Beach chair and lateral decubitus setup—pros and cons

CHAPTER 3 Beach chair and lateral decubitus setup—pros and cons



COL, Edward D. Arrington, MD, CPT(P) Stephen A. Parada, MD, LTC Bryant G. Marchant, MD



Key points



image Arthroscopic shoulder procedures are becoming increasingly popular as technology and arthroscopic instruments continue to evolve.

image Shoulder surgeons routinely use either the lateral decubitus position or the beach chair position for their cases, or their choice depends on the planned procedure.

image No difference has been proven in outcomes between lateral decubitus and beach positioning for shoulder arthroscopy procedures.

image Proper setup, including positioning and draping, is essential regardless of the planned patient position.

image Complications are rare: traction injuries may occur with the lateral decubitus position, whereas neurovascular injuries and cerebral hypoperfusion may result from the beach chair position.


Introduction


Shoulder arthroscopy and arthroscopic shoulder procedures have gained widespread popularity in the diagnosis and treatment of many pathologic shoulder conditions. Shoulder arthroscopy can be performed in either the lateral decubitus or beach chair position, and optimal positioning is essential for successful shoulder arthroscopic procedures. Positioning is routinely based on the surgeon’s familiarity with the arthroscopic shoulder orientation and the potential need for additional surgical procedures, such as an open procedure. Regardless of the position used, adequate positioning should allow for maximum access for surgery about the shoulder, the ability to move and rotate the shoulder, and ergonomic handling of arthroscopic instruments.


Positioning the patient correctly and safely can be a challenge during shoulder surgery, whether or not it is done arthroscopically or as an open procedure. Some shoulder surgeons use one position exclusively for all procedures regardless of the anticipated pathology in order to create familiarity with the setup. Other shoulder surgeons, after preoperative planning, routinely plan the positioning depending on the specific nature of the case and based on the anticipated pathology. While it is rare that a particular procedure can be performed exclusively in a certain position, pros and cons, as well as various complications, are specific to each position.



Lateral decubitus


Although the shoulder arthroscopy was first performed in 1931, it was not as used as extensively as knee arthroscopy until the 1980s, when its use became more popular. The lateral decubitus position has been a traditional position for shoulder arthroscopy, and it is now used exclusively by many surgeons. Lateral decubitus positioning is facilitated through the use of several different types of commercially available traction apparatus. This equipment, allows weight to be used to pull traction both longitudinally on the arm and laterally at the axilla to permit lateral translation of the glenohumeral joint. Distraction of the glenohumeral joint provides optimum visualization during arthroscopic procedures.1–3 In the lateral decubitus position, the surgeon and assisting surgeon can function on both the anterior and the posterior aspects of the shoulder, while ideally visualizing separate monitors (Fig. 3-1).


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FIGURE 3-1 Overview of the lateral decubitus operating room setup.


(Modified from a sketch by David J. Wilson, MD.)



Description of setup (figs. 3-1 to 3-12)


After induction of anesthesia, the patient is placed in the lateral decubitus position on a padded table with the well side down. The operating room table setup can be augmented with a gel pad or bean bag. Care is taken to pad all bony prominences. Particular attention is specifically directed to the proximal fibula of the downside leg in order to protect the peroneal nerve from compression. A pillow is also placed between the legs. A small gel pad is used as an axillary roll to reduce any risk of compression of the downside axilla. The head is padded so that the longitudinal axis of the neck is in a neutral position, and not abducted or adducted. The down ear is padded and the eyes protected during the case.


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FIGURE 3-2 Operating room bed setup with bean bag and sheet.


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FIGURE 3-3 Padded arm board for the down elbow.


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FIGURE 3-4 Axillary roll. This type is an inflatable axillary roll; however, an IV bag wrapped in a towel also works well.


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FIGURE 3-5 Patient positioned with two people holding while the vacuum suction to the bean bag is applied.


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FIGURE 3-6 At the edge of the bean bag where the leg meets the bag is a sharp point that should be padded to avoid potential pressure sores.


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FIGURE 3-7 A pillow under the bottom leg and between the bottom and top leg are used to prevent any leg compression injuries.


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FIGURE 3-8 Two towels are used on top of the bean bag, and then tape is secured to the table over the towels to secure the patient firmly to the table. Care is taken not to apply too much pressure or to squeeze in too tightly the bean bag.


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FIGURE 3-9 A, Patient setup. B, Posterior view of the lateral decubitus position using a beanbag. C, Predraping padded lateral decubitus position using a commercially available lateral position system.


(A modified from a sketch by David J. Wilson, MD.)


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FIGURE 3-10 A, Operative arm balanced suspension. Superior view of the lateral decubitus position. B, With operative setup. The arm is usually abducted between 45 and 60 degrees.


(A modified from a sketch by David J. Wilson, MD.)


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FIGURE 3-11 Final setup. The patient is turned 90 degrees (or up to 180 degrees) away from the anesthesia machine in order to facilitate anterior and posterior access to the shoulder.


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FIGURE 3-12 Final balanced suspension setup with the arm abducted about 50 degrees and a lateral strap is used to facilitate the visualization of the glenohumeral joint. Care must be taken to ensure the lateral suspension strap is around a padded arm sleeve.


To support the body in the lateral decubitus position, a bean bag is utilized. Excessive trunk motion or loss of positioning can occur if the bean bag loses suction pressure. This may be minimized with the use of straps or tape around the trunk, securing the patient to the operating room table. Alternatively, commercially available lateral positioning systems, such as those commonly used for hip arthroplasty cases, also may be used to provide a more stable support without compromising the intraoperative position of the patient. In the lateral decubitus position, the patient is tilted approximately 20 to 30 degrees posterior to orient the glenoid parallel to the floor.4


The drapes are applied judiciously in an effort to maximize the surgical field about the shoulder, both anteriorly and posteriorly. For an arthroscopic case, two arthroscopy drape drains can be used to collect as much effluent as possible. The operative side axilla is commonly sealed off with a sterile sponge and a sterile adhesive after prepping. Planned incision sites are made away from acne and pustules if possible to avoid potential contamination with Proprionibacterium.5


The arm is placed into a padded sleeve with the thumb pointing toward the ceiling and then is attached to one of the commercially available traction systems. These systems consist of a support that attaches to the end of the table and then uses a pulley system with weights to pull longitudinal balanced suspension on the arm and lateral traction in the axilla to obtain glenohumeral joint distraction.1–3 These pulleys and weights can be adjusted to provide abduction and forward flexion of the shoulder. The ideal forward flexion is 20 to 30 degrees and the ideal abduction is 25 to 45 degrees, although most surgeons adjust the abduction and forward flexion to personal preferences. Intraoperative changes in glenohumeral abduction, forward flexion, and lateral translation position are obtained easily by adjusting the pulley system. Intraoperative rotation of the humeral head can be adjusted by changing the position of the arm in the sleeve or by rotation of the entire sleeve.





Advantages of the lateral decubitus position


The lateral decubitus position has the following advantages:


1. It maintains steady joint distraction that enhances visualization in the glenohumeral joint and subacromial space.

Related posts:

Open surgical solutions for posterior instability of the shoulder Clinical history, examination, arthroscopic findings, and treatment of multidirectional instability Recognition and management of combined instability and rotator cuff tears Rehabilitation after posterior instability repair—open vs. arthroscopic Open bony augmentation of glenoid bone loss—the latarjet and variants—surgical technique Nonoperative rehabilitation for traumatic and atraumatic glenohumeral instability

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Jan 21, 2017 | Posted by in ORTHOPEDIC | Comments Off on Beach chair and lateral decubitus setup—pros and cons

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