than in LS or LS tasks [72,102]. This research utilises EMG to investigate the effects of isometric and isotonic contractions and finds that potentially due to the physical support for the arms during RALS, LS produces a greater level of muscular activation.
Discussion
Based on the 94 primary studies identified over a 28-year span, EMG is presented as a well-established and reliable tool for quantifying the muscular demands associated with RALS, LS, and LS-related tasks. While consistent findings within the 12 included comparative literature indicate that RALS may result in lower muscular activation than LS, particularly in the deltoid and trapezius muscle groups [39,84,102], these results should be interpreted with caution. It must also be noted that most of the evidence base (n = 62) serves to establish the baseline physical demands of LS. These muscle groups are subject to sustained isometric contraction during LS, a demand that appears to be mitigated by the physical support provided in RALS. Such evidence is important in substantiating anecdotal claims that RALS reduces the physical strain experienced by surgeons [27,61]. This scoping review offers a comprehensive synthesis of EMG research in the context of LS and RALS, an area of growing importance in surgical ergonomics. By systematically mapping 94 studies over a 28-year period, the review identifies key trends, methodological approaches, and gaps in the literature, particularly in relation to muscle activation and fatigue in surgeons. The available comparative studies suggest a trend toward lower muscular activation during RALS than LS, particularly in selected upper-body muscle groups. However, this finding should be interpreted cautiously because the comparative evidence base remains limited, heterogeneous, and was not formally appraised for methodological quality. The significance of EMG in abdominal laparoscopic and robot-assisted laparoscopic surgery lies in the integration with complementary tools such as EEG, kinematic analysis, and questionnaires, providing a multidimensional understanding of surgeon workload. The study’s rigour is demonstrated through adherence to JBI and PRISMA-ScR guidelines, a registered protocol, and a robust search strategy peer-reviewed by experts. This work not only consolidates existing evidence but also lays the groundwork for future meta-analyses and longitudinal studies, with practical implications for surgical training, tool design, and occupational health.
There were clear trends that emerged within this field over time with the first studies emerging in the 1990s and early 2000s being foundational and observational in their nature [19,21,23]. This established EMG as a potentially reliable and rigorous tool to quantify the physical demand that LS subjected on surgeons. With the emergence of RALS, research studies began to take an interest in the comparison between RALS and LS in terms of muscular demand, with studies investigating different aspects of muscular demand including muscle activation with RMS [46,58] and muscle fatigue using median frequency [2,16]. As time has progressed into the 2020s, the number of research papers in this field has increased on average per year, with research looking to optimise and investigate surgeon ergonomics using new technologies. These technologies included wearable sensors, motion capture systems, augmented reality and simulated training [85].
The methodologies involving and surrounding EMG have also varied vastly. Multi-faceted analysis often sees the use of EMG taking both a leading and supporting role within studies. Often EMG has been paired with questionnaire-based assessments to investigate surgeon perceptions of workload [30,51], along with EEG which can objectively provide insight into cognitive demand and act as counterbalance between cognitive and physical demands [16,84]. Kinematic analysis has also been incorporated with EMG research, with accelerometers and motion capture being used to analyse the joint angles and posture of surgeons [27,69,92]. This is important to provide context on the external outputs that muscle activation produces.
The variations in methodology, outcome measures and muscle groups investigated within this literature base shows that EMG is not only trusted, but also a versatile tool in the arsenal of investigating muscular demand. Its ability to be used to detect muscle activation in both fine and gross motor movements, along with isotonic and isometric contractions, makes it, potentially, the ideal tool for the dynamic environment of the operating theatre. That being said, this makes it incredibly difficult to ensure standardised practise between EMG studies as there are many extraneous variables within an operating theatre. Although efforts are made to normalise the data, the unpredictable nature of the surgical environment and the variability within surgeries make this type of research difficult to directly compare. This may offer some explanation as to why there are some contrasting results within this field. An important way to mitigate this risk may be to use other tools such as EEG [16,84], accelerometers [27,69], questionnaires [30,47,84] and motion capture cameras [85].
