MEJA OPERASI (Operating Table)

DEFINITION

An operating table, sometimes called operating room table, is the table on which the patient lies during a surgical operation. This surgical equipment is usually found inside the surgery room of a hospital. An improvised suitable operating table can be composed of two kitchen tables that are placed from end to end. However, such an improvised operating table should be cleaned throughly by scrubbing it with soap and water, then dried with a clean towel. A blanket that is folded double is placed on top of the improvised operating table. A waterproof sheet is placed over the folded blanket. Then, a loundered ordinary sheet is placed over the waterproof sheet.

HISTORY

The rise of the operating chair, and later, the operating table, began during the period when lithotomic procedures were prevalent in Europe. Lithotomy was the practice of removing bladder stones, which wasn’t considered a safe operation until the 20th century, but had to be done bladder stones were very painful and often deadly if left inside the body. In fact, from 1771-1773, at the Charité and Hôtel Dieu hospitals in Paris, anywhere from a third to a half of lithotomy patients died.  Since Lithotomies were considered one of the most common and dangerous operations of the 18th century, so surgical tables were developed for hospitals to aid in these procedures. These tables had adjustable backrests to hold the patient in a semi-vertical position and restrained his arms and hands. Lithotomy tables were one of the first specialized furniture developed for surgical purposes.

OPERATING CHAIRS

From the 18th the 19th century, operating chairs were actually a little more common than operating tables, possibly because chairs were often used in bedchamber operations. Operating chairs provided surgeons with free access to the operating field, especially the neck, face, and upper limb areas. Operating chairs were also associated with operations done on “stronger patients” who could withstand lots of blood loss, since sitting upright led to an increased quantity of blood loss. Also, chairs were beneficial because they adequately restrained the patient, which was beneficial when patients lost consciousness. 

By the late 19th century, most operating chairs were wooden straight backs with numerous hooks to hold restraining straps. Chairs were also suspended off the ground so patients couldn’t push against the floor to brace themselves, which would cause movement.

OPERATING TABLE

The first operating tables of the 19th century were more like long wooden benches supported by adjustable legs and backrest. There were also adjustable bars located at the foot of the table which acted as footrests, restraining straps, and a waterproof covering.

In the 1850’s: most tables like long wooden benches supported by adjustable legs…adjustable backrest…adjustable bars at foot of table for footrests…and restraining straps…covered with wool rug or horsehair mattress, which was covered with waterproof covering during surgery.

1850’s- Carl Emmert (professor of surgery) invented “Paris model” operating table – which could rotate 360 degrees horizontally and could be adjusted vertically and in length …also could be adjusted as chairs well. 
Jaromir von Mundy – stretched that could be also transformed into an operating table, so transfer of patient from stretcher to table, which was often harmful was unnecessary …popular w country doctors and field surgeons.

NURSING CONSIDERATIONS FOR SURGICAL POSITION

The most common surgical positions are supine, Trendelenburg, reverse Trendelenburg, prone, lithotomy, sitting and lateral positions. The perioperative nurse needs to understand the basics of these positions, how to provide pressure management and how to prevent positioning injuries. These positions are discussed in the following sections.

Consideration of head positioning is of special note in several of these positions. Extended local pressure on the scalp can lead to localized postoperative alopecia.  Symptoms usually develop within a few days to a week after surgery. Sometimes scalp pain, swelling, or exudate may be present before the actual loss of hair occurs. Research has shown that repositioning the head every 30 minutes helps to reduce the likelihood of this problem.

When head and neck surgery is performed, a ring-shaped head rest or small pillow is often utilized for head immobilization and to support cervical alignment, reduce the strain on neck muscles and reduce occipital pressure. A soft pillow will distribute the weight of the head more evenly as compared to a doughnut-shaped head rest with a hole in the center.

Supine Position

Supine (dorsal recumbent) is the most common surgical position as it is the natural position of the body at rest. This position is used for any anterior approach procedure and most extremity and thoracic procedures.

