Surgical Positioning – General Considerations
Safe positioning of the surgical patient is the responsibility of the entire surgical
team. Two concepts are the basis for surgical positioning.
1. Access to the surgical site, airway, intravenous line(s), and monitoring devices
must be provided
2. Compromise to the patient’s integumentary, nervous, respiratory,
musculoskeletal, and cardiovascular systems must be prevented
Several factors must be considered prior to positioning the patient for the
procedure including:

Basic anatomy and related physiology must be understood

Factors specific to each patient must be considered
-
Planned surgical procedure
-
Primary condition
-
Underlying conditions
-
Allergy status
-
Age
-
Size
-
Nutritional status
-
Planned anesthetic

Knowledge of positioning equipment and supplies is imperative

Proper body mechanics must be implemented

Injury to the patient and surgical staff must be avoided
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
-
Chemical
-
Electrical
-
Mechanical (gravity, friction, shearing)
-
Thermal
Surgeon and anesthesia provider preferences must be considered
For the safety and comfort of the patient – as well as your own safety, many basic
safety measures must be followed each time the patient is transferred or positioned.

Patient identification and assessment (including allergy status and surgical site
confirmation) occurs prior to transportation to the OR

A minimum of two individuals should be available to assist the mobile patient

A minimum of four individuals should be available to assist the immobile
patient

The patient is assessed prior to arrival in the OR and preparations are made in
advance

All patient care devices (such as oxygen and IV administration equipment,
Foley catheter, and drainage collection devices) must be protected during
transfer or positioning

Adequately cover the patient – to provide warmth and privacy

Provide comfort devices (such as a pillow) and adjust the head of the transport
device or OR table to a comfortable level, as the patient’s condition allows

The wheels of both the OR table and transportation device must be locked and
the mattress stabilized
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
Lift, rather than slide the patient to prevent friction and shearing injuries
(transfer devices may be used)

The patient is moved slowly to maintain control of the body and allow for
circulatory changes

Pressure points and bony prominences should be padded to prevent gravity
related injuries

The patient’s skin should not come in direct contact with any metallic table
parts, accessories, or unpadded surfaces to prevent electrical and gravity
related injuries

No part of the patient may extend beyond the table surface

Restraints are used whenever indicated

The anesthetized patient is not moved without permission from the anesthesia
provider. The anesthesia provider directs movement of the patient.

The anesthesia provider is responsible for maintaining the patient’s airway
and may not be able to help lift the patient

The armboard may not extend beyond a ninety degree angle

The patients legs may not be crossed

The patient must be protected from injury during movement of the OR table

Patient care supplies (e.g. Mayo stand) and personnel may not rest on the
patient

The patient’s eyes must be protected from drying and abrasion

Excessive torsion, flexion, and/or extension of any part of the patient’s body
must be avoided
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Prior to any surgical intervention, the patient must be transported to the operating
room, transferred to the OR table, have the appropriate monitors applied, and receive
their planned anesthetic. Patient monitoring and anesthesia are presented in detail in the
video entitled Preoperative Case Management.
A number of methods are used to transport the surgical patient to the OR. The
patient may be carried or allowed to ambulate as well as use a wheelchair, gurney, or
their hospital bed. In the hospital setting, use of a gurney and the patient’s bed are the
most common. The basic concepts that relate to patient transportation via a gurney or the
patient’s bed are as follows:

The guardrails should be in the upright and secure position

The safety belt is secured, if necessary

The wheels are in the correct position

Transport the patient slowly, feet first – be certain that all parts of the patient’s
body are within the guardrails

Use good body mechanics

Never leave the patient unattended
The patient is transferred to the OR table using one of the two following methods.
1. The mobile patient may be able to more him or herself to the OR table
independently.

A minimum of two nonsterile team members should be available to assist
with transfer of a mobile patient

Position the gurney next to the OR table

Instruct the patient not to move until you give the command
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
Be sure that the wheels of both the gurney and the OR table are locked

One individual should be positioned at the side of the gurney and the other
at the side of the OR table

Brace your bodies against the gurney and OR table to prevent any
unexpected movement

Instruct the patient to keep their blanket on and move to the OR table

Assist the patient any way you can – for example, move the pillow from
the gurney to the OR table or assist by lifting a fractured extremity

Apply the safety strap, then remove the gurney
2. The immobile patient will be unable to assist with the transfer and will have to
be moved onto the OR table.

