# Surgeons' physiological parameters and surgical performance: a systematic scoping review

Léa Pascal, Simon Ducarroz, Sarah Skinner, Quentin Cordier, Jean-Christophe Lifante, Stéphanie Mazza, Antoine Duclos

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## To cite this version:

Léa Pascal, Simon Ducarroz, Sarah Skinner, Quentin Cordier, Jean-Christophe Lifante, et al. Surgeons' physiological parameters and surgical performance: a systematic scoping review. Patient Safety in Surgery, 2025, 19 (1), pp.27. 10.1186/s13037-025-00445-z. http://hal-05326229

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# Surgeons' physiological parameters and surgical performance: a systematic scoping review

Léa Pascal<fnref n="1" />,<fnref n="2" />*, Simon Ducarroz<fnref n="1" />, Sarah C. Skinner<fnref n="1" />,<fnref n="2" />, Quentin Cordier<fnref n="1" />,<fnref n="2" />, Jean-Christophe Lifante<fnref n="1" />,<fnref n="3" />, Stéphanie Mazza<fnref n="4" /> and Antoine Duclos<fnref n="1" />,<fnref n="5" />

**Abstract**

**Background** Wearable sensors enable objective, non-invasive and accurate measurement of surgeons' physiological parameters that potentially impact surgeon performance and patient outcomes. This scoping review aimed to explore studies measuring surgeons' sleep, stress or physical activity using wearable sensors and to identify research gaps.

**Methods** A systematic search of PubMed and Scopus was conducted following PRISMA-ScR guidelines, for English-language articles published from January 1, 1950 to June 1, 2025. We included original quantitative studies measuring sleep, stress or physical activity in practicing or training surgeons, either as a parameter to investigate, or a determinant of performance. Data on physiological parameters, surgeon and surgical procedure, operating room (OR) setting, performance, study design, objectives, and findings were extracted using a predefined form.

**Results** Among 100 included studies, 88 measured stress, 9 sleep, and 5 physical activity. Stress was primarily assessed intraoperatively while sleep and physical activity during extended period inside/outside the OR. Most studies investigated the relationship between physiological parameters and surgeon attributes or within team role (43%), patient or surgical procedure (32%), OR setting, specific changes, or methods (17%). Six studies (6%) examined stress-performance links, with conflicting findings. Three studies (3%) suggested poor sleep may increase medical error risk, with inconsistent conclusions on burnout. Only one study quantified the influence of these parameters on patient outcomes.

**Conclusion** Tangible evidence linking surgeons' physiological parameters and performance in the OR remains limited. Available sensor technologies nowadays represent emerging opportunities to close this gap and improve understanding of how surgeon-related human factors impact patient safety.

**Keywords** Surgeon, Sleep, Stress, Physical activity, Wearable sensors, Performance

<footnote>*Correspondence:</footnote>

<footnote>Léa Pascal
lea.pascal@chu-lyon.fr</footnote>

<footnote n="1">¹Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France</footnote>

<footnote n="2">²Health Data Department, Hospices Civils de Lyon, Lyon, France</footnote>

<footnote n="3">³Department of Endocrine Surgery, Hospices Civils de Lyon, Lyon, France</footnote>

<footnote n="4">⁴Lyon Neuroscience Research Center (CRNL), INSERM U1028, CNRS UMR5292, Université Lyon 1, Université de Lyon, Lyon, France</footnote>

<footnote n="5">⁵Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, US</footnote>
## Introduction

Surgeons work in stressful and demanding environments under time pressure [1], which require high-level technical and decision-making skills [2]. Regardless of patient characteristics and procedure complexity, a surgeon's performance in the operating room may be affected by his/her own stress [3, 4], sleep debt [5, 6, 7], and physical activity levels [8]. The measurement of these physiological parameters has long been focused on subjective evaluations, including self-questionnaires [9, 10], or proxy variables, like performing operations after a night shift [11]. However, in order to fully understand the link between these parameters and surgeon performance, the parameters must be accurately measured. Recent technological advances have provided new opportunities for monitoring various human physiological information in real-time using wearable sensors [12]. These devices have the advantage of providing objective and precise measurements of individual physiological data that surgeons can continuously and non-invasively record inside or outside the operating room at an affordable price.

Recent systematic reviews investigating the measurement of surgeons' stress, sleep or physical activity using a wearable sensors were either limited to simulated environments [7], only included residents [13], did not assess the effect of physiological parameters on surgical performance [14, 15, 16] or were focused on a single metric [17]. No previous reviews have systematically synthesized knowledge on these three physiological parameters, regardless of the metric used, in real and simulated surgical settings, for surgeons of any level of expertise, and assessed their relationship with surgeons' performance and their potential determinants. In this scoping review, we aimed to explore the use of wearable sensors to measure surgeons' stress, sleep or physical activity in quantitative studies, and to provide a summary of the current knowledge on this topic for the surgical community. In particular, we sought to determine whether the influence of these physiological parameters on surgeon performance and patient outcomes were investigated, to describe the principal methods used and findings reported in available studies, and to identify the remaining research gaps in the field.

## Methods

### Literature search

The protocol of this review was registered with the Open Science Framework Registries (https://osf.io/wqpuz). A systematic search of PubMed and Scopus was last performed on June 3, 2025 in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines [18] (see checklist in Additional file 1). Search algorithms used for each database are detailed

in Additional file 2, and were built in three parts with keywords and Medical Subject Heading (MeSH) terms related to:

i. the surgeon ("surgeon");

AND

ii. sleep, stress, or physical activity ("sleep" OR "fatigue" OR "sleep wake disorders" OR "circadian rhythm" OR "stress" OR "stress, psychological" OR "stress, physiological" OR "occupational stress" OR "physical activity" OR "exercise" OR "walking");

AND

iii. sensors, physiological signals or indicators linked to sleep, stress or physical activity ("sensor*" OR "tracker*" OR "tracking" OR "wearable device*" OR "wearable electronic devices" OR "monitoring, physiologic" OR "electrocardiography" OR "ECG" OR "electrocardiogram" OR "galvanic skin response" OR "skin temperature" OR "electrodermal activity" OR "EDA" OR "electrodermal" OR "heart rate" OR "blood pressure" OR "cardiovascular response*" OR "electroencephalography" OR "EEG" OR "electroencephalogram" OR "EOG" OR "electrooculogram" OR "EMG" OR "electromyogram" OR "actigraph*" OR "actimetry sensor" OR "polysomnography" OR "PSG" OR "pedometer" OR "accelerometer" OR "step count*").

Additional limits were applied to include only original studies published in English-language between January 1, 1950, and June 1, 2025. In Scopus, since it was not possible to specify the month, we selected studies published before 2026 and manually verified that all included articles were published no later than June 1, 2025. Bibliographies of included articles and of any relevant review article were considered for additional studies.

## Eligibility criteria and study selection

Studies including practicing surgeons or surgeons in training (fellows, residents, interns) in any specialty were eligible. To be retained, papers had to measure sleep, stress or physical activity of the surgeon using a wearable sensor, either during a surgical procedure (real or simulated) or not. These physiological parameters had to be considered either as: (1) a parameter to investigate, according to the characteristics of the patient or surgical procedure, the surgeon, the operating room setting, or methodological considerations, (2) a criterion to measure the impact of a specific intervention, or (3) a determinant of surgeon's performance or well-being. Articles
investigating fatigue, burnout, mental workload, anxiety, muscular activity, muscular stress or ergonomics without measuring sleep, stress or physical activity with wearable sensors were excluded. To be eligible, studies measuring stress had to explicitly define the indicator as a measure of “stress” or “strain”. Studies assessing sleep, stress or physical activity using blood or saliva samples only (e.g. to determine levels of salivary cortisol or pro-inflammatory gene expression) were excluded. Only original quantitative research studies published in English in peer-reviewed journals were included. Consequently, editorials, commentaries, letters, news articles and reviews were excluded. Three authors (LP, in pairs with either SD or QC) independently screened titles and abstracts of all publications identified and then evaluated the full texts of selected articles to determine their eligibility for inclusion in this scoping review. At each step, disagreements were resolved through discussion and consensus, and a third author (AD) was consulted if needed.

## Data extraction and analysis

For each selected study, we systematically extracted data using a predetermined form (see Additional file 3), including details about each study's population characteristics, setting and objectives; the human parameters measured (the type of physiological parameters measured, the type of sensor used, the period studied, etc.); the outcomes studied (if the physiological parameter was considered as a determinant of surgeon's performance or well-being); the determinants or characteristics of the patient or surgical procedure, the surgeon, the operating room setting, or methodological considerations related to surgeon's physiological parameters; the study design used; and the main findings reported.

We rated the study design according to the method primarily employed to analyze the surgeons' physiological parameters of interest (sleep, stress or physical activity). Observational studies were categorized either as cross-sectional, when they provided a snapshot of the parameters of interest at a single period of time, or as longitudinal, when observations of the same individuals were repeated over time to allow the evaluation of intra-individual change. In interventional experimental studies, the participants were randomly assigned to the intervention whereas in quasi-experimental studies the intervention was not randomized.

We summarized the settings and population characteristics of the included studies in Table 2. Table 3 presents the characteristics of the sensors (in terms of signal detection type, anatomical location where the sensors were worn, monitored indicators, and wearing periods) according to the type of physiological parameters studied. The number of publications by physiological parameter over time was represented using a bar plot in

Fig. 2. In Fig. 3 we described the studies into two main categories according to their objectives. The studies in the first category considered the surgeons' physiological parameters as a parameter to investigate according to the characteristics of the patient or surgical procedure, the surgeon, the operating room setting, or methodological considerations, or as a criterion to measure the impact of a specific intervention. The studies in the second category considered the physiological parameters as determinants of the surgeons' performance or well-being. Table 4 summarizes the methodological characteristics and main findings of articles classified in the second category.

