The positive effect of music in motivating people has already been studied in a wide variety of areas of life, especially in physical leisure activities (15). In therapeutic settings, too, the beneficial effects of music are used, for example, for pain management (16) or supportive therapy in cancer patients (17). From the perspective of the occupational setting, music is also played at work: In many hospitals, it is common practice to play music in the OR during surgical procedures (4, 5). Here, music is being played in the background for the purpose of entertaining surgical staff, which must be distinguished from music being played in the preoperative setting to reduce anxiety among patients before surgery (18). The decision as to whether music will be played in the OR or the kind of music that is chosen is predominantly the privilege of the senior surgeon (19).
The effect of music in this specific occupational setting is difficult to quantify. For other, nonhospital occupational settings, a study showed that background music is likely to reduce worker attention and performance (20). For the OR setting, findings have shown that music is one of several mental distractors that might influence surgical performance negatively, but results differ (21, 22). A recent meta-analysis stated that the evidence to definitively determine whether music has a beneficial effect on surgical performance in a simulated setting is not sufficient (23). When analyzing the effect of music in the OR, music is often just one factor among others comprising the general background noise there. The amplitude of background noise, in turn, depends on the specialty; e.g., an obstetrics OR has a comparably high baseline noise level (24).
Nonetheless, it is difficult to quantify the effect of music on surgical outcome. This is due to the varying test persons (advanced surgeons vs. beginners), different music genres and SPLs, as well as differing complexity of the tasks to be performed (7). Finally, there might be a difference between measurement under standardized training conditions (with usage of simulators) or in the actual environment of an OR. In our study, we used a standardized training setting for laparoscopic exercises that were performed by surgical novices in order to control the relevant influencing factors. Laparoscopy is an adequate tool because it combines manual and neurocognitive requirements. The effect of noise (in general) on laparoscopic performance specifically is controversial. For experienced surgeons, one study showed that background noise at 113 dB had a negative impact on surgical laparoscopic performance (25), whereas another study on the effect of noise at 80–85 dB and background music showed no difference in task performance in terms of the time taken to complete a task (26). Here, one must keep in mind that those noise levels are higher than most recommended standards for an occupational environment (27). The SPLs used in the two studies also differed greatly, which makes a comparison difficult, but as an explanation it was assumed that experienced surgeons can effectively "block out" noise and music on a higher SPL of 80–85 dB. This is probably due to the high levels of concentration required to perform a complex surgical task. Recent studies of abdominal surgeries showed that surgeons' concentration was not impaired by measured noise levels (28) and there were hints that music might even reduce the heart rate, blood pressure, and muscle effort of surgeons while at the same time increasing the accuracy of surgical tasks (29).
In this context, the effect of routine and training in manual tasks seems to play an important role: Especially younger surgeons (i.e., interns or residents) seem more likely to be distracted by disturbing factors in the OR (30, 31), not only by music but also telephone calls (32). Under distracting conditions, the medical interns showed a significant decline in task performance (overall task score, task errors, and operating time) and significantly increased levels of irritation toward both the assistant handling the laparoscope in a nonoptimal way and the sources of social distraction.
Due to the fact that the influence of music on performance outcome of laparoscopic techniques in a real-life setting is controversial and methodologically difficult to quantify, outcome measurements performed using laparoscopic box training tools under standardized conditions might offer a feasible approach. To date, the effect of music exposure at different SPLs on the training performance of laparoscopic novices has not been evaluated systematically under standardized conditions. Therefore, we chose a highly standardized stetting for this study in order to maintain the ability to transfer the findings to a real-life OR setting. Simulation-based training in minimally invasive surgery has been validated for the “Luebecker Toolbox” (13). Transferability of the task content to a (sub)-realistic setting could be demonstrated (14). Nonetheless, besides training, individual talent also constitutes an important factor in mastering laparoscopic skills (33). The influence of SPL on laparoscopic tasks has not been evaluated yet, although a positive impact on accuracy has already been shown for relaxing auditory influences, such as classical music on laparoscopic tasks (34). Our data are in line with these preliminary data that background music at a moderate SPL of 70 dB has a positive effect on performance in comparison to higher or lower SPL, although the highest total relative improvement in all exercises was within the 60 dB group. In this context, it might be relevant that most participants did not feel distracted by the music in our study. In contrast to a real-world setting within an OR there were no other pressuring factors that might have influenced performance. This fits to the results that overall course satisfaction was very high.
Limitations
Our study design shows several potential limitations. Although a high standardization in the study design was intended, performance outcome of surgical techniques (such as laparoscopy) is methodologically difficult to quantify. Studies have shown that it is difficult to predict baseline laparoscopic surgery skills (35). Moreover, our findings could have been relevantly biased due to differing subjective music perceptions, i.e., some students probably liked the music being played better than others, with a varying effect on their performance (“arousal-and-mood-hypothesis”) (36). Studies have also shown that a listener's fondness of the music being played influences their performance (37). Furthermore, we did not use virtual reality simulators and therefore were not able to track the movement of the probands. Thus, the accuracy factor as part of the overall performance could not be recorded accordingly. In addition, the cohort size was relatively small; however, it could still deliver significant results.
In addition, the implication of transferring study results from a simulator to the OR has not been clarified yet, although it is likely that the skills themselves can be transferred (38–40). Further analyses might focus on other factors that might influence the performance of standardized laparoscopic tasks, e.g., differing music genres.