A minimum of four nonsterile team members should be available to assist
with transfer of an immobile patient

Position the gurney next to the OR table

If necessary, explain the transfer procedure to the patient

One individual should be positioned at the side of the gurney, another at
the side of the OR table, and one at the head and foot of the gurney

Brace your bodies against the gurney and OR table to prevent any
unexpected movement

Keep the patient covered and transfer him or her to the OR table using the
preferred method

Apply the safety strap, then remove the gurney
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The three basic surgical positions and their common variations are demonstrated
in the video that accompanies this study guide. Here you will learn which body region(s)
may be accessed when the patient is in each position, the potential hazards to the patient,
and the precautions that must be taken to prevent injury to the patient. Keep in mind that
there are many variations to all of these procedures. The patient’s situation, surgeon and
anesthesia provider preference, product differences, and school or facility policy may
cause a variance.
Supine Position
Typically, the patient is placed in the supine or dorsal recumbent position prior to
the administration of anesthesia. The patient may remain in the supine position for the
procedure or be repositioned, as needed, once anesthetized. Any additional procedures
such as application of antiembolism devices, insertion of a Foley catheter, or
application/insertion of additional monitoring devices are performed prior to
repositioning. Once the patient is anesthetized, you must seek permission from the
anesthesia provider to reposition the patient. The anesthesia provider usually assumes the
leadership role in positioning the anesthetized patient, giving the commands to the other
surgical team members.
Body regions that may be accessed with the patient in the supine position include:

Anterior lower extremity

Pelvis

Abdomen

Chest/Breast
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
Shoulder

Head and neck

Upper extremity
The following potential hazards and necessary precautions apply to the patient in
the supine position.
Potential Hazard
1. Brachial plexus injury



2. Ulnar nerve injury

3. Pressure injury to skin, blood vessels, 
and nerves






4. Back and neck pain





5. Hypo/hyperthermia





6. Corneal drying and abrasion
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Precautionary Action(s)
Position armboard at less than a 90º
angle
Pad elbows
Place arms on armboards with palms
facing upward
Place arms next to patient’s body with
palms facing inward
Pad all bony prominences
Uncross ankles
Be sure restraining devices are not
restrictive
Use egg crate padding or gel pads on
the OR table
No part of the patient’s body is to
extend beyond the padded OR table
Excessive torsion, flexion, and/or
extension of any part of the patient’s
body must be avoided
Legs are parallel and the spine is in
alignment
Provide lumbar support pillow
Head is stabilized on a pillow or foam
headrest
Adjust OR temperature
Provide or remove blankets
Implement use of hypo/hyperthermia
unit
Solutions (IV and irrigation) correct
temperature
Provide warm humidified inhalation
agents
Lubricate eyes
Secure eyes in the closed position
Prevent pressure on the eyelids


7. Foot drop
8. Electrical injury
Use padded foot board
No part of the patient’s body is allowed
to contact any metal object
Trendelenburg’s Position
Trendelenburg’s position is a modification of the supine position. It is used to
displace the abdominopelvic organs cephalad to provide better visualization of the
surgical site. Another benefit of the Trendelenburg position is that blood flow to the
lower body is reduced and venous drainage is promoted. Conversely, the position may be
used to increase blood flow to the upper body, as in the treatment of shock or for
distention of blood vessels to be cannulated.
Body regions that may be accessed with the patient in the supine position
include:

Pelvis

Lower abdomen
The following potential hazards and necessary precautions apply to the patient in
the Trendelenburg’s position, in addition to those previously listed for the supine
position.
Potential Hazard
1. Cardiovascular and respiratory
compromise

Precautionary Action(s)
Decrease angle of OR table
Return patient to supine position as
soon as possible
Flex leg section of the OR table