## Results

### Studies settings and population

Our search strategy identified 913 records (see Fig. 1). Excluding duplicates, we reviewed 835 article titles and abstracts, of which 155 references met criteria for full-text review.

Ultimately, 100 studies were selected for analysis (Table 1). Eighty-nine (89%) articles were published during the 2010–2025 period vs. 11 (11%) in the 1985–2009 period (Fig. 2). Eighty-eight articles (88%) studied stress, 9 (9%) sleep, and 5 (5%) physical activity. Two articles investigated the relationship between physiological parameters: one between sleep and stress, and the other between physical activity and stress. The majority of the studies were monocentric (78%) and focused on real surgical environments (73%) rather than simulated procedures.

The studies included a median (min-max) population of 11 (1-273) surgeons (Table 2). Among the 75 studies that assessed physiological parameters intraoperatively or perioperatively only, a median of 50 (9-793) surgical procedures, patients, or simulated tasks were studied. For the 25 other studies, the physiological parameters were measured continuously or repeatedly during extended periods of daily life, inside or outside the operating room. The most represented surgical specialties were digestive and general surgery (39%), orthopaedic and trauma surgery (33%), and cardiothoracic and vascular surgery (22%).

### Methods used to measure physiological parameters of the surgeon

Stress was primarily measured through cardiac activity (77%) or electrodermal activity (EDA) (10%) (Table 3). Cardiac activity was assessed using either electrocardiography (ECG), a bioelectrical signal that captures the heart's electrical activity, or photoplethysmography (PPG), an optical signal that detects blood volume changes with each heartbeat via light absorption through the skin. EDA reflects variations in the skin's electrical conductance due to sweat gland activity, which is
<figure><img src="image_4.png" /><figcaption>**Fig. 1** Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) flow diagram</figcaption></figure>

regulated by the sympathetic nervous system. Sensors were primarily worn on the thorax or upper limb. Heart rate and heart rate variability (HRV) served as physiological signal in most studies (52%). HRV is a measure of the variation in time intervals between consecutive heartbeats, reflecting autonomic nervous system regulation of cardiac activity. Stress was monitored intraoperatively in the majority of the studies (85%). These studies included samples of 1 to 162 operations per surgeon. Half of them used baseline measurements (55%).

Sensors used to measure sleep or physical activity were worn continuously for durations ranging from less than 1

