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.
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
- http://en.wikipedia.org/wiki/Operating_table
- Operating table, thefreedictionary.com
- Operating table, dictionary.reverso.net
- 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
- http://bhatmanjim.weebly.com/the-operating-table.html
- http://www.steris.com/media/PDF/support/education/StudyGuides/M1721EN_SG%202_Interoperative%20Patient%20Positioning_7-10.pdf