Background: While fatigue is an inevitable aspect of performing surgical procedures, lack of consensus remains on its effect on surgical performance. The aim of this systematic review was to assess the effect of non-muscular fatigue on surgical outcome. Methods: MEDLINE and Embase were searched up to 17 January 2023. Studies on students, learning, duty-hour restrictions, muscle fatigue, non-surgical or subjective outcome, the weekend effect, or time of admission were excluded. Studies were categorized based on real-life or simulated surgery. The Cochrane risk-of-bias tool was used to assess RCTs and the Newcastle–Ottawa scale was used to assess cohort studies. Due to heterogeneity among studies, data pooling was not feasible and study findings were synthesized narratively. Results: From the 7251 studies identified, 134 studies (including 1 684 073 cases) were selected for analysis (110 real-life studies and 24 simulator studies). Of the simulator studies, 46% (11 studies) reported a deterioration in surgical outcome when fatigue was present, using direct measures of fatigue. In contrast, only 35.5% (39 studies) of real-life studies showed a deterioration, observed in only 12.5% of all outcome measures, specifically involving aggregated surgical outcomes. Conclusion: Almost half of simulator studies, along with one-third of real-life studies, consistently report negative effects of fatigue, highlighting a significant concern. The discrepancy between simulator/real-life studies may be explained by heightened motivation and effort investment in real-life studies. Currently, published fatigue and outcome measures, especially in real-life studies, are insufficient to fully define the impact of fatigue on surgical outcomes due to the absence of direct fatigue measures and crude, post-hoc outcome measures. The aim of this systematic review was to assess the effect of non-muscular fatigue on surgical outcome. While most simulator studies that reported an effect of fatigue reported a negative effect, in real-life studies, a large range of findings was found, with inconclusive supporting evidence. While this discrepancy could be explained by heightened motivation and effort investment in real-life studies, the current evidence on fatigue and surgical performance is worrisome; current fatigue and outcome measures used, especially in real-life studies, are insufficient, stemming from the absence of direct fatigue measures and crude, post-hoc outcome measures. Lay Summary: At some point, surgeons become tired, just like anyone else. While in other jobs, people start to perform worse as they get tired, it is not known whether this is also true for surgeons. It is important to know this because patients may be worse off if their surgeon is tired. The aim of this study was to find out if being tired affects how surgeons do their work. Medical databases were searched through for studies on tired surgeons and the impact of fatigue on their work. Some studies looked at tired surgeons during real surgery and other studies looked at tired surgeons during sessions on surgery simulators. More than 7000 studies were examined and 134 of them were selected. They included over 1.6 million surgeries. Among these studies, 110 investigated real surgeries and 24 looked at simulated surgical sessions. Interestingly, almost half of the studies looking at simulated surgeries found that being tired had a negative effect on the simulated surgery. However, in real surgeries, this happened in only one-third of studies. The difference between real surgery and simulator surgery could be because in real surgeries surgeons always try to do their best, even when fatigued, because they are dealing with real patients. Another reason could be that the tools used to check whether surgeons are tired or whether the surgery went well are not very good. To help both surgeons and patients, there is a need to find better ways to determine if surgeons are truly tired and to make sure the tests are better. [ABSTRACT FROM AUTHOR]