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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_627_Библиотеки_им_академика_М_И_Перельмана
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FIGURE 3-21 Addition of arm sleds.
If the patient is in lithotomy position, a piece of foam padding is placed
between the hand and the stirrup bracket to protect the hand from pressure
injury (Fig. 3-22).
FIGURE 3-22 Arm tuck in a lithotomy position with extra foam to protect the hand.
CHEST STRAP
Perioperative Considerations
Strapping the chest helps to secure the patient to the bed.
Chest straps should be used if anticipating significant bed tilt to the left or
right, or if significant Trendelenburg is required to prevent slippage on the
bed and keep the perineum exposed.
Generally, this should not (and typically does not) impact the ability to
ventilate.
Equipment
Protective towel
Chest strap, Velcro, or long role of thick, wide tape
Technique
Refold towel to make a long, narrow band and lay across the lower chest
roughly lower than the level of the nipples, so as not to interfere with the
surgical field.
Place the strap across the chest and anchor it to bed; or if using tape, tape
circumferentially around patient and bed 3-4 times (Fig. 3-23).
FIGURE 3-23 Chest strap utilizing towel and tape. Also note the hand position and
protection.
May place a patient warming device on top of or above this strap.
If desired, check ventilation at this stage, prior to preparation and draping
the patient; if the strap is causing interference, reposition with the
anesthesiologist’s hand on top of chest while strapping/taping to ensure
sufficient laxity—although loosening may increase slippage.
PRONE (IE, KRASKE) POSITIONING
Perioperative Considerations
Also referred to as “Kraske” positioning (though this more specifically
refers to prone jackknife), prone positioning allows improved exposure of
the posterior perineum, gluteal cleft, and anterior anal canal.
Allows more ergonomic positioning for the surgeon to operate on or
around the anus and improves exposure for assistants.
Prone position allows restricted access to the airway and usually requires a
patient to be endotracheally intubated, although laryngeal mask may be
feasible.
The risk of upper extremity injury/neuropraxia exists with prone
positioning. Arms are usually positioned with hands above the head on
arm boards, and care should be taken to avoid shoulder dislocation on
rotation of the arms into this position. The ulnar nerve at the elbow should
not be compressed and should be protected with padding. Chest rolls
should not place undue pressure on the arms, such as to limit perfusion.
Anterior abdominal incisions or an ostomy are not contraindications to the
prone position, although hard structures such as tubes should be padded to
prevent pressure ulceration.
Equipment
Patient stretcher positioned adjacent to operating table
Padded arm boards ×2
Large transverse pelvic roll; can be constructed by large wrap of
blankets/pillow, usually at least 20 cm in diameter
Two medium longitudinal chest rolls; rolled blankets and/or fluid bags can
be used, usually at least 7 cm in diameter
Foam padding ×2 or pillows for knees
Stack of blankets ×2 to support head and feet; foam head support
Straps or tape rolls/towels to secure patient to a table
Wide tape and benzoin adhesive for buttock taping, as needed
Technique
The patient should have an airway placed and secured and other facial and
neck protective measures (eg, eyes, teeth, lines) in place while the patient
is in stretcher. A Foley catheter is placed at this time, as needed.
OR table padding is set up—stack of blankets and foam for head support,
two longitudinal chest rolls stretching from clavicle to anterior superior
iliac spine, padded arm board on the side of table away from stretcher,
rotated cephalad, large transverse pelvic roll, padding for knees, and stack
of blankets for feet. If additional jackknife flexure of the bed is
anticipated, ensure that padding is set up for that flexure point (Fig. 3-24).
FIGURE 3-24 Bed setup for the prone position.
The patient stretcher should be elevated above OR table and locked in
place immediately next to the OR table. With the patient’s arms at their
side, flip patient onto the table with six personnel working as a team—one
or more anesthesia personnel controlling head, one person
elevating/rotating the feet and attending to the urethral catheter, two on
stretcher side flipping patient over onto the table, and two on table side
with arms outstretched who receive patient as they flip over and lift/adjust
the patient into proper position as needed (Fig. 3-25).
FIGURE 3-25 Positioning prior to flip to the prone position.
Move the stretcher away and place second padded arm board in matching
position.
Carefully rotate the patient’s arms down to the floor and then up onto arm
boards, taking care not to dislocate the shoulder by rotating the arm too far
posteriorly. Ensure the elbow is either free or padded to avoid pressure on
the ulnar nerve where it passes just medial to the olecranon process (Fig.
3-26).
FIGURE 3-26 The position of the shoulder once in position.
Check sites of potential pressure and alleviate as needed—elbows, knees,
and feet may require additional support. The penis should point downward
toward the feet and should not be under excess pressure, with care taken to
pad the catheter tubing where it lies against the skin to prevent skin
ulceration.
Place a strap or belt across thighs; place additional securing straps on chest
and arms if table tilt anticipated.
Flex the bed as needed for jackknife positioning. Recheck security and
pressure points after flexing.
Buttocks may be taped apart to allow additional anal or gluteal cleft
exposure.
If hirsute, shave buttocks in areas where tape will be applied, usually a
few centimeters to either side of center of planned operative field.
Paint benzoin or another adhesive in a longitudinal stripe on each buttock.
Place the end of tape roll within center of adhesive area, pointing at and a
few centimeters from center of operative field. While one person firmly
holds this tape end in place, another pulls roll of tape tautly down and
slightly cephalad and affixes tape strip to the side and bottom of bed with
generous contact area. Repeat on other buttock. Place a second stripe of
tape if needed as support.
Place a short longitudinal piece of tape orthogonally over retracting piece
and incorporating stripe of adhesive to reinforce security of retracting tape
(Figs. 3-27 and 3-28).
FIGURE 3-27 Tape secured to the buttocks.
FIGURE 3-28 Final positioning with tape in the prone position.
RECTAL IRRIGATION
Perioperative Considerations
Irrigation can be instilled with a rectal catheter, which can be clamped to
keep irrigation in the rectum at the outset of surgery, or can be left in after
drainage to further evacuate air or liquid from the colon during the
operation.
Water or saline irrigation can be used to remove fecal matter from an
insufficiently cleared rectum for purposes of colonoscopy or transanal
maneuvers.
Iodine rectal irrigation can be used in an effort to decrease pelvic
infections.
40% alcohol solution irrigation (ie, Turnbull’s solution) can be used in an
effort to decrease pelvic cancer recurrences.
Equipment
34Fr Pezzer (ie, mushroom) catheter (Fig. 3-29)
FIGURE 3-29 Pezzer catheter.
Lubricant
40-cm rod or jumbo cotton-tip applicator
Collection bag
Gauze
Applicator(s) of choice, depending on source of irrigation
Bulb syringe with bulb removed for bottled irrigation solution
Irrigation tubing for bagged irrigation
Technique
With lubricant applied and rod or applicator inserted into the catheter end,
apply tension to straighten catheter tip and gently insert the catheter into
the rectum (Figs. 3-30 and 3-31). Remove the rod/applicator and gently
tug catheter down so tip sits upon anorectal ring, occluding the anus.
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