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  1. Proper positioning of the patient during the operative period is important to optimize surgical exposure and reduce the risk of positioning-related injuries.

  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. Certain procedures (eg, robotic surgery) 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 is 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 minimize problems associated with positioning during the perioperative period.

  11. Increased vigilance is necessary to minimize the potential for visual injury in high-risk patients during the perioperative period.

  12. The report by the ASA Task Force on Perioperative Visual Loss is an excellent source of current information and consensus expert opinion on this devastating problem.


Surgical posture or positioning in the perioperative context refers to the manner of situating the patient’s body for the surgical procedure. The goal of positioning is to maximize anatomic exposure for the surgical procedure. Hippocrates advised primum non nocere (to first do no harm). Thus, intraoperative positioning should make surgical exposure ideal while optimizing patient safety. While anesthesia-related morbidity secondary to inadequate ventilation and oxygenation has decreased due to better physiologic monitoring and the implementation of minimum American Society of Anesthesiologists (ASA) monitoring standards, complications secondary to positioning are on the rise. Many positioning injuries (eg, peripheral nerve injuries) fall under the legal doctrine of res ipsa loquitur (the thing speaks for itself), implying that the injury sustained is self-evident and would not have occurred without the negligence of another party. 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, that 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 positions are described, ...

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