CENTER OF THE ACTION The table's setup should align with surgeon comfort and optimal abdominal access.

The surgical site is marked. The patient's been draped. The time out has been performed. Has anyone checked if the patient's position and the table's setup will give the surgeon the access he needs and the comfort he deserves? Both are critical but often overlooked factors in the successful outcomes of laparoscopic cases.

Helpful force
Obviously, properly positioning the patient addresses a number of safety issues, but from the surgeons' perspectives, it's important that patients are placed in ways that let them easily reach all areas of the abdomen.

Gravity plays a part in this effort. During laparoscopy cases, surgeons rely on its force to retract the mobile structures of the abdomen: the stomach or large and small bowel, for example, which is difficult if not impossible to retract by conventional means. A table that's easily maneuverable — tilted to the side or into Trendelenburg and reverse Trendelenburg positions — lets gravity do its thing and improves a surgeon's access to targeted anatomy.

However, standard OR tables are limited in their laparoscopic-friendly maneuverability. They tend to be heavy and slow, with limited movement and versatility. Patients are put in stirrups for several lower abdomen procedures, which can further hamper movement of the table. There's more trouble if you can't position table surfaces low enough to give surgeons comfortable access to the abdominal cavity. In my opinion, widespread improvements in laparoscopic table design need to match the advancements made in fracture table design for orthopedics. A similar user-friendly focus has yet to be applied to general surgery tables, but it would be most welcome.

Protect the patient
Managing the table, patient positioning, table attachments, lifts and instrument aids are critical at the start of the procedure in order to perform procedures effectively. Why not discuss these things during pre-op huddles or perhaps even the pre-procedure time out?

The entire surgical team is responsible for ensuring patients remain secure and safe when adjusting the table mid-procedure. The anesthesiologist typically is the one who pushes the directional buttons while watching that Mayo stands or side tables don't interfere, and alerts the OR staff that the table is moving and in which direction it's being adjusted. It's also critical for surgeons, anesthesia providers, nurses and techs to communicate about any patient movement that may occur — an extremity potentially slipping off an armboard or stirrup — when the surgical surface is adjusted to avoid unintended injury to the patient.

Be sure the surgical team has access to proper and effective patient positioning aids. I've started using newly designed stirrups that are more easily adjustable, both vertically and laterally, with good fixation and ease of adjustment, which is especially important in laparoscopy where surgeons are constantly shifting positions throughout procedures — from between patients' legs to either side of the table — to improve access to the abdominal cavity.

Use patient stabilizers, including straps on the legs of patients placed in the lithotomy position, and foot plates and shoulder pads on patients in the Trendelenburg and reverse Trendelenburg positions. Patients can shift significantly on the table if they're not properly supported in those 2 directions. Also be aware that patients in deep reverse Trandelenburg have diminished venous return from the lower extremities, so it's important to have sequential compression devices working on their legs during these situations.

SAFETY MEASURES The entire surgical team is responsible for ensuring patients remain secured to the surface when the table is adjusted mid-procedure.

Constant communication
It's absolutely critical that the OR team discuss room setup and ensure instruments, positioning devices and patients are positioned properly before the case starts. For example, I've started to use more assistive devices during procedures: camera and instrument holders that attach to the table rail. If your surgeon wants to add these useful attachments to the mix, be sure the table can accommodate them in various positions.

These factors aren't as much of an issue in ORs where staff are familiar with surgeons' preferences or in facilities where fixed teams work with specific docs. But in many facilities where teams work in numerous ORs and shifts change in the middle of the day or case, ensuring the room is properly set up can be a challenge.

Physicians' preference cards are geared toward ensuring needed instrumentation is at the ready and typically don't include easy ways to document the details of their preferred room setup, but make note of the table and equipment orientation for specific cases. Or simply take pictures of patients properly positioned (before draping and in such a way to maintain their privacy), table alignments, positioning aids, instrument holders and surgeon lifts in a variety of configurations for various procedures and specific surgeons.

ERGONOMIC STUDIES
What's the Optimal Table Height?

LOWER LIMIT Research shows the operating surface should be 64 to 77cm off the floor during laparoscopic cases.

Four clinical studies, including my own in the journal Surgical Endoscopy, assessed how high the operating surface should be during laparoscopy to improve surgeon ergonomics. They all concluded that the table should be set so surgeons using long, pistol grip instruments can position their forearms close to parallel with the floor, without having to flare their elbows and lift their shoulders. That typically means patients should be positioned lower than they would during open procedures. Ultimately, finding the optimal table height and configuration demands compromising between spine and arm position, and the muscle effort and fatigue of the respective muscle groups.

My study determined table height should put instruments at or 10cm below the surgeons' elbows in order to maximize their comfort and decrease muscle strain, which translates to 64 to 77cm off the floor. Tables need to be even lower for surgeons operating near the anterior abdomen wall instead of the posterior wall. Additionally, operating on bariatric patients in the Trendelenburg and reverse Trendelenburg positions presents particular challenges related to proper instrument positioning and surgical access.

How low a table can go is often determined by how much the surface is tilted or how deep it's placed in the reverse Trendelenburg position. During upper-abdominal surgery, for example, the table can be lowered only so far in reverse Trendelenburg before its front hits its base. In that situation, surgeons should stand on 1 or 2 lifts to have the proper torso and arm posture for the duration of the case. When surgeons stand between the patient's legs during procedures, the foot of the table is down, limiting how low the table can go. In those instances, surgeons should consider standing on a lift and placing needed foot-pedal controls on another in order to keep their arms close to parallel and avoid having their hands positioned near their shoulders.

Changing the orientation of the table during laparoscopic cases is also very useful. Moving it away from the anesthesia machine and at a 45-degree angle to the anesthesia provider lets the surgical team place towers and monitors near the patient's head, which gives surgeons straight-on views of the monitors — an ideal arrangement for improving ergonomics.

— Ramon Berguer, MD, FACS