Access to the Abdominal Cavity

Positioning of the Patient for Laparotomy

• Main Objective
  • The primary goal of positioning is to provide a clear and facilitated exposure of the operative field.
  • Elevate deep, hard-to-reach operative areas.
  • Keep organs adjacent to the operative site at a distance.
• Securing the Patient
  • Ensure secure, non-traumatizing fastening of the anesthetized patient on the operating table.
  • Fixation must allow for multiple intraoperative repositionings of the patient in vertical, horizontal, and sagittal directions.
  • Eliminate any localized pressure on exposed body parts of the abdomen and limbs.
  • All potential intraoperative position changes should be checked preoperatively.
• Preventing Positioning Injuries
  • Soft, wide-area padding can reliably prevent such injuries.
  • Risks are minimized using rubber and foam cushions, air bladders, and soft cloths.
  • Patients with chronic arterial circulation issues are especially at risk.
• Note
  • The surgeon is responsible for the correct positioning of the patient.
• Modern Operating Tables
  • Enable optimal patient positioning, intraoperative X-ray and fluoroscopy control, good corrosion-proof disinfection, and high operational reliability.
  • Suitable portioned anatomical adaptation and seamless transition between applying and releasing tension in the operative field are possible with electro-hydraulically divided table plates.
  • Common operating tables today allow for adjusting the height and repositioning of the patient in all desired directions from a single control panel at the head of the table.
  • However, positioning must always consider the patient’s circulatory situation. For instance, with the upper body elevated, the legs must also be elevated to prevent blood from pooling in the lower half of the body.
  • Before draping, attach electrodes for thermal or electrocauterization to the patient.
• Standard Patient Positioning
  • The normal position for the patient is horizontal (Figure 1-6a).
  • The patient lies on their back with their head tilted backward for easy access by the anesthetist and legs stretched out.
  • Legs are secured above and below the knees with wide, soft straps.
  • Arms should be extended out at an 80° angle on both sides of the body, allowing the anesthetist to access venous and arterial lines for infusion therapy and intraoperative monitoring.
  • Extending the arms and securing them in cushioned holders with sterilizable straps facilitates necessary repositioning and prevents patient slippage.
• Upper Abdomen Operations
  • With the upper body elevated, gravity causes the small intestine to fall away, not obstructing the surgery (Figure 1-6b).
  • The operative field can be elevated by sliding a continuously inflatable rubber cushion under the patient, which conforms to the body’s shape and reliably avoids pressure injuries.
  • To close the wound without tension, the air from the cushion is released.
• Lower Abdomen Operations
  • For procedures in the lower abdomen, the Trendelenburg position, with the head down, allows the small intestine to fall back into the upper abdomen (Figure 1-6c).
• Complex Abdomens
  • For difficult cases with adhesions, where the bowels are stuck to the anterior and lateral abdominal wall, hyperextending the patient can significantly ease the operation.