Operating Room Setup and Patient Positioning in MIS

Abstract

Crucial in any surgery, the performance and the outcome depend not only on the surgeon’s skills and patient preparation but also on the setup of the operating room (OR) and positioning of the patients. In endo-laparoscopic surgery, we work with technology like cameras, monitors, insufflators, energy devices, and more. They are connected and interconnected by several cables and tubings. It is vital for patient’s and OR Staff’s safety that they be easily accessible in a fast and timely manner in case of any emergency or unexpected event. Avoid entangling of cables, or interaction between tubing and cables will make your surgery safer, elegant, and less stressful.

Crucial in any surgery, the performance and the outcome depend not only on the surgeon’s skills and patient preparation but also on the setup of the operating room (OR) and positioning of the patients. In endo-laparoscopic surgery, we work with technology like cameras, monitors, insufflators, energy devices, and more. They are connected and interconnected by several cables and tubings. It is vital for patient’s and OR Staff’s safety that they be easily accessible in a fast and timely manner in case of any emergency or unexpected event. Avoid entangling of cables, or interaction between tubing and cables will make your surgery safer, elegant, and less stressful.

Moreover, the correct position of the patient to the endo-laparoscopic devices, monitor, and procedures is fundamental. The position depends on the procedure we intend to perform and where the surgical team will position in relation to the patient and the video monitor. Also, to surmount challenges like visceral retraction, we may need to tilt the patient, requiring preparation to avoid patient falling or sliding from the OR table.

Operating Room Setup

It depends on the size of your operating theater and the provision for the support of additional equipment. In general, the endo-laparoscopic camera system is on a cart and can be easily rolled and placed around the operating table accordingly. In other cases, the endo-laparoscopic camera system can be mounted on a boom arm and can be readily shifted around; in this so-called Integrated Operating Theater, additional monitors are placed on a swing arm that can be moved and adjusted to best fit the surgeon’s needs. In general, the monitor stands along the axis: surgeon—target organ, the rest of the devices like insufflator, energy device, camera controller, recording, etc., can be placed nearby the operating table and are easy to access for monitoring and setup.

It is essential to plan everything ahead and before the patient is positioned on the table. Once the patient is draped, it will be cumbersome to reposition any devices. Allow enough space for the anesthesia team to move around and monitor the patient; if you need additional equipment like ultrasound, C-arm, various energy devices, laser, etc., plan and simulate the position. It is also essential to check that all the devices are correctly plugged in, powered, and working perfectly. For the OR Staff and the surgical team, allow good interaction and spacing. Usually, the operating surgeon and the camera assistant stand together on the same side of the patient and the opposite side of the targeted organ, allowing space for triangulation and the assistant on the contralateral side to help.

Figures 1a, b, 2a, b, and 3 are typical operating room setups for different surgical procedures.

Fig. 1

Endo-laparoscopic system: (a) Endo-laparoscopic-cart mounted, (b) Boom-arm mounted

Fig. 2

Suggested OR setup in (a) large room, (b) small room

Fig. 3

Varying positions of the surgical team depending on the procedure

Introduction to Patient Positioning

Similar to exposure in open surgery, patient positioning is a necessary preparation in MIS; knowledge of the conduct of the operation provides comprehension of appropriate port placements and potential movement of the surgical team around the patient. Optimal patient positioning prevents inadvertent patient movement, protects the patient from injuries, ensures unhindered access to the port insertion area, and unencumbered instruments over and surgical team traffic around the patient.

The positioning augmented by intervals of unnatural positions (head down or up, or lateral tilt) allows gravity to retract the viscera away from the workspace. The prolonged operative time and maneuvering may generate compression, ischemia, shear, or stretch events that can cause positioning injuries like skin and tissue breakdown, transient neuropathies, compartment syndrome, and rhabdomyolysis [1]. The 2017 review by Zilloux and Krupski revealed the belief these are rare events and comprehensive data on the general incidence is lacking; however, they gauged that postoperative neuropathies range 0.10–3.2% for MIS, 0.8–6.6% for robotic-assisted surgeries and suggests the overall incidence to be 2–5% [2, 3].

Factors such as operative time, body mass index (BMI), and the American Society of Anesthesiologists (ASA) physical status classification contributed to the development of positioning injuries. According to the study by Gelpi-Hammerschmidt et al. on renal surgeries, lengthy procedures (>5 h) have an increased chance of developing rhabdomyolysis. Correspondingly, other studies confirmed a decrease in positioning injuries and postoperative creatinine kinase as operative time decreases. BMI in both extremes is associated with an increased risk for injuries. High BMI presumably aggravates the underlying forces that produce damage, while the rationale for low BMI is the lack of subcutaneous soft tissue padding to protect the neurovascular structures. The poor ASA classification is linked to factors (malnutrition, diabetes, and peripheral vascular disease) that make a patient prone to neuromuscular insults [2].

