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16.1. Patient Positioning and Operating Room Setup:
Splenectomy
Joseph B. Petelin, M.D., F.A.C.S.
A. Operating Room Setup
1. The operating room (OR) is set up the same regardless of the position of the patient. The anesthesia machine is at the head of the bed. A monitor is placed at the shoulder of the patient on each side of the patient’s head, regardless of patient position. The OR technician or nurse stands on the patient’s left, toward the feet. The back table and mayo stand will be in that area.
Most surgeons use a standard mayo stand at the foot to store the standard equipment for laparoscopic splenectomy (this is labeled MAYO 1 in the diagram). In addition, some surgeons find that a second mayo stand located on the patient’s left at the level of the hip provides for efficient placement of the tools (scissors, harmonic dissector, graspers, and clip appliers) most frequently used during the procedure.
2. Equipment
The general complement of laparoscopic and open equipment is needed for laparoscopic splenectomy. Most of this equipment is placed on the mayo stand at the foot of the table; less frequently used items may be stored on the back table.
a. Special laparoscopic splenectomy equipment may be needed for laparoscopic splenectomy.
i. It is wise to have a wide-mouthed (>4-cm-long jaws) grasper available, if possible, in the event that emergency vascular control is necessary.
ii. An endovascular linear stapler is a very useful device for controlling and dividing the splenic hilum. It may also be used for division of the short gastric vessels. In the absence of a wide-mouthed grasper, it may be used for temporary control of the splenic hilum in an emergency.
iii. Ligatures and/or sutures of “0” and “2-0” braided nonab- sorbable material may used for control of the splenic vessels.
iv. An automatic clip applier is useful for control of smaller vessels.
v. Harmonic scissors have made a huge impact on the dissec- tion around the spleen. The lienocolic ligament and the short
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gastric vessels are effectively controlled and divided with this instrument.
b. Laparotomy equipment
This is usually placed on the back table for use in the case of an emergency.
B. Patient Positioning: Introduction
The importance of patient positioning for laparoscopic splenectomy cannot be overemphasized. Four alternatives are possible: supine, lithotomy, right lateral decubitus, and anterolateral (partial right lateral decubitus, 40°–50°). A bean bag greatly facilitates patient positioning in the latter three approaches.
The supine and lithotomy positions, initially reported in the early 1990s, have largely been replaced by the lateral and partial lateral positions. The former are currently only used for patients with massive splenomegaly (>20 cm length), pediatric or very thin patients, or those in whom concomitant surgery (e.g., laparoscopic cholecystectomy) is planned.
C. Supine Position
Presently, few surgeons prefer the supine position for adult laparoscopic splenectomy uncomplicated by massive splenomegaly or the need to perform concomitant procedures. The patient is placed supine on the operating table with lower extremities together and the upper extremities at the patient’s sides (Figure 16.1.1). The surgeon stands on the patient’s right side and the assistant on the patient’s left. The assistant operates the camera and manipulates an instrument for retraction or to otherwise assist. (See Chapter 16.2, Figure 16.2.1, for port placement scheme.)
1. Advantages
Setup and positioning time is significantly shorter when the supine position is utilized. The location of the initial port (often periumbilical) is also more familiar to the surgeon than the sites used when the patient is in the lateral posi- tion. Exploration of the abdomen for accessory spleens is thought to be easier with the patient in the supine position. Conversion to laparotomy is also facili- tated in this position. Concomitant surgery, for example, laparoscopic cholecys- tectomy, is easier to accomplish in this position.
2. Disadvantages
Exposure of the left upper quadrant, the spleen, the tail of the pancreas, the posterolateral ligaments, and the short gastric vessels is significantly more dif- ficult when using the supine approach. These problems have been held respon- sible for the increased operative time and blood loss encountered in patients undergoing laparoscopic splenectomy in the supine position.
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D. Modified Lithotomy Position
In the modified lithotomy approach, the legs are placed in stirrups such that the thighs are parallel to the anterior abdominal wall. The arms are tucked at the sides. Except for the positioning of the legs, this position is similar to the supine approach. The patient’s left side can be elevated by placing a roll under it, thus achieving a partial lateral position. With the patient thus positioned, a space exists between the legs in which the surgeon can stand (Figure 16.1.2). The cam- eraperson is located on the right of the patient and the first assistant stands on the patient’s left in most cases. The first assistant can also stand on the right side
Figure 16.1.1. Supine position for splenectomy.
