Complications Associated With Patient Positioning in Urologic Surgery

Versatility of Single Port Retroperitoneal Low Anterior Access: Early Outcomes in Multiple Procedures

Purpose: This study aimed to assess early outcomes of the single port (SP) robotic low anterior access (LAA) for all upper urinary tract surgeries. In addition, it aimed to explore the impact of clinical factors, notably Body Mass Index (BMI), on post-operative outcomes and length of hospital stay. Materials and Methods: Overall, 76 consecutive patients underwent SP robotic surgery with LAA involving all upper urinary tract pathologies, with data collected prospectively. Baseline characteristics, intra- and post-operative outcomes, pain levels, and opioid use were analyzed. Statistical methods, including logistic regression and locally weighted scatterplot smoothing analysis, were used to assess same-day discharge (SDD) predictors and the association between BMI and SDD probability. According to the Institutional Review Board (IRB) protocol, only data recorded in our electronic medical record system was included. Results: Ten different procedures were performed with LAA, with no need for conversion to open surgery and complication rates in line with the literature (30 days: 5%, 90 days: 6.6%). Notably, 77.6% of patients were discharged on the same day. A significant association was found between BMI and prolonged hospital stay, particularly in obese patients (BMI ≥30 kg/m2). Post-operative pain was generally low (median VAS: 4), with over 70% discharged without opioid prescriptions. Conclusions: The novel LAA is a versatile approach for various upper urinary tract surgeries, including in obese patients. While achieving satisfactory post-operative outcomes, increased BMI correlated with a reduced likelihood of SDD. Further studies, including larger cohorts and multicenter collaborations, are warranted to explore anesthesiologic management and validate these findings.

Prevention of complications in endourological management of stones: What are the basic measures needed before, during, and after interventions?

Objective

This narrative review aims to describe measures to minimise the risk of complications during percutaneous nephrolithotomy (PCNL), ureteroscopy, and retrograde intrarenal surgery.

Methods

A literature search was conducted from the PubMed/PMC database for papers published within the last 10 years (January 2012 to December 2022). Search terms included "ureteroscopy", "retrograde intrarenal surgery", "PCNL", "percutaneous nephrolithotomy", "complications", "sepsis", "infection", "bleed", "haemorrhage", and "hemorrhage". Key papers were identified and included meta-analyses, systematic reviews, guidelines, and primary research. The references of these papers were searched to identify any further relevant papers not included above.

Results

The evidence is assimilated with the opinions of the authors to provide recommendations. Best practice pathways for patient care in the pre-operative, intra-operative, and post-operative periods are described, including the identification and management of residual stones. Key complications (sepsis and stent issues) that are relevant for any endourological procedure are then be discussed. Operation-specific considerations are then explored. Key measures for PCNL include optimising access to minimise the chance of bleeding or visceral injury. The role of endoscopic combined intrarenal surgery in this regard is discussed. Key measures for ureteroscopy and retrograde intrarenal surgery include planning and technique to minimise the risk of ureteric injury. The role of anaesthetic assessment is discussed. The importance of specific comorbidities on each step of the pathway is highlighted as examples.

Conclusion

This review demonstrates that the principles of meticulous planning, interdisciplinary teamworking, and good operative technique can minimise the risk of complications in endourology.

Postoperative rhabdomyolysis following otoplasty: an autopsy case report

Postoperative rhabdomyolysis is a significant complication that can arise from prolonged surgery, causing potential harm to the kidneys and leading to acute renal failure. Despite its importance, the incidence of rhabdomyolysis following ear reconstruction surgery remains undocumented in the literature. In this report, we present a case study of a male patient in his forties who underwent otoplasty for ear reconstruction after the amputation of his right ear due to a physical assault. The surgery lasted for 8 h under general anesthesia, and unfortunately, the patient developed postoperative rhabdomyolysis, which resulted in severe renal failure and ultimately an unrecoverable cardiac arrest, leading to his death. The autopsy findings indicated no identifiable lesions except for organ congestion, while histopathology revealed acute tubular necrosis of the kidney and muscle rhabdomyolysis. Previous literature has explored the association between surgical duration, location, and rhabdomyolysis, underscoring that this condition is an infrequent yet preventable consequence of prolonged surgery. The co-occurrence of rhabdomyolysis and acute renal injury in this case suggests the presence of comorbidity, emphasizing the need for prompt action to mitigate the negative consequences of rhabdomyolysis. Awareness and early intervention are crucial in preventing and managing this condition effectively.

Effect of patient positioning on anesthesiologic risk in endourological procedures

Objective

The objective is to compare supine and prone positions in terms of arterial blood gas during lithotripsy endourology procedures in different stages.

Material and Methods

Cases of during lithotripsy endourology procedures in our department from March to September 2020 were included prospectively. The variables registered were body mass index, age, the American Society of Anesthesiologists (ASA) score, diabetes mellitus, positive end-expiratory pressure (PEEP), FiO2, stone size, stone location, procedural type, position, procedure duration, PaO2, SaO2, PaCO2, pH, and dynamic compliance. PaO2, SaO2, PaCO2, pH, and dynamic compliance were recorded at the beginning of the procedure, 5 min later, 15 min later, and at the end of the procedure.

