10.1. Patient Positioning and Operating Room Setup for Laparoscopic Treatment of
Gastroesophageal Reflux Disease
Dennis Blom, M.D.
Jeffrey H. Peters, M.D.
A. Room Setup
1. The two body positions that are utilized for minimally invasive gastroesophageal reflux disease (GERD) procedures and which are described in this chapter are the modified lithotomy and the supine position.
2. The laparoscopic equipment is set up the same way for both positions.
The two video monitors are positioned at the head of the operating table on either side of the anesthesiologist (Figures 10.1.1, 10.1.2).
3. Standard laparoscopic equipment is needed. This equipment can be housed within ceiling-mounted adjustable columns in specifically designed laparoscopic operating rooms or on mobile units that can be moved between different standard operating rooms.
4. A suction/irrigation system, monopolar cautery, harmonic scalpel, or other energy source facilitate the operation.
5. Given the increased manpower needed to perform laparoscopic antire- flux procedures (surgeon, first assistant, camera holder, scrub nurse/
technician), there is much interest in and development of robotic assistants and adjustable table-mounted retractors and retractor holders. Several voice-controlled camera holders are now commer- cially available. These devices can reduce the need for extra assistance and may, in some settings, better serve the surgeon by performing repetitive, tedious tasks without fatiguing and with less motion artifact.
6. The authors routinely use intermittent antiembolic compression devices on both lower extremities, regardless of patient position, to improve venous return and to decrease the chances of deep vein throm- bosis.
7. A urinary catheter is routinely placed after the induction of general anesthesia.
8. Securing the patient to prevent slippage off the table is particularly important given the 20° to 45° incline of the operating table, especially
10.1. Patient Positioning and Operating Room Setup 93
if the patient is obese. A number of different methods can be used to secure the patient in position.
9. A pelvic extension can be placed at the caudal end of the OR table, padded and tilted upward to act as a stop. It is far enough forward so that it does not interfere with the surgeon standing between the legs and provides excellent security against slippage.
a. Similarly, kidney rests can be attached to the sides of the OR table, padded, and placed against the buttocks to prevent the hips from sliding downward.
b. Another option is to use a “bean bag,” which is placed under the patient; then, suction is applied to the bag. The bean bag forms a mold of the patient and helps secure the position.
c. Alternatively, and probably least secure, is the use of a gel roll secured to the table, usually with tape, just below the patient’s coccyx. Commercially available thigh straps that are designed to Figure 10.1.1. Operating room setup with patient in modified lithotomy posi- tion. The scrub nurse and the tables holding the operating instruments and tools would be located at the foot of the patient or just off to the side of either the left or right foot.
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Figure 10.1.2. Operating room setup with patient in supine position. The scrub nurse and the tables holding the operating instruments and tools would be located at the foot of the patient or just off to the side of either the left or right foot.
hold the patient from sliding downward off the table may also be used.
d. In conjunction with one or several of the above measures to secure the abdominopelvic region, the chest should also be secured. Straps or tape can be placed across the padded thorax, out of the operative field, provided all potential pressure areas, such as the elbows and hands, are properly padded. An upper body convection heat device may be used to keep the patient warm throughout the procedure.
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B. Patient Positioning
1. Several options exist for patient positioning during the performance of laparoscopic antireflux procedures.
a. Most surgeons place the patient in a modified lithotomy position, with 20° to 45° of reverse Trendelenburg or with the patient’s thorax elevated in a Fowler’s position (Figures 10.1.1, 10.1.2). This incline allows the abdominal viscera, specifically the transverse colon and small bowel, to fall downward toward the pelvis out of the visual and operative field.
b. The patient’s arms may be padded and tucked at his sides, or abducted 90° on arm boards.
i. The lower extremities are abducted either on a specialized fracture table or placed in stirrups with the hips and knees slightly flexed. Care must be taken not to flex the hips more than approximately 20° so that the thighs lie in the same plane as the anterior abdominal wall. Excess flexion will hinder the free movement, especially downward, of the external portions of the instruments in the lower ports (Figure 10.1.3).
ii. When using stirrups, each of the lower extremities should be placed into the stirrups at the same time to prevent hip and back injury. Each knee should be placed in line with the contralateral shoulder. Care should be taken to avoid exces- sive pressure on the portion of the calf that is in contact with the stirrup. Nerve injury or pressure necrosis can result if the leg is improperly positioned. The lower legs can be secured in the stirrups in several ways:
1. Velcro straps.
2. Strips of broad cloth tape placed over folded towels that are placed over the anterior lower leg.
3. Ace bandages that are wrapped around both the leg and the stirrup.
iii. The surgeon stands between the patient’s legs, allowing a coaxial approach to the operative field, with the operative field and video monitors in his line of vision. The surgeon should be free to use both hands for dissection and suturing.
This position allows better triangulation of the laparoscopic instruments and is a more ergonomically comfortable and natural position.
iv. The first assistant stands to the patient’s left and the camera operator to the patient’s right.
v. The scrub nurse/technician is then free to stand to either the surgeon’s right or left depending on surgeon preference and special considerations.
c. Alternatively, the patient may be placed supine in a 20° to 45°
reverse Trendelenburg position (see Figure 10.1.2). This position may be necessary in patients whose legs cannot be abducted and in those in whom, despite abduction of the legs, there is not WHE10 6/16/2005 2:12 PM Page 95
Figure 10.1.3. Side view of patient in modified lithotomy and reverse Trende- lenburg position.
enough room for the surgeon to stand between the legs because of the table and/or equipment.
i. The monitors and the other equipment are positioned the same as for the modified lithotomy position.
ii. The surgeon performs the operation from the patient’s right side. In this location the surgeon loses the advantages of a coaxial approach.
iii. The first assistant and the camera operator stand on the patient’s left.
C. Selected References
Bowrey DJ, Peters JH. Current state, techniques and results of laparoscopic antireflux surgery. Semin Laparosc Surg 1999;6:194–212.
Peters JH, DeMeester TR, Crookes PA, et al. The treatment of gastroesophageal reflux with laparoscopic fundoplication: prospective evaluation of 100 consecutive patients with typical symptoms. Ann Surg 1998;228:40–50.
Soper NJ. Laparoscopic management of hiatal hernia and gastroesophageal reflux. Curr Probl Surg 1999;36:765–840.
Underwood RA, Dunnegan DL, Soper NJ. Prospective randomized trial of bipolar elec- trosurgery vs. ultrasonic coagulation for division of the short gastric vessels during laparoscopic Nissen fundoplication. Surg Endsoc 1999; 3:763–768.
