Surgical Positioning 101: A Guide for New OR Staff and Residents

For new operating room (OR) staff and surgical residents, mastering surgical positioning (https://www.schuremed.com/aristos/) is a crucial but often underestimated component of patient care. Proper positioning impacts not only surgical access and success but also patient safety, comfort, and postoperative recovery. This guide aims to demystify the fundamentals of surgical positioning, highlight key considerations, and offer practical tips to build confidence in the OR.

• Why Surgical Positioning Matters

Surgical positioning is not just about laying the patient on the table-it's a precise, strategic alignment tailored to the type of surgery being performed. The right position optimizes the surgeon's access to the operative site, reduces the risk of intraoperative complications, and minimizes postoperative issues such as nerve injuries or pressure ulcers.

Incorrect or careless positioning can result in:
Peripheral nerve damage (e.g., ulnar nerve palsy, brachial plexus injury)
Compromised ventilation or circulation
Muscle or joint strain
Pressure sores and skin breakdown

• Pre-Positioning Checklist

Before beginning any surgical procedure, every member of the OR team-surgeons, anesthesiologists, circulating nurses, and surgical technologists-must collaborate on patient positioning. Use this checklist to ensure a safe setup:

1. Review the Procedure Requirements: Know what position the surgery requires-this influences padding, support, and table accessories.
2. Assess the Patient: Consider age, BMI, comorbidities (especially diabetes, neuropathies, and vascular conditions), and any mobility restrictions.
3. Confirm Anesthesia Plan: General vs. regional anesthesia can affect the patient's ability to tolerate certain positions.
4. Protect Pressure Points: Use gel pads, foam cushions, or specialty devices to protect elbows, heels, sacrum, and other bony prominences.
5. Secure the Patient: Straps or supports must hold the patient safely in place without impeding circulation or causing discomfort.
6. Document Positioning: It's part of your medical-legal responsibility.

• Common Surgical Positions and Their Applications

1. Supine Position

Description: Patient lies flat on their back with arms at the sides or extended on armboards.

Common Procedures: Abdominal surgeries, hernia repairs, cardiac procedures.

Key Considerations:

Ensure head and spine alignment.
Pad heels, elbows, and occiput.
Watch for shoulder hyperextension if arms are abducted.

2. Prone Position

Description: Patient lies on their stomach, often with head turned to the side or supported in a headrest.

Common Procedures: Spine surgeries, rectal operations, and some posterior leg or shoulder procedures.

Key Considerations:

Intubation must be completed before turning the patient.
Protect eyes and avoid facial pressure.
Support chest and pelvis to allow free abdominal movement.

3. Lateral Position

Description: Patient lies on one side, with the operative side facing up.

Common Procedures: Thoracotomies, hip replacements, kidney surgeries.

Key Considerations:

Use axillary roll under the lower arm to prevent brachial plexus injury.
Double-check padding under knees and ankles.
Stabilize with beanbags or foam positioners.

4. Lithotomy Position

Description: Supine with legs elevated and supported in stirrups.

Common Procedures: Gynecological, urological, and colorectal surgeries.

Key Considerations:

Check stirrup placement to prevent peroneal nerve damage.
Simultaneously elevate/lower both legs to avoid hip dislocation.
Watch for compartment syndrome during long cases.

5. Trendelenburg and Reverse Trendelenburg

Trendelenburg: Head down, feet elevated.

Reverse Trendelenburg: Head elevated, feet down.

Common Procedures:
Trendelenburg: Lower abdominal and pelvic surgeries.
Reverse Trendelenburg: Upper abdominal, head, and neck procedures.

Key Considerations:

Be mindful of respiratory limitations due to diaphragm pressure.
Watch for sliding; secure patient with shoulder braces or anti-slip mats.
Monitor blood pressure shifts.

• Special Considerations for Safe Surgical Positioning

Pressure Ulcer Prevention

Prolonged procedures increase the risk of pressure injuries. Use pressure-distributing surfaces, reposition when feasible, and always check high-risk areas.

Nerve Injury Avoidance

Common nerve injuries include:

Ulnar nerve: from compression at the elbow
Brachial plexus: from excessive arm abduction or head rotation
Peroneal nerve: from stirrup compression at the fibular head

Ensure padding and limb alignment are appropriate and periodically checked.

Respiratory and Hemodynamic Support

Positioning can directly affect ventilation and venous return. Close coordination with anesthesia is essential, especially in compromised or obese patients.

Equipment Familiarity

OR tables, positioning devices, and specialized supports differ between institutions. New staff should request hands-on orientation and practice setup for common positions.

• Communication and Teamwork

Effective surgical positioning is a team effort. The "time-out" phase before incision is the last opportunity to review and confirm the patient's positioning and padding. Encourage open dialogue between team members if there are concerns.

Here's a simple mnemonic to remember during pre-op setup: P.A.S.S.

P: Position verified and appropriate
A: Anesthesia-aware and assisted
S: Secure and supported
S: Skin and nerves protected

• Documentation: What to Record

Accurate documentation supports quality care and protects against legal liability.
Note:

Final position and any deviations from standard
Devices or supports used
Pre-existing conditions that influenced positioning
Skin checks before and after
Time of repositioning if needed during surgery

• Training Tips for New OR Staff

Observe and Ask Questions: Learn from experienced team members. Take time to understand the rationale behind every setup.
Hands-On Practice: Participate in simulation training or dry-run setups with OR equipment.
Use Visual Aids: Anatomy posters, positioning charts, and digital references can reinforce memory.
Stay Updated: Guidelines evolve-especially regarding safety standards and new positioning devices.

• Final Thoughts

Surgical positioning is both an art and a science. While often overshadowed by technical surgical tasks, it is a foundational skill that can dramatically influence patient outcomes. For new OR staff and residents, investing time in learning positioning principles builds clinical confidence, fosters patient trust, and upholds the highest standards of operative care.

In every case, remember that behind every positioning protocol is a patient relying on you for comfort, dignity, and safety. Get the position right, and you set the stage for surgical success.

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