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caudad to the camera person. (See Chapter 16.2, Figure 16.2.1, for accompany- ing port placement scheme.)
1. Advantages
Some surgeons feel more comfortable doing the case from between the legs.
This approach also decreases the crowding at the operating table, by allowing the cameraperson and the first assistant to stand alone on opposite sides of the patient. Obviously, if a robotic camera holder is to be used, crowding is less of an issue.
Figure 16.1.2. Modified lithotomy position for splenectomy.
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2. Disadvantages
It takes more time to place the patient in this position compared to the supine, lateral, or anterolateral positions. The legs are placed into the stirrups and then secured, after which the “foot” of the table must be detached. There is also a low incidence of stirrup-related complications associated with this position. The latter can largely be avoided by carefully positioning and padding the legs.
E. Lateral Position
A full lateral position (right lateral decubitus) is often preferred for laparo- scopic splenectomy (Figure 16.1.3). Here, the patient’s left upper extremity is either suspended from an attached table support or is supported across the patient’s chest with a pillow. A soft roll is placed under the right axilla in a trans- verse direction. The lower extremities are usually partially flexed with a pillow between the knees. The shoulders and lower extremities are strapped or taped to the table to prevent movement. The midportion of the OR table is flexed and the
“kidney rest” is elevated to maximize the distance between the left costal margin and the left iliac crest.
When using the lateral position, the surgeon and one assistant both stand on the patient’s right side. The assistant operates the camera while standing cepha- lad to the surgeon. A second assistant may stand on the patient’s left in this sit- uation. If needed, they may assist by using an instrument passed through a more posterior port in the flank. The anesthesia personnel are located at the head of the table. (For port placement schemes, see Chapter 16.2, Figures 16.2.3, 16.2.4.)
1. Advantages
The lateral position usually provides excellent exposure of the posterior lig- aments, the hilar structures, the tail of the pancreas, and the short gastric vessels.
Many authors have reported less blood loss and shorter operative times when this approach is used.
2. Disadvantages
Initial port placement is slightly more difficult and dangerous with the patient in the full lateral position. In this position, the spleen shifts to a more medial location where the risk of injury is greater. Extra care must be taken to ensure safe placement of the first trocar. The use of visually directed ports facil- itates the insertion of the initial trocar. Left upper extremity suspension from a transverse rod has the potential disadvantage of obstructing instrument maneu- vers during the case; therefore, placement of the left upper extremity on a pillow is preferred.
Exploration of the abdomen for accessory spleens, concomitant surgery (e.g., laparoscopic cholecystectomy), and conversion to laparotomy are more dif- ficult from this position than from other positions. This position is nearly impos- sible to use in patients with massive splenomegaly because visualization of the vital structures is obscured by the splenic mass.
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F. Anterolateral (Partial Right Lateral Decubitus) Position
The anterolateral position represents an attractive compromise position that incorporates the benefits of both the supine and lateral approaches for laparo- scopic splenectomy. A bean bag placed under the patient facilitates positioning.
Figure 16.1.3. Lateral position for splenectomy.
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A shoulder roll is placed beneath the patient’s right axilla. The patient is initially placed in the full lateral position, then laid back to a 45° position, and then the bag is deflated to harden it into position (Figure 16.1.4). Pillows are placed between the patient’s upper and lower extremities. Straps are placed across the shoulders and the hips to secure the patient to the table. The kidney rest is ele- vated and the table is flexed to maximize the distance between the left costal margin and the left iliac crest. For this position, the surgeon and first assis- tant/camera operator both stand on the patient’s right side. A second assistant could stand on the patient’s left side. If it becomes necessary to tilt the patient to a more supine position, the first assistant/camera operator may move to the patient’s left side.
Figure 16.1.4. Right anterolateral decubitus position for splenectomy.
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1. Advantages
The partial lateral position usually provides excellent exposure of the pos- terior ligaments, the hilar structures, the tail of the pancreas, and the short gastric vessels. Initial access to abdomen is usually easier and less dangerous than a full lateral approach. Tilting the OR table to the right (counterclockwise, when viewed from the feet) will yield the equivalent of a full lateral position. Tilting the OR table to the left (clockwise) will yield the equivalent of a supine posi- tion, facilitating the search for accessory spleens, concomitant surgery (e.g., laparoscopic cholecystectomy), and conversion to laparotomy.
2. Disadvantages
There are no particular disadvantages associated with using this position unless the OR table cannot be rotated as described above.
G. Selected References
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