Chapter 27

1. Proper positioning of the patient during the operative period is important for optimal surgical exposure and outcome.

2. Understanding the pathophysiologic changes and special considerations associated with each position helps reduce positioning-related morbidity.

3. Improper positioning during surgery can lead to spinal cord ischemia, postoperative peripheral neuropathies, muscular sprain injuries, ischemic injury to skin and muscles, and visual loss.

4. Perioperative peripheral nerve injuries are the second most common cause of professional liability among anesthesiologists.

5. New and advanced surgical procedures (robotic) may involve unconventional and extreme positioning techniques, necessitating better understanding of the physiologic consequences of positioning and enhanced vigilance to prevent injury to the patient.

6. Male gender, extremes of body habitus, and prolonged hospitalization are risk factors for postoperative peripheral neuropathies.

7. A thorough assessment of risk factors for complications related to positioning should be an integral part of the preoperative evaluation.

8. As part of the informed consent, risks and benefits associated with positioning should be discussed with the patient.

9. Description of intraoperative positioning techniques and measures taken to prevent injury should be documented in the anesthetic record.

10. Familiarity and understanding of the American Society of Anesthesiologists (ASA) Task Force on Prevention of Perioperative Peripheral Neuropathies may help with minimizing the problems associated with positioning during the perioperative period.

11. Special attention needs to be paid to minimize the potential for visual injuries in high-risk patients during the perioperative period.

12. A report by the ASA Task Force on perioperative blindness is an excellent source of current information and consensus expert opinion on this devastating problem.

The term surgical posture or positioning in the perioperative context denotes the body position in which a patient is placed for the surgical procedure. The main purpose of "positioning" is to maximize anatomic exposure for the surgical procedure. In Epidemics, Book I, Second Constitution, Hippocrates advised primum non nocere, "to first do no harm." Thus intraoperative positioning should make surgical exposure ideal while optimizing patient safety. In spite of anesthesia-related morbidity secondary to inadequate ventilation and oxygenation improving as a result of better physiologic monitoring and ASA standards on minimum monitoring, complications secondary to positioning are on the rise. Many problems arising from positioning such as peripheral nerve injuries fall under the legal doctrine of Res ipsa loquitur. This Latin phrase literally means "the thing speaks for itself" and implies that the injury sustained is so evident that it would not have occurred without negligence from someone else. Thus the plaintiff needs only to prove the injury. In cases of res ipsa loquitur, the burden of proof falls on health care providers to prove their innocence (ie, the care provided was not negligent). Therefore, safe intraoperative patient positioning is crucial, and a clear protocol must be in place and followed by all members of the perioperative team.

This chapter discusses the positions that are commonly used during surgical procedures (supine, lithotomy, sitting, head down, prone, and lateral decubitus). The rationale and technique for safe establishment of each of these ...

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