Principles of Operative Positioning

Daniel R. Fish

Perioperative Considerations

Positioning should be aimed at maximizing surgical access and ease, while minimizing risk of positioning-related injuries.
When required, patient position can always be modified during a surgical procedure, often without compromising the sterile field significantly. Nonetheless, optimal efficiency and sterility are achieved with good preoperative planning and positioning from the start of the operation.
A well-coordinated team can enact major position changes (eg, flip from supine to prone for an abdominoperineal resection) on a routine basis without incurring significant delays.

SUPINE POSITIONING

Perioperative Considerations

Most often used for open procedures where anal access is extremely unlikely to be needed—ileostomy closure, ileostomy creation, open right hemicolectomy, and open small bowel surgery—or for patients after previous anorectal resection with permanent anal closure.
Most commonly used with legs strapped and arms out, although it can be combined with adjunctive techniques such as arm tucking or a chest strap (see later).
Supine position bears little risk of positioning-related injuries and is often the default position whenever surgically appropriate.

Technique

Arms should be abducted <90 degrees on padded arm boards in neutral position, with straps loosely across the forearms.
Legs can be supported with a pillow under the knees to maintain mild flexion and with padding under the heels to prevent pressure ulcers, with a belt or strap across the thighs snuggly.
Legs and chest should be covered with blankets or warmed air devices to maintain body temperature.

LITHOTOMY POSITION

Perioperative Considerations

Lithotomy, or separation of the legs, is one of the most commonly used positions in colorectal surgery as it offers readily available access to the perineum.
Should be considered for any surgery where access to the anus is needed, including perianal surgery, transanal surgery, intraoperative colonoscopy, transanal stapling (eg, end-to-end anastomosis stapler), coloanal anastomosis, or retraction maneuvers via the rectum or the vagina.
Should also be considered for any surgery where standing between the legs could be useful (eg, laparoscopic right, transverse, left, or subtotal colectomy or flexure mobilizations).
Different leg retraction devices and positions pose varying levels of risk of nerve, joint, and compartment injuries to the legs, as well as exacerbating back pain in patients with radiculopathy. These are all minimized through proper positioning and padding.
Compartment syndrome is an unusual, but well-described, risk of lithotomy position. It is thought to relate to decreased perfusion to the leg compartments and seems to correlate with obesity and weight of the extremity, the severity of angle of elevation, and overall time spent in lithotomy position. For patients at risk, legs can be changed in or out of lithotomy position as needed during a procedure without major breaks in sterile technique.
Lithotomy is frequently combined with maneuvers that complement laparoscopy (eg, arm tuck), Trendelenburg position (eg, chest strap), or anal or rectal preparation techniques (eg, rectal washout, anal everting sutures).
Warmed air devices or blankets should be applied to the chest to help maintain body temperature, as the lower body cannot be blanketed.

Technique

Place lower extremity pneumatic compression devices.
Once the airway is secured, move the patient down on bed to have anus beyond the edge of the body portion of the bed, while ensuring proper padding on the sacral area.
Attach leg supports of choice (see specific lithotomy types), placing both legs in supports simultaneously to minimize spinal torsion.
Remove/lower the leg portion of bed, or spread the legs if utilizing a split-leg table (see split-leg lithotomy).
Readjust body/pelvis on the bed as needed to optimize the position of perineum (Fig. 3-1).

FIGURE 3-1 ▪ Lithotomy position with “hangover” of the sacrum for anal access.

For procedures requiring minimal or no anal or perineal access (eg, laparoscopic right hemicolectomy for a tattooed lesion), positioning the pelvis such that sacrum/coccyx are fully supported correlates with the lowest risk of pressure-related injury.

For procedures requiring anal access for surgery, intubation, or stapling, the anus should hang slightly off the edge of the bed (˜2-7 cm) to facilitate the perineal portion of the procedure.

For procedures requiring access to the perineum posterior to the anus, the anus should hang further off of the bed (˜5-15 cm) to allow exposure of the entire operative field. The perineum can be further exposed by propping the pelvis up with a folded blanket placed under the sacrum.

