Patient Positioning

There are two basic types of setup, one for upper abdominal surgery and another for lower abdominal surgery.

Setup for Upper Abdominal Surgery

There are two options for laparoscopic cholecystectomy, with modifications for the various advanced laparoscopic procedures.

 Basic Laparoscopic Cholecystectomy. For laparoscopic cholecystectomy the patient is placed in a supine position, with a monitor on each side of the patient at the shoulders.

The “American” position of the patient. The surgeon stands on the left side of the patient facing a monitor, with the camera assistant to the left of the surgeon. The first assistant is opposite the surgeon on the right side of the patient. The scrub technician will be standing to the right of the first assistant, opposite the surgeon, allowing him or her to hand across instruments appropriately (Fig. 1.1a).

The “French” position of the patient. The patient can alternatively be positioned with legs spread, the surgeon standing between the legs (inverted Y position). The monitors are on each side of the head of the patient, the camera assistant at the surgeon’s right, and the first assistant at the left (Fig. 1.1b). The scrub technician stands at the right side of the surgeon next to the camera assistant. A Mayo stand can be used to position the preferred instruments on the surgeon’s right side, where they are easily accessible.

The surgeon should also be able to see vital parameters such as blood pressure, pulse rate, cardiac, and end tidal CO2 monitoring.

The room therefore should be sufficiently large to allow a virtual division into three sections: one for the anesthesiologist and his or her instrumentation, one for the patient and TV monitors, and the third section for the instrumentation of the scrub technician.

 Setup for Advanced Upper Abdominal Surgery. For all upper gastrointestinal operations the surgeon ideally stands between the patient’s legs, facing a TV monitor, with the first assistant to the right and the camera assistant to the left of the patient (Fig. 1.2). This enables the surgeon to have a straight view of the relevant TV monitor. A Mayo stand for the surgeon’s instruments is usually placed to the surgeon’s right. The scrub technician stands to the left.

For laparoscopic splenectomy the patient is positioned at 60°, using a bean-bag to elevate the left side, with the surgeon standing on the right side of the patient facing a left upper monitor. The first assistant is opposite the surgeon on the patient’s left. The camera assistant ideally stands to the left of the surgeon, in which case the scrub technician stands next to the first assistant. The positions are discussed in more detail in the chapter on splenectomy.

It is very important when installing a patient for an advanced upper abdominal procedure to avoid deep venous thrombosis. The patient’s legs are spread, the thighs extended to avoid a conflict between the knees of the patient and the hands of the surgeon, and the ankles comfortably padded with the use of leg squeezers.

Patient

Positioning