In the supine position, the patient’s back and spinal column are resting on the table mattress, which may be a pressure management pad (a pad specifically designed and constructed to minimize pressure problems). The arms rest easily at the side of the body with the palms facing the body or with the palms down and fingers extended on the mattress. When the arm is resting on an arm board, the arm must be positioned at less than a 90 degree angle from the body with palms up to limit the pressure on the radial and ulnar nerves. The restraint strap should be placed about two inches above the knee.

Compression of the popliteal area should be avoided as venous thrombosis could result. The position of the head should place the cervical, thoracic and lumbar vertebrae in a straight line.  Back aches and pressure-point reactions are the two main complications associated with the supine position. Potential pressure areas in the supine position are the occiput, scapula, olecranon, sacrum, coccyx and calcaneus (indicated with dots in the illustration below). If an effective surgical table pressure management mattress is not used, these areas should be positioned using a pressure reducing device, such as those made from gel, foam, air, or fluid. Compromised patients (diabetic, obese, hypotensive, underweight and those having a procedure lasting more than two hours) should have either protective padding specifically placed under the elbows, sacrum, heels and occiput or be positioned on a clinically proven surgical table pressure management pad. The circulatory system is affected from the supine position as a result of the horizontal body position and the changed effects of gravity. The respiratory system is also affected, since vital capacity of the lungs will be less than in the erect

position. The supine position does allow for a more even distribution of ventilation from apex to the lung bases.

Supine Position

Trendelenburg

A German urologist named Trendelenburg first introduced this position. It is a variation of the supine position, with the upper torso being lowered and the feet raised. This very common position allows optimal visualization of the pelvic organs during laparoscopy and lower abdominal procedures. It is also used to improve circulation to the cranium during sudden drops in blood pressure. Any variant of this position should be maintained only as long as necessary. The respiratory system is affected when a patient is in the Trendelenburg position due to the weight of the abdominal contents on the diaphragm.

The patient should be returned to the supine position slowly to allow the body to adjust to the physiologic changes from this movement. The method of restraining a patient from sliding off of the table is also a consideration. Some shoulder post-style restraint devices can put a large amount of pressure on the subclarian vessels and brachial plexus and may cause injury.

Trendelenburg Position

Reverse Trendelenburg

Reverse Trendelenburg is known as the head up and feet down position. This is used frequently to provide access for head and neck procedures. In this position, the patient must be supported with a padded foot board, body restraint (to prevent flexion or buckling of the knees) and a lift sheet that stabilizes the arms (from above the elbow to the fingers). Reverse Trendelenburg isoften used during procedures such as laparoscopic cholecystectomy, head and neck surgeries and laparoscopic Nissen fundoplication as it aids in visualization and decreases blood supply to those areas.

Respiratory function is less affected in this position but, venous circulation can be compromised when the legs are in the downward placement for an extended time. Application of support hose, elastic stockings, or automatic compression devices can be used to help assist with venous return. Sequential compression stockings are usually applied for prophylaxis against deep vein thrombosis. Return to the supine position after reverse Trendelenburg should be done slowly to avoid an overload to the cardiovascular system

Reverse Trendelenburg Position

Prone Position

In the prone position the patient is lying with the abdomen on the operating table mattress. This position and variations of this position provide surgical access to the cervical spine, back, rectal area and lower extremities. The patient is usually anesthetized in the supine position on a stretcher then rolled onto the operating table. The patient should be turned using at least four people while the anesthesia provider maintains the airway and stabilizes the head. The turning movement should be slow, gentle and uniform by all four team members. Hypotension is a common problem that can occur when an anesthetized patient is rapidly turned. Careful checking of the fingers is mandatory so that correct anatomical positioning can be ensured after placing the patient in the prone position.