Use padded shoulder braces


Use antiembolism devices
Raise leg section of the OR table


2. Pressure injury to skin, blood vessels,
and nerves
Note: Special attention is given to the
peroneal nerves
3. Patient movement toward the head of
the OR table
4. Venous stasis
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
5. Blood pressure changes
slowly prior to leveling the table
Level the OR table slowly
Reverse Trendelenburg Position
The reverse Trendelenburg position is a modification of the supine position. It is
used to displace the abdominal organs caudad to provide better visualization of the
surgical site. Other benefits of the reverse Trendelenburg position is that blood flow to
the upper body is reduced, venous drainage is promoted, and respiration is facilitated.
Body regions that may be accessed with the patient in the reverse
Trendelenburg position include:

Upper abdomen

Head and neck
The following potential hazards and necessary precautions apply to the patient in
the reverse Trendelenburg position, in addition to those previously listed for the supine
position.
Potential Hazard
1. Patient movement toward the foot of
the OR table


2. Venous stasis
3. Blood pressure changes



Precautionary Action(s)
Use a padded foot board
Safety strap is placed approximately 2”
distal to the knees
Pillows or the kidney lift may be used
Use antiembolism devices
Level the OR table slowly
Lithotomy Position
The lithotomy position is a modification of the supine position.
Body regions that may be accessed with the patient in the lithotomy position
include:

Perineum
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
Anus and rectum

Vagina

Urethra
The following potential hazards and necessary precautions apply to the patient in
the lithotomy position, in addition to those previously listed for the supine position.
Potential Hazard
1. Crushing or shearing injury to the hand


2. Pressure injury to skin, blood vessels,
and nerves


Note: Special attention is given to the
peroneal nerves




3. Back, knee, and hip pain



4. Blood pressure changes

5. Venous stasis
6. Cardiovascular and respiratory
compromise




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Precautionary Action(s)
Arms are placed on armboards
If arms are positioned at the patient’s
sides, the hands must be observed
during table movement
Pad feet and ankles
Be sure restraining devices are not
restrictive
Excessive torsion, flexion, and/or
extension of any part of the patient’s
body must be avoided
The legs may not come in direct
contact with the stirrups
Stirrups are adjusted to an equal height
and length
Legs are raised and lowered slowly and
simultaneously by two individuals
Buttocks rests completely on the OR
table
Stirrups are adjusted to an equal height
and length
Legs are raised and lowered slowly and
simultaneously by two individuals
Legs are raised and lowered slowly and
simultaneously by two individuals
Use antiembolism devices
Restrict accompanying use of
Trendelenburg’s position
Decrease leg height and hip flexion
Return patient to the supine position as
soon as possible
Fowler’s Position
The Fowler’s position is a modification of the supine position. Fowler’s position
provides improved access to the surgical site and reduces blood flow to the upper body,
promotes venous drainage, and facilitates respiration. Air embolism is a potential concern
when the patient is in the Fowler’s position.
Body regions that may be accessed with the patient in the Fowler’s position
include:

Breast

Head and neck

Shoulder
The following potential hazards and necessary precautions apply to the patient in
the Fowler’s position, in addition to those previously listed for the supine position.
Potential Hazard
1. Blood pressure changes
Note: Postural hypotension is of special
concern
2. Respiratory compromise
3. Venous stasis
4. Patient movement on the OR table
5. Pressure injury to skin, blood vessels,
and nerves
Note: Special attention is given to the
sciatic nerves
Precautionary Action(s)
 Make adjustments to the OR table
slowly
Note: A pneumatic compression device
may be useful in combatting postural
hypotension
 If arms are not placed on a armboard,
they will be placed and restrained on a
pillow resting across the abdomen,
NOT on the chest
 Use antiembolism devices
 Padded footrest may be used
 Upper body may be restrained
 Neurosurgical headrest may be used
 Pad pressure points
Note: Special attention is given to the
ischial tuberosities
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Lateral Position
The lateral position is also referred to as the lateral recumbent or lateral decubitus
position. The patient in the right lateral position is placed on the OR table with the right
side downward, exposing the left side of the body. All preoperative procedures, such as
Foley catheter insertion, must be performed prior to placement in the lateral position.
Body regions that may be accessed with the patient in the lateral position include:

