1. Surgical Patient Positioning
ST210
Concorde Career College, Portland

2. Positioning Objectives:
List the basic surgical positions and analyze the use of each
Identify basic positioning aids and describe the use of each

3. Positioning Objectives:
List the steps for placing the patient in the basic surgical positions and list the potential hazards and safety precautions that relate to each position

4. Surgical Technology Lecture Series 2000©
Power-Point®

5. Production Notes Series Editor - Teri Junge, MEd, CSFA, CST, FAST
Primary Author - Kevin Frey CST, MA
Coauthor and Executive Editor - Bob Caruthers CST, PhD
Series Editor - Teri Junge, MEd, CSFA, CST, FAST

6. Table of Contents General Information Patient Safety Equipment
Patient Positions

7. General Information

8. Position Determination
General factors
Surgical procedure
Surgeon’s preference
Technique of anesthetic administration
Patient factors
Age
Size (height and weight)
Cardiopulmonary status
Preexisting conditions

9. Responsibilities Choice of position is made by surgeon and anesthetist
The surgeon will ensure the patient is properly positioned
Safe positioning of the surgical patient is the responsibility of the entire surgical team

10. Timing of Positioning
Patient is not positioned or moved until the anesthetist indicates it is okay to do so
Factors that influence time of positioning
Site of surgical procedure
Age and size of patient
Type of anesthetic administered
Pain associated with moving conscious patient

11. Patient Safety
Patient Safety

12. Safety Properly identify patient Operating table and gurney locked
Mattress secured to operating table
Minimum of 2 people assist an awake patient during transfer
Person on “gurney side” helps patient move to operating table
Person on “operating table side” prevents patient from falling off the narrow table

13. Safety (continued)
Minimum 4 persons to move unconsciousness, obese, or weak patients
Move on the count of three
Anesthetist controls timing
Anesthetist controls head and neck at all times
Lift - do not slide or pull the patient
Surgeon is responsible for stabilizing un-splinted fractures during move

14. Safety (continued)
Anesthetized patient is moved slowly to allow circulatory system to adjust
Body parts not to extend beyond table edges, rest on metal parts, or unpadded surfaces
Body exposure kept to minimum
Prevent hypothermia
Maintain patient’s dignity (especially awake patient)

15. Safety (continued) Protect arms
Prevent accidental IV removal
Avoid hyperextension of arm board
Be sure patient in the supine position has not crossed legs
Uncrossed to avoid neurovascular compromise

16. Safety (continued)
Chest rolls are used in the prone position to facilitate respiration
Protect patient’s fingers and skin at flex points of table
Mayo stand must not rest on patient
If table raised during procedure; Mayo stand must also be raised

17. Respiratory System Requirements
Unhindered diaphragmatic movement
Patent airway
Prevent hypoxia
Some hypoxia may be unavoidable
Facilitate inhalation anesthesia
No constriction about neck or chest
Place arms at sides, on arm boards, not crossed on the chest

18. Circulatory System Requirements
Adequate circulation required
Maintain BP
Provide oxygenated blood to tissue
Facilitate venous return,
Prevent thrombus formation
Pressure on peripheral blood vessels avoided
Body support and safety straps not too tight

19. Peripheral Nervous System Requirements
Avoid prolonged pressure or stretching on peripheral nerves
Injury can range from sensory and motor loss to paralysis
Positioning devices that come in contact with patient must be well padded

20. Peripheral Nerves (continued)
Frequent sites of injury
Divisions of the brachial plexus
Due to extreme positions of head and arm
Ulnar nerve
Radial nerve
Peroneal nerve
Extremity nerves damaged by compression against bone, stirrups, or operating table
Facial nerve

21. Musculoskeletal System Requirements
Anesthetized patients lack muscle tone or control
Strain on muscles results in injury
Body alignment must be maintained