If the patient is anticipated to be in significant Trendelenburg especially for extended periods, prepare for ˜2-7 cm of slippage toward the head of the bed that will likely occur.

LITHOTOMY WITH CANDY CANE STIRRUPS

Perioperative Considerations

Provides little support for the joints of the legs and should only be used for short cases (eg, <30 minutes in length), such as colonoscopy or perianal procedures.
Pneumatic compression devices may still be used, despite the short duration of the case and lighter degree of anesthesia.

Technique

Place brackets on the lowest portion on side rail of body portion of the table and then secure candy cane bars so that they are orthogonal to the plane of the bed (Fig. 3-3).
Simultaneously lift both legs, flexing hips and knees to minimize unhealthy abduction/adduction at knee and ankle joints, and place the feet in stirrups such that one strap cradles fore- to midfoot and one strap cradles heel (Fig. 3-4).
If the knees or ankles are excessively torqued, the angle of the candy canes at their bed attachment may be modified to bring them into good position (Fig. 3-5).

FIGURE 3-3 ▪ Candy cane stirrups in place.

FIGURE 3-4 ▪ Proper positioning of the stirrup on the heel and midfoot, avoiding pressure on the Achilles tendon.

FIGURE 3-5 ▪ Adjustment of the angle of the stirrups at the bed to bring legs and hips into proper alignment.

LITHOTOMY WITH BOOT-TYPE STIRRUPS (eg, YELLOWFINS)

Perioperative Considerations

Boot-type stirrups provide better support for the joints of the legs and are preferable to candy canes for cases >30 minutes in length.
Peroneal nerve injury is the most common positioning injury associated with boot-type stirrups, resulting in a sensory neuropathy without motor deficit, and utilizing proper technique is aimed at avoidance of pressure on the lateral aspect of the tibial head to avoid this injury.
Pressure on the popliteal fossa should be avoided by rotating the boot toward the floor such that the foot is flat in the bottom of the boot (“standing in the stirrup”), taking pressure off of the posterior calf. Also avoid stirrup boots that reach too high posteriorly into the popliteal fossa.
The leg can be moved up and down as needed during the case. Keeping the knee low (close to in line with the hip) helps avoid interference with laparoscopy in the upper abdominal field or with a low
abdominal incision. On the contrary, elevating the foot as high as possible provides maximal access to the posterior perineum. The leg should be tested in all anticipated positions prior to draping and inspected for safety in each.
When combining arm tucking with boot lithotomy, protection of the hands using padding is essential to aid in prevention of traumatic finger injury during movement of stirrups (see arm tucking).

Technique

Place brackets on the lowest portion of side rail of body portion of the table and then secure boot-type stirrups firmly (Fig. 3-6).
Adjust the boots to be lying parallel and adjacent to leg portion of the bed and move boots up on bars to position closest to hips, with boot toes facing forward and soles of feet orthogonal to the bed. Boots should be just slightly loosened on the bars so that they can be manipulated easily but without unintentional slippage (Fig. 3-7).

FIGURE 3-6 ▪ Bracket for boot-type stirrups on the table near the table break.

FIGURE 3-7 ▪ Placing the legs into the boot-type stirrups.
Move the legs simultaneously into stirrups and remove/lower the foot of the bed, as described earlier.
Place a large piece of foam padding between the lateral aspect of the knee/lower leg and the stirrup, and place a small piece of foam padding between the tubing of the pneumatic compression devices and the patient’s foot to minimize pressure (Fig. 3-8).
While standing at the end of the stirrup and supporting the leg with one’s body, moderately loosen one stirrup boot and position it with the following principles:

The foot, knee, and opposite shoulder should form a line.

There should be minimal to no pressure on the lateral knee/lower leg to avoid peroneal nerve injury.

The plantar foot should sit flat in the bottom of the stirrup, and the weight of the leg should be resting on this portion of the foot, not on the posterior calf (Fig. 3-9).

The knee should be neutrally rotated, not outwardly or inwardly (Fig. 3-10).

The knee should be flexed, but not excessively as to interfere with surgery. The distance between the heel and the table should be customized for each patient’s leg length (Fig. 3-11).

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