week to a maximum of 14 months. Total sleep duration was monitored in all of the studies assessing sleep. All sleep-related metrics were measured using an accelerometer, with or without photoplethysmography, worn on the wrist, arm or ankle. The sensors used in seven of the nine studies were validated for total sleep time against polysomnography, the gold standard for assessing sleep. Step counts were measured using a pedometer or accelerometer in the five studies evaluating physical activity. Surgeons did not achieve the recommended 10 000 steps per day for healthy adults [19] while at work, averaging 4800–6000 steps in two studies. However, daily step
<table><caption>**Table 1** Summary of included studies</caption><thead><tr><th>First author</th><th>Publication Year</th><th>No. of surgeons</th><th>Multicentric</th><th>Real/ Simulated surgery</th><th>Surgeon's physiological parameter</th><th>Surgeon's performance or wellbeing</th><th>Characteristics of the patient, procedure, surgeon, operating room setting or methods</th><th>Specific intervention</th><th>Design</th></tr></thead><tbody><tr><td>Abahuje et al [82]</td><td>2023 16</td><td>No</td><td>No</td><td>Real</td><td>Stress</td><td>Stress</td><td>Roles and dynamics within the OR team - Resident supervision and attending leadership</td><td>Observational longitudinal</td><td>Observational longitudinal</td></tr><tr><td>Abd et al [96]</td><td>2012 8</td><td>No</td><td>No</td><td>Real</td><td>Physical activity</td><td>Stress</td><td>Roles and dynamics within the OR team - Healthcare professionals (surgeons vs. anesthesiologists)</td><td>Observational cross-sectional</td><td>Observational cross-sectional</td></tr><tr><td>Abdelrahman et al [20]</td><td>2016 1</td><td>No</td><td>No</td><td>Real</td><td>Stress</td><td>Stress</td><td>Patient and surgical procedure - Surgical technique (open, laparoscopic, etc.)</td><td>Interventional experimental</td><td>Interventional experimental</td></tr><tr><td>Alghamlas et al [52]</td><td>2025 16</td><td>No</td><td>No</td><td>Real</td><td>Stress</td><td>Stress</td><td>Surgeon's characteristics - Level of experience</td><td>Observational longitudinal</td><td>Observational longitudinal</td></tr><tr><td>Alobid et al [21]</td><td>2011 15</td><td>No</td><td>No</td><td>Real</td><td>Stress</td><td>Stress</td><td>Patient and surgical procedure - Surgical technique (open, laparoscopic, etc.)</td><td>Interventional experimental</td><td>Interventional experimental</td></tr><tr><td>Amirian et al [71]</td><td>2014 29</td><td>No</td><td>No</td><td>Simulated</td><td>Stress</td><td>Stress</td><td>Surgeon's activities - Pre-call, on-call, post-call</td><td>Observational longitudinal</td><td>Observational longitudinal</td></tr><tr><td>Amirian et al [91]</td><td>2014 29</td><td>No</td><td>No</td><td>Real</td><td>Sleep</td><td>Sleep</td><td>Surgeon's activities - Pre-call, on-call, post-call</td><td>Observational longitudinal</td><td>Observational longitudinal</td></tr><tr><td>Amirian et al [92]</td><td>2015 29</td><td>No</td><td>No</td><td>Real</td><td>Sleep</td><td>Sleep</td><td>Surgeon's activities - Pre-call, on-call, post-call</td><td>Observational longitudinal</td><td>Observational longitudinal</td></tr><tr><td>Angus et al [83]</td><td>2022 18</td><td>missing</td><td>No</td><td>Simulated</td><td>Stress</td><td>Stress</td><td>Roles and dynamics within the OR team - Resident supervision and attending leadership</td><td>Interventional quasi-experimental</td><td>Interventional quasi-experimental</td></tr><tr><td>Arora et al [49]</td><td>2010 11</td><td>No</td><td>No</td><td>Real</td><td>Stress</td><td>Stress</td><td>Patient and surgical procedure - Stressful, non stressful procedure (auto-evaluation with STAI)</td><td>Observational cross-sectional</td><td>Observational cross-sectional</td></tr><tr><td>Ashkenazi et al [50]</td><td>2024 3</td><td>No</td><td>No</td><td>Real</td><td>Stress</td><td>Stress</td><td>Patient and surgical procedure - Patient BMI</td><td>Observational longitudinal</td><td>Observational longitudinal</td></tr><tr><td>Awad et al [53]</td><td>2021 7</td><td>No</td><td>No</td><td>Real</td><td>Stress</td><td>Stress</td><td>Surgeon's characteristics - Level of experience</td><td>Observational cross-sectional</td><td>Observational cross-sectional</td></tr><tr><td>Awad et al [74]</td><td>2022 2</td><td>No</td><td>No</td><td>Real</td><td>Stress</td><td>Stress</td><td>Surgeon's activities - Time in the OR vs. Other professional activities</td><td>Observational longitudinal</td><td>Observational longitudinal</td></tr><tr><td>Awtry et al [116]</td><td>2025 38</td><td>Yes</td><td>Yes</td><td>Real</td><td>Stress</td><td>Stress</td><td>Patient morbi-mortality</td><td>Observational longitudinal</td><td>Observational longitudinal</td></tr><tr><td>Awtry et al [84]</td><td>2024 37</td><td>Yes</td><td>Yes</td><td>Real</td><td>Stress</td><td>Stress</td><td>Roles and dynamics within the OR team - Team familiarity</td><td>Observational longitudinal</td><td>Observational longitudinal</td></tr><tr><td>Bakhsh et al [85]</td><td>2019 10</td><td>No</td><td>No</td><td>Simulated</td><td>Stress</td><td>Stress</td><td>OR environment and distractions - Type of simulation</td><td>Interventional quasi-experimental</td><td>Interventional quasi-experimental</td></tr><tr><td>Berguer et al [22]</td><td>2001 28</td><td>No</td><td>No</td><td>Simulated</td><td>Stress</td><td>Stress</td><td>Patient and surgical procedure - Surgical technique (open, laparoscopic, etc.)</td><td>Observational longitudinal</td><td>Observational longitudinal</td></tr><tr><td>Böhm et al [23]</td><td>2001 2</td><td>No</td><td>No</td><td>Real</td><td>Stress</td><td>Stress</td><td>Patient and surgical procedure - Surgical technique (open, laparoscopic, etc.)</td><td>Interventional experimental</td><td>Interventional experimental</td></tr><tr><td>Brunner et al [54]</td><td>2024 18</td><td>No</td><td>No</td><td>Simulated</td><td>Stress</td><td>Stress</td><td>Surgeon's characteristics - Level of experience</td><td>Observational cross-sectional</td><td>Observational cross-sectional</td></tr><tr><td>Budden et al [55]</td><td>2023 17</td><td>No</td><td>No</td><td>Real</td><td>Stress</td><td>Stress</td><td>Surgeon's characteristics - Level of experience</td><td>Observational longitudinal</td><td>Observational longitudinal</td></tr><tr><td>Caballero et al [108]</td><td>2024 11</td><td>missing</td><td>No</td><td>Simulated</td><td>Stress</td><td>Stress</td><td>Methodological considerations - AI technique</td><td>Observational longitudinal</td><td>Observational longitudinal</td></tr></tbody></table>
<table><caption>Table 1 (continued)</caption><thead><tr><th>First author</th><th>Publication Year</th><th>No. of surgeons</th><th>Multicentric</th><th>Real/ Simulated surgery</th><th>Surgeon's physiological parameter</th><th>Characteristics of the patient, procedure, surgeon, operating room setting or methods</th><th>Specific intervention</th><th>Design</th></tr></thead><tbody><tr><td>Caballero et al [109]</td><td>2025 9</td><td>missing</td><td>Simulated</td><td>Stress</td><td></td><td>Methodological considerations - AI technique</td><td></td><td>Observational longitudinal</td></tr><tr><td>Cap et al [56]</td><td>2022 5</td><td>No</td><td>Real</td><td>Stress</td><td></td><td>Surgeon's characteristics - Level of experience</td><td></td><td>Observational longitudinal</td></tr><tr><td>Carnevali et al [65]</td><td>2023 16</td><td>No</td><td>Real</td><td>Stress</td><td></td><td>Surgeon's characteristics - Psychometric characteristics</td><td></td><td>Observational longitudinal</td></tr><tr><td>Cleary et al [32]</td><td>2018 12</td><td>No</td><td>Simulated</td><td>Stress</td><td></td><td>Patient and surgical procedure - Time points during surgery</td><td></td><td>Observational longitudinal</td></tr><tr><td>Coleman et al [93]</td><td>2019 17</td><td>Yes</td><td>Real</td><td>Sleep</td><td></td><td>Surgeon's activities - Pre-call, on-call, post-call</td><td></td><td>Observational longitudinal</td></tr><tr><td>Coleman et al [118]</td><td>2023 224</td><td>Yes</td><td>Real</td><td>Sleep</td><td>burnout</td><td></td><td></td><td>Observational longitudinal</td></tr><tr><td>Coleman et al [95]</td><td>2024 171</td><td>Yes</td><td>Real</td><td>Sleep</td><td></td><td>Surgeon's activities - Home call</td><td></td><td>Observational longitudinal</td></tr><tr><td>Cozzarelli et al [24]</td><td>2024 5</td><td>Yes</td><td>Real</td><td>Stress</td><td></td><td>Patient and surgical procedure - Surgical technique (open, laparoscopic, etc.)</td><td></td><td>Observational cross-sectional</td></tr><tr><td>De Louche et al [33]</td><td>2024 11</td><td>No</td><td>Real</td><td>Stress</td><td></td><td>Patient and surgical procedure - Time points during surgery</td><td></td><td>Observational longitudinal</td></tr><tr><td>Dedmon et al [34]</td><td>2019 2</td><td>missing</td><td>Real and Simulated</td><td>Stress</td><td></td><td>Patient and surgical procedure - Time points during surgery</td><td></td><td>Observational longitudinal</td></tr><tr><td>Del Rosario et al [57]</td><td>2024 17</td><td>No</td><td>Real</td><td>Stress</td><td></td><td>Surgeon's characteristics - Level of experience</td><td></td><td>Observational longitudinal</td></tr><tr><td>Demirtas et al [76]</td><td>2004 12</td><td>missing</td><td>Real</td><td>Stress</td><td></td><td>Surgeon's activities - Operating vs. office days</td><td></td><td>Observational longitudinal</td></tr><tr><td>Ducarme et al [35]</td><td>2015 75</td><td>Yes</td><td>Real</td><td>Stress</td><td></td><td>Patient and surgical procedure - Time points during surgery</td><td></td><td>Observational longitudinal</td></tr><tr><td>Engelmann et al [100]</td><td>2014 16</td><td>No</td><td>Real</td><td>Stress</td><td></td><td></td><td>Noise optimization in the OR</td><td>Interventional quasi-experimental</td></tr><tr><td>Erestam et al [103]</td><td>2021 17</td><td>No</td><td>Simulated</td><td>Stress</td><td></td><td>Intraoperative pause including a sugar-containing drink</td><td>Interventional experimental</td><td>Interventional quasi-experimental</td></tr><tr><td>Essibayi et al [43]</td><td>2025 1</td><td>No</td><td>Real</td><td>Stress</td><td></td><td>Patient and surgical procedure - Type of procedure</td><td></td><td>Observational longitudinal</td></tr><tr><td>Feng et al [25]</td><td>2015 4</td><td>missing</td><td>Simulated</td><td>Stress</td><td></td><td>Patient and surgical procedure - Surgical technique (open, laparoscopic, etc.)</td><td></td><td>Interventional quasi-experimental</td></tr><tr><td>Ganne et al [36]</td><td>2016 4</td><td>missing</td><td>Real</td><td>Stress</td><td></td><td>Patient and surgical procedure - Time points during surgery</td><td></td><td>Observational longitudinal</td></tr><tr><td>Grantcharov et al [113]</td><td>2019 1</td><td>No</td><td>Real</td><td>Stress</td><td>Technical skills</td><td></td><td></td><td>Observational cross-sectional</td></tr></tbody></table>