22. Soft Tissue Requirements
Body weight distributed unevenly on operating table
Weight on bony prominences can lead to skin ulceration
Tissue folded under skin of obese patient will not receive proper perfusion
Debilitated patients and diabetics are at high risk for decubitus ulcers
Wrinkled sheets and edges of positioning devices under the patient can cause pressure on skin

23. Patient Access Anesthetist must be able to Attach monitoring devices
Administer anesthesia
Observe patient
Maintain access to airway and IV sites

24. Equipment

25. Operating Table Electric or manual hydraulic Metal top
3 hinged sections: head, body, leg
Allow patient to be manipulated; flexed
Joints of table referred to as breaks
Flexing the table is referred to as breaking

26. Operating Table (continued)
Metal crossbar between two upper sections to elevate kidney area
X-ray penetrable top extends length of table for insertion of X-ray cassette
Rubber; foam mattress adhered with Velcro®
Foot extension board for tall patient; also used with lithotomy position

27. Operating Table (continued)
Table is manipulated into desired position either by electronic controls or lever-operated hydraulic system
Control set on back, side, foot, or flex
Brake is set to maintain table position

28. Table Accessories Safety belt (knee strap)
Placed over thighs 2” above knees
Circulator should be able to pass fingers between strap and patient
Some straps attached at sides of table; others fastened in middle
Blanket placed on patient between skin and belt
Belt placed over, not under blanket

29. Table Accessories (continued)
Anesthesia screen
Metal bar attaches to head of table to hold drapes off patient’s face
Substitute for IV poles
Lift sheet (draw sheet)
Folded sheet placed horizontally across top of sheet on operating table
Can be used in moving patient

30. Table Accessories (continued)
Lift sheet (continued)
Arms can be enclosed in sheet with hands placed palm down or turned inwards toward body
Finger tips must extend beyond edges of sheet
Tuck sheet under patient’s sides
Do not tuck under sides of mattress

31. Table Accessories (continued)
Arm boards
Support arms
Provide access to IV
Support arm or hand where surgical site is located
Hand placed palm up on board to prevent ulnar nerve pressure and abnormal shoulder rotation Exceptions
Prone position
Upper arm of lateral position

32. Table Accessories (continued)
Arm boards (continued)
Arm board can be adjusted to different angles
Never abduct arm more than 90 degrees from shoulder
Double arm board
Arms positioned one above the other
Also called overhead arm support

33. Table Accessories (continued)
Wrist straps
Narrow straps placed around wrists to secure hand and arm to arm board
Hand table (upper extremity table)
Slipped under mattress on one side of table
Other end of table supported by legs
Can use 2 arm boards placed side-by-side; not as effective or safe

34. Table Accessories (continued)
Shoulder braces
Padded concave supports to prevent patient from slipping off table when using Trendelenburg position
Acromion processes must rest on braces, not muscles or soft tissue near the neck

35. Table Accessories (continued)
Kidney rests
Padded concave pieces that slide under mattress on kidney elevator
Placed snugly against body to provide stability in kidney position

36. Table Accessories (continued)
Body (hip) restraint strap
A wide belt or tape (preferred) is used
Placed over patient’s hips to help secure patient in lateral position

37. Table Accessories (continued)
Hemorrhoid strap
Benzoin spray
3” wide adhesive tape
Strips placed approximately 4” lateral to surgical site
Use 2 strips per side
Spread buttocks when patient is in Kraske position

38. Table Accessories (continued)
Stirrups (candy canes)
Metal poles placed in holder on each side of operating table to support legs and feet in lithotomy position
Feet supported by canvas or fabric loops, suspending the legs

39. Table Accessories (continued)
Metal footboard
Foot extension board placed perpendicular to table to keep patient from slipping off operating table in reverse Trendelenburg
Used to prevent foot drop during extended procedures

40. Table Accessories (continued)
Donut
Ring-shaped foam pad for head
Also used to protect pressure points
Bolsters
Used to elevate specific part of body
Chest roll
Axillary roll

