Patient Positioning in the Operating Room (2023)

How to position a patient?

Safe positioning of the patient for surgery in the operating room is the shared responsibility of the surgeon, anesthetist and OR nurses. Although the ultimate objective is to provide optimal access to the surgical site, consideration must be given to how positioning may adversely affect the patient. It is important therefore that this objective be carefully balanced against the potential cardiopulmonary, neuromuscular and skin effects of the desired position.

After studying thisPatient Positioningcourse you are familiar with the most common complications:

  • Cardiopulmonary complications
  • Neuromuscular injuries
  • Soft tissue complications

Preoperative Considerations

Besides assessing their cardiorespiratory function, there should be a preoperative evaluation of the patient's risk of developing pressure sores. It is also important to determine if the patient has any physiological or anatomical impairments and ascertain how they may affect and be affected by positioning. If there is doubt, and where possible, the awake patient should be placed in the desired position to determine if they are able to tolerate it. As far as possible, blankets and sheets are used to both keep the patient warm and protect their dignity. Whether conscious or not, patient dignity should be maintained at all times.

Cardiopulmonary Effects

The surgical patient's cardiovascular and respiratory function may be adversely affected by both be general and regional anesthesia. In the context of these effects, compensatory mechanisms are impaired and placing the patient in unnatural positions may cause significant cardiorespiratory compromise. There is also a risk of deep vein thrombosis (DVT) in the lower limbs as a result of impaired cardiovascular function. This is then a risk factor for developing pulmonary embolism (PE). DVT prophylaxis should be implemented as per local protocol.

Neuromuscular Injuries

The anesthetized patient, apart from being unable to sense and report unnatural strain on neuromuscular structures, is also more likely to have unnatural strain placed on these structures. This is due to the action of anesthetic agents and/or muscle relaxants. Prolonged compression or stretching of nerves may lead to temporary or permanent impairment while improper alignment may lead to joint and muscle injuries. If not done carefully, OR staff moving joints that are not stabilized by normal muscle function may inadvertently cause the joints to dislocate.

Soft Tissue Complications

The skin and underlying soft tissue are at great risk of pressure complications in the surgical patient under anesthesia. While immobile and/or unconscious, prolonged pressure on dependent areas underlying bony prominences cannot be appropriately responded to. In addition, there may be impaired perfusion of these areas due to the cardiovascular effects of the anesthetic and surgery. Proper positioning and use of appropriate padding are essential in preventing the development of pressure sores. Pressure complications may also be caused by equipment if it care is not taken when positioning it in relation to the patient. If necessary padding should be placed between the patient and items like wires and intravenous lines. Besides pressure sores, inappropriate movement of patient on the operating table may result in blisters and abrasions. The patient should be properly secured to the surgical table so that its movements do not cause the patient to move.

Surgical Table and Accessories

There are a number of surgical table accessories available to aid safe patient positioning. These accessories and the surgical table should be cleaned and checked as per local protocol. For a more detailed elaboration on the use of the surgical table, refer to the course: "Surgical Table"

Leg or table straps Surgical Table and Accessories

When using straps to tie down the legs of the patient, to prevent the patient from falling or standing up, the following needs to be taken in consideration: pinching when the straps are to tight; nerve damage because of straps wrongly positioned or too tight; the position of the diathermy return electrode, this can not be under the leg straps.

Patient Positioning in the Operating Room (1)

Patient Positioning on the Surgical Table

Positioning

Transfer to Surgical Table

Before transferring the patient to the bed the brakes should be applied. The awake patient may be able to transfer themselves to the surgical table and lie in supine position prior to anesthesia. If not then 4 qualified members of OR staff are required for safe transfer. The following are required: a patient transfer roller board.

Procedures Supine

The majority of surgical procedures are performed in supine position. This includes open as well as laparoscopic abdominal procedures.

Equipment and personnel Supine

Transfer equipment as above. As well as: draws sheet; headrest or pillow; arm supports and pressure point padding (foam or gel pads or pillows).

Head and neck Supine

A pillow or headrest is used to support the head.

