Patient positioning in laparoscopic surgery: Tricks and tips
J. Agostini , N. Goasguen , H. Mosnier ∗
Service de chirurgie digestive, hôpital de la Croix-Saint-Simon, groupe hospitalier les Diaconesses-la-Croix-Saint-Simon, 125, rue d’Avron, 75020 Paris, France
Introduction
By the very fact that a patient is positioned on the operation table, he or she runs a risk of complications. Patient positioning is an integral part of the surgical gesture and the surgical and anesthetic teams have the role and responsibility of assuring that positioning is optimal both for surgical efficacity and for patient safety. Laparoscopic surgery has been associated with specific complications secondary to extreme patient positions and also to prolonged operative times (the so-called ‘‘learning curve’’). The goal of this article is to define the strategies of patient positioning.
Operative injuries can be of three types:
- nerve injury due to compression or stretching;
- rhabdomyolysis;
- compartment syndromes.
To study these iatrogenic complications, the American Society of Anesthesiologists used registries of Insurance company claims. Thus the ‘‘American Society of Anesthesiologists Closed Claims Project’’ [1] collected more than 4000 claims from 35 insurance companies.
Nerve complications represented 16% of the complaints. Of these, 28% involved the ulnar nerve, 20% involved the brachial plexus, 16% the lumbosacral plexus while 5% were injuries of the sciatic nerve or branches thereof. Lumbosacral and spinal cord lesions clearly occur more frequently during spinal anesthesia [2] and are more related to complications of anesthesia technique than to the method of patient positioning.
Possible mechanisms include stretching, compression and ischemia. These mechanisms can unmask or aggravate a pre-existing disease (diabetic neuropathy, etc.). Thin patients are more vulnerable because the cushion of subcutaneous fat that protects the nerves from compression is reduced. This is particularly true for ulnar nerve compression. In general, these lesions are not permanent but postinjury recovery may require as much as a year.
The purpose of this article is to describe the most frequent complications, their mech-anisms and the means to prevent them.