41. Table Accessories (continued)
Suction bean bag
Placed on top of operating table
Patient lays on the bean bag
Suction attached to one end of bag
As air is withdrawn the pad hardens and is molded to the patient’s body by the surgical team

42. Table Accessories (continued)
Suction bean bag (continued)
Suction disconnected to release
To allow air to reenter, valve is squeezed
Excellent positioning device for stabilizing patient in lateral position

43. Table Accessories (continued)
Wilson Frame
For thoracic spinal surgery
Used to open the intervertebral spaces

44. Table Accessories (continued)
Trauma attachments
Used for extraction during procedures such as ORIF, nail or rod insertion, and percutaneous pinning

45. Table Accessories (Continued)
OSI Jackson Table
Modular table system used primarily for spinal procedures
Choice of flat table top or open frame
Carbon construction facilitates fluoroscopy use

46. Patient Positions

47. Supine (Dorsal) Position
Patient lies on back
If arms at side, supported by draw sheet, palms down
If arms on arm boards, palms up
Legs straight and in line with head and spine
Hips parallel to spine

48. Supine (continued) Safety belt across thighs 2” above knees
Pillows placed under head, under knees, under lumbar curvature
Protect heels from pressure
Feet must not be in prolonged plantar flexion (foot drop)

49. Supine (continued) Procedures Modifications Anterior surface of body
Extremities
Modifications
Procedures on face or neck: Place rolled towel lengthwise along upper boarder of scapula to slightly hyperextend neck and/or lower head section of operating table

50. Supine (continued) Knees slightly flexed with a pillow under each
Modifications (continued)
Modified dorsal recumbent (frog leg)
Knees slightly flexed with a pillow under each
Thighs externally rotated
Soles of feet rest on table top

51. Trendelenburg Position
Supine with head tilted downward
Safety belt 2” above knees
Shoulder brace may be used
Lung volume decreased
Heart mechanically compressed by pressure of organs against diaphragm

52. Trendelenburg (continued)
Level entire table slowly at end of procedure
Procedures
Lower abdomen or pelvis to allow abdominal viscera to fall away from surgical site

53. Reverse Trendelenburg Position
Supine with head tilted upward
Padded foot board may be necessary
Small pillows placed under knees and lumbar curvature
Donut for the head
Safety belt 2” below the knees
Footboard may be used to retain patient on table

54. Reverse Trendelenburg (continued)
Procedures
Upper abdomen
Allows abdominal viscera to fall away from surgical site
Examples: gallbladder, biliary tract, splenectomy
Thyroidectomy
Facilitates breathing and decreases blood supply to surgical site

55. Fowler’s (Sitting) Position
Start with patient in the supine position
Buttocks at flex in table
Knees over lower break
Foot section lowered slightly to flex knees
Body section raised becoming the “back” of the chair
Arms rest on armboards parallel to operating table
Alternative: Secure arms to large pillow placed on lap

56. Fowler’s (continued) Safety belt placed 2” above the knees
Table tilted slightly head downward
Table resembles modified armchair
Procedures
Shoulder
Nasopharyngeal
Facial
Breast reconstruction

57. Lithotomy Position
Wrap ankle and foot of patient with towel, leggings, or cotton boots for padding against canvas loops
Transfer head section to foot end of table to serve as foot extension
Place stirrup on side of table that will not be used for patient transfer

58. Lithotomy (continued)
Start with the patient in the supine position
Arms placed on armboards
Hands not to extend along table where fingers could be crushed in breaks while leg section is lowered or raised
Buttocks resting along break between body and leg section
Place other stirrup
Stirrups must be of equal position and at an appropriate height according to length of patient’s legs

59. Lithotomy (continued)
When anesthetist gives permission, both legs are raised simultaneously by two persons
Support the foot, ankle, and calf
Flex the knees and legs; place inside the stirrup posts
Place feet in canvas loops
First loop of canvas around ankle
Second loop around sole of foot

