Principles of Safe Positioning
Positioning balances two competing needs: optimal surgical exposure and protection of the patient's skin, nerves, circulation, and respiratory function. The surgical team - surgeon, anesthesia provider, and surgical tech/RN - shares responsibility for safe positioning, padding of bony prominences, and maintaining correct body alignment throughout the case.
Supine Position
| Detail | Description |
|---|
| Common procedures | Abdominal, cardiac, most general surgery cases |
| Pressure points | Occiput, scapulae, olecranon, sacrum, coccyx, calcaneus |
| Nerve risk | Ulnar nerve (if arms not properly padded/positioned), brachial plexus (arm abduction over 90 degrees) |
| Key precautions | Arms secured at less than 90 degrees abduction, safety strap 2 inches above knees, heel padding |
Trendelenburg Position
| Detail | Description |
|---|
| Common procedures | Lower abdominal and pelvic laparoscopic surgery |
| Physiologic effect | Increases venous return and intracranial/intraocular pressure; shifts abdominal contents cephalad for pelvic exposure |
| Risk | Brachial plexus injury from shoulder braces, airway/ventilation compromise, retinal complications with prolonged steep angles |
Lithotomy Position
| Detail | Description |
|---|
| Common procedures | Gynecologic, urologic, colorectal, and vaginal procedures |
| Pressure points | Popliteal space, lateral fibular head |
| Nerve risk | Common peroneal nerve (lateral fibular head compression against stirrup), femoral nerve (excessive hip flexion), saphenous nerve |
| Key precautions | Both legs raised and lowered simultaneously and slowly to avoid hip strain; padded stirrups; avoid pressure on the calf/peroneal area |
Prone Position
| Detail | Description |
|---|
| Common procedures | Spinal surgery, posterior fossa neurosurgery, some rectal procedures |
| Pressure points | Face/eyes, chest, iliac crests, knees, toes, breasts and genitalia (must hang free) |
| Nerve risk | Brachial plexus injury, ulnar nerve injury; postoperative visual loss from ocular pressure |
| Key precautions | Chest rolls or a specialized frame to allow free abdominal excursion and reduce venous pressure; eyes checked and padded; arms positioned to avoid excess shoulder abduction |
Lateral (Kidney) Position
| Detail | Description |
|---|
| Common procedures | Thoracic surgery, renal surgery, hip surgery |
| Pressure points | Dependent ear, dependent shoulder/axilla, greater trochanter, lateral malleolus |
| Nerve risk | Brachial plexus compression (requires an axillary roll below, not in, the axilla), peroneal nerve compression at the dependent leg |
| Key precautions | Axillary roll placement, pillow between legs, kidney rest/table break used cautiously, dependent eye and ear checked |
Fowler's (Sitting) Position
| Detail | Description |
|---|
| Common procedures | Some neurosurgical and shoulder procedures |
| Risk | Venous air embolism, hypotension, sciatic nerve stretch injury |
| Key precautions | Gradual position changes, sequential compression devices, careful hemodynamic monitoring |
Key Exam Points
- Document position, positioning devices used, and the personnel who assisted, per facility policy and AORN recommended practices.
- Never leave a positioned but not yet secured patient unattended.
- Safety straps should never be placed directly over a joint; the standard is roughly 2 inches above the knee for supine positioning.
- Pad all bony prominences that will bear weight in the given position before final securing.
- Position-related nerve injury is one of the most frequently tested positioning topics - know which nerve is at risk for each position.