<table><caption>**Table 1 (continued)**</caption><thead><tr><th>First author</th><th>Publication Year</th><th>No. of surgeons</th><th>Multicentric</th><th>Real/ Simulated surgery</th><th>Surgeon's physiological parameter</th><th>Surgeon's performance or wellbeing</th><th>Characteristics of the patient, procedure, surgeon, operating room setting or methods</th><th>Specific intervention</th><th>Design</th></tr></thead><tbody><tr><td>Gupta et al [78]</td><td>2012</td><td>6</td><td>missing</td><td>Real</td><td>Stress</td><td></td><td>Roles and dynamics within the OR team - Operator vs. assisting or teaching</td><td></td><td>Observational longitudinal</td></tr><tr><td>Haffar et al [48]</td><td>2022</td><td>3</td><td>No</td><td>Real</td><td>Stress</td><td></td><td>Patient and surgical procedure - Ergonomics</td><td></td><td>Observational longitudinal</td></tr><tr><td>Haffar et al [26]</td><td>2022</td><td>1</td><td>No</td><td>Real</td><td>Stress</td><td></td><td>Patient and surgical procedure - Surgical technique (open, laparoscopic, etc.)</td><td></td><td>Observational longitudinal</td></tr><tr><td>Haffar et al [27]</td><td>2023</td><td>1</td><td>No</td><td>Real</td><td>Stress</td><td></td><td>Patient and surgical procedure - Surgical technique (open, laparoscopic, etc.)</td><td></td><td>Observational cross-sectional</td></tr><tr><td>Heemskerk et al [28]</td><td>2014</td><td>2</td><td>missing</td><td>Real</td><td>Stress</td><td></td><td>Patient and surgical procedure - Surgical technique (open, laparoscopic, etc.)</td><td></td><td>Interventional experimental</td></tr><tr><td>Ingram et al [90]</td><td>2024</td><td>12</td><td>missing</td><td>Simulated</td><td>Stress</td><td></td><td>OR environment and distractions - Distractions</td><td></td><td>Interventional quasi-experimental</td></tr><tr><td>James et al [114]</td><td>2011</td><td>11</td><td>No</td><td>Simulated</td><td>Stress</td><td>Prefrontal cortical activity</td><td></td><td></td><td>Observational longitudinal</td></tr><tr><td>Jatkinson et al [97]</td><td>2005</td><td>8</td><td>No</td><td>Real</td><td>Physical activity</td><td></td><td>Roles and dynamics within the OR team - Healthcare professionals (surgical vs. medical professional)</td><td></td><td>Observational cross-sectional</td></tr><tr><td>Jevsevar et al [67]</td><td>2021</td><td>21</td><td>No</td><td>Real</td><td>Stress</td><td></td><td>Surgeon's activities - Time in the OR vs. Other professional activities; Surgeon's characteristics - Sleep (Physiological measure)</td><td></td><td>Observational longitudinal</td></tr><tr><td>Jones et al [37]</td><td>2015</td><td>6</td><td>No</td><td>Real</td><td>Stress</td><td></td><td>Patient and surgical procedure - Time points during surgery</td><td></td><td>Observational longitudinal</td></tr><tr><td>Joseph et al [58]</td><td>2016</td><td>22</td><td>No</td><td>Real</td><td>Stress</td><td></td><td>Surgeon's characteristics - Level of experience</td><td></td><td>Observational longitudinal</td></tr><tr><td>Jukes et al [86]</td><td>2017</td><td>40</td><td>Yes</td><td>Simulated</td><td>Stress</td><td></td><td>OR environment and distractions - Type of simulation</td><td></td><td>Interventional quasi-experimental</td></tr><tr><td>Kambakamba et al [104]</td><td>2024</td><td>5</td><td>No</td><td>Real</td><td>Stress</td><td></td><td></td><td>Remote supervision with augmented-reality glasses</td><td>Interventional quasi-experimental</td></tr><tr><td>Kent et al [66]</td><td>2021</td><td>10</td><td>No</td><td>Real</td><td>Stress</td><td></td><td>Surgeon's characteristics - Stress level (subjective measure)</td><td></td><td>Observational longitudinal</td></tr><tr><td>Khan et al [45]</td><td>2023</td><td>2</td><td>No</td><td>Real</td><td>Stress</td><td></td><td>Patient and surgical procedure - Complexity of the procedure</td><td></td><td>Observational cross-sectional</td></tr><tr><td>Khan et al [44]</td><td>2022</td><td>3</td><td>No</td><td>Real</td><td>Stress</td><td></td><td>Patient and surgical procedure - Type of procedure</td><td></td><td>Observational cross-sectional</td></tr><tr><td>Klein et al [88]</td><td>2010</td><td>10</td><td>No</td><td>Real</td><td>Stress</td><td></td><td>OR environment and distractions - Modern vs. standard OR</td><td></td><td>Interventional quasi-experimental</td></tr><tr><td>Kuhn et al [38]</td><td>2013</td><td>10</td><td>No</td><td>Real</td><td>Stress</td><td></td><td>Patient and surgical procedure - Time points during surgery</td><td></td><td>Observational longitudinal</td></tr><tr><td>Kwon et al [59]</td><td>2021</td><td>8</td><td>Yes</td><td>Real</td><td>Stress</td><td></td><td>Surgeon's characteristics - Level of experience</td><td></td><td>Observational longitudinal</td></tr></tbody></table>
<table><caption>**Table 1 (continued)**</caption><thead><tr><th>First author</th><th>Publication Year</th><th>No. of surgeons</th><th>Multicentric</th><th>Real/ Simulated surgery</th><th>Surgeon's physiological parameter</th><th>Characteristics of the patient, procedure, surgeon, operating room setting or methods</th><th>Specific intervention</th><th>Design</th></tr></thead><tbody><tr><td>Kwon et al [39]</td><td>2020</td><td>5</td><td>No</td><td>Real</td><td>Stress</td><td>Patient and surgical procedure - Time points during surgery</td><td></td><td>Observational longitudinal</td></tr><tr><td>Langelotz et al [73]</td><td>2008</td><td>8</td><td>No</td><td>Real</td><td>Stress</td><td>Surgeon's activities - Pre-call, on-call, post-call</td><td></td><td>Observational longitudinal</td></tr><tr><td>Leitsmann et al [101]</td><td>2020</td><td>missing</td><td>missing</td><td>Real</td><td>Stress</td><td></td><td>Noise optimization in the OR</td><td>Interventional experimental</td></tr><tr><td>Louridas et al [105]</td><td>2015</td><td>20</td><td>No</td><td>Simulated</td><td>Stress</td><td></td><td>Mental practice</td><td>Interventional experimental</td></tr><tr><td>Maddox et al [60]</td><td>2015</td><td>13</td><td>No</td><td>Simulated</td><td>Stress</td><td>Surgeon's characteristics - Level of experience</td><td></td><td>Observational cross-sectional</td></tr><tr><td>Maher et al [107]</td><td>2013</td><td>26</td><td>No</td><td>Simulated</td><td>Stress</td><td></td><td>Stress management training</td><td>Interventional quasi-experimental</td></tr><tr><td>Mazzella et al [61]</td><td>2023</td><td>1</td><td>No</td><td>Real</td><td>Stress</td><td>Surgeon's characteristics - Level of experience</td><td></td><td>Observational longitudinal</td></tr><tr><td>McCormick et al [115]</td><td>2012</td><td>27</td><td>Yes</td><td>Real</td><td>Sleep</td><td>Risk of medical error</td><td></td><td>Observational longitudinal</td></tr><tr><td>Modi et al [69]</td><td>2019</td><td>33</td><td>missing</td><td>Simulated</td><td>Stress</td><td>Surgeon's characteristics - Performance stability within time pressure</td><td></td><td>Observational longitudinal</td></tr><tr><td>Murphy et al [98]</td><td>2015</td><td>15</td><td>No</td><td>Real</td><td>Physical activity</td><td>Roles and dynamics within the OR team - Healthcare professionals (radiologists and clinicians)</td><td></td><td>Observational cross-sectional</td></tr><tr><td>Narayanan et al [102]</td><td>2024</td><td>5</td><td>No</td><td>Real</td><td>Stress</td><td></td><td>Music in the OR</td><td>Interventional experimental</td></tr><tr><td>Payne et al [81]</td><td>1986</td><td>8</td><td>No</td><td>Real</td><td>Stress</td><td>Roles and dynamics within the OR team - Healthcare professionals (surgeons vs. anesthesiologists)</td><td></td><td>Observational cross-sectional</td></tr><tr><td>Pérez-Salazar et al [29]</td><td>2024</td><td>9</td><td>missing</td><td>Simulated</td><td>Stress</td><td>Patient and surgical procedure - Surgical technique (open, laparoscopic, etc.)</td><td></td><td>Interventional experimental</td></tr><tr><td>Pierce et al [87]</td><td>2018</td><td>6</td><td>No</td><td>Simulated</td><td>Stress</td><td>OR environment and distractions - Type of simulation</td><td></td><td>Interventional quasi-experimental</td></tr><tr><td>Pimentel et al [40]</td><td>2019</td><td>2</td><td>No</td><td>Real</td><td>Stress</td><td>Patient and surgical procedure - Time points during surgery</td><td></td><td>Observational longitudinal</td></tr><tr><td>Prichard et al [79]</td><td>2012</td><td>5</td><td>No</td><td>Real</td><td>Stress</td><td>Roles and dynamics within the OR team - Operator vs. assisting or teaching</td><td></td><td>Observational longitudinal</td></tr><tr><td>Quick et al [119]</td><td>2019</td><td>20</td><td>No</td><td>Real</td><td>Stress</td><td>Operative time</td><td></td><td>Observational longitudinal</td></tr><tr><td>Quick et al [62]</td><td>2017</td><td>19</td><td>No</td><td>Real</td><td>Stress</td><td>Surgeon's characteristics - Level of experience</td><td></td><td>Observational longitudinal</td></tr><tr><td>Robinson et al [72]</td><td>2019</td><td>17</td><td>Yes</td><td>Real</td><td>Stress</td><td>Surgeon's activities - Pre-call, on-call, post-call</td><td></td><td>Observational longitudinal</td></tr><tr><td>Rosenberg et al [47]</td><td>1987</td><td>15</td><td>Yes</td><td>Real</td><td>Stress</td><td>Patient and surgical procedure - Type of anesthesia</td><td></td><td>Observational longitudinal</td></tr><tr><td>Schuetz et al [112]</td><td>2008</td><td>18</td><td>No</td><td>Simulated</td><td>Stress</td><td>Technical skills</td><td></td><td>Observational longitudinal</td></tr></tbody></table>
<table><caption>Table 1 (continued)</caption><thead><tr><th>First author</th><th>Publication Year</th><th>No. of surgeons</th><th>Multicentric</th><th>Real/ Simulated surgery</th><th>Surgeon's physiological parameter</th><th>Characteristics of the patient, procedure, surgeon, operating room setting or methods</th><th>Specific intervention</th><th>Design</th></tr></thead><tbody><tr><td>Sharma et al [77]</td><td>2010</td><td>5</td><td>No</td><td>Real</td><td>Stress</td><td>Surgeon's activities - During surgery vs. during vigorous exercise</td><td></td><td>Observational longitudinal</td></tr><tr><td>Shinohara et al [89]</td><td>2024</td><td>6</td><td>No</td><td>Simulated</td><td>Stress</td><td>OR environment and distractions - Wearable chair</td><td></td><td>Interventional quasi-experimental</td></tr><tr><td>Siler et al [41]</td><td>2023</td><td>273</td><td>Yes</td><td>Simulated</td><td>Stress</td><td>Patient and surgical procedure - Time points during surgery</td><td></td><td>Observational longitudinal</td></tr><tr><td>Singh et al [30]</td><td>2018</td><td>8</td><td>missing</td><td>Simulated</td><td>Stress</td><td>Patient and surgical procedure - Surgical technique (open, laparoscopic, etc.)</td><td></td><td>Interventional quasi-experimental</td></tr><tr><td>Skinner et al [68]</td><td>2025</td><td>37</td><td>Yes</td><td>Real</td><td>Stress</td><td>Surgeon's characteristics - Physical activity (Physiological measure)</td><td></td><td>Observational longitudinal</td></tr><tr><td>Smith et al [31]</td><td>2000</td><td>28</td><td>No</td><td>Simulated</td><td>Stress</td><td>Patient and surgical procedure - Surgical technique (open, laparoscopic, etc.)</td><td></td><td>Interventional quasi-experimental</td></tr><tr><td>Sochacki et al [94]</td><td>2018</td><td>21</td><td>No</td><td>Real</td><td>Sleep</td><td>Surgeon's activities - Number of calls</td><td></td><td>Observational cross-sectional</td></tr><tr><td>Sochacki et al [117]</td><td>2019</td><td>21</td><td>No</td><td>Real</td><td>Sleep</td><td>Burnout</td><td></td><td>Observational cross-sectional</td></tr><tr><td>Soelling et al [99]</td><td>2024</td><td>38</td><td>Yes</td><td>Real</td><td>Physical activity</td><td>Surgeon's characteristics - Physical activity (Subjective measure)</td><td></td><td>Observational longitudinal</td></tr><tr><td>Song et al [80]</td><td>2009</td><td>1</td><td>No</td><td>Real</td><td>Stress</td><td>Roles and dynamics within the OR team - Operator vs. assisting or teaching</td><td></td><td>Observational longitudinal</td></tr><tr><td>Takács et al [70]</td><td>2024</td><td>missing</td><td>missing</td><td>Simulated</td><td>Stress</td><td>Surgeon's characteristics - Posture</td><td></td><td>Interventional cross-sectional</td></tr><tr><td>van Houwelingen et al [63]</td><td>2020</td><td>8</td><td>No</td><td>Real</td><td>Stress</td><td>Surgeon's characteristics - Level of experience</td><td></td><td>Observational longitudinal</td></tr><tr><td>Weenk et al [75]</td><td>2018</td><td>20</td><td>No</td><td>Real</td><td>Stress</td><td>Surgeon's activities - Time in the OR vs. Other professional activities</td><td></td><td>Observational longitudinal</td></tr><tr><td>Wetzel et al [111]</td><td>2010</td><td>30</td><td>Yes</td><td>Simulated</td><td>Stress</td><td>Technical and non-technical skills</td><td></td><td>Observational longitudinal</td></tr><tr><td>Wetzel et al [106]</td><td>2011</td><td>16</td><td>Yes</td><td>Simulated</td><td>Stress</td><td></td><td>Stress Management Training</td><td>Interventional experimental</td></tr><tr><td>Wilson et al [46]</td><td>2020</td><td>1</td><td>No</td><td>Real</td><td>Stress</td><td>Patient and surgical procedure - Complexity of the procedure</td><td></td><td>Observational cross-sectional</td></tr><tr><td>Yamada et al [110]</td><td>2023</td><td>4</td><td>missing</td><td>Real</td><td>Stress</td><td>Methodological considerations - Sensor placement</td><td></td><td>Observational cross-sectional</td></tr><tr><td>Yamamoto et al [64]</td><td>1999</td><td>12</td><td>Yes</td><td>Real</td><td>Stress</td><td>Surgeon's characteristics - Level of experience</td><td></td><td>Observational longitudinal</td></tr></tbody></table>
<table><caption>**Table 1 (continued)**</caption><thead><tr><th>First author</th><th>Publica-<br>tion<br>Year</th><th>No. of<br>surgeons</th><th>Multicentric</th><th>Real/<br>Simu-<br>lated<br>surgery</th><th>Surgeon's<br>physi-<br>ological<br>parameter</th><th>Characteristics of the patient, procedure, surgeon,<br>operating room setting or methods</th><th>Specific<br>intervention</th><th>Design</th></tr></thead><tbody><tr><td>Yamanouchi et<br>al [42]</td><td>2015</td><td>2</td><td>missing</td><td>Real</td><td>Stress</td><td>Patient and surgical procedure - Time points during<br>surgery</td><td></td><td>Observational longitudinal</td></tr><tr><td>Zonshayn et al<br>[51]</td><td>2024</td><td>1</td><td>No</td><td>Real</td><td>Stress</td><td>Patient and surgical procedure - Patient BMI</td><td></td><td>Observational<br>cross-sectional</td></tr></tbody></table>