Torso Supine

Care should be taken to ensure that head and spine are in alignment horizontally with the hips parallel to each other. A completely horizontal back is not physiological and a small pillow may be used to support the lumbar spine, especially during long cases. The surgical table may also be adjusted to semi-Fowler's position slightly flexing the hips and knees.

Limbs Supine

The arms may be positioned in extension and in less than 90 degrees abduction supported by padded arm supports. The palms should be in supination. Alternatively the arms may be positioned adducted (with the elbows extended) at the patient's sides with the palms facing inward and secured with the draw sheet by encircling the arms and then tucking it underneath the patient not under the mattress.

The legs should be positioned in parallel and not cross or touch each other. Pillows may be positioned underneath the knees slightly flex them.

Complications/Considerations/Hazards Supine

The supine position may cause significant impairment of respiratory function in patients with pulmonary disease and in the obese. Aortocaval compression may occur in pregnant patients and a wedge should be placed under their right side to provide tilt of 15 degrees.

Abduction beyond 90 degrees should be avoided as it places the brachial plexus at risk of injury from stretching. To reduce the risk of compression of the ulnar nerve within the ulnar groove the palms should be positioned in supination if arms are positioned in abduction. If the arms are adducted the palms should face the patient in order to minimize the risk of ulnar and radial nerve compression.

Although there is a risk of pressure sores developing at all bony prominences, the areas where they most occur are the elbow, sacrum and heels. Care should be taken to ensure these areas are appropriately protected with padding.

Pressure complications may also develop in areas where equipment comes into contact with the patient. The upper arms for example if the draw sheet is secured too tightly over IV or blood pressure cuff tubing.

Patient Positioning in the Operating Room (2)

Supine Position

Procedures Trendelenburg

The Trendelenburg position is a variation of the supine position where the surgical table is tilted such that the patient's head is below their feet. This position is typically required to improve visualization during lower abdominal and pelvic surgery.

Equipment and personnel Trendelenburg

The following may be required in addition to what is required for standard supine positioning: straps or tape; shoulder supports; bean bag supports and non-slip surgical table padding.

Head and neck Trendelenburg

In addition to measures taken during standard supine positioning, shoulder supports may be used to prevent the patient slipping during movement of the table.

Torso Trendelenburg

As with the standard supine position, care is taken to ensure alignment of the head, spine and hips in a physiological manner. Non slip surgical table padding may be used.

Limbs Trendelenburg

With standard supine positioning measures taken, tape and/or straps are used to ensure that the patient is properly secured to the surgical table. For a more detailed elaboration on the use of safety straps with the surgical table, refer to the course: ''Surgical Table''

Complications/Considerations/Hazards Trendelenburg

The Trendelenburg position has significant cardiovascular effects which are poorly tolerated by patients with cardiovascular disease. Increases in central venous pressure and mean arterial pressure may lead to compromise. For this reason efforts are made to minimize the time spent in this position, restrict the degree of tilt to less than 45 degrees and to move in and out of the position in controlled manner. The displacement of intra-abdominal contents against the diaphragm can cause respiratory function impairment significantly worse to that experienced in the supine position. The presence of a pneumoperitoneum may exacerbate this impairment. The measures taken to preserve cardiovascular function are also taken to preserve respiratory function.

The risks posed to the peripheral nervous system are the same as with the supine position. The brachial plexus is at risk of compression injury if shoulder supports are positioned in such a manner as to cause root compression at the level of the neck. Centrally the position raises both intracranial pressure and intraocular pressure posing a risk to patients known with intracranial hypertension. Prolonged surgery in Trendelenburg position may cause loss of vision on the basis of ischemic optic neuropathy.

Potential pressure complications are the same as for supine positioning with the skin and soft tissue over the shoulder also at risk if supports are used there.

Procedures Reverse Trendelenburg

The reverse Trendelenburg position is a variation of the supine position where the surgical table is tilted such that the patient's head is above their feet. This position is typically used for upper abdominal procedures and in head and neck surgery.