Results

Thirty patients in prone position and 30 in lithotomy position were included in this study. Patients in prone position underwent percutaneous nephrolithotomy, and patients in supine/lithotomy underwent retrograde intrarenal surgery or ureteroscopy. Statistically significant differences were found in PEEP, duration, PaO2 at the beginning, SaO2 at the beginning and at the end of the procedure, PaCO2 at the beginning and at minute 5 and pH at the beginning of the surgery. The saturation PaO2 increased significantly on prone position and was statistically significantly better at the end of the surgery.

Conclusions

Both prone and supine positions were safe regarding anesthesiologic risk and had no clinically relevant differences in terms of individual comparisons in arterial blood gas parameters in static moments of the procedure. Prone position was related to an increase in PaO2 and a drop in PaCO2 gradually from the beginning to the end of the surgery.

A Novel Positioning Technique for Olecranon Fracture Fixation

Various positioning techniques have been described for the osteosynthesis of olecranon fractures, each with their own pros and cons. The supine position is time-efficient and better suited in a polytrauma setting but frequently requires an assistant to maintain optimal limb positioning. Also, adequate fluoroscopic imaging is not possible without moving the operative extremity outside the sterile field. We describe a simple and reproducible method addressing these limitations while providing excellent surgical access and intraoperative imaging.

Factors Associated With Peripheral Nerve Injury After Pelvic Laparoscopy: The Importance of Surgical Positioning

BACKGROUND

Nerve damage after abdominal and pelvic surgery is rare but potentially serious. The incidence of peripheral nerve injury is difficult to assess, and rates of between 0.02% and 21% have been cited in the literature. Signs and symptoms of this type of injury may appear immediately after surgery or a few days later.

PURPOSE

This study was developed to assess the rate of peripheral nerve injury after pelvic laparoscopy and to identify associated risk factors.

METHODS

A pilot prospective cohort study was conducted between March 2018 and April 2019 on 101 patients with a 1-month follow-up using two semistructured clinical interviews. We carried out a descriptive analysis followed by univariable and multivariable logistic regression analyses.

RESULTS

Thirteen patients were found to have peripheral nerve injuries, representing a rate of 12.9%. Overall, 14 injuries (five severe and nine mild) were detected. One patient had two mild injuries. In this study, the risk of injury was found to increase 1.77-fold (OR = 1.77, 95% CI [1.13, 2.76], p = .007) for each hour the patient was in the Trendelenburg position.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The longer the patient is in the Trendelenburg position, the greater the risk of peripheral nerve damage. Patients aged 60 years or less also face a higher risk of nerve injury.

Position-related anesthesiologic considerations and surgical outcomes of prone percutaneous nephrolithotomy: a review of the current literature

The aim of the current study was to perform a critical review of existing literature and report the potential morbidity of patient positioning during urological surgeries as well as evaluate the surgical outcomes and anesthesiologic benefits and risks of prone percutaneous nephrolithotomy (PCNL). A narrative review of the current literature has been performed. Articles related to position-related injuries and complications under general anesthesia in prone positions were selected, studied, and considered for the current review. We found that under general anesthesia, the prone position improved the oxygenation of patients and increased the elimination of carbon dioxide. A potential risk for position-related anesthesiologic side effects was reported for longer spine surgeries in a prone position. The injuries and position-related side effects were extremely rare following prone PCNL since the mean duration of the procedure was significantly shorter than that of spine surgery. In conclusion, the prone PCNL remains the most often utilized and preferred approach globally with well-established success and complication rates. Clinical outcomes of prone PCNL do not demonstrate an increased rate of anesthesiologic complications compared to the supine approach. Standardization of turnover of the position, and reduction of the operative time warrant a faster and complication-free recovery.

Preventing patient positioning injuries in the nonoperating room setting

PURPOSE OF REVIEW

Postprocedural positioning injuries are an under-appreciated source of morbidity for patients. These injuries may not present until days after anesthesia and may be missed for multiple reasons including the distracting injury of the procedural site, illness of the patient, lack of follow-up, and insufficient awareness of this type of injury. Risks for these adverse events are exacerbated in the nonoperating room anesthesia (NORA) population for several reasons. These patients tend to be older and sicker than patients presenting to the operating room, increasing the risk of an injury. Proceduralists and anesthesia providers are usually consultants, not the primary care team, so may have limited patient follow-up. This review will discuss the risk factors for position-related injuries and how to prevent them with proper positioning and padding.

RECENT FINDINGS

The mainstay of preventing periprocedural positioning injuries is careful positioning of the patient and proper padding of pressure points. This may be particularly challenging because of physical constraints and positioning requirements for NORA procedures, as well as preference for radiolucent positioning materials. Recent studies have shown the potential benefit of monitoring somatosensory evoked potentials (SSEP) in high-risk patients.

SUMMARY

Careful consideration of patient positioning and thorough understanding of peripheral nerve and pressure injuries is essential for anesthesia providers to avoid positioning injuries during NORA procedures.

VIDEO ABSTRACT

http://links.lww.com/COAN/A87.

Comparison outcomes of percutaneous nephrolithotomy in prone and flank position in obese patients: A randomized clinical trial

BACKGROUND

The aim of this study was to compare the complications of percutaneous nephrolithotomy (PCNL) surgery in Flank and Prone positions in patients with a BMI above 30.

