13 Visceral and transplantation surgery 13

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13 Visceral and transplantation surgery

13.1 Neck – 158

13.1.1 Supine position – 158

13.1.2 Supine position, neurosurgical headrest – 160

13.2 Open laparotomy – 162

13.2.1 Supine position (median and transverse laparotomy, incision right or left parallel to the costal margin) – 162

13.2.2 Lithotomy position – 164

13.3 Laparoscopic operations – 166

13.3.1 Supine position – 166

13.4 Heidelberger position (position for Kraske access) – 168

13.4.1 Modified prone position – 168

13.5 Lateral position – 170

13.5.1 Modified lateral position – 170

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13

13.1

Neck

13.1.1

Supine position

. Figs. 13.1, 13.2.

Indications

Operations to the thyroid/parathyroid: thyroid operations (e.g. hemithyroidec- tomy), thyroid operations of tumours with systematic lymphadenectomy (e.g. total thyroidectomy).

Operations to the oesophagus: operations to the oesophagus (e.g. anasto- motic connection with stomach pull-up, resection of Zenker’s diverticula).

Operations to cysts and embryonal duplications of the oesophagus: e.g.

medial or lateral cysts in the neck, cervical oesophagus duplication.

Preparations

4 Arm positioning devices 4 Gel ring

4 Padded arm protection Positioning

4 Standard operating table position 1, position 2 or universal operating table

4 Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices

4 Normal positioning of the operating table in the theatre

4 When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure

4 Possibly pad the shoulders with a flat padded cushion

4 Tilt the operating table in the Trendelenburg position, raise the back plate by 20–30°, lower the leg plates and head section (by hand)

4 Position the head on a gel ring, possibly slightly turned to the side and reclined

4 Position both arms at the body with arm protection, forearm slings, clips or other positioning aids or the infusion arm in supination position with 90° abduction on the arm positioning device

4 Apply the neutral electrode and connect to the HF surgery device

4 Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection

4 Position the operating lights 4 Patient warming system

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. Fig. 13.1. Supine position with raised back plate and lowered head plate

. Fig. 13.2. The head is reclined and held in a stable position with a gel ring

13.1 · Neck

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13

13.1.2

Supine position, neurosurgical headrest

. Figs. 13.3, 13.4.

Indications

Operations to the thyroid: thyroid operations for tumours with systematic lymphadenectomy, e.g. total thyroidectomy and systematic lymphadenectomy of compartments 2, 3 and 4 (mediastinum via sternotomy).

Operations to cysts and embryonal duplications of the oesophagus: cysts and embryonal duplications of the oesophagus (e.g. medial or lateral cysts in the neck, cervical oesophagus duplication).

Preparations

4 Arm positioning devices 4 Padded arm protection

4 Neurosurgical headrest, wedge cushions, block cushions, knee half roll Positioning

4 Standard operating table position 1, position 2, universal operating table or beach-chair operating table

4 Fasten and pre-position the neurosurgical headrest to the head part of the operating table

4 Tilt the operating table in the Trendelenburg position, move the patient towards the head end until the shoulders are flush with the upper edge of the operating table

4 Lift the legs and fix the wedge and block cushion under the buttocks and thighs

4 Lift the back plate by 20–30°, possibly lower the leg plates

4 Position and fix the head in the neurosurgical headrest, possibly slightly turned to the side and reclined

4 Position both arms at the body with arm protection, forearm slings, clips or other positioning aids or the infusion arm in supination position with 90° abduction on the arm positioning device

4 Apply the neutral electrode to the upper arm and connect to the HF sur gery device

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. Fig. 13.3. Supine position with raised back plate, adapted connection bar, fastening piece and one-piece horseshoe-shaped headrest

. Fig. 13.4. The head is reclined and held in a stable position with a one-piece horseshoe- shaped headrest, thus providing better side access

13.1 · Neck

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13

13.2

Open laparotomy

13.2.1

Supine position (median and transverse laparotomy, incision right or left parallel to the costal margin)

. Figs. 13.5–13.9.

Indications

All operations to the ventral abdominal organs and the abdominal wall and for emergency operations such as acute abdomen.