The respiratory system is the most vulnerable to complications during the prone position. When lying prone, chest movement is limited, thus decreasing vital capacity and tidal volume. Padded chest rolls (extending bilaterally from the shoulders to the iliac crest) or a special prone positioning frame will allow for chest movement so that the respiratory system is not compromised or restricted. Extra pressure pads should be applied to the chest, knees and ankles as the pressure exerted in the prone position is usually greatest on these areas. A small pillow should be placed under the patient’s feet to prevent pressure from developing over the foot dorsum and to facilitate venous return by slightly elevating the lower extremities.

Prone Position

Jack Knife

Prone Position

Lithotomy Position

Lithotomy is the most extreme of the supine positions. When the patient is supine, the buttocks are brought to the lower break in the table and the legs are raised and abducted to give surgical access to the perineal and rectal area. Procedures on the prostate, vagina, groin and rectum are performed in the lithotomy position. This is the second most common surgical position. When positioning the patient into lithotomy, two team members are needed to lift and position the legs slowly and simultaneously to avoid causing back strain and hip dislocation in the patient. Proper placement of the legs in the stirrups is also critical. The stirrups should be of equal height and attached to the OR table at the same level. If additional exposure is needed, flexion or internal rotation should be done at the hip and not at the knee.

Patient positioning must be checked to maintain hip-knee-foot alignment so as to avoid over abduction of the knee. Extreme care should be taken with patients who have hip prosthetics. Newer, booted stirrup systems have been designed that incorporate hydraulic power to assist with proper stirrup positioning thus minimizing the potential for patient or healthcare worker injury. These booted stirrups help ensure correct anatomical alignment, which is very difficult to achieve with the candy-cane style stirrups shown in the illustration below. When the patient is finally positioned, the bottom of the operating table is lowered for access to the surgical site. When the table end is lowered and then raised again, the patient’s fingers must not be near the table break as injury could easily occur.

Positioning the patient in lithotomy has a great risk for causing patient injury if not performed appropriately.Respiratory function of the patient in lithotomy is impaired due to the extreme flexion of the thighs creating an increase in intra abdominal pressure againt the diaphragm, which decreases the tidal volume. Venous pooling can occur in the splanchnic region during the operative procedure from the gravity flow of blood from the elevated legs. Circulation is enhanced by using support hose while the legs are in strirrups or leg holders. Pressure management pads should be used to line the leg holders to prevent pressore sores and nerve damage to the perineal, popliteal and calcaneous areas.                                                                              

Lithotomy Position

Sitting Position

The sitting (Fowler’s) position is another variation of the supine position. This position is usually used for neurosurgery, some facial operations, breast reconstruction and some shoulder surgeries. To place the patient in this position, the patient is first supine on the operating table. The position of the body in relation to the breaks in the operating table is carefully adjusted to prevent abnormal pressure points. The head of the table is slowly raised to 90 degrees while the legs are lowered and the knees are slightly flexed. The feet are placed against a padded foot board to prevent foot drop. The arms are rested on a pillow on the lap with the elbows flexed at 90 degrees or supported to the patient’s side on padded arm boards or on a multi-task arm board. Once the positioning is complete, the cervical, thoracic and lumbar sections of the spine should be aligned. The more erect the patient, the greater the need to support the torso and shoulders. There are several head rests available to stabilize the head.

The sitting position causes most of the patient’s weight to be on the dorsum of the body. Extra pressure management pads should be placed under the buttocks and small of the back. Excessive pressure in these areas could damage the sciatic nerve. Padding also needs to be under the elbows, knees and heels. Respiratory function in this position is usually not affected but hypotension is a great risk due to the venous pooling in the torso and lower extremities. Antiembolic stockings or elastic bandages along with sequential compression devices are typically used to help limit venous pooling by supporting venous return. In the sitting position, a very dangerous complication can occur when the operative site  is located above the heart (i.e.,neurosurgery). An air embolism can form, caused by the negative venous pressure between the operative site and the right atrium. Prophylactically, a Doppler ultrasound probe is placed over the chest wall and a central venous catheter is inserted into the pulmonary artery or right atrium to assist with the early diagnosis and treatment of an air embolism. If an air embolism is diagnosed, the exposed area should be sealed or packed with saline soaked sponges or irrigated to prevent further aspiration of air. The anesthesia provider can aspirate the air from the right atrium through the central venous line.  When the procedure is finished, the patient should be moved back slowly to the supine position while allowing the patient’s internal systems to make hemodynamic adjustments. The patient should be monitored closely during this repositioning.

