Before and after placing a patient in the steep Trendelenburg position, meticulous attention to positioning is crucial for preventing complications, particularly nerve injuries. It's a collective responsibility, involving the entire surgical and anesthesia team, to ensure the patient is positioned correctly using the appropriate equipment. Anesthesia personnel play a key role, especially in managing the positioning of the upper body.
For patients, particularly those who are obese, arms need to be tucked securely, possibly using sleds to prevent undue pressure and displacement. The ulnar nerve, due to its superficial location, is particularly susceptible to injury when arms are tucked, placed on sleds, or on armboards. However, the risk of injury can be minimized by tucking the arms and using protective measures such as foam or gel wraps around the arms and specifically around the ulnar nerve area. Care should be taken to remove any objects, like IV tubing clamps, that could press on the arm before applying these protective wraps. Additionally, the placement of fingers and hands must be carefully managed to prevent injury as the operating table moves, ensuring they are appropriately padded.
Testing the steep Trendelenburg position before patient draping is essential to observe any potential movement of body parts. Slipping can be prevented with strategic positioning such as knee flexion, lithotomy positioning, using a cinch strap or Velcro strap padded with materials like eggcrate across the upper chest, and employing antiskid bedding. While shoulder braces are an option, they should be used with caution due to the risk of brachial plexus nerve injury from pressure on the acromion and clavicle.
Once in the steep Trendelenburg position, it is important to check the patient's positioning frequently to mitigate risks. This position increases the likelihood of nerve damage, with potential for cervical spine injury from excessive pressure on the head, brachial plexus injury from caudad pressure on the shoulders, and injuries to the common peroneal nerve from prolonged lithotomy position, which also raises the risk for compartment syndrome and rhabdomyolysis.
After all positioning adjustments are made, and necessary lines are placed, the operating room (O.R.) staff is responsible for moving the robot into position for docking when the surgeon is ready. Although positioning the robot does not directly involve the anesthesia or surgical team, vigilance is necessary to prevent the robot's arms from pressing against the patient, highlighting the collaborative effort required to ensure patient safety.