Equipment and personnel Reverse Trendelenburg

The following may be required in addition to what is required for standard supine positioning: straps or tape; padded foot boards; bean bag supports and non-slip surgical table padding.

Head and neck Trendelenburg

A pillow or headrest is used to support the head.

Torso Reverse Trendelenburg

Non slip surgical table padding may be used as with the Trendelenburg position.

Limbs Reverse Trendelenburg

With standard supine positioning measures taken, tape and/or straps are used to ensure that the patient is properly secured to the surgical table. For a more detailed elaboration on the use of safety straps with the surgical table, refer to the course:''Surgical Table''

Complications/Considerations/Hazards Reverse Trendelenburg

Depending on the degree of tilt, the reverse Trendelenburg position causes pooling of blood in the abdominal vessels and lower limbs resulting in decreased venous return and cardiac output. Anesthesia impairs the patient's ability to compensate and may result in cardiovascular compromise, especially in patients with cardiovascular disease. Measures to counter these cardiovascular effects include administration of IV fluid and the use of pneumatic compression stockings.

The risks posed to the peripheral nervous system are the same as with the supine position. At extreme degrees of reverse Trendelenburg there is a risk of cerebral hypoperfusion as with Fowler's position.

Potential pressure complications are the same as for supine positioning with the skin and soft tissue over the heels also at risk if foot boards are used.

Patient Positioning in the Operating Room (3)

Trendelenburg Position

Procedures Lithotomy

In lithotomy position, the patient is supine with their legs supported in stirrups such that they are elevated and apart with both the hips and knees flexed. In standard lithotomy position the degree of flexion in both joints is between 80 to 90 degrees. The degree of hip and knee flexion may however vary depending on the procedure and the surgeon's preference. The position provides optimal access to the perineum and pelvis and is typically used in gynecological, rectal and urological procedures.

Equipment and personnel Lithotomy

Lithotomy stirrups or slings are required in addition to the equipment used for standard supine positioning. There are a variety of both available with some risks specific to the type used. Commonly used stirrups include Allen stirrups and knee cradles.

The patient is shifted down towards the foot of the surgical table such that the buttocks rest at the edge of the lower back plate. For a more detailed elaboration on the lower back plate and other parts of the surgical table, refer to the course:

Head and neck Lithotomy

Depending on the patient's height, shifting the patient results in the head and neck no longer being positioned on the surgical table headrest. A pillow should be used to support the head.

Torso Lithotomy

Flexion of the hips usually eliminates normal lumbar lordosis and may aggravate previous lower back pain in some patients. In others the position may eliminate the need for a pillow to support the lumbar spine. The patient's thoracic spine may now be positioned on the lower back plate with some requiring a pillow support there.

Limbs Lithotomy

The legs are lifted into the sling or stirrups simultaneously and in a coordinated fashion to avoid causing muscle strain or hip dislocation. Although 2 qualified members staff are typically sufficient, more may be required for larger patients. When raising the legs simultaneously, the hips and knees should be flexed simultaneously as well. Only once both legs are secured in their elevated position should the leg plates of the surgical table be removed or lowered. When the legs are lowered the flexed knees are brought together in the midline with the hips flexed. Then only are both joints extended as the legs are gently lowered.

The arms should ideally positioned in abduction on padded arm supports as for supine positioning. With the arms adducted, the hands are at risk of injury when the leg plates are being removed/ reattached or raised/lowered.

Complications/Considerations/Hazards Lithotomy

Placing the patient in lithotomy does not in and of itself cause cardiovascular compromise. Pregnant and obese patients as well as those with an intraabdominal mass may experience impaired venous return resulting in a drop in blood pressure. This is on the basis of raised intra abdominal pressure. Respiratory function may be compromised by abdominal contents splinting the diaphragm. Obese patients are more at risk.