METHODS

In this randomized clinical trial patients were randomly assigned to PCNL treatment in one of two groups undergoing PCNL under fluoroscopic guidance in Flank or Prone positions. Patient demographic information, stone number, size and location, stent duration, hospital stay, blood loss, Creatinine, hemoglobin, hematocrit changes, and arterial blood gas changes and acid-base hemostasis were collected.

RESULTS

In this study, 60 patients were examined, which were divided into two groups of 29 people, prone and 31 people. Mean stone size was 3.16 ± 0.82 cm. arterial blood gases did not differ significantly between two groups. The SFR (stone free rate) in the prone and flank groups was 91.02% and 86.89%, respectively. However, SFR and Complications in the prone and flank groups were not significantly different (p value of 0.081 and 0.13, respectively).

CONCLUSIONS

According to the results of this study, PCNL complications and acid-base changes is not significantly different in flank and prone positions in obese patients. However, SFR is slightly lower in flank group. Thus, PCNL in flank position is not superior to prone position in obese Patients. It is recommended to choose each of these surgical methods according to the surgeon's facilities and skills.

Position-Related Postoperative Peripheral Neuropathy After Laparoscopic Colorectal Surgery: A Comparative Single-Center Prospective Cohort Study

Background: Laparoscopic colorectal surgery requires perioperative positioning in the dorsal lithotomy position and intermittent Trendelenburg position. This position is associated with postoperative peripheral neuropathy (PPN), which is a substantial cause of anesthesia-related claims. The objective of this study was to assess the incidence of PPN of patients positioned in lithotomy position with shoulder braces, and second to compare this group with patients positioned on the foam mattress Pink Pad^®. Materials and Methods: This consecutive single-center prospective cohort study of 155 patients undergoing colorectal surgery was performed between November 2014 and June 2015. After initial results the implementation of the Pink Pad took place and a total of 52 patients were included between May 2016 and February 2017 to compare the two groups. Results: Positioning with the shoulder brace regimen during laparoscopic colorectal surgery was related to the development of PPN in 33% of cases, as opposed to 15% with Pink Pad. Positioning with shoulder braces increased the risk of PPN with an odds ratio of 3.14 (95% confidence interval: 1.10-8.992) when compared with positioning on Pink Pad. Conclusion: Position-related PPN is an important complication after laparoscopic colorectal surgery. This study concludes that careful attention should be paid to positioning and favors Pink Pad over positioning with shoulder braces. Prolonged time in anesthesia is a predictor of PPN. Clinical Trial Number: H-2-2014-FSP75.

Flexible Ureteroscopy as the New Standard for the Management of Renal Transplant Urolithiasis <15 mm: A Single-Center Experience

Objectives: To determine the safety and efficacy of flexible ureteroscopy in the treatment of transplant urolithiasis. Materials and Methods: We reviewed a single-center series of 2652 patients who underwent surgical treatment for nephrolithiasis at our institution from 2009 to the present day to identify all patients undergoing ureteroscopy for treatment of transplant lithiasis. Results: We identified 18 patients who underwent ureteroscopy for treatment of urolithiasis within the transplanted kidney or ureter. The majority of the procedures were performed using a retrograde approach with flexible ureteroscopy, with one patient undergoing antegrade ureteroscopy and two patients requiring semirigid ureteroscopy. Holmium:yttrium-aluminum-garnet laser lithotripsy was utilized in all but one case, which was performed using basket extraction. There were no intraoperative complications reported. Four patients had small stone fragments on postoperative imaging, three of which were observed. One patient required repeat ureteroscopy for persistent distal ureteral stone. Conclusion: Retrograde ureteroscopy is a feasible, safe, and effective intervention for the treatment of transplant lithiasis. Minimal intraoperative or postoperative complications were reported, and only one patient required additional intervention for residual stone burden.

The Modified Prone Jack-knife Position for the Excision of Female Urethral Diverticula

BACKGROUND

Female urethral diverticula (UD) are an uncommon and often overlooked aetiology in women presenting with lower urinary tract symptoms, urethral pain, and recurrent urinary tract infection. With increasing awareness, appropriate imaging is more commonly undertaken with consideration given to surgical management.

OBJECTIVE

The video presented demonstrates the technique for excising large and/or complex UD using a modified prone jack-knife position-a position that offers excellent surgical access and allows the surgeon to operate in a more ergonomic position.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective review of the data on patients undergoing excision of UD at a tertiary referral unit was performed.

SURGICAL PROCEDURE

Urethral and suprapubic catheters (±insertion of ureteric stents) were placed in supine position. UD excised in the modified prone jack-knife position (±placement of a Martius flap).

MEASUREMENTS

Subjective cure rate, recurrence rate, rates of postoperative urinary incontinence, need for secondary incontinence procedure, and postoperative complications were measured.

