Evaluating surgeons' stress using heart rate variability during minimally invasive surgery for gastric cancer: a single-center prospective cohort study.

PURPOSE: Surgeon stress during minimally invasive distal gastrectomy may vary by approach and experience, but objective data are limited. We evaluated the effects of robotic assistance and surgeons’ experience on surgeon stress using the low-frequency/high-frequency ratio.

METHODS

In this single-center prospective cohort (September 2023–March 2025), four surgeons performed robot-assisted or laparoscopic distal gastrectomy in 40 patients. Intraoperative heart rate variability was continuously recorded, and sympathetic dominance was indexed by the low-frequency/high-frequency ratio. Postoperative workload was assessed with the NASA Task Load Index. The operation was divided into 10 standardized steps from trocar placement to specimen extraction; perioperative outcomes were collected.

RESULTS

Median intraoperative low-frequency/high-frequency ratio was 2.0 (0.4–8.6) before and 1.0 (0.14–4.81) after normalization. Among qualified surgeons, robotic surgery reduced stress versus laparoscopy, most notably during suprapancreatic lymph node dissection. Qualified surgeons showed higher stress levels during laparoscopic surgery compared to non-qualified surgeons, with this difference being particularly significant during suprapancreatic lymph node dissection. The NASA Task Load Index corroborated lower mental and physical demand, effort, and frustration with robotic surgery. Non-qualified surgeons reported higher subjective mental load than qualified surgeons.

CONCLUSIONS

Robotic assistance reduces surgeon stress during technically demanding steps that require precise manipulation in distal gastrectomy. Stress may increase as surgeons gain experience and responsibility.