Both of the arms should be tucked during laparoscopic surgery. While this does limit the anesthesiologist’s access to the arms, and their vascular access, it facilitates surgeon positioning and access during the case, especially for pelvic dissections. It is important to discuss this with the anesthesiologist prior to positioning so they have all access planned, which is required for the case. Pressure points, such as the elbows, and the hypothenar aspect of the hand should be carefully padded to prevent pressure injury prior to tucking.

Patients should be afxed to the bed in multiple points to prevent any slippage during surgery. Pelvic surgery often requires steep Trendelenburg positioning, and this may cause the patient’s anus to slip above the bed break. Similarly in a total colectomy or exure mobilization, the patient may go through extremes in position­ing from Trendelenburg to reverse Trendelenburg and steep lateral positioning. In patients undergoing surgery in a supine position, it is helpful to place a strap across the thighs as well and the chest, taking care to avoid the patient’s neck. In lithotomy position, the stirrups will serve as one point of xation, and a chest strap should act as a second. We also recommend the use of xation pads such as the Pink Pad™ (Xodus Medical, New Kensington, PA, USA). These devices are pads consisting of a high-friction foam which prevents patient slippage during extreme positioning.