OR indicates operating room; STAI, State-Trait Anxiety Inventory

counts over the whole day approached this target, with mean or median values of 9400–9800 steps in two additional studies. Physical activity intensity was reported in one study based on the number of calories burned per day.

**Summary of the studies evaluating the relationship between surgeons' physiological parameters and characteristics of the patient, procedure, surgeon, operating room setting or methods, or a specific intervention**

Eighty studies (80%) investigated the association between surgeons' physiological parameters and characteristics of the patient, surgical procedure, surgeon or operating room setting (Fig. 3). Characteristics studied were about the patient or surgical procedure (n = 32, 32%), the surgeons' activities (n = 13, 13%), their role and dynamics in the operative room team (n = 10, 10%), their characteristics (n = 20, 20%), and the operative room environment and distractions (n = 6, 6%). The majority of the study designs were observational (n = 65, 81%) rather than interventional (n = 15, 19%). Among observational studies, 49 (75%) analyzed data in a longitudinal way and 16 (25%) in a cross-sectional way. Five interventional studies were experimental and ten quasi-experimental.

Seventy-one (89%) studies were interested in stress. Among them, 56 (79%) were observational and 15 interventional (21%). The main characteristics studied were related to the patient and surgical procedure (n = 32, 45%) (surgical technique [20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31]; different steps during the surgery [32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42]; type of procedure [43, 44]; complexity [45, 46]; type of anesthesia [47]; ergonomics [48]; stressful vs. non stressful procedure [49]; patient BMI [50, 51]). Other characteristics investigated were linked to the surgeons (n = 19, 27%) (level of experience [52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64]; psychometric characteristics [65]; subjective measure of stress level [66]; physiological measure of sleep [67] or physical activity [68]; performance stability within time pressure [69]; posture [70]), their activities (n = 8) (pre-call/on-call/post-call [71, 72, 73], time in the OR vs. other professional activities [67, 74, 75]; operating vs. office days [76]; during surgery vs. during vigorous exercise [77]), their role and dynamics in the operative room team (n = 7) (operator vs. assisting or teaching [78, 79, 80]; type of health care professional: surgeons vs. anesthesiologists [81]; resident supervision and attending leadership [82, 83]; team familiarity [84]), and the operative room environment and distractions (n = 6) (type of simulation [85, 86, 87]; modern vs. standard operative room [88]; wearable chair [89]; distractions [90]).

Five observational studies evaluated the effect of surgeons' professional activities on sleep (pre-call/on-call/
<figure><img src="image_5.png" /><figcaption>**Fig. 2** Number of publications over time by surgeon physiological parameter</figcaption></figure>

post-call [91, 92, 93]; number of calls [94]; home call [95]).

Four observational studies assessed either surgeons' roles within the OR team (type of health care professional: surgeons vs. anesthesiologists [96], surgical vs. medical professional [97], radiologists vs. clinicians including surgeons [98]) or surgeons' characteristics (subjective measure of physical activity [99]) in relation to their physical activity as measured using a wearable sensor.

Eight studies (8%) measured the impact of behavioral or organizational interventions on surgeon's stress (noise optimization in the operative room [100, 101]; music in the OR [102]; intraoperative pause including a sugar-containing drink [103]; remote supervision with augmented-reality glasses [104]; mental practice [105] or stress management training program [106, 107]) (Fig. 3). Among them, five were experimental and three quasi-experimental.

Three observational studies (3%) examined methodological considerations related to stress levels (Artificial Intelligence techniques for prediction [108, 109]; sensor placement [110]).

We retrieved no interventional studies related to sleep or physical activity.

**Summary of the studies evaluating the association between surgeons' physiological parameters and their performance or well-being**

Nine (9%) studies evaluated the association between surgeons' stress or sleep on his/her performance or well-being (Fig. 3). No articles explored the effect of physical activity on these outcomes. All of these studies were observational, seven analyzed the data longitudinally, and two cross-sectionally. Surgeon performance was reported based on technical and non-technical skills, operating time, physiological measurements, burnout, risk of medical error, and patient morbi-mortality. Technical skills were evaluated using diverse metrics. Wetzel et al. employed the Objective Structured Assessment of Technical Skills (OSATS), comprising a procedure-specific checklist and a global rating scale assessing dimensions such as respect for tissue, time and motion, instrument handling, and operative flow [111]. They also used End Product Assessment (EPA) to evaluate the final operative outcome such as anastomosis integrity, tissue approximation, and hemostasis, focusing on outcome quality rather than procedural execution. Schuetz et al. utilized motion analysis metrics (e.g., path length, angular path) and recorded intraoperative failures including blood loss, missed clips, or vessel injury [112]. Grantcharov et al. employed the Operating Room Black Box® platform with the Generic Error Rating Tool (GERT) to identify any deviation that caused or risk patient harm, such as grasper slips, needle-induced bleeding, or
<table><caption>**Table 2** Summary of studies settings and population characteristics</caption><thead><tr><th>Studies settings and population characteristics</th><th>N = 100 studies</th></tr></thead><tbody><tr><td><strong>Number of surgeons</strong></td><td></td></tr><tr><td>median (range)</td><td>11<br>(1-273)</td></tr><tr><td>missing</td><td>2 (2)</td></tr><tr><td><strong>Number of surgical procedures<sup>(a)</sup></strong></td><td></td></tr><tr><td>median (range)</td><td>50<br>(9-793)</td></tr><tr><td>missing</td><td>6 (8)</td></tr><tr><td><strong>Surgical specialty<sup>(b)</sup></strong></td><td></td></tr><tr><td>General and digestive surgery</td><td>35 (39)</td></tr><tr><td>Orthopaedic and trauma surgery</td><td>29 (33)</td></tr><tr><td>Cardiothoracic and vascular surgery</td><td>20 (22)</td></tr><tr><td>Urology</td><td>12 (13)</td></tr><tr><td>Gynecologic and obstetric surgery</td><td>9 (10)</td></tr><tr><td>Neurosurgery</td><td>6 (7)</td></tr><tr><td>Other <sup>(c)</sup></td><td>10 (11)</td></tr><tr><td>missing</td><td>11 (11)</td></tr><tr><td><strong>Surgeon's position</strong></td><td></td></tr><tr><td>Attending only</td><td>28 (33)</td></tr><tr><td>Non-attending only (intern, resident, or fellow)</td><td>17 (20)</td></tr><tr><td>Both included</td><td>39 (46)</td></tr><tr><td>missing</td><td>16 (16)</td></tr><tr><td><strong>Geographical area of the study or of the author's affiliations<sup>(b)(d)</sup></strong></td><td></td></tr><tr><td>Europe</td><td>47 (48)</td></tr><tr><td>North America</td><td>36 (37)</td></tr><tr><td>Asia</td><td>11 (11)</td></tr><tr><td>Oceania</td><td>3 (3)</td></tr><tr><td>South America</td><td>1 (1)</td></tr><tr><td>missing</td><td>3 (3)</td></tr><tr><td><strong>Number of centers</strong></td><td></td></tr><tr><td>Monocentric</td><td>65 (78)</td></tr><tr><td>Multicentric</td><td>18 (22)</td></tr><tr><td>missing</td><td>17 (17)</td></tr><tr><td><strong>Real or simulated environment<sup>(b)</sup></strong></td><td></td></tr><tr><td>Real</td><td>73 (73)</td></tr><tr><td>Simulated</td><td>28 (28)</td></tr></tbody></table>

Data are n(%) otherwise stated

inadvertent thermal injury [113]. Non-technical skills were assessed using the Observational Teamwork Assessment for Surgery (OTAS), which evaluates domains such as communication, coordination, leadership, and situational awareness. Physiological measurements used as

indirect indicators of performance included prefrontal cortex (PFC) activity, measured with near-infrared spectroscopy (NIRS), which detects hemodynamic changes in the PFC as a surrogate for cognitive engagement [114]. The predicted risk of medical error was derived using the SAFTE (Sleep, Activity, Fatigue, and Task Effectiveness) model, which quantify the risk of cognitive impairment risk based on effectiveness scores falling below validated thresholds [115]. Patient morbi-mortality was assessed via major intraoperative or 30-day postoperative complications, prolonged ICU stay and mortality within 30 days of surgery [116]. Finally, burnout was evaluated using the Maslach Burnout Inventory [117, 118] and daily self-reported surveys capturing daily feeling of burnout [118].

