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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 2-16 Wound protector.
Lighted Pelvic Retractors (Fig. 2-17)
FIGURE 2-17 Abdominal handheld retractors.
Fazio (Figs. 2-17C and 2-18)
FIGURE 2-18 Abdominal retractors.
Britetrac (Fig. 2-17A)
St. Mark (Fig. 2-17B)
Deaver (Fig. 2-17D)
Sweetheart (Fig. 2-17E)
Deep Pelvic Instruments (Fig. 2-19)
FIGURE 2-19 Clamps, scissors, and forceps.
Clamp, Kelly, extra-long, 14 in (Fig. 2-19A)
Clamp, Tonsil, extra-long, 9½ in (Fig. 2-19B)
Clamp, Allis, extra-long, 10 in (Fig. 2-19C)
Scissors, Metzenbaum, curved, 11 in (Fig. 2-19D)
Scissors, Jones DuBois, 10½ in (Fig. 2-19E)
Scissors, Harrington, 11 in (Fig. 2-19F)
Forceps, Gerald, extra-long, 12 in (Fig. 2-19G)
Forceps, DeBakey, 9 in (Fig. 2-19H)
Forceps, Russian, 10 in (Fig. 2-19I)
Sponge stick, straight, long, 9¾ in
Needle holder, Crile Wood, diamond jaw, 10 ⅜ in
Staplers (Fig. 2-20)
FIGURE 2-20 Mechanical staplers.
GIA 80 (Fig. 2-20A)
TA 60 (Fig. 2-20B)
Endo GIA 60 (Fig. 2-20C)
PI 30 (Fig. 2-20D)
EEA 31 (Fig. 2-20E)
Suggested Reading
Steele SR, Hull T, Read TE, Saclarides T, Senagore A, Whitlow C, eds. The ASCRS Textbook of Colon
and Rectal Surgery. 3rd ed. New York, NY: Springer Publishing; 2016.
Chapter 3
Principles of Operative Positioning
DANIEL FISH
Perioperative Considerations
Positioning should be aimed at maximizing surgical access and ease, while
minimizing risk of positioning-related injuries.
When required, patient position can always be modified during a surgical
procedure, often without compromising the sterile field significantly.
Nonetheless, optimal efficiency and sterility are achieved with good
preoperative planning and positioning from the start of the operation.
A well-coordinated team can enact major position changes (eg, flip from
supine to prone for an abdominoperineal resection) on a routine basis
without incurring significant delays.
SUPINE POSITIONING
Perioperative Considerations
Most often used for open procedures where anal access is extremely
unlikely to be needed—ileostomy closure, ileostomy creation, open right
hemicolectomy, and open small bowel surgery—or for patients after
previous anorectal resection with permanent anal closure.
Most commonly used with legs strapped and arms out, although it can be
combined with adjunctive techniques such as arm tucking or a chest strap
(see later).
Supine position bears little risk of positioning-related injuries and is often
the default position whenever surgically appropriate.
Equipment
Leg and arm belts, straps, or tape/towels
Folded blankets or foam pads
Pneumatic compression devices for bilateral lower legs
Technique
Arms should be abducted <90 degrees on padded arm boards in neutral
position, with straps loosely across the forearms.
Legs can be supported with a pillow under the knees to maintain mild
flexion and with padding under the heels to prevent pressure ulcers, with a
belt or strap across the thighs snuggly.
Legs and chest should be covered with blankets or warmed air devices to
maintain body temperature.
LITHOTOMY POSITION
Perioperative Considerations
Lithotomy, or separation of the legs, is one of the most commonly used
positions in colorectal surgery as it offers readily available access to the
perineum.
Should be considered for any surgery where access to the anus is needed,
including perianal surgery, transanal surgery, intraoperative colonoscopy,
transanal stapling (eg, end-to-end anastomosis stapler), coloanal
anastomosis, or retraction maneuvers via the rectum or the vagina.
Should also be considered for any surgery where standing between the
legs could be useful (eg, laparoscopic right, transverse, left, or subtotal
colectomy or flexure mobilizations).
Different leg retraction devices and positions pose varying levels of risk of
nerve, joint, and compartment injuries to the legs, as well as exacerbating
back pain in patients with radiculopathy. These are all minimized through
proper positioning and padding.
Compartment syndrome is an unusual, but well-described, risk of
lithotomy position. It is thought to relate to decreased perfusion to the leg
compartments and seems to correlate with obesity and weight of the
extremity, the severity of angle of elevation, and overall time spent in
lithotomy position. For patients at risk, legs can be changed in or out of
lithotomy position as needed during a procedure without major breaks in
sterile technique.
Lithotomy is frequently combined with maneuvers that complement
laparoscopy (eg, arm tuck), Trendelenburg position (eg, chest strap), or
anal or rectal preparation techniques (eg, rectal washout, anal everting
sutures).
Warmed air devices or blankets should be applied to the chest to help
maintain body temperature, as the lower body cannot be blanketed.
Equipment
Operating room (OR) table with removable leg portion (preferable) or leg
portion that can fold downward to 90 degrees
Leg stirrups of choice (see individual sections) with attachment brackets
Foam padding
Folded blanket as needed to prop sacrum
Technique
Place lower extremity pneumatic compression devices.
Once the airway is secured, move the patient down on bed to have anus
beyond the edge of the body portion of the bed, while ensuring proper
padding on the sacral area.
Attach leg supports of choice (see specific lithotomy types), placing both
legs in supports simultaneously to minimize spinal torsion.
Remove/lower the leg portion of bed, or spread the legs if utilizing a splitleg table (see split-leg lithotomy).
Readjust body/pelvis on the bed as needed to optimize the position of
perineum (Fig. 3-1).
FIGURE 3-1 Lithotomy position with “hangover” of the sacrum for anal access.
For procedures requiring minimal or no anal or perineal access (eg,
laparoscopic right hemicolectomy for a tattooed lesion), positioning the
pelvis such that sacrum/coccyx are fully supported correlates with the lowest
risk of pressure-related injury.
For procedures requiring anal access for surgery, intubation, or stapling,
the anus should hang slightly off the edge of the bed (∼2-7 cm) to facilitate
the perineal portion of the procedure.
For procedures requiring access to the perineum posterior to the anus, the
anus should hang further off of the bed (∼5-15 cm) to allow exposure of the
entire operative field. The perineum can be further exposed by propping the
pelvis up with a folded blanket placed under the sacrum.
If the patient is anticipated to be in significant Trendelenburg especially for
extended periods, prepare for ∼2-7 cm of slippage toward the head of the bed
that will likely occur.
LITHOTOMY WITH CANDY CANE STIRRUPS
Perioperative Considerations
Provides little support for the joints of the legs and should only be used for
short cases (eg, <30 minutes in length), such as colonoscopy or perianal
procedures.
Pneumatic compression devices may still be used, despite the short
duration of the case and lighter degree of anesthesia.
Equipment
Bed attachment brackets (Fig. 3-2)
FIGURE 3-2 Brackets attached to the side of the bed, allowing for proper angle
attachment of the candy cane stirrups.
Candy cane bars with two-strap foot stirrups attached
Technique
Place brackets on the lowest portion on side rail of body portion of the
table and then secure candy cane bars so that they are orthogonal to the
plane of the bed (Fig. 3-3).
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