RESULTS AND LIMITATIONS

A total of 121 patients were operated on in the study period. The mean follow-up time was 10 mo (range 3-40). The most frequent presenting symptoms included a vaginal mass (n = 76, 63%), followed by dysuria (n = 72, 60%) and pelvic pain (n = 71, 59%). An identifiable aetiological factor was present in 45 patients, including traumatic vaginal delivery (18, 15%), prior periurethral surgery (17, 14%), and urethral dilatation (10, 8%). All patients underwent postvoiding magnetic resonance imaging (MRI) to confirm the diagnosis and plan surgery. UD ranged in maximum diameter from 8 to 48 mm, with a mean of 43 mm (standard deviation 9.24). The most common anatomical location was midurethral (55, 46%), followed by distal (36, 30%), proximal (25, 21%), and full length (5, 4%). Most UDs were single in configuration (74%), followed by multiloculated (15%), saddle shaped (7%), and circumferential (5%). On preoperative videourodynamics, 17 (14%) had stress urinary incontinence. UD excision was undertaken in the modified prone jack-knife position in all cases. A Martius flap was utilised in 36 (30%). The median postoperative postvoiding residual was 26 ml (interquartile range 0-40). In total, 88 (73%) patients were continent postoperatively and 16 (13%) experienced de novo stress urinary incontinence. Of the 37 with pre-existing stress incontinence symptoms, 20 (54%) were continent after operation. A total of 14 patients had subsequent autologous fascial sling at 6 mo. In total, five symptomatic recurrences occurred (4%); of these patients, three elected to undergo surgical excision, all of whom had symptom resolution and were continent after operation. A total of 11 patients (9%) experienced a Clavien-Dindo grade I-II complication within 90 d after operation. Five patients complained of dyspareunia, which resolved by 6 mo.

CONCLUSIONS

The modified prone jack-knife position facilitates excellent access for excision of both simple and complex UDs. This positioning of the patient is not widely recognised amongst urologists. Using this approach, there were low rates of symptomatic recurrence and de novo stress incontinence at medium-term follow-up. Associated urinary incontinence resolves in over half of patients following UD excision; hence, we advocate deferring any incontinence procedure until after the results of surgery are established.

PATIENT SUMMARY

Surgical removal of urethral outpouching (diverticula) in women is challenging due to its potential to damage the nearby sphincter muscle, which controls continence, or the urethra tube. Placement of patients on their front, rather than on their back, provides excellent access for the surgical removal of urethral diverticula. With this approach, we achieved excellent rates of cure and low rates of urinary incontinence at an average follow-up of 10 mo.

Decreasing the prospect of upper extremity neuropraxia during robotic assisted laparoscopic prostatectomy: a novel technique

Risk of intraoperative neuropathic injury in minimally invasive surgery has been established as a leading complication. Continuous intraoperative neuromonitoring (IONM), such as upper extremity somatosensory evoked potentials (ueSSEPs), to decrease peripheral nerve injury due to positional stress has been described. Robotic-assisted laparoscopic prostatectomy (RALP) requires steep Trendelenberg, which may predispose patients to upper extremity neuropraxia. Subdermal stimulating electrodes were placed on the patients' bilateral wrists over the ulnar nerve and the nerve was stimulated. Realtime waveforms were compared to baseline data to prevent and detect injury to the ulnar nerve. Established intervention criteria, indicating risk for neuropathic damage necessitating intraoperative patient repositioning, was a 50% loss in amplitude or a 10% increase in latency. One hundred and forty three patients received RALP with IONM. 17 of 143 patients (11.8%) met ueSSEP intervention criteria. Only weight was significantly different between the two groups (p = 0.04). Mean reduction in amplitude was 79.9% (SE 4.1). Average amplitude loss duration was 22 min (SE 4.0). Weight and BMI were correlated to the degree of amplitude reduction (p = 0.03 and < 0.01), while operative time and DM approached significance (p = 0.09 and p = 0.14). This is the first study to use IONM to reduce the risk of nerve injury during genitourinary surgery. Realtime nerve monitoring using ueSSEP allowed for upper extremity intraoperative monitoring and repositioning. This may decrease the risk of upper extremity neuropraxia due to malpositioning during RALP. Weight and BMI were identified as risk factors for possible nerve injury. Further data collection and analysis to preoperatively stratify patients for application of IONM during RALP is currently ongoing.

Intraoperative peripheral nerve injury related to lithotomy positioning with steep Trendelenburg in patients undergoing robotic-assisted laparoscopic surgery - A systematic review

AIMS

To examine the incidence of intraoperative peripheral nerve injury, symptoms, risk factors, functions, and quality of life in patients undergoing robotic-assisted laparoscopic surgery to lithotomy positioning with steep Trendelenburg.

DESIGN

A systematic review.

DATA SOURCES

The Cochrane Library catalogue, PubMed, EMBASE, CINHAL and SveMed + databases were searched from January 2000 - February 2019.

REVIEW METHODS

Titles and abstracts were screened for inclusion. Full-text assessments of each paper were conducted by two reviewers. The quality of the included papers was assessed using the Mixed Methods Appraisal Tool. Descriptive statistics and thematic analysis were used to synthesize the data.

RESULTS

Eleven quantitative studies were included with three themes: (a) incidence of intraoperative peripheral nerve injury; (b) upper extremity intraoperative peripheral nerve injury related to steep Trendelenburg positioning; and (c) lower extremity intraoperative peripheral nerve injury related to lithotomy positioning. The overall incidence of intraoperative peripheral nerve injury in robotic-assisted laparoscopic urologic, gynaecologic and colorectal surgery was 0.16%-10.0% and the symptoms appeared immediately after surgical procedures. Risk factors for intraoperative peripheral injury were prolonged operative time, high American Society of Anesthesiologists scores, comorbidities and high body mass index.