Among the 6 studies that evaluated the effect of surgeon stress on his/her performance [111, 112, 113, 114, 116, 119], two reported an impact on technical performance—one showing an adverse effect on technical performance [113], and the other suggesting a negative effect on manual surgical skills and a positive effect on technical errors [112] (Table 4). One study found that increased stress during the first 5 min of surgery was associated with a significant reduction in major surgical complications [116].

Of the three studies evaluating the effect of surgeons' sleep on their performance or burnout [115, 117, 118], one showed that the estimated fatigue—derived from surgical residents' sleep and wake periods—increased their predicted risk of medical error compared to well-rested historical controls [115], while another reported that losses in sleep duration and consistency was associated with higher feelings of daily burnout [118].

## Discussion

### Main findings

This systematic scoping review shows that the emerging field of research related to surgeons' sleep, stress and physical activity, evaluated using wearable sensors, has significantly developed since 2010. Most of the retrieved articles focused on the surgeons' intraoperative stress during the procedure only. Sleep and physical activity were less frequently investigated, and were measured during extended periods both inside and outside of the operating room. The majority of studies explored variations of the surgeons' physiological parameters according to numerous characteristics related to the patient or surgical procedure, the surgeons' attributes or roles, and the operative room setting. A limited number of studies aimed to measure the association between those parameters and surgeon's performance or well-being. Of these, only one publication evaluated the potential effects of surgeons' physiological parameters on their patients' clinical outcomes.

<footnote>(a) Or patients, simulated tasks, trauma activations when sleep, stress or physical activity of the surgeon was assessed intraoperatively or perioperatively only (75 studies). The 25 other studies assessed these physiological parameters during extended periods in/out the operating room (during calls, workdays, etc.)</footnote>

<footnote>(b) Total percentage may be superior to 100% as multiple categories are possible per study</footnote>

<footnote>(c) Otolaringology surgery (n = 4), Pediatric surgery (n = 2), ophthalmic surgery (n = 2), oral and maxillofacial surgery (n = 1), plastic surgery (n = 1)</footnote>

<footnote>(d) For 43 (43%) studies the geographical area was not specified and we analyzed the author's affiliation instead if all affiliations were from the same country</footnote>
<table><caption>**Table 3** Sensor characteristics, monitored indicators and wearing periods used to measure surgeons' physiological parameters</caption><thead><tr><th></th><th>Stress<br>n=88</th><th>Sleep<br>n=9</th><th>Physical activity<br>n=5</th></tr></thead><tbody><tr><td rowspan="5">Physiological or Motion signal detection</td><td>Heart activity (ECG or PPG)</td><td>77 (77)</td><td>6</td></tr><tr><td>Electrodermal activity</td><td>10 (10)</td><td></td></tr><tr><td>Blood pressure</td><td>8 (8)</td><td></td></tr><tr><td>Respiratory activity</td><td>8 (8)</td><td></td></tr><tr><td>Motion (Accelerometer)</td><td>3 (3)</td><td>3</td></tr><tr><td rowspan="4">Anatomical Location of the sensor</td><td>Brain activity</td><td>3 (3)</td><td>Motion (Accelerometer)</td><td>3</td></tr><tr><td>Thermoregulation</td><td>3 (3)</td><td>Motion (Pedometer)</td><td>2</td></tr><tr><td>Chest/thorax</td><td>42 (57)</td><td>Elevation (Altimeter)</td><td>1</td></tr><tr><td>Wrist</td><td>11 (15)</td><td>Wrist</td><td>8</td></tr><tr><td rowspan="10">Monitored Indicators / Parameters</td><td>Arm</td><td>9 (12)</td><td>Arm</td><td>7</td></tr><tr><td>Ankle</td><td>4 (5)</td><td>Ankle</td><td>1</td></tr><tr><td>Head</td><td>4 (4)</td><td></td><td></td></tr><tr><td>Other*</td><td>4 (5)</td><td></td><td>Hip/belt</td><td>2</td></tr><tr><td>missing</td><td>23 (23)</td><td>missing</td><td>1</td></tr><tr><td>HR</td><td>52 (52)</td><td>Total sleep duration</td><td>9</td></tr><tr><td>HRV</td><td>52 (52)</td><td>Sleep deprivation</td><td>3</td></tr><tr><td>Electrodermal Activity</td><td>10 (10)</td><td>Total wake time or awakenings / Sleep interruptions</td><td>3</td></tr><tr><td>BP/MAP</td><td>8 (8)</td><td>Sleep efficiency</td><td>2</td></tr><tr><td>Respiratory rate / Minute ventilation</td><td>8 (8)</td><td>Sleep onset latency</td><td>2</td></tr><tr><td>Energy expenditure</td><td>6 (6)</td><td>Duration of sleep stages (REM, deep, or light sleep)</td><td>1</td></tr><tr><td rowspan="5">Wearing duration per surgeon or average No. of procedures per surgeon, according to the type of sensor wear period</td><td>Alpha, theta, beta, and gamma waves; sensory-motor rhythm (SMR); Concentration and Tension</td><td>3 (3)</td><td>Quality of sleep (no further precisions)</td><td>1</td></tr><tr><td>Heat flux / Body temperature</td><td>3 (3)</td><td>Sleep consistency</td><td>1</td></tr><tr><td>Other†</td><td>3 (3)</td><td></td><td></td></tr><tr><td>Intraoperative or perioperative measure, with baseline</td><td>41 (41)</td><td></td><td></td></tr><tr><td>No. of procedures, median (range) (4 missing)</td><td>7 (1-50)</td><td></td><td></td></tr><tr><td>Intraoperative measure only, without baseline</td><td>34 (34)</td><td></td><td></td></tr><tr><td>No. of procedures, median (range) (4 missing)</td><td>10 (1-162)</td><td></td><td></td></tr><tr><td>Continuous or multiple measures 24 h a day</td><td>8 (8)</td><td>Continuous measures 24 h a day</td><td>9</td></tr><tr><td>≤ 1 week</td><td>3</td><td>≤ 1 week</td><td>2</td></tr><tr><td>10 days</td><td>1</td><td>2 weeks</td><td>1</td></tr><tr><td>1 to 3 months</td><td>3</td><td>1 to 3 months</td><td>4</td></tr><tr><td>missing</td><td>1</td><td>6 months</td><td>2</td></tr><tr><td>Continuous or multiple measures while at work</td><td>5 (5)</td><td></td><td></td></tr><tr><td>≤ 1 week</td><td>4</td><td></td><td></td></tr><tr><td>missing</td><td>1</td><td></td><td></td></tr></tbody></table>

Two studies, each measuring two physiological parameters of the surgeon, were counted twice

Total percentage may be superior to 100% as multiple categories are possible per study

ECG indicates Electrocardiography; PPG, Photoplethysmography; REM, rapid eye movement

Data are n (%) otherwise stated

* Palm (n = 2), foot (n = 1), neck (n = 1)

† Cardiac index (n = 1), Interbeat intervals (n = 1), Real time stress percentage (n = 1)
<figure><img src="image_6.png" /><figcaption>**Fig. 3** Studies aims and design by surgeon physiological parameter. In this bubble plot, dots' size is proportional to the total numbers of articles. Total number of articles is indicated inside each dot. Two articles assessed the surgeon's characteristics related to sleep and physical activity in relation to stress, all measured using wearable sensors. One article is counted twice on the left side of the figure, as it addresses both surgeon's activities and sleep-related physiological characteristics in relation to physiological stress. Another article is counted twice on the right side, assessing the effect of stress on both technical and non-technical skills. Obs. indicated Observational studies; Int., Interventional studies. a Prefrontal cortex activity</figcaption></figure>

This highlights a critical gap in current research. Future studies should better acknowledge the potential role of these factors to support both surgeon health and patient safety.

## Comparison with other studies

This review identified a diversity of physiological signals used to objectively measure acute stress of the surgeon, including heart activity, electrodermal activity, blood pressure, respiratory activity, motion, brain activity, or thermoregulation. In their systematic review, Georgiou et al. [14] in 2017 observed the same spectrum of tools with the addition of salivary biomarkers, as their inclusion criteria were not limited only to measurement using a wearable sensor. Their findings indicated that salivary biomarkers have recently gained popularity during real or simulated surgical procedures. However, saliva cannot be collected continuously inside or outside of the operating room, and measurement of salivary biomarkers requires technical skills, and is not automated. Torkamani et al. identified other physiological signals such as eye-tracking metrics, electromyogram activity, body movements and kinematics to measure mental stress or workload without differentiating between them [15]. Consistent with the systematic review by Budden

