Patient Positioning Proper positioning of the patient is essential for patient safety, comfort of the operator, and optimal visualization of the pelvic organs. There may be advantages to positioning the patient while awake to reduce the frequency of positioning-related complications. Laparoscopy is performed on an operating table that can be tipped to create a steep, head-down (Trendelenburg) position that allows the bowel to move out of the pelvis to facilitate visualization after the cannulas is placed. The footrest can be dropped to allow access to the perineum. The patient is placed in the low lithotomy position, with the legs appropriately supported in stirrups and the buttocks protruding slightly from the lower edge of the table (Fig. 23.1). The thighs are usually kept in the neutral position to preserve the sacroiliac angle, reducing the tendency of
Figure 23.1 Patient positioning: the low lithotomy position. The patient’s buttocks are positioned so that the perineum is at the edge of the table. The legs are well supported with stirrups, with the thighs in slight ﬂexion. Too much ﬂexion may impede the manipulation of laparoscopic instruments while in the Trendelenburg (head-down) position.
bowel to slide into the peritoneal cavity. The feet should rest ﬂat, and the lateral aspect of the knee should be protected with padding or a special stirrup to avoid peroneal nerve injury.
The knees should be kept in at least slight ﬂexion to minimize stretching of the sciatic nerve and to provide more stability in the Trendelenburg position. The arms are positioned at the patient’s side by adduction and pronation to allow freedom of movement for the surgeon and to lower the risk for brachial plexus injury (Fig. 23.2). Care must be exercised to protect the patient’s fingers and hands from injury when the foot of the table is raised or lowered. After the patient is properly positioned, the bladder should be emptied with a catheter and a uterine manipulator positioned in the endometrial cavity and secured either by an intracavitary balloon or attached to the cervix as appropriate.
The arrangement of instruments and equipment is important for safety and efficiency. The orientation depends on the operation, the instruments used, and whether the surgeon is right-or left-handed. An orientation for a right-handed operator is shown in Figure 23.2.
For pelvic surgery, the television monitor is typically placed at or over the foot of the table within the angle formed by the patient’s legs. If two monitors are available, one may be positioned at each foot of the patient allowing both the surgeon and the assistant the opportunity to view the surgical field without having to turn the head.
The surgeon usually stands by the patient’s left side, at an angle facing the patient’s contralateral foot. The nurse or technician and instrument table are positioned near the foot of the operating table to avoid obscuring the video monitor. The insufﬂator may be placed on the patient’s right side, in front of the surgeon, to allow continuous monitoring of the inﬂation rate and intra-abdominal pressure. The energy source (e.g., electrosurgical or ultrasonic generator) may be positioned on the patient’s right side to permit visualization of the power output.
Figure 23.2 Operating room organization. The patient’s arms are at the sides. The right-handed surgeon stands on the patient’s left. Instruments and equipment are distributed around the patient within view of the surgeon. For pelvic surgery, the monitor should be located between the patient’s legs.