Operating Theater Setup

Fig. 3.1

Images (a–f) illustrate the sequence of steps to correctly position the patient on the modular operating table. It is important to note that, in (f), the support behind the operative shoulder has been removed to guarantee a greater inter-operatory mobility of the limb

Fig. 3.2

A trapezoidal wedge pillow can serve in lieu of the modular operating table

Fig. 3.3

It is of paramount importance to have a proper head positioner to keep the patient’s head firmly in place during the operation. The endotracheal tube for respirator and anesthesia should be placed on the side opposite to the shoulder that will be operated

The mobility of the arm can be improved if the table segment that supports the operative shoulder is removed (Fig. 3.4). According to the surgeon’s preference, an arm holder can also be useful to rest the forearm of the operative limb at the level of the elbow.

Fig. 3.4

The table segment that supports the operative shoulder can be removed to achieve a greater degree of mobility of the limb

The greatest disadvantage of the beach-chair position is the difficulty in obtaining a full axillary projection with the C-arm. Furthermore, beach-chair positioning is recommended for arthroscopic fixations of fractures to the greater tuberosity of the humerus [9–12].

Supine position . This has the advantage of keeping the limb in a position that permits a true axial visualization without moving the arm (which is very useful for unstable fractures). However, the shoulder has a smaller range of movement compared to the beach-chair position. In our opinion, this surgical position is better suited for cases of percutaneous fixations after a closed reduction. It could be useful to shift the patient laterally so that the operative shoulder is toward the outside of the Table. A radiolucent table could then possibly be used to provide additional support.

The image intensifier needs to always be present in the operating room when performing an osteosynthesis, and it should be available also during a prosthetic replacement. The correct placement of the image intensifier is fundamental: even though it is usually placed behind the patient’s head [13–17] or on the side being operated on [18], in our opinion the most functional position is contralateral to the fracture. This makes it possible to obtain a good visualization without the C-arm getting in the surgical team’s way (Fig. 3.5). It is of paramount importance that the lower operating part of the table be cleared so that the C-arm can pass unobstructed. After placing the patient on the table, but before preparing the surgical site, a few tests should be carried out to ensure that the image intensifier can access every plane. Moreover, correctly defining the orientation of the C-arm is also useful in obtaining a true anteroposterior (AP) view.

Fig. 3.5

The image intensifier should be positioned contralateral to the operative limb in order to get the best visualizations without getting in the way of the surgical team

The same preliminary tests should be performed if the C-arm is positioned behind the patient’s head (parallel to the longitudinal axis of the patient), making sure the image intensifier does not get in the anesthesiologist’s way. As a matter of fact, the anesthesiologist usually stands behind the patient’s head: this place is both convenient and strategic in case a rapid intervention is required because it does not interfere with the surgeons, who can keep on working unobstructed and at their best. The endotracheal tube for the anesthesia should be positioned in the corner of the mouth opposite to the side that is being operated on (Fig. 3.3).

Most of the cases only require two surgeons; in case a third one is needed, this additional member of the surgical team usually stands on the other side of the table by the nonoperative limb. In this way, the anesthesiologist is placed between the surgeons; however, it could also be useful for the anesthesiologist to stand by the patient’s healthy side, leaving the place behind the subject’s head for the third surgeon (Fig. 3.6).

Fig. 3.6

I first surgeon, II second surgeon, III third surgeon, A anesthesiologist, N operating nurse, P patient, R image intensifier. The black arrow indicates that the position of the third surgeon can be on either side of the patient depending on the type of surgery

The type of anesthesia needs to be discussed with the patient. The options available are either general anesthesia or brachial plexus block that can be potentially accompanied by sedation [13, 16, 19, 20]. Because of the close proximity of the surgical site to the subject’s head, we prefer the former option; furthermore, general anesthesia also ensures a greater degree of tranquility in case the operation lasts longer than expected or if a minor surgery turns into a prosthetic replacement or in an open reduction and internal fixation.