Operations to the distal oesophagus, cardiac orifice and diaphragm, e.g.

grafts for achalasia, fundoplication and diaphragm resection.

Operations to the liver and bile ducts, e.g. hemihepatectomy on the right and left, hepatic fork resection, liver transplants.

Operations to the stomach, duodenum, e.g. gastrectomy, total or subtotal, formation of a stomach tube for stomach pull-up.

Operations to the pancreas, spleen, e.g. Whipple’s operation, reconstruction of the spleen after injury, subtotal or total splenectomy.

Operations to the small intestine, colon, e.g. resection of the small intestine, appendectomy, colon partial resection of the ascending, transverse and descending colon and the sigma.

Operations to the adrenal glands; all bilateral operations to the adrenal glands, adrenalectomy.

Operations to the abdomen wall/peritoneum, e.g. herniotomy for scar hernias, inguinal hernias and peritonectomy.

Operations for abdominal trauma, traumatic injuries to all abdominal organs.

Operation for organ donation

Operation for organ transplantation, liver transplants, kidney transplants, pancreas/kidney transplants, cluster transplants.

Preparations

4 Arm positioning devices Positioning

4 Standard operating table position 1, position 2 or universal operating table

4 Spread out and pad both arms on the arm positioning devices 4 Apply the neutral electrode and connect to the HF surgery device

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. Fig. 13.6. Supine position with vacuum mat and arms in abduction . Fig. 13.7. Positioning the head on a double wedge cushion

. Fig. 13.8. Maximum 90° abduction and supination position of the arms . Fig. 13.9. Plexus prophylaxis by raising the shoulders 13.2 · Open laparotomy

. Fig. 13.5. Supine position with arms in abduction

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13.2.2

Lithotomy position

. Figs. 13.10–13.13.

Indications

Operations to the rectum and anus: low anterior rectum resection, rectum extirpation, anal resections, pelvic exenteration and sacrum resections.

Transanal operations using retractors (Parks, Gelpi) or using Bues instruments.

The lithotomy position is preferred for transanal access to processes bet- ween 3 o’clock and 9 o’clock CRL, i.e. on the back wall and side walls of the anal canal. Processes at 12 o’clock CRL, i.e. on the anal front wall, are accessed preferably in the Heidelberg position (7 Sect. 13.4) (fistula extirpation and fistulotomy, sphincteroplasty, overlapping sphincteroplasty, perianal throm- bectomy, haemorrhoidectomy, abscess incision, transmural adenomectomy, mucosectomy and anastomotic procedures).

Preparations

4 Arm positioning devices

4 2 Goepel leg holders or 2 special pneumatic leg holders and 2 adapter pieces

4 Gel pads

4 Short vacuum mat

4 Possibly 2 shoulder supports Positioning

4 Standard operating table position 2 or universal operating table

4 Normal or diagonal position of the operating table in the theatre

4 Spread out and pad both arms on the arm positioning devices 4 Fit the Goepel leg holders in the corresponding adapter pieces 4 Position the legs and remove the leg plates

4 Position the pelvis slightly over the edge of the buttocks plate

4 Check the leg positioning: lower the still raised legs until the thighs are nearly horizontal

4 Possibly position the legs again in this phase and raise them again after the end

4 Position the operating lights 4 Patient warming system Risks

Risk of pressure sores in the area of the sacrum.

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. Fig. 13.10. Lithotomy position with Goepel leg holders

. Fig. 13.11. Lithotomy position in Trendelenburg with vacuum mat and leg holders with one-hand operation, good decubitus and plexus prophylaxis

. Fig. 13.13. Diagram showing the optimum positioning of the legs in the lithotomy po sition

. Fig. 13.12. Positioning with lowered leg holders and positioned on vacuum mat 13.2 · Open laparotomy

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13.3

Laparoscopic operations

13.3.1

Supine position

. Figs. 13.14–13.17.

Indications

Laparoscopic cholecystectomy, fundoplication, sigma and colon resection, evaluation.