CONCLUSION

Intraoperative peripheral nerve injuries are rare, but occasionally serious when related to lithotomy positioning with steep Trendelenburg. Operating room nurses have a responsibility both for positioning patients and for being familiar with the technological developments that will influence the preoperative handling of patients.

IMPACT

This systematic review emphasizes the need for operating room nurses together with surgical team to have knowledge about mechanisms for injury, positioning, anatomy/physiology, and evaluation of risk factors to ensure that patients are not exposed for intraoperative peripheral nerve injuries. Increased robotic-assisted laparoscopic surgery necessitates further research examining the incidence of intraoperative peripheral nerve injury related to positioning and how these affect patients' function and the quality of life.

Well-Leg Rhabdomyolysis After Prolonged Knee Arthroscopy: A Case Report

CASE

We present the case of an obese patient who underwent combined arthroscopic and open multiligamentous knee reconstruction who, 3 months later, required revision arthroscopic anterior cruciate ligament and posterior cruciate ligament reconstruction with open lateral collateral ligament and posterolateral corner reconstruction lasting 6 hours 30 minutes. The patient developed rhabdomyolysis of the nonoperative leg after the revision procedure. Both procedures were performed in a hemilithotomy position with a commonly used leg positioner.

CONCLUSIONS

Complications secondary to patient positioning are a source of unnecessary patient morbidity. Surgeons should be mindful of the nonoperative extremity, particularly during prolonged cases in obese patients. Prompt diagnosis and multidisciplinary treatment can lead to the resolution of symptoms without long-term sequelae.

Analgesic effect of trigger point injection and EMLA for shoulder pain in patients undergoing total laparoscopic hysterectomy: A randomized controlled study

BACKGROUD

The purpose of this study was to evaluate the effects of trigger point injection (TPI) and eutectic mixture local anesthetics (EMLA) cream on the postoperative shoulder pain in patients undergoing total laparoscopic hysterectomy.

METHODS

In this randomized, single-blinded, and controlled study, total 75 patients were randomly allocated to TPI group (n = 25), EMLA group (n = 25), and control group (n = 25). TPI group received TPIs with 2 mL of 0.2% ropivacaine, and EMLA group received an occlusive dressing with EMLA cream 2 g on both shoulders. Overall, abdominal, and shoulder pains were evaluated at rest and in motion on postoperative day 3.

RESULTS

The incidence of shoulder pain was significantly reduced in EMLA group (56%) compared to control (88%) or TPI (88%) groups (P = .025 in both); the severity of shoulder pain was mitigated in EMLA and TPI groups compared to control group (P < .001, each). Consequently, the overall pain decreased in EMLA group and TPI group (P = .023). The patients with exercise habit (n = 31) showed lower incidence of pain than patients without exercise habit (n = 26) (P = .002, P = .005, and P = .037 in overall, abdominal, and shoulder pain, respectively). TPI or EMLA treatments decreased shoulder pain irrespective of exercise habit (P = .001 and P < .001, respectively), but decreased overall pain only in patients without exercise habit (P = .019). Lastly, EMLA lowered overall pain score at the time of first analgesic request in ward compared to control group (P = .02).

CONCLUSIONS

TPI and EMLA with occlusive dressing effectively reduced the shoulder pain after total laparoscopic hysterectomy.

Patient positioning for robot-assisted laparoscopic benign gynecologic surgery: A review

Robotic surgical platforms are now in widespread use in the practice of gynecology all over the world. The introduction of robotic surgery has required some modifications of patient positioning when compared to standard laparoscopic surgery. Optimal patient positioning is likely to be the most essential step of robotic surgery as it provides the technical feasibility to have adequate access to the pelvic structures for performing the surgery. It is prudent to pay attention to preventing patient shifting in Trendelenburg position because of tendency of sliding down toward the direction of the head. Inappropriate patient positioning is associated with inadequate exposure of the operative field as well as detrimental complications that may lead to long-term side effects. These issues can be reduced with use of proper or strategic positioning technique. The purpose of this review is to highlight important points to properly position patient for robot-assisted laparoscopic benign gynecologic surgery and protect patient from position-related injuries.

The Prevention and Recognition of Ulnar Nerve and Brachial Plexus Injuries

Perioperative peripheral nerve injury is a serious yet preventable perioperative complication. Since the inception of the American Association of Anesthesiologists Closed Claim Project, the incidence of peripheral nerve injury has remained constant with an overall reported prevalence rate of 15% to 16%. To date, the most frequent nerve injuries are ulnar nerve neuropathy and brachial plexus injury. This article will review the clinical presentation, pathophysiology, causative and risks factors, and preventive measures for the two most common nerve injuries. Knowledge of the anatomical structures and components of peripheral nerves prone to injuries during surgery can assist in defining precautionary actions in the perioperative setting. Positioning techniques in the operating room, early recognition of neuropathies, and use of a perioperative tool in the postoperative setting are keys to reduce significant clinical complications.