60. Lithotomy (continued)
Lower section of mattress is removed
Leg section of table is lowered
Lower leg or ankles must not touch any metal part of the stirrup
Buttocks must be even and not extend beyond table edge
Extension beyond edge causes strain on lumbosacral muscles and ligaments due to body weight placed on sacrum

61. Lithotomy (continued)
Conclusion of surgical procedure
Raise leg section
Replace mattress
When anesthetist gives permission, both legs are extended, brought together, and lowered slowly and simultaneously by two persons
Prevents hypotension as blood reenters legs and leaves the torso
Essential to avoid lower back strain
Reapply safety belt
Safety belt not applied when patient is in lithotomy

62. Lithotomy (continued)
Lung compliance is decreased by pressure of thighs on abdomen
Diaphragmatic movement restricted
Procedures
Perineal
Vaginal
Urological
Rectal

63. Prone Position Patient lays on abdomen (face down)
Chest rolls pre-placed on operating table
Extend from clavicles to iliac crest to facilitate respiration
Patient is anesthetized and intubated in the supine position on the gurney
When anesthetist gives permission, patient is slowly rolled onto abdomen on operating table by team of at least 4 people

64. Prone (continued) Breasts moved laterally
External genitalia toward foot of table
Arms
Placed along side of body with palms up or towards side of body
Can cause pressure on breasts
Placed on armboards, angled with elbows flexed
Palm downward
When moving arm, lower toward floor rotating in an upward in natural movement

65. Prone (continued) Procedures Head turned to one side; use a donut
Pillow under anterior of ankles
Safety belt above the knees
Procedures
Spine
Posterior aspect of lower extremity

66. Kraske (Jackknife) Position
Modification of the prone position
Hips over center break between body and leg sections of operating table
Chest rolls employed
Arms on arm boards; elbows flexed; palms down
Head to the side on donut
Pillow under ankles
Safety belt below the knees

67. Kraske (continued)
Leg section lowered; entire table tilted head downward so hips are elevated above body
Return patient to level position slowly
Remove safety belt when moving table parts
Venous pooling occurs cephalad and caudad
Kraske position not tolerated well by patients
Procedures
Rectal
Pilonidal sinus

68. Knee-Chest Position Modification of the prone position Foot extension
Table flexed at center break
Leg section at right angle to operating table
Patient kneels on lower section
Knees are flexed at right angle to body
Head turned to side; placed on donut

69. Knee-Chest (continued)
Arms placed on pillow near head with elbows flexed
Safety belt above the knees or tape used
Pillows placed on foot board and taped into place
Procedures
Spine

70. Lateral Position
Anesthesia administered with the patient in the supine position, then repositioned onto the non- operative side
Turned by no fewer than 4 people
As patient is turned, patient’s back drawn to edge of operating table
Arms placed on overhead armboard; lower arm palm up; upper arm slightly flexed with palm down

71. Lateral (continued) Lower leg flexed at knee Upper leg straight
Large pillow placed lengthwise between legs to prevent pressure on peroneal nerve
Safety belt or wide tape placed over hip to provide stability
BP taken from lower arm
Small roll under axilla to relieve pressure

72. Lateral (continued) Procedures Shoulders in alignment
Head in cervical alignment
Supported by pillow between shoulder and neck to prevent stretching the neck, brachial plexus, aid in maintaining patent airway
Procedures
Thorax
Kidney
Retroperitoneal space

73. Kidney Position
Modification of lateral position with flank region over kidney elevator
Short kidney rest attached to elevator at patient’s back
Longer rest placed on front below level of iliac crest to prevent pressure on abdominal organs
Table slightly flexed
Kidney elevator raised to increase space between lower ribs and iliac crest

74. Kidney Position (continued)
Safety strap or wide tape placed after table flexed and elevator raised
Entire table tilted head downward until surgical area is horizontal
For all lateral positions, keep shoulder, hip, knee, and ankle in alignment
Before closure, table is flattened to allow better approximation of tissues
Procedures
Kidney