et al. [16], we observed that many of the included studies assessing intraoperative stress failed to adhere to Laborde and al.'s recommendations [120] to measure baseline stress for accurate estimation of HRV changes induced by the surgical task. Although an ideal baseline recording that would apply under all circumstances does not exist, Quintana et al. proposed to define the baseline level of HRV as "the non-task situation that best controls for the presence of task comparison" [121]. In our scoping review half of the articles evaluating stress used heart rate or HRV measurement. This growing interest in HRV was also reflected in the systematic review of The et al. [17], which specifically focused on the use of HRV as an indicator of surgeons' stress during surgery. As observed in our scoping review, Torkamani et al. highlighted that the number of studies focusing on intraoperative stress assessment has increased over the last decade [15]. These results are in line with the rise of discrete subjective and continuous objective measurements, which were used together by the majority of the studies they reviewed. This trend is supported by the inherent limitations of subjective questionnaires and the need for precise and real-time measurement provided by wearable sensors. Nevertheless, despite technological advancements, wearable devices continue to face challenges related to data
<table><caption>**Table 4** Key characteristics and findings of studies assessing stress or sleep effects on surgeon performance or well-being</caption><thead><tr><th>Reference</th><th></th><th>No. of surgeons</th><th>Real / Simulated environment</th><th>Indicators</th><th>Surgeon's performance or well-being</th><th>Study design</th><th>Main findings</th></tr></thead><tbody><tr><td>Awtry et al. 2025 [116]*</td><td>Stress</td><td>38</td><td>Real</td><td>HRV</td><td>Patient morbi-mortality</td><td>Observational longitudinal study</td><td>Increased surgeon sympathovagal balance during the first 5 minutes of surgery was associated with significantly reduced major surgical complications (aOR, 0.63; 95%CI, 0.41–0.98; P = .04).</td></tr><tr><td>James et al. 2011 [114]</td><td>Stress</td><td>11</td><td>Simulated</td><td>HRV</td><td>Prefrontal cortical activity</td><td>Observational longitudinal study</td><td>HRV was not a predictor for changes in brain activity, after adjustment for subject expertise.</td></tr><tr><td>Quick et al. 2019 [119]</td><td>Stress</td><td>20</td><td>Real</td><td>EDA</td><td>Operative time</td><td>Observational longitudinal study</td><td>Resident stress poorly correlated with operative times regardless of case difficulty (Pearson coefficient range 0.0-0.22).</td></tr><tr><td>Schuetz et al. 2008 [112]*</td><td>Stress</td><td>18</td><td>Simulated</td><td>EDA</td><td>Technical skills</td><td>Observational longitudinal study</td><td>Surgeon stress reactions without recovery showed larger laparoscopic extensions of movement but fewer intra-operative failures than stress reactions followed by recovery or the absence of significant stress reactions</td></tr><tr><td>Wetzel et al.2010 [111]</td><td>Stress</td><td>30</td><td>Simulated</td><td>HR, HRV</td><td>Technical and non-technical skills</td><td>Observational longitudinal study</td><td>HR and HRV measures were not related to surgical performance.</td></tr><tr><td>Grantcharov et al. 2019 [113]*</td><td>Stress</td><td>1</td><td>Real</td><td>HRV</td><td>Technical skills</td><td>Observational cross-sectional study</td><td>Rates of events were significantly higher (47–66 per cent higher) in the higher stress quantiles than in the lower stress quantiles.</td></tr><tr><td>Coleman et al. 2023 [118]*</td><td>Sleep</td><td>224</td><td>Real</td><td>TST, Sleep consistency</td><td>Burnout</td><td>Observational longitudinal study</td><td>Losses in sleep duration and consistency were associated with higher feelings of daily burnout (P < 0.05).</td></tr><tr><td>McCormick et al. 2012 [115]*</td><td>Sleep</td><td>27</td><td>Real</td><td>TST, SOL, Sleep interruptions, Quality of sleep</td><td>Risk of medical error</td><td>Observational longitudinal study</td><td>Residents were predicted to have a mean (SD) of 22% (10%) increased risk of medical error attributable to fatigue, whose estimated level was derived from sleep and awake periods of surgeons.</td></tr><tr><td>Sochacki et al. 2019 [117]</td><td>Sleep</td><td>21</td><td>Real</td><td>TST, Sleep deprivation</td><td>Burnout</td><td>Observational cross-sectional study</td><td>There was no significant association between the number of hours of sleep and burnout.</td></tr></tbody></table>

aOR indicates adjusted Odds Ratio; SD, Standard Deviation; HRV, heart rate variability; EDA, electrodermal activity; HR, heart rate; TST, total sleep time; SOL, sleep onset latency.

*Studies demonstrating a significant effect.

accuracy, as well as real-time data processing and feedback [122]. Integrating artificial intelligence (AI) with wearable technology may help address these limitations. AI enables for the automated analysis of large volumes of multimodal physiological data collected from wearable sensors, allowing for real-time, personalized feedback and early detection of potential health risks [123]. In our review, two studies by Caballero et al. [108, 109] applied AI models to ergonomic and physiological parameters—including electrodermal activity, blood pressure, and body temperature—to predict stress levels during robotic-assisted surgery. These predictive tools may help prevent the potential harm of excessive stress on surgeon health and patient safety, and support timely interventions such as scheduled breaks to optimize recovery and performance. AI-enhanced monitoring offers predictive

and preventive benefits beyond the reactive nature of sensor-only methods. However, its application is still emerging in this field and requires further research to validate its effectiveness and facilitate integration, particularly by addressing key methodological and ethical challenges. Similar to the results of our review, Torkamani et al. [15] and Budden et al. [16] found that almost all of the articles included in their systematic reviews aimed to assess the effect of a wide range of determinants on HRV.

In our scoping review, the evidence on the potential link between stress and surgeon technical performance was sparse and conflicting. A decade ago, Arora et al. [3] aimed to systematically review articles evaluating the relationship between stress and technical or non-technical performance. Their results suggested that an excess amount of stress may impair technical performance.
However, stress was not always objectively measured and the link with performance was indirectly established. Indeed, authors found that laparoscopic procedures were associated with higher stress levels and poorer technical performance than open and robotic surgery, and that experienced surgeons had lower stress levels and better technical performances compared with junior surgeons. Conversely, moderate levels of stress in surgery residents were accompanied by improvements in technical performance on task trainers based on subjective stress assessment [10]. This is consistent with optimal performance observed in athletes [124] or in the workplace [125] under non-excessive level of stress. This positive effect of stress was reported by Awtry et al., the only study in our review examining patient outcomes, which found that increased objective stress in surgeons at the start of surgery was associated with a significant reduction in major surgical complications [116]. As noted by the authors, the predominantly elective nature of the procedures and the potential insufficient volume of highly complex cases may have limited the intensity of stress experienced, thereby enabling optimal performance. Furthermore, only attending surgeons were included in the study, and their experience may have mitigated the potentially harmful effects of stress on performance [111], likely through more effective coping strategies than those used by novices [126]. While acute stress during surgery may either enhance or impair immediate performance depending on its intensity, chronic work-related stress has been identified as a significant risk factor for surgeon burnout [127]. However, few studies in our review examined long-term stress. Robinson et al. reported that a single night of in-house call induced substantial physiological stress in acute care surgeons, evidenced via a reduction in HRV, which persisted until the third post-call day [72]. Further research is needed to clarify the relationship between persistent post-call stress and burnout, and to identify factors influencing physiological recovery.

Similar to the findings of the McCormick study on the risk of medical error included in our review [115], the systematic review of Whelehan et al. in 2020 [7] suggested that sleep deprivation could impair surgeons' technical skills in simulated environments. However, sleep was measured objectively with a wearable sensor (actigraphy) in only one of the articles included in the review. Other studies concluded that patients who were operated on by a sleep-deprived surgeon [128] or a surgeon who had worked the night before [11, 129, 130, 131] did not appear to be at an increased risk of experiencing adverse outcomes, unless the surgeon had limited sleep opportunities during his previous night of work [129]. However, all of these studies measured sleep either by asking the surgeons to report the number of hours they slept themselves, which can be source of bias [132], or with a binary

contextual variable (surgeon operating the day after night work), which does not provide precise information on the quantity and quality of sleep. Furthermore, when the number of sleep hours [128] or sleep opportunities were collected [129], a six-hour threshold was chosen whereas the recommended amount of sleep for a healthy adult is seven or more hours [133]. Finally, sleep opportunity, defined as “the time period between the end of the last overnight index procedure and the beginning of the first daytime postnighttime procedure” [129], may be a very rough indicator of the number of hours the surgeon actually slept. The impact of sleep on patient outcomes still remains controversial, and there is a lack of studies accurately and reliably assessing sleep using direct objective measurement. Despite the paucity of tangible evidence, the Accreditation Council for Graduate Medical Education (ACGME) introduced restrictive duty-hour policies for residents in the United States in 2003 and in 2011 that shortened maximum shift lengths and mandated minimum time off after overnight on-call duty [134]. A national cluster-randomized trial conducted in 2016 concluded that, compared to standard duty-hour policies, flexible, less-restrictive duty-hours policies for surgical residents were associated with noninferior patient outcomes and no significant difference in residents' satisfaction with overall well-being and education quality [134].

In our review, unlike Sochacki et al. [117], Coleman and al. found that sleep loss was associated with burnout, along with in-house or home calls, suggesting both physical and emotional pressure exerted by calls [95, 118]. Additionally, in these attending acute care surgeons sleep-monitored 24/7 over 6 months, more frequent in-house calls were associated with poorer sleep consistency—reflecting higher variability in a surgeon's sleep timing, which was further associated with increased feelings of daily burnout. Those findings are consistent with other studies suggesting that sleep deprivation and circadian misalignment due to shift work could play a critical role in healthcare professionals burnout [135, 136, 137]. Circadian misalignment occurs when an individual's internal biological clock (endogenous circadian rhythm) becomes unsynchronized with external factors such as sleep-wake timing, light exposure, or work schedules [138, 139]. Regular sleep timing is considered essential for the proper entrainment of the circadian rhythm [140], yet this consistency is frequently compromised in shift workers. Burnout is very common among surgeons, with an estimated prevalence of 40% [141, 142], and is associated with a 2.5-fold increases risk of involvement in medical error [143]. The American Academy of Sleep Medicine emphasizes the urgent need for further research on the role of sleep deprivation and circadian misalignment in physician burnout, as well as the evaluation of targeted countermeasures [144]. Such efforts
are essential to enhancing both physician well-being and patient safety.

We only identified five eligible studies evaluating surgeons' physical activity using pedometers, accelerometers or altimeters. The characterization of physical activity was mainly limited to step counts. Only one study measured physical activity intensity, but it did not report whether surgeons met WHO recommendations for moderate or vigorous physical activity per week [145, 146]. Most studies aimed to compare the daily number of steps between individuals with different roles in the operating room. To our knowledge, no study investigated the effect of the quality or quantity of surgeons' physical activity levels on their surgical performances. Higher quality of life scores were found in surgeons whose aerobic exercise activities, measured by self-assessment questionnaires, were consistent with the CDC recommendations [9]. These findings point to a significant gap in the literature. While physical activity may influence not only surgeons' well-being but also their capacity to perform under physically demanding conditions, its role remains largely unexplored.

