Surgery has changed dramatically in the last 10 or 15 years, and so should many of the practices related to the Trendelenburg position — especially steep Trendelenburg. Laparoscopic and robotic cases, practically unheard of when many of us were residents, are now standard. We're tackling increasingly complex and longer procedures on heavier patients. Taken together, those factors should strongly influence whether, and to what degree, we decide to tilt our patients backwards to gain better access.

I visit a lot of hospitals and surgery centers and watch a lot of surgeons operate. So I see firsthand that a lot of folks are still operating as though it's 1996, instead of adapting to the often-challenging realities of 2016. Here are 12 suggestions to consider before you lower the head and raise the feet of another patient.

1. Don't do it out of habit. Trendelenburg positioning — especially steep positioning — often happens because it's what surgeons have been trained to do. The general rule should be, don't do it automatically or out of habit. Think about it first. Ask whether it's going to be beneficial. And ask whether steep positioning would add anything that regular Trendelenburg (less than 30 degrees) wouldn't. Traditionally, when people want to do something in Trendelenburg, they automatically go to steep, figuring the more, the better. And now they're doing it with both robotic and laparoscopic cases, both of which can last longer and thereby increase the odds of complications.

2. Know your anatomy. Trendelenburg is all about exposure — being able to get the bowel out of the way and see the pelvis. But the bigger parts of the bowel — the rectum and the sigmoid, which always seem to be in the way — are independent of gravity. No matter what you do to the patient, that part of the intestine doesn't move. I think some surgeons have the false notion that steep Trendelenburg is going to make a difference with that fixed anatomy, but it won't.

3. Consider whether regular Trendelenburg is steep enough. There always comes a point where giving more Trendelenburg is not going to be helpful. If you've tilted the table 20 degrees and you still can't get the bowel out of the way, will 40 degrees improve the situation? The answer is probably no. Surgeons sometimes lose perspective on that.

4. Consider the patient. Ventilating patients, especially obese patients, in Trendelenburg is challenging, because the gut is pushing against the diaphragm and it becomes very difficult for people to breathe. What's the patient's BMI? Has he had any respiratory or ventilation difficulties in the past? Rarely, Trendelenburg has also been associated with cases of retinal detachment and blindness. The pressure in the face and behind the eyes can become severe. If patients have some degree of retinal detachment or glaucoma, or some other ocular condition, Trendelenburg may worsen it.

5. Beware of longer surgeries. When you keep a patient's head down for a long time — longer than 3 or 4 hours — the patient ends up receiving 3 or 4 liters of water, which in turn follows gravity and goes into the patient's face, causing edema. That may cause airway difficulties and a difficult extubation. These patients often end up having to spend the night in an ICU.

6. Plan ahead with robotic cases. When complications develop during other types of cases, you can lower the table. But during robotic cases, you can't modify the position of the patient, so length of exposure is even more crucial. If the case is going to be long, steep Trendelenburg may be hazardous.

7. Know the math. Overall, complications that occur in steep Trendelenburg are probably in the 1% to 2% range. So it can be easy to dismiss or downplay the concern. But if you do a thousand cases a year, 1% translates to 10 cases a year. And you certainly can't consider that an insignificant number. When robots started becoming popular, 10 or so years ago, the first operations were relatively short prostatectomies, which require steep Trendelenburg. But as gynecologists followed the lead of urologists and began doing longer and more complex surgeries in the steep position, they didn't always consider the kinds of complications that might develop, and a lot of lawsuits followed. Still, however, I'd guess that about 80% of the time, the tendency is to automatically go to steep Trendelenburg.

8. Know what you're asking for. Some tables can only tilt 25 degrees, while others may go to 40. A surgeon who isn't aware, or paying attention, may ask for maximum Trendelenburg, potentially putting the patient at 40 degrees, when 25 was all he really wanted or needed. Remember, the steeper the tilt, the more potential there is for complications.

9. Don't use straps and harnesses. These are muscle and pressure point injuries — or worse — waiting to happen. And the steeper the tilt, the more pressure there is. Remember, if you're operating on a 300-pound patient, roughly 50% of that weight is being shifted to the upper back, and that can cause muscle breakdown. There have even been cases of rhabdomyolysis caused by steep Trendelenburg. When muscle breaks down, protein particles can damage kidneys and cause other potentially life-threatening problems. Fortunately, most now realize we need to use other mechanisms to prevent sliding.

10. To prevent sliding, use devices that distribute force equally. The best way to keep patients from sliding is to use an air pad or other device that distributes force equally all over the body. The first thing I do is place a 3-foot by 5-foot surgical sheet horizontally in the middle of the table, corresponding to the patient's arm position. I then put a layer of egg-crate foam on top of that, and make sure it's securely taped to the table. Bean bag positioners, which mold to the body, are also effective ways to prevent sliding, as are gel-type mattresses that work like memory foam. Many commercial products are available. The key is to use something you don't have to attach to the patient. Just having the patient lie down should do the trick.

11. Protect the arms. Be sure to tuck the patient's arms with sheets or arm sleds. If you put them in arm boards and the patient slides, that can put a lot of pressure on the brachial plexus and lead to neuromuscular injuries. Well-padded arm sleds made of rigid plastic material can help protect and stabilize the arms of obese patients.

12. Don't forget the patient's face. Often there's a drape over the patient's face, and nobody's checking the face. But it can be an important consideration. If, say, the procedure has entered its third hour, you may see ballooning (edema) in the face, and that should be a cue to stop the case or reverse the Trendelenburg before the situation gets worse.

Only when necessary
Remember, longer procedures and steeper tilts can be a dangerous combination. Only recently has there been an increased awareness that we ought to be a little more conservative with Trendelenburg, especially steep Trendelenburg. We know now we should always be assessing whether it's really needed. That reflection is likely to help us realize that in many cases the potential risks outweigh the benefits. OSM