Sitting Position

Lateral Position 

The lateral position (also called Sims’ position, "park bench" position, lateral decubitus, or lateral recumbent) places the patient on the nonoperative side so surgery can be performed on the hip, chest, or kidney. The right or left lateral positions depends on the side that the patient will be lying on. For example, if the patient is to be in the right lateral position, then the right side is down and the left side (operative side) is up.

The patient is first placed in the supine position, anesthetized and then slowly and carefully moved to the lateral position. Positioning devices must be readily available before repositioning occurs. A pillow is placed under the patient’s head to provide appropriate alignment with the spine. The knee and hip of the bottom leg are flexed to stabilize the patient in this position. The top leg is straight or slightly flexed with a pillow put lengthwise between the legs. Extra padding is placed on the inside aspect of the bottom knee to prevent pressure on the peroneal nerve. The feet and ankles are protected against foot drop and pressure with padding of pillows. The torso is then supported with pillows, rolls, sandbags, or surgical positioning systems. The shoulders, hips and legs are usually secured with an adjustable restraint strap fastened to the operative table. The upper arm is placed on a multi-task arm board that is padded or on a pillow in front of the patient. The lower arm is flexed and placed on a padded arm board. Radial pulses should be monitored throughout the procedure to ensure adequate circulation. A pulse oximeter, usually placed on the lower hand, may also be used to check the perfusion.

The greatest problem with the lateral position is pressure and nerve damage; therefore, special care is taken to provide appropriate padding. Respirations may also be compromised due to the pressure on the lateral chest wall. To aid in chest expansion, a padded roll can be placed under the lower axilla.

Lateral Position

Summary

Proper patient positioning focusing on pressure management requires not only a knowledge of anatomy and physiology but also familiarity with appropriate positioning devices and solid teamwork. Every member of the surgical team must continually assess the patient throughout the procedure to ensure that pressure management is a focal point of patient care. Positioning must be carefully planned and executed to minimize risks and maintain optimal patient safety. In review, the following interventions should be addressed when positioning a patient:

• Check with the surgeon and anesthesia provider to determine the position that the patient will be in during the surgical procedure
•  Review the patient’s chart and assess the patient’s condition before attempting to position a patient
• Gather the appropriate positioning devices to ensure that padding is intact before using
• Use high quality pressure management mattresses and aids
• Request positioning help if needed before the patient is moved
• Pad bony prominences to prevent pressure and skin breakdown
• Protect superficial nerves from pressure or straining
• Secure and support extremities so they won’t fall off the bed or be in contact with any hard surface. Make sure legs are uncrossed to prevent circulatory problems or pressure on nerves Ensure that no equipment or devices are resting on the patient Attempt to properly align all body parts when positioning
• Do not overextend a body part
• Maintain the patient’s dignity and privacy during positioning by preventing unnecessary exposure
• Use the team approach when moving a patient
• When positioning a patient, use slow, smooth movements
• Always use good body mechanics when moving a patient

REFERENSI

1. http://en.wikipedia.org/wiki/Operating_table
2. Operating table, thefreedictionary.com
3. Operating table, dictionary.reverso.net
4. Robinson, Victor, Ph.C., M.D. (editor) (1939). "Improvising an Operating Table". The Modern Home Physician, A New Encyclopedia of Medical Knowledge. WM. H. Wise & Company (New York)., Operation, page 555
5. http://bhatmanjim.weebly.com/the-operating-table.html
6. http://www.steris.com/media/PDF/support/education/StudyGuides/M1721EN_SG%202_Interoperative%20Patient%20Positioning_7-10.pdf