Chapter 1: Operating Room Setup and Patient Positioning

SUPINE POSITION

• For all right hemicolectomies, extended right hemicolectomies, and ileocolic resections, patients are placed in the supine position. The patient should be placed on either a bean bag or a gel pad to aid in securing her or him on the operating room (OR) table. Each arm should be protected by a gel pad, covering the whole length of the arm. The wrist and hand should be covered with a separate gel pad as well. The arms should be tucked in using a separate bedsheet. Make sure that the wrist is in the anatomical position, with the thumb up.

• All pressure points should be well padded.

• Check with the anesthesiologist after this step to make sure that all the intravenous (IV) lines are working. Make sure to wrap the plastic IV line lock with gauze to prevent any pressure on the skin.

• If the patient is obese, then position him or her off center on the bed, toward the ipsilateral side of the area of dissection. For example, in right hemicolectomy, place the patient on the bed off center to the right side; this is because during laparoscopy, the patient will be turned left side down, and being off center increases the safety margin if the patient were to slide. In addition, this creates space to help secure the left arm on the bed; otherwise, it might fall off the bed when the patient is tilted.

LITHOTOMY POSITION

• The lithotomy position should be the standard position for any left-sided or rectal resection, Hartmann’s reversal, and any case where splenic flexure takedown is anticipated.

• The lithotomy position should be considered in certain cases of ileocolic resection for Crohn’s disease, where there is an entero-sigmoid fistula. In this situation, you might need to do a sigmoid resection and use a circular stapler to establish gastrointestinal continuity. The lithotomy position will also allow access to the anus for a rigid or flexible sigmoidoscopy to leak test the repair or the anastomosis.

• The lithotomy position should be considered if the location of the lesion is not clear; or if the indication for the procedure is a small lesion, then access to the perineum is important because intraoperative colonoscopy can be used to determine the location of the lesion if it is not detected laparoscopically.

• If in doubt, one can place the patient supine, with the hip at the “break” of the table so that he or she can be placed in the lithotomy position, if needed, without having to shift the patient down.

• To place the patient in the lithotomy position, coordinate with the anesthesia team so they can control the head of the patient and the endotracheal tube.

• Make sure that there is an extra length for the IV lines prior to moving the patient. This move will require at least three people: one on either side of the bed and another holding the leg, in ...