The impact that these studies could have on the wider clinical setting as well as within teaching and training cannot be understated. It’s role in providing live biofeedback flexibly in a vast range of contexts allows it to move beyond its common research use in the 1990s and 2000s of quantifying muscular demand solely. Research has consistently demonstrated that more experienced surgeons have a reduced muscular demand compared to less experienced surgeons [44,70]. This could mean that a future application for EMG could lie within the training curricula, helping trainee surgeons to objectively track their ergonomic efficiency and develop an awareness about reducing unnecessary muscle activation, hence reducing musculoskeletal injury. EMG may show potential as a training tool, with multiple studies reporting lower muscle activation in experienced surgeons, suggesting a role for biofeedback-informed ergonomic training. Although variables such as procedure type, operative duration, patient characteristics, and intraoperative positioning were not systematically analysed due to heterogeneity and inconsistent reporting, narrative trends indicate that these factors may influence muscular workload. Explicit consideration and reporting of these variables in future studies would enhance translational relevance and applicability to real-world surgical practice and may increase EMG’s use as a training tool.
Furthermore, the review highlights that ergonomic comparison within the surgical setting goes beyond just RALS and LS both individually and when compared. The variation in results when considering different tools highlights a future requirement to consider surgeon ergonomics more carefully when designing tools. Some studies state that the re-designing of instruments can reduce muscular demand in the forearm [83], but others found no difference between the traditional instruments and re-designed instruments [47,75]. This is particularly concerning when some tools were labelled as “ergonomic” handles, proving that there needs to be a closer collaboration between medical engineers and surgeons to make equipment that is both surgically effective and ergonomically efficient.
It is important to note that although this review has highlighted areas of strength in the use of EMG within the literature, it has also highlighted gaps that future research could look to address. Most studies that investigated LS and RALS were cross-sectional or observational studies that offer a brief insight into a surgeon’s muscular demand during a live surgery [16,19,21,23,30,31,61]. However, considering that a lot of these studies use the high rates of musculoskeletal injury among surgeons as a rationale, it is important that an understanding of long-term surgical impact [117]. This means that more longitudinal studies are required to track changes in muscle activation and levels of muscular fatigue throughout a surgeon’s career. In addition, research has begun to investigate how patients’ unique factors affect surgeon ergonomics, such as how BMI was found to influence the muscular demand for a surgeon [51] but has not yet fully explored this. Finally, when considering the comparisons between RALS and LS, there is currently a limited number of studies. This means that with all the muscles in the body, there needs to be more research investigating key areas mentioned to be points of injury such as the shoulders, upper back and wrists [112–114]. When this evidence base builds to more than a few studies on each muscle group, a greater case could be made for the introduction of RALS into more hospital trusts. Addressing the gaps identified within the literature using EMG as a tool will produce a more holistic picture of surgeon ergonomics with greater ecological validity. It is also necessary to acknowledge that there may be the potential for publication bias within this evidence base of identified studies that predominantly reports findings favourable to robotic systems. This may reflect an effect where neutral or negative ergonomic results are not published.
Finally, the number of papers included in this study (n = 94) shows that a future next step may be to conduct a quantitative meta-analysis. This will allow for a quantitative summary to be created of the individual research areas identified within this review, increasing the generalisability of the findings and potentially providing a more objective interpretation of the field.
Conceptual framework for methodological consistency in EMG-based surgical ergonomics research
The heterogeneity identified across the included studies highlights an opportunity to improve comparability and translational relevance through greater methodological alignment in future EMG-based surgical research. Based on common approaches observed throughout this scoping review, a preliminary conceptual framework is proposed to guide future investigations without imposing prescriptive standards.
Muscle group selection
The literature demonstrates a strong focus on the deltoids, trapezius, forearm, biceps, and triceps muscles, reflecting their relevance to reported musculoskeletal complaints among surgeons. Future studies may benefit from explicitly justifying muscle selection based on task demands, surgeon posture, and reported injury prevalence, while prioritising these commonly studied upper-limb and shoulder stabilising muscles to facilitate cross-study comparison.