In addition to the risk of upper extremity nerve injuries similar to those associated with supine positioning, there are a number of lower extremity nerves at risk of injury. The type of stirrup may have bearing on which nerves are affected. The fibular head should be kept free or well padded to avoid compression of the common fibular nerve. Compression of the saphenous nerve may occur at the level of the medial femoral epicondyle and appropriate padding should be used here as well. To avoid stretching of the sciatic nerve, hip and knee flexion should be restricted to within the patient's normal range of motion. Care should also be taken to avoid compressing this nerve at the level of the popliteal fossa. With respect to the musculoskeletal system, the hip is at risk of dislocation when the legs are being raised and lowered. The anesthetic team should be informed prior to raising or lowering the legs. If placed in adduction at the patient's sides, there is a risk of injuries to the hands when the leg plates are moving or being moved. Compartment syndrome is a rare potential complication thought to occur during long cases on the basis of tissue hypoperfusion.

Potential pressure complications are the same as for supine positioning with the type of stirrup used posing specific risks to skin and soft tissue over the malleoli; fibular heads; tibial condyles and femoral epicondyles.

Variant Lithotomy

The Lloyd Davies position is a variant of the lithotomy position. The key differences being that the degree of hip flexion is less than with the lithotomy position and the patient is also placed in approximately 30 degrees Trendelenburg. It is used for gynecological and colorectal pelvic surgery.

Patient Positioning in the Operating Room (4)

Lithotomy Position

Procedures Lateral

The lateral position has the patient lying on their side. The position is described in relation to the patient's dependent non operative side. Left lateral means that the patient's left side is on the surgical table and their right side is operated on. This position allows access to the hip, retroperitoneal space and thorax.

Equipment and personnel Lateral

The patient is anesthetized in supine position. Thereafter they must be safely turned to lateral position. 4 qualified members of staff are required to safely turn the patient. More staff may be required to assist with handling of equipment such as intravenous lines and infusion pumps. All actions are at the verbal direction of the staff member in charge of the patient's head, neck and airway. In addition to equipment used for supine positioning, the following may be required: bean bag supports, anterior and posterior body supports, gel rolls and table straps or tape.

Head and neck Lateral

An anesthetically qualified staff member is responsible for moving the head and neck, protecting the airway and coordinating the actions of the other staff members. Coordination of movement is required so to maintain neutral alignment of the head and neck and prevent injuries. An example of how this may be performed is as follows:

Torso Lateral

The torso is supported using body supports attached to the sides of the surgical table. First a body the support is placed posteriorly at the level of the sacrum and then anteriorly at the level of the pubic symphysis. The supports should be padded in order to prevent pressure complications. Alternatively or additionally, a strap may be used at the level of the hips to secure the patient to the surgical table. A gel roll is placed between the chest and surgical table just caudal to the axilla in order to prevent compression of axillary structures and the dependent arm.

Limbs Lateral

Both arms are supported in front of the patient. The dependent arm is supported slight flexion with the palm in supination on a padded arm support. The non dependent arm is supported on a padded angled arm support. The support should allow height and angled adjustment so that the non dependent arm is supported in abduction and flexion away from the surgical site. This arm should be pronated. Care should be taken to not abduct the non dependent arm beyond 90 degrees.

The dependent leg is flexed slightly at the hip and the knee with padding placed lengthwise between it and the non dependent leg. For both legs there should be adequate padding over the bony prominences at the ankles and knees. The hip of the dependent leg should also be adequately padded.

Variant Lateral

A variant of the lateral position is the lateral position with table flexion. Here, the patient is positioned with a "break" in the surgical table. The patient's iliac crest is positioned over the table's point of flexion with or without the use of a kidney rest being placed underneath the patient. Flexion of the surgical table should be done using its preprogrammed function so as to ensure the patient is moved into position in a slow and controlled manner. This position is particularly useful in retroperitoneal surgery.

Complications/Considerations/Hazards Lateral

Pooling of blood in the abdominal vessels and legs may cause cardiovascular compromise. If there is flexion with the use of a kidney rest, compression of the inferior vena cava may occur causing further compromise. Perfusion to both arms radial should be monitored throughout the procedure. This can be clinically or using pulse oximetry. Lateral positioning produces a ventilation perfusion mismatch which may result in the patient's oxygen requirements increasing.