Guideline Implementation: Positioning the Patient

Every surgical procedure requires positioning the patient; however, all surgical positions are associated with the potential for the patient to experience a positioning injury. The locations and types of potential injuries (eg, stretching, compression, pressure injury) depend on the position. Factors that may increase the patient's risk for an injury are the length of the procedure and risk factors inherent to the patient (eg, weight, age, frailty). AORN's updated "Guideline for positioning the patient" provides guidance on injury prevention practices for all surgical positions including supine, Trendelenburg, reverse Trendelenburg, lateral, lithotomy, prone, and sitting positions and modifications of these positions. This article focuses on the key points of the guideline covering the use of prophylactic dressings, neurophysiological monitoring, and safely positioning the patient in the supine and prone positions. Perioperative RNs should review the complete guideline for additional information and for guidance when writing and updating policies and procedures.

Optimal dose of succinylcholine for laryngeal mask airway insertion: systematic review, meta-analysis and metaregression of randomised control trials

OBJECTIVES

To evaluate the optimal dose of succinylcholine for laryngeal mask airway (LMA) insertion and all related morbidities.

DESIGN

Systematic review, meta-analysis and metaregression of randomised controlled trials (RCTs).

DATA SOURCE AND STUDY ELIGIBILITY CRITERIA

A comprehensive search of RCTs in the PubMed, Embase, the Cochrane Library and the ClinicalTrials.gov registry up to July 2016 and articles that evaluated the use of succinylcholine chloride for LMA insertion were included in the analyses. The relative risk (RR) and the corresponding 95% CIs were determined.

INTERVENTION

Succinylcholine as the coinduction agent and the doses were divided into mini (≤0.3 mg/kg) and low (0.3-1.0 mg/kg) doses for dose-dependent effect analyses.

PRIMARY AND SECONDARY OUTCOMES

The primary outcome was the first-attempt LMA insertion failure rate. Secondary outcomes included all related adverse events.

RESULTS

Data from 10 RCTs comprising 625 participants showed that succinylcholine reduced the first-attempt LMA insertion failure rate (RR, 0.22; 95% CI 0.12 to 0.43), coughing and gagging (RR, 0.26; 95% CI 0.15 to 0.45) and laryngospasm (RR, 0.14; 95% CI 0.05 to 0.39). The use of succinylcholine did not result in a significant increase of postoperative myalgia (RR, 2.58; 95% CI 0.79 to 8.44) and did not reduce the risk of postoperative sore throat (RR, 0.76; 95% CI 0.55 to 1.03). Subgroup analysis further showed that low-dose succinylcholine reduced the LMA insertion failure rate and its related coughing and gagging when compared with mini dose.

CONCLUSION

The use of succinylcholine compared with none can facilitate LMA insertion and reduce insertion-related reflexes without significant postoperative myalgia. However, additional prospective studies with a larger sample size are required to fully evaluate the dose-dependent effect and complications of succinylcholine for LMA insertion.

[Surgical positioning techniques in urology : Tips and tricks]

Correct positioning of patients during preoperative preparations is essential for success of the intervention to avoid any positioning trauma and to provide the best access to the targeted structures. The appropriate positioning (and optimal performance) means that complications are avoided and also makes an essential contribution to the smooth course of the surgical intervention. A correct position is essential particularly in urology because the organs assigned to the discipline of urology are anatomically mostly difficult to reach. A further important function of the correct positioning technique is the avoidance of injuries to the patient. This article summarizes the most common positioning techniques in urological interventions with special emphasis on the explanation of practical advice, helpful tips and possible complications that can enable even junior surgeons to correctly perform the appropriate positioning technique.

Patient positioning during minimally invasive surgery: what is current best practice?

Introduction

Positioning injuries are a known surgical complication and can result in significant patient morbidity. Studies have shown a small but significant number of neurovascular injuries associated with minimally invasive surgery, due to both patient and case-specific factors. We sought to review the available literature in regards to pathophysiological and practical recommendations.

Methods

A literature search was conducted and categorized by level of evidence, with emphasis on prospective studies. The result comprised 14 studies, which were summarized and analyzed with respect to our study objectives.

Results

While incidence of positioning injury has been identified in up to one-third of prospective populations, its true prevalence after surgery is likely 2%-5%. The mechanism is thought to be intraneural disruption from stretching or pressure, which results in decreased perfusion. On a larger scale, this vascular compromise can lead to ischemia and rhabdomyolysis. Prevention hinges on addressing patient modifiable factors such as body mass index, judicious positioning with appropriate devices, and intraoperative team awareness consisting of recurrent extremity checks and time management.

Conclusion

The risk for positioning injuries is underappreciated. Surgeons who perform minimally invasive surgery should discuss the potential for these complications with their patients, and operative teams should take steps to minimize risk factors.

Prospective assessment of positioning-related pain in robotic urologic surgery

This was a prospective study to assess positioning-related pain in 20 awake volunteers in the dorsal lithotomy (DL) and lateral decubitus (LD) positions. Each volunteer was put through the series of discrete, sequential steps used to achieve a final position; each step had two options. The Wong-Baker scale (WB) was used to rate pain for each option and the preferred option and ad lib comments were recorded. We found that awake volunteers could clearly and immediately distinguish differences in pain levels between position options. For the DL position, volunteers favored having the arms slightly flexed and pronated as opposed to being straight and supinated reflected by statistically less painful WB scores and option preference. Volunteers preferred having the neck flexed as opposed to being flat. For the LD position, volunteers reported statistically lower pain scores and preference for a foam roll for axilla support as opposed to a rolled blanket, the table flexed without the kidney rest as opposed to a raised kidney rest, and the over arm board as oppose to stacked blankets for contralateral arm support. Ad lib comments from the volunteers supported the above findings. To our knowledge, ours is the first study to demonstrate objective preferences for variations in surgical positioning using awake volunteers. This exercise with awake volunteers resulted in immediate changes in positioning for real robotic surgery patients in our practice.