Preparations

4 Arm positioning devices 4 Short vacuum mat

4 Possibly 2 shoulder supports, radial adjusting clamp and body supports Positioning

4 Spread out and pad both arms on the arm positioning devices 4 Spread the leg plates and fix the legs

4 Possibly fix the shoulder supports at the side rails of the head plate and support both shoulders

4 Possibly fit the radial adjusting clamps on both sides to the side rails of the base plate, and position the body supports at the pelvis

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. Fig. 13.14. Supine position with legs in abduction and maximum 90° abduction of the arms in supination position

. Fig. 13.17. Positioning with in abduction, legs, lateral tilt and Treudelenburg position . Fig. 13.16. Positioning on vacuum mat, operating table tilted to the left and Trendelenburg position

13.3 · Laparoscopic operations

. Fig. 13.15. Positioning on short vacuum mat and legs in abduction

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13.4

Heidelberg position (position for Kraske access)

13.4.1

Modified prone position

. Figs. 13.18, 13.19.

Indications

Operations to the rectum and anus: transmural adenoma resection, fistula extirpation, grafts and tightening operations, pelvic exenteration and sacrum resection

Transanal operations using retractors (Parks, Gelpi) or using Bues instru- ments.

The lithotomy position is preferred for transanal access to processes bet- ween 3 o’clock and 9 o’clock CRL, i.e. on the back wall and side walls of the anal canal (see there). Processes at 12 o’clock CRL, i.e. on the anal front wall, are accessed preferably in the Heidelberg position (fistula extirpation and fistulotomy, sphincteroplasty, overlapping sphincteroplasty, perianal thromb- ectomy, haemorrhoidectomy, abscess incision, transmural adenomectomy, mucosectomy and anastomotic procedures).

Preparations

4 Special head positioning cushions for the prone position 4 Thorax, pelvic and wedge cushions, padded roll

4 Possibly special bolster for prone position 4 Special leg holder (rectal positioning device) Positioning

4 Transfer to the prepared operating table in the induction room 4 Position both tables next to each other, with the prepared table lowered 4 Place the patient in prone position on the padded cushion of the operating

table and take him into the theatre

4 Possibly diagonal positioning of the operating table in the theatre

4 Position the head on the special head positioning cushion 4 Position the arms on the arm positioning devices

4 Position the knees and lower legs at double right angles, position them in the adapted special leg holders and spread the legs

4 Apply the neutral electrode and connect to the HF surgery device 4 Arrange self-adhesive covers for preoperative skin disinfection 4 Position the operating lights

4 Patient warming system

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. Fig. 13.18. Prone position with special device

. Fig. 13.19. Arm and head positioning in prone position

13.4 · Heidelberg position (position for Kraske access)

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13.5

Lateral position

13.5.1

Modified lateral position

. Figs. 13.20–13.22.

Indications

Stomach pull-up, nephrectomy

Preparations

4 Gel ring, gel cushion, Goepel leg holders, lateral supports, radial adjusting clamp, padded cushions (normal and flat) and wedge cushion or tunnel cushion, body belt

Positioning

4 Fit the radial adjustment clamp at the side rail of the head plate, position the Goepel leg holder and place a gel padded mat on the operating table 4 Stretch the arm on the side not being operated

4 Move the patient onto the healthy side, with the back near to the edge of the operating table

4 Gradually hinge open the operating table by lowering the pelvic and back plate (operating table in roof position)

4 Raise the head plate and position the head on a padded cushion with gel ring to leave the ear free

4 Position and fix the arms

4 Move the lower arm forwards so that the weight of the upper body does not lie directly on the shoulder

4 Thorax 90° position, pelvis 45° position

4 Fit the radial adjustment clamp to the small side rails of the leg plates and position the body supports at the level of the coccyx and symphysis 4 1st possibility: position the legs with the padded cushions (normal and

flat) and possibly wedge cushions

4 Fix the lower leg and the positioning aids with the body belts 4 2nd possibility: position the legs with the tunnel cushion 4 Possibly position the upper leg in outer rotation

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. Fig. 13.20. In the lateral position, the pelvis is at the highest point on the operating table adjusted to the flex position

. Fig. 13.22. The operating table is moved as far as possible towards the head to allow for an optimum flex position

. Fig. 13.21. The pelvis is tilted 20–40° back and the legs are positioned with a tunnel cushion

13.5 · Lateral position