The patient's dependent ear and eye should be properly positioned so they a free from pressure. The eyes should be taped shut. The brachial plexus is at risk of injury at various points. The head neck should be maintained in neutral alignment to avoid stretching the cervical nerve roots. Furthermore there is a risk of stretching injury to the plexus with positioning of the non dependent arm and care should be taken not to abduct it beyond 90 degrees. In the dependent arm, an axillary roll (placed under the chest not in the axilla) is used to prevent compression of the plexus. As with the supine position, the radial and ulnar nerve should be properly padded at prominences. In the dependent leg the fibular nerve is at risk of compression at the level of the knee.

There is a risk of pressure sores developing over all bony prominences. In the dependent arm the elbow is of particular concern. In the legs there should be appropriate padding placed to protect soft tissue over the hip, knees and malleoli.

Procedures Prone

The prone position is used to position patients to allow posterior procedures to be performed. These include: some craniotomies; spinal procedures as well as procedures on the buttocks and anus. The jackknife and kneeling positions are variants of the prone position. The former is used for hemorrhoidectomies or pilonidal sinus procedures, while the latter is used for lumbar laminectomies and discectomies as well as some rectal procedures.

Equipment and personnel Prone

The patient is anesthetised in supine position on the transfer stretcher or trolley. Thereafter they must be safely turned and positioned prone - on a specialized surgical table or frame. 4 qualified members of staff are required to safely turn the patient. More staff may be required to assist with handling of equipment such as intravenous lines and infusion pumps. All actions are at the verbal direction of the staff member in charge of the patient's head, neck and airway. This person should be anesthetically qualified. In addition to equipment used for supine positioning, the following may be required: specialized headrests such as a Mayfield headrest; a specialized prone positioning such as a Wilson laminectomy frame; lateral body supports, gel chest rolls and table straps.

Head and neck Prone

An anesthetically qualified staff member is responsible for moving the head and neck, protecting the airway and coordinating the actions of the other staff members. Coordination of movement is required so to maintain neutral alignment of the head and neck and prevent injuries. An example of how this may be performed is as follows:

  • If a frame is used it should be positioned on the surgical table prior to induction of anesthesia and lined up to support the patient from the level of the shoulders to the hip. The transfer trolley should be a slighter higher height than the surgical table (and vice versa during repositioning).
  • Thereafter the patient is rolled "down" into prone position onto the surgical table. Two staff members positioned at the side of the table support the torso and position the patient on the frame or chest rolls. The fourth staff member supports the lower body.
  • The head can be placed in a foam or gel headrest facing downwards or supported on a pillow and turned to the side. If a Mayfield headrest is used, it is positioned on the patient prior to turning. Thereafter, the surgeon supports the head in proper alignment while the headrest's attachment is secured to the surgical table.

Once in position, there should be a check made to ensure spinal alignment. Whether on the side or face down, the eyes, cheeks and ears should be completely free from compression.

Torso Prone

As mentioned above, the torso is supported from the level of the shoulders to the hips. This allows free movement of the chest and abdomen during ventilation. Care should especially be taken to ensure that there is no undue compression of the breasts in a female patient and the genitalia in a male patient.

Limbs Prone

The arms are positioned in a "hands up" position supported on padded arm supports. This means the elbows are flexed and the palms pronated. Additional padding should be placed underneath the elbows. The legs are flexed (less than 90 degrees) at the knees and hips with padding placed underneath the knees and ankles with the toes lifted and free from compression. A table strap may be used across the middle of the thighs.

Variants Prone

The jackknife and kneeling positions are variants of the prone position. The former is used for hemorrhoidectomies or pilonidal sinus procedures, while the latter is used for lumbar laminectomies and discectomies as well as some rectal procedures. In the kneeling position, the lower backplate is replaced with a padded platform which is used to support the legs flexed (to 90 degrees) at the hips and knees.

Both these variants carry significant additional cardiovascular risks for the patient and should be attempted only in appropriately selected patients and by properly trained personnel.

