WHE15 6/16/2005 2:18 PM Page 150 15.1. Colorectal Resections: Patient Positioning and Operating Room Setup Tonia M. Young-Fadok, M.D., M.S., F.A.C.S. A. Room Layout: General Consideration 1. Is the operating room large enough to accommodate the equipment necessary for a minimally invasive procedure? This is a basic consideration when a laparoscopic case is assigned to an operating room (OR) not usually used for laparoscopic procedures or when performing an advanced procedure for the first time. Compared to an open case, laparoscopic procedures require consid- erably more space to accommodate the towers, monitors, and other specialized equipment. 2. Positioning of the OR table. In most minimally invasive colorectal resections, a portion of the procedure is carried out extracorporeally. To ensure optimal visualization for this part of the case, it is important that the operating table be well positioned beneath the OR lights. The orientation of the operating table (obliquely, longitudinally, or transversely) in relation to the anesthesia equipment, the shape of the room, and the OR doors also needs to be carefully considered because of the large amount of equipment that must be arrayed about the OR table. A poor table position may impede the repositioning of TV moni- tors or other equipment or hamper the circulating nurse’s ability to move about the room. 3. Two basic body positions are utilized for colorectal resections, the supine position and the modified lithotomy position. The choice of body posi- tion affects the subsequent OR setup. Surgeon preference and the type of pro- cedure to be performed dictate the position choice. 4. The supine position may be used for simpler procedures where limited colonic mobilization is required and when access to the perineum for circular stapling or colonoscopy is not necessary. Examples of such procedures are cre- ation of ileostomy or colostomy, small bowel resection, ileocecectomy, and right hemicolectomy. In contrast, some laparoscopic surgeons nearly always utilize the modified lithotomy position, regardless of the specific operation to be per- formed, because it permits the surgeon or assistant to stand between the legs to dissect or retract when working in the upper abdominal quadrants. This spot is ideal for flexure takedown and separation of the omentum from the transverse colon. 5. The modified lithotomy position is uniformly used for left-sided col- orectal resections and for subtotal colectomy. This position provides access to WHE15 6/16/2005 2:18 PM Page 151 15.1. Colorectal Resections 151 the perineum for stapling or colonoscopy and, as described above, provides an excellent vantage point from which the surgeon can carry out portions of the procedure. For these reasons, some experts utilize this position for all colorec- tal resections. 6. Bilateral arm tuck. Most laparoscopic surgeons place and tuck both arms at the patient’s sides when performing colorectal resections regardless of which body position is used. This arrangement provides the surgical team full access to both the left and the right sides. The arms are tucked only after the anes- thesia team has had the opportunity to place intravenous and arterial lines as well as a blood pressure cuff, pulse oximeter, and the rest of their equipment. The inside and the outside aspects of the arms must be well padded before tucking. 7. Most equipment should be in position or in the room ready to be moved into position before the patient is brought into the room. This will expedite the commencement of the operation. Depending on the room size, it may be neces- sary to keep certain pieces of equipment that are required for a single aspect of the case or that may not be needed at all in the corridor immediately outside the room. Examples of this type of equipment include the ultrasound machine and the colonoscopy/endoscopy tower. 8. This chapter is concerned with body position on the table and OR setup. The figures also illustrate where the surgeon, first assistant, and, if utilized, the cameraperson would likely stand during the procedure. Port placement options are discussed in the next chapter. Most port placement schemes can be utilized in conjunction with either the supine or the modified lithotomy position. However, the left lateral decubitus position for sigmoid colectomy requires a unique port arrangement that is briefly mentioned in that section. 9. Methods of securing the patient to the OR table are discussed in a sep- arate section. The issue is not revisited in subsequent sections. The approaches to a variety of other operating room setup and patient positioning issues are the same regardless of which colorectal segment is being removed. Rather than repeat the discussion in each section devoted to a different type of resection, the information is given once and the reader is referred back to the earlier section. 10. Utilizing the figures. All but one of the following sections concern one or several different types of segmental colorectal resections. Right hemicolec- tomy is considered separately whereas sigmoid colectomy, low anterior resec- tion, and abdominoperineal resection are discussed together. Finally, the OR setup and port arrangement for distal transverse, splenic flexure, and proximal descending segmental colectomy are presented. 11. Scrub nurse position. There are two basic strategies in regard to the position of the scrub nurse. The first is to place the scrub nurse, the instrument table, and the mayo stand at the foot of the table, either directly below the table or off the left or right foot (see Figures 15.1.2, 15.1.3). It is often possible, depending on the specific operation, to place the elevated mayo stand over the draped legs. The alternate approach, which is the preference of the author, is to position the scrub nurse at the head of the table (see inset in Figure 15.1.5). In this case the elevated mayo stand is placed over the head of the patient and the scrub nurse stands off the patient’s right shoulder. The instrument table is posi- tioned behind the nurse toward the right-hand corner of the room. The anesthe- sia machine and equipment should be placed behind the anesthetist and to the left of the patient’s head. This approach can be used for any segmental colec- WHE15 6/16/2005 2:18 PM Page 152 152 T M Young-Fadok tomy. In this chapter, in all but one of the figures the scrub nurse has been placed at or to the side of the foot. B. Methods of Securing the Patient to the Operating Table 1. A number of methods can be used to help secure the patient’s position on the OR table. This is especially important because steep or “radical” body positions are often needed during laparoscopic bowel cases. Surgeon custom and preference largely determine which method(s) are utilized. It is important to note that there is controversy regarding the efficacy and safety of some of these methods. Some surgeons feel very strongly that one or another of these methods is quite dangerous and should be avoided. No systematic study of these posi- tions in the setting of minimally invasive procedures has been carried out. Some methods can be used regardless of whether the patient is in the supine or the modified lithotomy position; others apply to one or the other position. A brief description of each method follows. a. Ankle straps: These can be used to prevent patient movement. The ankles must be well padded and the straps placed so that the blood flow to the feet is not restricted (for supine position). b. Stirrups: These are necessary when placing the patient in the modified lithotomy position. The stirrups serve to anchor the patient as well as to suspend the legs in an abducted position. There are a variety of stirrup designs to choose from on the market today. These stirrups cradle the lower legs below the level of the knee. Venodyne stockings should be placed on the legs before placing the legs into the stirrups. The legs are secured in the stirrups either with the attached straps or with Ace bandages that are wrapped around the stirrup and leg. The stirrups should be adjusted so that no pressure is placed on the lateral aspect of the leg near the knee to avoid a nerve injury. c. Bean bag: This device is placed beneath the patient’s trunk. Suction is applied to this device after the sides of the bag have been rolled up around the arms and the bag has been molded about the patient. It is important to note that the bean bag works best if it is itself anchored to the table (not the cushions) via Velcro or some other means (for both supine or modified litho- tomy position). d. Chest taping: The patient can be further secured by placing a 3-inch piece of tape across the chest from table to table to keep the bean bag from giving way. The tape is placed at the level of the manubrium. It is important to place a pad between the tape and the chest wall so as to protect the skin ( for both supine or modified lithotomy position). e. Table strap: Standard for almost all cases done in the supine position, Velcro table straps are attached to the sides of the table WHE15 6/16/2005 2:18 PM Page 153 15.1. Colorectal Resections 153 and wrapped over the legs to secure the lower extremities (supine position only). f. Shoulder braces: Most surgeons agree that shoulder braces are potentially quite dangerous (potential for brachial plexus or shoulder injury) and, therefore, do not recommend their use.