As more number of major and lengthy surgeries are done laparoscopically. I'm looking for some clear-cut guidelines or recommendations in this regard especially degree of head down tilt allowed or duration of surgery allowed for steep Trendlenberg position etc especially considering the kind of devastating adverse effects such extreme position can cause.
Trendelenburg's position allows a surgeon greater access to pelvic organs but the risks must be assessed as diminished lung capacity (respiratory distress) and venous pooling toward the patient’s head (retinal detachment and ischemic optic neuropathy).
It is recommended to check patient positioning and make adjustments based on the patient physiological status for cases taking longer periods by relieving Trendelenburg's position when feasible to reduce these risks.
Steep Trendelenburg's (30 – 40 degrees head-down) position is associated with a high risk of intra-operative injuries. I doubt the presence of any recommendations or guidelines regarding that patients' safety is our target.
With due regards, "Can you kindly specify your point more as to why do you need such extremes in position"? Then it may be more likely to offer advice! These positions should never be taken lightly as the brief question begs? Regards,
The Trendelenburg position (proposed by the author for widespread use in 1885) provided for a body tilt of 30 - 45° or more relative to the horizontal plane (https://ru.wikipedia.org/wiki/%D0%9F%D0%BE%D0%BB%D0%BE%D0%B6%D0%B5%D0%BD%D0%B8%D0%B5_%D0%A2%D1%80%D0%B5%D0%BD%D0%B4%D0%B5%D0%BB%D0%B5%D0%BD%D0%B1%D1%83%D1%80%D0%B3%D0%B0#:~:text=%D0%9F%D0%BE%D0%BB%D0%BE%D0%B6%D0%B5%D0%BD%D0%B8%D0%B5%20%D0%A2%D1%80%D0%B5%D0%BD%D0%B4%D0%B5%D0%BB%D0%B5%D0%BD%D0%B1%D1%83%D1%80%D0%B3%D0%B0%20%E2%80%94%20%D0%BE%D1%81%D0%BE%D0%B1%D0%BE%D0%B5%20%D0%BF%D0%BE%D0%BB%D0%BE%D0%B6%D0%B5%D0%BD%D0%B8%D0%B5%2C%20%D0%B2,%E2%80%941924)%20%D1%81%201880%20%D0%B3%D0%BE%D0%B4%D0%B0.), although another (English-speaking) source indicates 15-30 degrees (https://en.wikipedia.org/wiki/Trendelenburg_position#cite_note-Ostrow-1 , https://doi.org/10.4037/ajcc1997.6.3.172 ). In my practice (laparoscopic appendectomy, revision of pelvic organs and laparoscopic gynecology) I use an angle of inclination up to 30 degrees (there is no protractor in the operating room - I won't say for sure), and sometimes a small turn to the right / left side, sufficient to perform these operations (when the bowel loops do not move back), and I agree with the anesthesiologist.
**In addition to the influence of the Trendelenburg position, one of the studies (which came first in Google search): "The influence of body position during laparoscopic operations on the dynamics of intraocular pressure", https://doi.org/10.25700/NJG.2020.04.04
Dear colleague. It is necessary to take into account the background and concomitant pathology. Conduct an orthostatic test on the eve of anesthesia and surgery. According to the results of which one can judge the permissible safe range of the reaction of the cardio-respiratory system. Implementation of the Trendelenburg position should not be instantaneous, but phased with the control of the reaction of the main parameters of the cardio-respiratory system and gas analysis on inhalation and exhalation, as well as in venous, and, if necessary, arterial blood
Sincerely, Mikhail Vasilyevich Prigorodov Saratov State Medical University. IN AND. Razumovsky
There is generally a paucity of guidelines, and with good reason. This article has a list of complications, and is a good review of problems to be aware of-
1. BMC Anesthesiol. 2018; 18: 117.
Published online 2018 Aug 21. doi: 10.1186/s12871-018-0578-5
PMCID: PMC6104011
PMID: 30131061
"Survey of anesthesiologists’ practices related to steep Trendelenburg positioning in the USA"
The publication below lists some of the protective measures relating to skin and pressure areas, but duration and angulation may still lead to problems, and do not address cardiovascular, respiratory, ocular or cerebrovascular complications.
2. "Safe and Standardized Trendelenburg Positioning"
"Avoid skin tears, pressure injuries and other complications by paying extra attention to common problem areas."
Emma Greene
Publish Date: August 9, 2020
https://www.aorn.org/outpatient-surgery/articles/outpatient-surgery-magazine/2020/august/safe-and-standardized-trendelenburg-positioning.
The Trendelenburg position gives the surgeon ample opportunity to operate in the pelvis without much interference of the bowels and omentum. However, it is important to monitor the respiratory function parameters while the patient is in this position. Anaesthetic machine with capnograph and an experienced anaesthetist in gynaecological endoscopic surgery will be of great value