Sleep, stress, and physical activity may be interconnected. Inadequate sleep has been shown to exacerbate stress responses, while elevated stress levels can, in turn, impair sleep quality [147]. Regular physical activity, on the other hand, is associated with reduced stress among working adults [148]. These associations are consistent with the findings from two studies included in our review, which examined the relationship between surgeons' physiological parameters and stress, as measured by heart rate variability (HRV). Specifically, Jevsevar et al. reported that longer sleep duration was linked to lower next-day stress levels [67], while Skinner et al. found that higher daily step counts during the week preceding surgery were associated with reduced stress at surgery onset [68].

## Strengths and limitations

Due to the heterogeneity of the study objectives and methodologies, we opted for a scoping review rather than a meta-analysis. This scoping review was conducted according to the PRISMA standards, using a predetermined protocol and form for data extraction before starting the article selection process. We systematically included all studies published from the advent of ambulatory physiological monitoring in the 1950s with the Holter monitor up to 2025 that quantified three key physiological factors using wearable sensors. Our scope was broad as we included both practicing surgeons and surgeons in training in real and simulated surgical environments. We considered observational and interventional studies investigating the physiological parameters of interest as either a determinant of surgeon performance

or well-being, a parameter to investigate according to characteristics of the patient, the surgical procedure, the surgeon, the operating room setting or methodological considerations, or a criterion to measure the impact of a specific intervention, based on any metric.

This scoping review has several limitations. We searched for articles from only two databases (PubMed and Scopus), and grey literature was not included. Relevant studies may not have been identified due to the choice of keywords in our search algorithms. In particular, there is a lack of consensus on the meaning of the concept of stress, and different terms are used interchangeably to refer to stress in some studies (stress, distress, strain, arousal, physiologic autonomic activation, autonomic response, mental workload). A widely used definition of stress is the one of Lazarus and Folkman, which states that stress is a condition or feeling experienced when a person perceives that the “demands exceed the personal and social resources the individual is able to mobilize” [149]. In the surgical context, a surgeon’s stress response in the operating room is the result of a balance between his or her individual resources (e.g., professional experience, psychological profile) and the external constraints or stressors [150], which may be linked to surgical complexity or patient risk (e.g., major bleeding, time pressure), organizational factors (e.g., workload intensity, unexpected events related to the operating room), but also personal or familial factors outside of the workplace (e.g., presence of young children, family conflicts) [151]. In our scoping review, we included studies that clearly indicated that the indicator used was a measure of “stress” or “strain”. Articles measuring mental workload were excluded, as it was considered a mobilization of extra energy through mental effort to respond to a difficult and complex task without necessarily having cognitive strain or adverse physiological effects, unlike stress [152]. Muscular stress or ergonomics issues were also out of the scope of this review, as they primarily assess localized musculoskeletal load or posture-related discomfort. Our objective was to examine broader physiological and mental states such as stress, physical activity, and sleep patterns, that reflect the surgeon's overall psychophysiological status during operations. However, this boundary is debatable. Some included studies assessed energy expenditure during orthopedic procedures as a surrogate for stress, alongside HR, HRV, respiratory metrics [26, 27, 44, 45, 50]. It could also be argued that these studies align more closely with the World Health Organization's definition of physical activity as “any bodily movement produced by skeletal muscles that requires energy expenditure.” [146] These studies compared energy expenditure across surgical techniques (robotic-assisted vs. conventional), procedure complexity, or patient BMI. Given the high prevalence of musculoskeletal pain and
injury among orthopedic surgeons [153], such find-
ings may offer valuable insights, for instance to inform
decisions regarding surgical approach selection or opti-
mize case scheduling according to physical demands
throughout the day. We also included studies on long-
term stress occurring both inside and outside the OR.
Although chronic stress involves distinct physiological
and psychological mechanisms compared to acute intra-
operative stress, examining both together is relevant, as
repeated or persistent exposure to acute stress without
adequate recovery may lead to chronic stress, poten-
tially impacting surgeon performance and well-being.
Similarly, although sleep and physical activity are behav-
ioural or lifestyle factors and stress a psychophysiological
response, all three are measurable with wearable sensors,
and examining them together enabled us to explore their
interconnections. Likewise, we included a broad range of
subjects and settings. Although physiological responses
and their effects on performance likely differ across sub-
groups included, making direct comparisons challenging,
our aim was not to compare them, but to capture the full
spectrum of how wearable technology is used to monitor
physiological parameters in surgeons, particularly in rela-
tion to performance. This inclusive approach enabled us
to identify methodological trends and highlight key gaps.
Notably, despite the broad scope of the included stud-
ies, only one addressed the impact on patient outcomes.
Finally, the heterogeneity of performance measures,
especially for technical skills, limits comparability across
studies.

Policy implications

Preventing healthcare related adverse events remains a
major global concern [154]. Nearly seven million surgi-
cal patients worldwide suffer severe complications every
year, including one million deaths [155]. Although iden-
tifying the drivers of surgical outcomes has traditionally
focused on the characteristics of both patients and surgi-
cal procedures, the performance and wellness of health-
care personnel in high-demanding environments like the
operating room are also crucial factors that should be
considered. Sleep deprivation has been shown to be det-
rimental to the performance of pilots and athletes [156,
157], but its real impact on surgeons' health and patients'
outcomes remains unclear. The majority of studies evalu-
ating complications among patients operated on by sur-
geons following a night on call did not highlight a higher
risk. Furthermore, evidence on the association between
surgeons' stress and their performance are conflicting,
and no study investigated the effect of surgeon's physi-
cal activity. Consequently, future research with accurate
measurements of physiological parameters is needed to
have a better understanding of their link with surgeon
performance.

Recent advancements in wearable sensor technology
allow real-time monitoring of individuals' physiologi-
cal data. Such non-invasive devices are now widely used
in healthcare for better patient management [158]. This
same technology also provides opportunities to mea-
sure daily variations in surgeons' physiological param-
eters inside or outside the operating room. Collecting
objective physiological data in this way could help clarify
whether these human factors impact surgical outcomes
and identify their key determinants. The integration of
artificial intelligence with wearable technology could
represent an opportunity for surgeons to receive per-
sonalized, real-time feedback on stress, sleep, and physi-
cal activity—possibly supporting more proactive health
management and helping anticipate excessive stress dur-
ing surgery. However, several critical challenges must
be addressed, including algorithmic bias, data quality
concerns, and ethical considerations related to privacy,
equity, and environmental sustainability [159]. Poor sleep
quality, negative stress or inadequate physical activity
may impair surgeons' daily performance. Stress manage-
ment training [13, 106], or the implementation of sleep
hygiene techniques and regular physical activity prac-
tices [8] present possible solutions to optimize surgeons'
physical and mental health that should be explored [4].
Just as elite athletes benefit from coaching, feedback,
preparation, and recuperation, surgeons could imple-
ment similar approaches inside and outside the operat-
ing room to investigate whether these methods improve
both their patients' outcomes and their own well-being
[160, 161]. Surgeons' stress and sleep can also be nega-
tively impacted by the operating room environment, lack
of team familiarity, long working hours and on-call duties
[84, 92, 118, 162, 163]. There is a need for optimization
of the systems surrounding the surgeon [164] such as the
operating room [165], and improvement of duty hour
regulation that optimize patient and physician safety
while preserving the best possible training for physicians
[166].

Conclusions

In conclusion, our review shows that the number of
publications on surgeons' stress, sleep or physical activ-
ity measured using wearable sensors has significantly
increased since the 2010s, and that current research
mostly focuses on intraoperative stress. Sleep and physi-
cal activity may be less studied due to the logistical chal-
lenges and lower acceptability of prolonged sensor use
outside the operating room. However, advances in wear-
able sensors autonomy, accuracy, and miniaturization
may enable an increase in future studies to non-invasively
collect high-quality, objective physiological data in daily
settings. Such developments may be facilitated by the
broader shift toward more preventive and personalized
healthcare. Evidence focused on the association between
these parameters and surgeon performance and well-
being is very limited, especially their potential influence
on patient clinical outcomes. Future research is needed
to fill this gap and acknowledge the importance of the
surgeon's human factors for improving patient safety.

**Supplementary Information**

The online version contains supplementary material available at https://doi.org/10.1186/s13037-025-00445-z.

**Additional file 1.** Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist

**Additional file 2.** Search algorithms

**Additional file 3.** Data extraction form

**Author contributions**

L.P., S.D., S.C.S., S.M. and A.D. participated in the research design. L.P., S.D., Q.C. and A.D participated in the selection of articles. L.P. and A.D participated in the data extraction, analysis and drafting of the manuscript. L.P., S.D., S.C.S., Q.C., J.-C.L., S.M. and A.D participated in the interpretation and critical revision of the manuscript.

**Funding**

This work was supported by European Research Council Starting Grant TopSurgeons (ERC-2018-STG 801660). The funding source had no involvement in the study design; the selection of articles, data extraction, analysis, and interpretation; the writing of the report; or in the decision to submit the article for publication. The researchers were independent from the funder.

**Data availability**

No datasets were generated or analysed during the current study.

**Declarations**

**Ethics approval**

Since this is a scoping review of previously peer-reviewed publications, ethical approval for this study is not needed.

**Protocol registration**

The protocol of this review was registered with the Open Science Framework Registries (https://osf.io/wqpuz).

**Competing interests**

The authors declare no competing interests.

Received: 17 April 2025 / Accepted: 16 July 2025

Published online: 01 October 2025

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