Bilateral position-related ulnar neuropathy at elbow in pediatric population and review of the literature

Perioperative ulnar neuropathies attributed to inappropriate arm positioning and padding during surgical procedures are commonly found in adults. However, their extremely rare incidence in the pediatric population may cause absent awareness of the risk of nerve injury in anesthetized pediatric patients. Furthermore, young patients respond to conservative treatment of neuropathy less favorably than adults and their response also depends on the pathomechanism of the ulnar nerve injury. A surgeon's or anesthetist's failure to recognize all of these specifics in children may result in substantial morbidity of young patients leading to lawsuits. Fortunately, with an adequate knowledge of surgical anatomy and types of procedures and positions in which the ulnar nerve is particularly vulnerable, and familiarity with measures to minimize the potential for neuropathy, this serious complication can be prevented. The aims of this review are to highlight personal experience and current knowledge of the rare position-related ulnar neuropathy, both from a clinical and anatomical-pathophysiological perspective, and to raise awareness about this rare but serious complication in the pediatric population.

The prone position during surgery and its complications: a systematic review and evidence-based guidelines

Surgery in the prone position is often a necessity when access to posterior anatomic structures is required. However, many complications are known to be associated with this type of surgery, as physiologic changes occur with increased pressure to anterior structures. While several studies have discussed postoperative vision loss, much fewer studies with lower levels of evidence have addressed other complications. A systematic literature review was conducted using 2 different databases, and 53 papers were regarded as appropriate for inclusion. Qualitative and quantitative analysis was performed. Thirteen complications were identified. Postoperative vision loss and cardiovascular complications, including hypovolemia and cardiac arrest, had the most number of studies and highest level of evidence. Careful planning for optimal positioning, padding, timing, as well as increased vigilance are evidence-based recommendations where operative prone positioning is required.

Obturator Compartment Syndrome Secondary to Pelvic Hematoma After Robot-Assisted Laparoscopic Radical Prostatectomy

Obturator nerve injury is a known injury after robot-assisted laparoscopic radical prostatectomy (RALP) and patients often present with motor and sensory deficits in the immediate postoperative period. We describe a 65-year-old male who presented with motor deficits, indicative of obturator neurapraxia after RALP upon waking from anesthesia. Work-up revealed an expansile hematoma possibly compressing the obturator nerve. After evacuation of the hematoma, the patient had immediate improvement of his neurologic deficits. Our patient's clinical vignette illustrates the importance of considering postsurgical hematoma in the differential diagnosis when patients present with signs and symptoms of obturator neurapraxia after RALP.

Patient Positioning and Skin Sequelae: Ischemic Epidermal Necrosis from Tight Padding During Cardiac Surgery

Careful positioning and padding of pressure points during surgery are recommended to prevent pressure ulcers, vascular injury, and nerve damage in an immobilized patient. However, overpadding may have unintended consequences. We report a case of ischemia-induced full-thickness epidermal necrosis secondary to tight foam padding during a cardiac surgery.

Management of complications arising from the treatment of small renal masses

This article offers a review of the complications, and management of such complications, associated with different modalities used for the treatment of the small renal mass.

Safety and Effectiveness of SAF-R, a Novel Patient Positioning Device for Robot-Assisted Pelvic Surgery in Trendelenburg Position

PURPOSE

We found current robotic positioning devices to be inadequate and cumbersome. Furthermore, we realized there were no premarket well-designed studies to prove their safety and efficacy. In this prospective pilot study, we aimed to investigate the safety and effectiveness of a novel patient-positioning device (SAF-R) to secure the patient in Trendelenburg (T-burg) position for robot-assisted pelvic surgery.

PATIENTS AND METHODS

Sixteen patients undergoing robot-assisted pelvic operation in T-burg position were enrolled. Patients were positioned using SAF-R board. Pressure sensor mats were used for real-time monitoring of the contact pressures and contact area on the shoulders and calves throughout the surgery. Data collection included patients' body mass index (BMI), time needed for positioning, total time in the T-burg position, contact pressure and contact area readings from the sensor mats, and the patient shifting distance on the table. Patients were also followed for 1-month postoperatively for any position-related adverse event.

RESULTS

The median age of the patients was 56.5 years with median BMI of 27.3. The median positioning time was 6 minutes, duration of T-burg position was 3.5 hours, and patient shift on the table was 1 cm. The contact pressure over the shoulders was in the safe range (< 80 mm Hg) before and at the end of the surgery in all cases (right: 13.12 ± 1.12 vs 20.25 ± 1.56 mm Hg, left: 12.84 ± 1.05 vs 19.60 ± 1.09 mm Hg, p = 0.001). The changes in the mean contact pressure over the calves and the mean contact area for the shoulders and calves during the T-burg position were not significantly different. No significant position-related complication was detected during follow-up.

CONCLUSIONS

SAF-R surgical board is a safe, reliable, and timesaving positioning device for patients undergoing robotic pelvic surgery in the T-burg position.