Complications/Considerations/Hazards Prone

With arms positioned "hands up", there is a risk of compression of the ulnar nerve at the elbow and stretching of the brachial plexus at the shoulder. In addition, no supports should be positioned directly in the axilla to avoid compressing the brachial plexus.

Soft tissue overlying the bony prominences is at risk of pressure complications and should be protected with additional padding. The female breast and male genitalia should be appropriately padded. The patellas are of particular concern if the patient is positioned kneeling. The knee joint may also be under unnatural strain and all the different tissue in and around the joint is at risk of injury. Compartment syndrome has been reported when there is prolonged positioning in the kneeling position.

Patient Positioning in the Operating Room (5)

Prone Position

Procedures Sitting

The sitting position is used to position patients for the following procedures: shoulder; posterior cervical spine and posterior cranial fossa.

Equipment and personnel Sitting

The patient is anesthetised in supine position. Thereafter they must be safely maneuvered into the sitting position. This is done using the surgical table's preprogrammed sitting setting in order to ensure slow and controlled movement into the position. Depending on the procedure, type of surgical table and accessories, 3 to 4 qualified members of staff may be required to safely position the patient's head into a specialized headrest after induction of anesthesia. Induction may also be performed with the specialized headrest already in position. Examples of such headrests include the Mayfield headrest used for craniotomies and the helmet headrest used for shoulder surgery. A padded foot board may also be required.

Head and neck Sitting

Following anesthesia, the patient's head is slowly elevated using the surgical table's pre programmed sitting setting to flex the patient at the hip. The degree of hip flexion and therefore head elevation is determined by the procedure to be performed. Neurosurgical procedures, for example, may require up to 90 degrees of hip flexion while a number of shoulder procedures only 45 degrees. The final degree of head elevation may also be affected if the surgical table is then tilted backwards as is the case in some procedures. When securing the head in the specialized headrest it is absolutely essential to ensure that spinal alignment is maintained and that the headrest is properly attached to both the patient and the surgical table. The strap used to secure the patient's chin may cause neck injuries if the strap remains in position while patient moves down the surgical table.

Torso Sitting

The patient's torso is flexed into a seated position. For some shoulder procedures a longitudinal segment of the backplate may need to be detached to allow access to and free movement of the joint. If this is the case it is important to ensure that the remaining segments properly support the patient's back. Additional padding should be used to protect the soft tissue over the scapulae.

Limbs Sitting

The legs are flexed at the hip and knees with the legs then gently lowered. This can be to varying degrees. The flexion of both sets of joints should be achieved using the surgical table's pre programmed setting to ensure safe and controlled movement into position. Small adjustments to the final position can be made manually. Padding should be placed under the buttocks, knees and heels. If the extent to which the legs are lowered warrants it, then a padded footboard should also be used to support the feet in flexion.

Complications/Considerations/Hazards Sitting

Cardiovascular compromise may occur by way of venous pooling reducing cardiac output. This deleterious effect can be ameliorated by administering IV fluid, tilting the surgical table to elevate the legs and using pneumatic compression stockings intraoperatively. Reductions in cardiac output and blood pressure are of particular concern in this procedure as there is a risk of reduction of cerebral perfusion pressure which may result in neurological complications such as stroke. Additional monitoring equipment such as a Doppler device may be required to monitor carotid blood flow. There are no directly deleterious effects on respiratory function.

Patient Positioning in the Operating Room (6)

Sitting Position

Evaluation

Hazards

Before prepping and draping, the patient should be checked to ensure that all potential hazards have been accounted for and appropriate action taken to counter them. This should all be properly documented as per local protocol.

Author: Incision Nurse(s)

Incision Nurse(s) are scrub nurses and nurse anesthetists creating courses for the Academy. The content we create is always checked by perioperative team members from client hospitals. By understanding their needs, we design what we believe to be the best solution to help healthcare professionals perform their daily tasks. The videos are intended to provide quick and concise overviews of the skills and concepts, relevant to the practice of scrub nurses and nurse anesthetists.

Patient Positioning in the Operating Room (7)

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