EMG outcome measures and normalisation
RMS amplitude and median frequency were the most frequently reported outcomes for muscle activation and fatigue, respectively. Consistent use of these metrics, alongside transparent reporting of normalisation procedures (e.g., %MVC), would allow for greater interpretability and allow for synthesis across studies despite unavoidable contextual variation in surgical tasks.
Task definition and study context
Clear differentiation between simulated, task-based, and full procedural settings is critical, as ecological validity varies substantially across these designs. Future research may benefit from providing detailed descriptions of task duration, complexity, and instrument characteristics to contextualise EMG findings and improve reproducibility.
Integration of complementary measure
Studies incorporating kinematic analysis, questionnaires, or EEG provided richer interpretation of EMG data by linking muscle activation to posture, cognitive demand, and perceived workload. Future investigations may benefit from adopting multimodal approaches to avoid reductionist interpretation of surgeon workload based solely on muscular demand.
Limitations
Although this scoping review provides a comprehensive map of the current evidence, there are several limitations that must be acknowledged. Firstly, in accordance with JBI guidelines for scoping reviews, a formal critical appraisal or risk-of-bias assessment was not performed. Consequently, the findings regarding the ergonomic advantages of certain surgical modalities should be viewed as identified trends within the literature base as opposed to evidence used to make clinical recommendation. Secondly, within the literature base, there was a significant imbalance with 62 studies focusing on manual LS and only 12 providing a direct comparison with RALS; this disparity limits the ability to draw broad generalizations regarding robotic ergonomics but does allow for gaps in research and potential trends to be identified. Also, many included studies were small, observational, simulation-based, or involved isolated tasks rather than live operative settings. Therefore, current ergonomic benchmarks may not accurately represent the true musculoskeletal workload experienced by clinicians in the operating theatre.
Furthermore, direct quantitative analysis was made difficult due to the methodological heterogeneity across study methodologies including variations in muscle selection, EMG normalisation techniques and task complexity. Additionally, the focus of this review was on EMG, so other factors such as cognitive or visual strain were not considered, as this was outside the scope of this article. Lastly, no dedicated grey literature search was conducted, and the search was limited to English-language publications only. This may have resulted in the omission of emerging literature.
Conclusion
This scoping review demonstrates that EMG is a well-established tool for assessing muscular demand in abdominal minimally invasive surgery. While the largest volume of evidence evaluates the ergonomic challenges of LS, a smaller but consistent evidence base suggests that RALS was associated with lower muscular activation, particularly in the upper body. However, this finding should be interpreted cautiously because the comparative evidence base remains limited, heterogeneous, and was not formally appraised for methodological quality. The field has evolved from foundational observational studies to sophisticated, multi-modal investigations incorporating technologies such as EEG, motion capture, and wearable sensors. Despite these advancements, generalisability remains limited due to the predominance of single-centre, cross-sectional designs. Future research should adopt longitudinal approaches to better understand the cumulative impact of surgical practice over a career. EMG may also hold promise as a biofeedback tool in surgical training, helping to reduce musculoskeletal injury through improved ergonomic awareness. Further research is needed to comprehensively quantify surgeon workload during minimally invasive procedures, including the development of a validated surgeon demand index or real-time monitoring tools such as a surgical tachograph, to better predict and prevent musculoskeletal injury. A future meta-analysis may be feasible, but only for carefully defined subgroups with comparable EMG protocols, task types, muscle groups, normalization procedures, and outcome measures.
Supporting information
S2 File. Full search strings for each database.
https://doi.org/10.1371/journal.pone.0354158.s002
(DOCX)
Acknowledgments
Thank you to John Barbrook at Lancaster University library and the research librarians at Lancashire Teaching Hospitals for their assistance informing the search strategy and peer review.
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