Retroperitoneal space

Hip

Hemithorax
The following potential hazards and necessary precautions apply to the patient in
the lateral position, in addition to those previously listed for the supine position.
Potential Hazard
1. Respiratory compromise
Note: Due to gravitational forces the lower
lung is better perfused, but contains less
residual air due to diaphragmatic and
mediastinal compression
2. Circulatory compromise
Note: Arterial circulation to the lower body
is restricted, as is venous return
3. Movement on the OR table









4. Pressure injury to skin, blood vessels,
and nerves
Note: The peroneal nerve, brachial plexus,
and the vascular structures of the axilla are
of special concern



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Precautionary Action(s)
Positive pressure ventilation is
implemented
Maintain cervical alignment
An axillary roll is placed
Use antiembolism devices
Avoid excessive compression of the
abdomen
Blood pressure is measured from the
lower arm
Lower leg is flexed
Safety strap is applied over the hip, if
possible
An upper body restraint may be
necessary
Pillows are placed between the knees
and ankles
An axillary roll is placed
Arms are placed on a double padded
armboard. The palm of the lower hand
faces upward and the palm of the upper
5. Foot drop


hand faces downward
The head is in alignment with the spine
Support foot and ankle of upper leg
Kidney Position
The kidney position is a modification of the lateral position.
Body regions that may be accessed with the patient in the kidney position include:

Retroperitoneal space
The following potential hazards and necessary precautions apply to the patient in
the kidney position, in addition to those listed for the supine and lateral positions.
Potential Hazard
1. Abdominal compression



2. Circulatory compromise




Precautionary Action(s)
The large kidney rest is attached
anteriorly
Both kidney rests must be well padded
Be sure patient is positioned correctly
over the kidney lift
Lower kidney lift as soon as possible
Reduce table flexion as soon as
possible
Be sure patient is positioned correctly
over the kidney lift
Lower kidney lift as soon as possible
3. Venous stasis
Note: Reducing table flexion will also
facilitate tissue approximation
 Use antiembolism devices
Note: The dependent arm and leg are at
greatest risk
4. Shoulder pain
5. Muscle strain to the torso




6. Blood pressure changes


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Place a chest roll
Use the least possible amount of table
flexion
Reduce table flexion as soon as
possible
Be sure patient is positioned correctly
over the kidney lift
Lower kidney lift as soon as possible
Fluid management
Sims’ Position
The Sims’ position is a modification of the left lateral position. This is the
preferred position for endoscopy performed via the anus. The patient is often awake is
able to assist with positioning.
Body regions that may be accessed with the patient in the Sims’ position include:

Anus
The potential hazards and necessary precautions that apply to the patient in the
supine and lateral positions apply to the Sims’ position.
Prone Position
Prior to placement in the prone position, the patient is anesthetized on the gurney
or another OR table. All preoperative procedures, such as Foley catheter insertion, must
be performed prior to placement in the prone position.
Body regions that may be accessed with the patient in the prone position
include:

Posterior lower extremity

Dorsal body surface

Spine

Posterior cranium
The following potential hazards and necessary precautions apply to the patient in
the prone position, in addition to those previously listed for the supine position.
Potential Hazard
1. Pressure on abdominal contents and

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Precautionary Action(s)
Use chest rolls
thoracic compression
Note: The vena cava and abdominal aorta
are of particular concern
2. Pressure injury to skin, blood vessels,
and nerves



Use axillary rolls
Use antiembolism devices
Move breasts laterally

Place arms on armboards, rather than at
the patient’s sides
Be sure all pressure on the male
genitalia is removed
Place pillows under the knees and
ankles
Place padding under the knees
Flex arms on armboards with the palms
facing downward or along the sides of
the body with the palms facing inward
Use antiembolism devices
Elevate lower portion of the legs
Lower and rotate arms for placement on
armboards




3. Venous statis
4. Shoulder injury



Kraske (Jackknife) Position
The Kraske position is a modification of the prone position.
Body regions that may be accessed with the patient in the prone position include:

Anus

Pilonidal area
The following potential hazards and necessary precautions apply to the patient in
the Kraske position, in addition to those previously listed for the supine and prone
positions.
1.
Potential Hazard
Blood pressure changes

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Precautionary Action(s)
Return the patient to the horizontal
position slowly