Surgical Positions and Skin Preparation

SURGICAL POSITIONS AND SKIN PREPARATION

SUPINE (DORSAL) POSITION

It is the most natural position for the body at rest.

Patient lies flat on the back with the arms secured at the sides with the lift sheet, and the palms extend along the side of the body.

Small padding placed under patient’s head and neck and under knees.

Vulnerable pressure points should be padded. Ex. Heels, elbows, sacrum

If procedure will be longer than one hour or patient is particularly vulnerable to pressure, egg crate or flotation mattress should be used.

A safety belt is placed across the thighs 2 inches above the knees.

If head is turned to one side, doughnut or special head rest should be used to protect superficial facial nerves and blood vessels.

Eyes should be protected by using eye patch, and ointment to prevent drying.

USES:

Used for procedures on the anterior surface of the body, such as abdominal, abdominothoracic, and some lower extremity procedures.

Modifications of the supine position are used for specific body areas: Procedures on the face or neck Shoulder or anterolateral procedures Dorsal recumbent position Modified dorsal recumbent Modified dorsal recumbent (frog-legged) Arm extension

TRENDELENBURG’S POSITION

The patient lies on his or her back in the supine position with the knees over the lower break of the operating bed. The knees must bend with the break of the operating bed to prevent pressure on the peroneal nerves and veins in the legs. The entire operating bed is tilted approximately 40 degrees downward at the head, depending on the surgeon’s preference. The foot of the operating bed is lowered to the desired angle.

USES:

Trendelenburg position is used for procedures in the lower abdomen or pelvis.

Advantages: tilt the abdominal viscera away from the

pelvic area for better exposure Disadvantages:

lung volume is decreased and the heart is mechanically compressed by the pressure of the organs against the diaphragm. ICP is increased.

REVERSE TRENDELENBURG’S POSITION

The patient lies on his or her back in the supine position. The mattress is adjusted so the surgical area is over the elevator bridge on the operating bed. If the elevator bridge is not used, the surgical area may be hyperextended by a shoulder roll. The entire operating bed is tilted 30-40 degrees so the head is higher than the feet: a padded footboard Is used to prevent the patient from sliding toward the tilt. The thigh safety belt is positioned 2 inches above the knees. Small pillows may be placed under the knees and the lumbar curvature. A small pillow or donut may stabilize the head.

USES:

Used for upper abdominal, head and neck, facial surgery

Advantages: facilitates breathing and decrease blood

supply to the surgical site (blood will pool caudually) during thyroidectomy.

allows the abdominal viscera to fall away from the epigastrium, giving access to the upper abdomen in laparoscopic gallbladder, biliary tract, or stomach procedures.

Disadvantages: Venous stasis can cause complications and

prevention of deep vein thrombosis is an important consideration.

FOWLER’S POSITION

Sitting position - Neuro surgery

SITTING POSITION – PRESSURE POINTS

SITTING POSITION

USES:

This position may be used for shoulder, nasopharyngeal, facial, and breast reconstruction procedures.

ADVANTAGES:

Better surgical exposure Less tissue retraction & damage Less bleeding Less cranial nerve damage More complete resection of lesion Ready access to airway, chest &

extremities Modern monitoring gives early warning of

venous air-embolism

DISADVANTAGES:

At risk for Venous air embolism May cause Hypotension (prevented by

stockings) Arms – if not well supported cause

brachial-plexus stretching

LITHOTOMY POSITION:

Exaggerated variation of supine position; can be dangerous and uncomfortable to patient.

Patient is placed in supine position with buttocks near lower break in the table (sacrum area should be well padded)

Feet are placed in stirrups or knee rests attached to operating table on both sides

Stirrup height should not be excessively high or low, but even in both sides

Padded stirrups (knee brace) must not compress vascular structures or nerves in the popliteal space

Pressure from the metal stirrups against the upper inner aspect of thigh/calf should be avoided

Legs should be raised and lowered slowly and simultaneously (may require two people)

LITHOTOMY POSITIONING - I

LITHOTOMY POSITIONING - II

FINAL LITHOTOMY POSITION

LITHOTOMY POSITION WITH STIRRUPS

LITHOTOMY POSITION

UROLOGY -- LITHOTOMY POSITION

LITHOTOMY POSITION

VARIOUS TYPES OF LITHOTOMY STIRRUPS

NERVE INJURIES IN LITHOTOMY

Peroneal nerve injury Saphenous nerve injury Femoral nerve injury Obturator nerve injury

USES:

Perineal, vaginal, rectal surgeries; combined abdominal-vaginal procedures

Advantages: Elevation of legs promotes translocation of

vascular volume centrally Disadvantages:

Areas supporting weight of legs prone for nerve injury