General Guidelines for Patient Positioning

Pressure Redistribution. The use of pressure dispersing devices and surfaces is critical to reducing pressure-induced skin and tissue breakdown. The bony prominences of the body are areas where weight-bearing points come in contact with surfaces for prolonged periods and are prone to developing these injuries. Dispersal of focal pressure may be achieved using various types of padding material (blanket, foam, pillow, silicone, towel, or visco-elastic).

Deep Venous Thrombosis (DVT) Prevention. MIS procedures have inherent factors (long operative time, extremes of positioning, and pneumoperitoneum) that contribute to the risk of developing DVT. The application of anti-thromboembolic stockings and/or sequential compression devices has been shown to minimize DVT incidence in MIS [4].

Upper Extremities Positioning [1, 3]. The most effective means of avoiding brachial plexus injuries is to secure the arms carefully at the patient’s sides, the palms resting against the patient with the elbows padded, and the draw sheet extends about the elbow and secured under the patient making sure it is not too tight to interfere with blood pressure cuff and intravenous lines. Avoid pronation of the arm, as this can expose the ulnar nerve to possible pressure. When arms are to be abducted, they should be placed level with the bed and not more than 90° from the patient’s side. Avoiding shoulder braces and wrist straps is advised; however, the shoulder braces should be positioned at the acromioclavicular joints when needed.

Lower Extremities Positioning [1, 3]. For the lower extremities, especially for the lithotomy position, four elements of positioning should be kept in mind: (1) angle of hip flexion—60–170°, should never be >180° as it places strain on the lumbar spine, (2) angle of knee flexion—between 90–120°, greater flexion can put a strain on the sciatic nerve, lesser flexion can promote venous stasis that may lead to DVT, (3) angle of hip abduction—90° or less, a greater angle can put a strain on the obturator nerve, and (4) degree of external hip rotation—should be kept to the minimal, any degree of external rotation can increase strain on the femoral, obturator, and sciatic nerve leading to nerve injury; the use of boot stirrup can provide improved positioning of the lower extremity.

Standard Surgical Positions in MIS

Supine (Fig. 4). The supine position is the most common surgical position, also called the “dorsal recumbent” position. MIS procedures in this position include those requiring access to the neck area, the abdominal cavity through anterior access, or for inguinal hernias. The patient is positioned with the head and spine in a horizontal line with the hips parallel to each other with the legs positioned straight and uncrossed. The arms are positioned at the patient’s sides or abducted. The table straps are applied loosely above the knees.

Fig. 4

Supine

Modified Lithotomy (Fig. 5). In this position, the hips are flexed, with legs abducted, the knees bent, and the buttocks at the edge of the table; the arms may be secured at the sides or abducted. Procedures using this positioning may require concurrent or sequential access to several quadrants of the abdominopelvic cavity and the perineal area.

Fig. 5

Modified lithotomy

Prone (Fig. 6). Generally used for cases requiring access to the esophagus, the back, and the retroperitoneal area using dorsal access. After induction of anesthesia, the patient is positioned face down with pads placed under the chest, hip, and thighs while verifying lung expansion is not restricted. The arms are brought down and forward next to the head, the elbows flexed, hands pronated, and padding at the elbows. The head may be turned to one side or placed on headrests designed to protect the airway.

Fig. 6

Prone

Lateral/Lateral Decubitus (Fig. 7). The patient lies down on the side contralateral to the intended workspace side. The lateral positioning is used for access to the thorax, kidneys, and retroperitoneal space. Paddings are situated at the head, thorax, and legs; the arms are placed on supports, and bracing supports may be positioned at the back or anterior at the hip area.

Fig. 7

Lateral decubitus

Common Modifications

Trendelenburg and Reverse Trendelenburg (Fig. 8a, b). This modification may be added to any of the basic positions by placing the body on an incline. The Trendelenburg position elevates the feet above the head at an inclination of about 15–30°; the reverse Trendelenburg does the opposite—head elevated above the feet. The former allows gravity to pull the intra-abdominal organs away from the pelvis; the latter, the viscera to fall away from the upper abdomen.

Fig. 8

(a) Trendelenburg and (b) Reverse Trendelenburg

Split Leg (Fig. 9). This variation applied to the standard supine position allows the surgeon to stand between the legs when the patient is in reverse Trendelenburg and be nearer to the upper abdomen access, which is frequently employed in bariatric and other upper gastrointestinal procedures.

Fig. 9

Split Leg

Head extension (Fig. 10). The neck extension modification in the supine position is specific for access to the thyroid and parathyroid. The patient is initially positioned supine and anesthesia induced via nasotracheal intubation. The shoulders are raised with padding or sandbag, and the neck is slightly extended with the head secured over a donut ring.

Fig. 10

Head extension