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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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anus and perineum.
This position should be considered for surgery where standing between the
legs could be useful, but where access to the anus is not likely to be
necessary (eg, laparoscopic right/transverse colectomy or left or total
colectomy with end ostomy).
Transanal stapling or colonoscopy is not impossible in this position, just
more difficult.
Split leg keeps the knee close to the level of the hip, which helps to avoid
interference with laparoscopic instruments pointed toward the upper
quadrants.
Split-leg table does not intrinsically secure the legs, and straps/wraps
should be placed to secure the patient if any significant table tilt is
anticipated.
It may not be possible to attach split legs to a table without a removable
leg portion.
Equipment
Split-leg table stirrups with included brackets ×2 (right and left)
Foam padding to place under the knees
Straps or tape/towels to secure the legs
Technique
Before the patient is placed on the table, place the split-leg brackets on the
lowest portion of side rail of body portion of the table and secure firmly.
The cephalad adjustment knob on the bracket secures the foot board to the
bed. The posterior facing adjustment knob allows abduction/adduction of
the hip and includes a guide for A, B, and C positions. The caudal
adjustment knob allows for hip flexion and extension (Fig. 3-12).
FIGURE 3-12 Brackets for the split leg.
If the patient is already on a standard table, have your assistant hold both
legs in the air while replacing the leg/foot of the bed with split legs. Rotate
the legs to position in parallel with bed (A position).
Once patient is moved down into position on the table, rotate and secure
legs simultaneously and equally in medium (Fig. 3-13) or severe split (Fig.
3-14) position as needed.
FIGURE 3-13 Positioning of the legs in the split-leg table.
FIGURE 3-14 “B” position on a split-leg table positioning.
Slightly elevate both legs ∼10 degrees using the caudal adjustment knobs
to avoid hip overextension. Place cylindrical or rolled piece of foam under
each knee to slightly flex knee, preventing knee overextension. Pad the
heel/ankle to decrease pressure points.
Secure each leg to split-leg table at two points, on the thigh above the knee
and on the leg below the knee, using straps or towels and tape (Fig. 3-15).
FIGURE 3-15 Padding and securing the leg in the split-leg table.
ARM TUCKING
Perioperative Considerations
Arm tucking allows increased flexibility for the surgical team to stand
adjacent to the patient.
The ability to stand at the shoulder is frequently useful for procedures such
as laparoscopic colon and rectal surgery, and arm tucking should be
performed routinely. For some procedures where the surgeon anticipates
working nearly exclusively on one side of the abdomen, the arm on the
opposite side should be tucked to allow two operators on that side, but the
arm on the same side of the dissection field can potentially be left out (eg,
tuck the left arm and leave the right arm out for laparoscopic right
hemicolectomy).
Arm tucking has the risk of nerve, joint, or compartment injury and limits
anesthesia from accessing the arms during the procedure for intravenous
access, blood pressure monitoring, or other procedures.
Equipment
Folded or doubled sheet with anterior and posterior leaves; Cleveland
Clinic arm sheet is two pieces sewn together with two vertical seams
Gauze padding for IVs and foam padding for stirrups
Arm sleds as needed
Technique
The folded sheet should be placed across the bed such that two leaves of
sheet protrude ∼12-18 in on either side of patient and the patient lies on
top of this sheet (Figs. 3-16 and 3-17).
FIGURE 3-16 Initial positioning of the sheet on the bed.
FIGURE 3-17 Two leaves of the sheet separated.
IVs and other devices on the arm should be padded away from skin with
gauze to prevent skin ulcerations.
While holding the patient’s hand and arm in position such that the thumb
is facing upward and arm is fully extended, the upper leaf of drape is held
up in the air by an assistant across the table. The lower leaf is wrapped
over the top of the arm and around it medially and posteriorly to snuggly
support the arm. Reconfirm the thumb facing upward (Fig. 3-18).
FIGURE 3-18 Positioning of the lower sheet and arm/hand.
The upper sheet is then wrapped tightly over the arm and tucked
underneath the arm and patient’s body until the arm is firmly fixed in
place. Check again that the thumb is up (Fig. 3-19).
FIGURE 3-19 Positioning of the upper sheet.
The arm should now be securely fixed and supported by the wrap and the
table and not require further support (Fig. 3-20).
FIGURE 3-20 Final positioning of the arm tucked.
In patients with wider girth, an insufficient amount of table may remain
laterally so as to preclude stable arm fixation. In this case, a padded arm
sled can be introduced to further reinforce the arm. This should be at the
level of the elbow or below, with the lower end passing beneath the table
pad, and should be pushed in as much as possible so as not to interfere
with comfortable stance of the surgeon, while taking care not to
overextend the elbow (Fig. 3-21).
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