3.3 Costumes and Props

A dermographic marker can be helpful to draw the approach and the useful landmarks (Fig. 3.7). For a transdeltoid approach, the longitudinal lateral axis of the humerus and the lateral contour of the acromion should be drawn; from this point distally measure 5 cm and trace a line perpendicular to the humeral diaphysis: the axillary nerve is usually located in this area [21]. For the deltopectoral approach, the useful landmarks are the acromion and the coracoid process. For the anterolateral approach, instead, only the contour of the acromion, the acromioclavicular joint, and the longitudinal lateral axis of the humerus need to be traced. When performing a fixation with percutaneous pinning, it can be very useful to mark the intersection of the deltoid with the humeral diaphysis (the axillary nerve branches in front of the deltoid tuberosity and it will be harder to damage it with the pins) and the coracoid process (which tells us the correct direction to insert the pins). The lines traced with the dermographic marker can be useful for surgeons to help them orient themselves during the procedure; they are also helpful to those who have to prepare the operating field by giving them an idea of the area they need to circumscribe with sterile drapes.

Fig. 3.7

With the appropriate dermographic marker, trace the landmarks useful to the specific surgical procedure: for the deltopectoral approach (blue line), highlight the site of the coracoid, of the conjoint tendon, of the coracoacromial ligament, of the deltoid insertion, of the acromion, and of the acromioclavicular joint (red lines)

Before preparing the surgical site , we recommend washing the axilla with chlorhexidine and a sponge. From our multicenter study mentioned in the beginning of this chapter, we can infer that the preoperative washing of the site can significantly reduce the risks of postsurgical infections (ODDS 0.13, p = 0.008) [1].

The drapes to prepare the operating field should not be chosen at random. Surgical drapes with circular aperture should only be used if there is the certainty that the procedure that will be performed is a closed reduction and percutaneous fixation. With this type of drape, in fact, it is not possible to perform a deltopectoral approach, which could be necessary if, during the procedure, the surgeons decided not to perform a closed reduction and internal fixation, opting instead for an open reduction and internal fixation or a prosthetic replacement. When using a U-drape, a sufficient portion of the mammary surface should remain exposed (Fig. 3.8a).

Fig. 3.8

(a) Preparing the surgical site can involve the use of a stockinette, which can be wrapped with a cohesive bandage; U-drapes need to be placed in such a way that a sufficient portion of the mammary surface remains exposed. (b–d) Steri-Drape can be useful to guarantee a safer procedure, but it must also ensure the shoulder’s complete mobility

The use of Steri-Drape (3M, Maplewood, Minnesota, St. Paul I-94 at McKnight Road) is debatable. It is better not to use it in cases involving percutaneous fixation because it could get in the way of the insertion point for the pins. Conversely, we recommend using it for open reductions and especially for prosthetic replacements. The complete coverage of the axilla can be achieved with the double layering technique used in hip surgery.

We suggest using a stockinette (Fig. 3.8); it should be unrolled no further than the distal extremity of the humerus, so as to isolate the hand and to allow for a safer procedure. It can be very helpful to wrap it with a cohesive bandage (e.g., Peha-haft, Paul Hartmann Ltd Heywood Distribution Park Pilsworth Road, Heywood, Lancashire) to prevent the stockinette from getting in the way or from unraveling; make sure the thumb is isolated, so the rotations during surgery can be controlled better.

As far as the instrumentation goes, we suggest preparing a range of equipment that would allow the surgical staff to deal with all surgical operations but which should be supplemented with specific items depending on the particular kind of surgery planned. The general tool kit should always include:

Self-retaining retractors (if there are not enough members in the surgical team)

Hohmann retractors of various sizes and one with a rounded end (to use on the humeral metaphysis)

Double hook retractors (to expose the glenoid cavity)

Fukuda retractors: two small and one large (to retract the humeral head without damaging it)

Electric drill and thread separator

Drills tips (a 2 mm and a 3.2 mm)

Richardson retractors (to retract muscle tissue and, in particular, the conjoint tendon toward the brachial plexus and deltoid)

Steinmann pins (to use as a joystick in case of a difficult reduction of multiple fragments)

Museaux clamps to clasp the humeral head in case it needs to be removed (especially if the dislocated head is in the axillary cavity)

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