Current issues in patient safety in surgery: a review

Current surgical safety guidelines and checklists are generic and are not specifically tailored to address patient issues and risk factors in surgical subspecialties. Patient safety in surgical subspecialties should be templated on general patient safety guidelines from other areas of medicine and mental health but include and develop specific processes dedicated for the care of the surgical patients. Safety redundant systems must be in place to decrease errors in surgery. Therefore, different surgical subspecialties should develop a specific curriculum in patient safety addressing training in academic centers and application of these guidelines in all practices. Clearly, redundant safety systems must be in place to decrease errors in surgery, in analogy to safety measures in other high-risk industries. Specific surgical subspecialties are encouraged to develop a specific patient safety curriculum that address training in academic centers and applicability to daily practice, with the goal of keeping our surgical patients safe in all disciplines. The present review article is designed to outline patient safety practices that should be adapted and followed to fit particular specialties.

Obesity in laparoscopic surgery

Since the 1980s, minimally invasive techniques have been applied to an increasing number and variety of surgical procedures with a gradual increase in the complexity of procedures being successfully performed laparoscopically. In the past, obesity was considered a contraindication to laparoscopy due to the higher risk of co-morbid conditions such as diabetes, hypertension, coronary artery disease and venous thromboembolism. Performing laparoscopic gynaecological procedures in morbidly obese patients is no longer a rare phenomenon; however, it does necessitate changes in clinical practice patterns. Understanding of the physiological changes induced by laparoscopy, particularly in obese patients, is important so that these may be counteracted and adverse outcomes avoided. Laparoscopy in obese patients confers certain advantages such as shorter hospital stay, less post-operative pain and fewer wound infections. In addition to these benefits, minimal-access surgery has been demonstrated as safe and effective in obese patients; however, specific surgical strategies and operative techniques may need to be adopted.

Secure patient positioning using Badillo/Trendelenburg restraint strap during robotic surgery

Steep Trendelenburg position is routine during robotic urologic and gynecologic surgery in order to optimize exposure of the pelvis. This position requires that the patient be properly secured as to avoid any movement during the procedure. We analyzed the safety and tolerability of a reusable strap with disposable cushions used during robotic assisted radical prostatectomy. The Badillo/Trendelenburg restraint is a harness which is placed on the table prior to patient transfer. The restraint is a Class I FDA-registered device (Pintler Medical, Seattle, WA). Patients were marked at the beginning and end of the case to determine if any movement had occurred. The Badillo/Trendelenburg restraint was employed in 1,200 consecutive RARP cases. The restraint was used by a single surgeon at two institutions. The operating table was marked from edge of the patients shoulder to the end of the head of table at the beginning and end of the case to determine if any movement had occurred. Maximum movement observed was 1 cm. All patients were questioned and a physical examination were done in the post operative period for any shoulder or nerve injury. No reports of shoulder or brachial injury. For patients undergoing robotic surgery with steep Trendelenburg position the Badillo/Trendelenburg restraint provides a secure, reliable and safe means of maintaining proper position without any patient movement.

Deltoid compartment syndrome as a complication of lateral decubitus positioning for contralateral elbow surgery in an anabolic steroid abuser

Compartment syndrome as a result of patient positioning for surgery is a rare but serious complication. Compartment syndrome as a result of anabolic steroid use is more rare. We present a unique case of compartment syndrome related to anabolic steroid use and patient positioning for complex distal humerus fracture fixation and also provide a review of the literature related to this topic.

Focal neuropathies following percutaneous nephrolithotomy (PCNL)--preliminary study

Introduction: Postoperative neurological complications in pelvic and renal surgery are a well-known clinical problem and their morbidities are important. We designed this study to determine prevalence and risk factors of such complications after percutaneous nephrolithotomy (PCNL) surgery.

Material and methods: A cross-sectional study was performed during February and July 2011 on 68 PCNL cases. Demographic data and surgery reports were gathered and comprehensive neurological physical examination carried out before and after surgery. Then, data was analyzed using software SPSS 18.

Results: The ultimate sample included 30 (46.2%) male and 35 (53.8%) female patients with a mean age of 47.9 ± 11.47 years. In intercostal and lumbosacral plexus area, sensory neurological complications occurred in 8 patients (12.31%), 4 men and 4 women. The most common involved dermatomes and nerves were T12 (8 cases). There was a significant correlation between prolonged duration of surgery and prevalence of sensory complications (p<0.010). The highest hemoglobin value drop after surgery occurred in patients with neurological complications (p<0.001). There were no correlations between age, tracts used, diabetes mellitus, BMI, hypertension, positioning of patients and side of surgery with incidence of sensory neurological complications. No motor neurological complications occurred.

Conclusion: Prolonged duration of PCNL and increased value of hemoglobin drop may lead to increased risk of neuropathy. Larger prospective studies with retroperitoneal imagings and patients’ follow up is suggested for better understanding of this complication.

The second "time-out": a surgical safety checklist for lengthy robotic surgeries

Robotic surgeries of long duration are associated with both increased risks to patients as well as distinct challenges for care providers. We propose a surgical checklist, to be completed during a second "time-out", aimed at reducing peri-operative complications and addressing obstacles presented by lengthy robotic surgeries. A review of the literature was performed to identify the most common complications of robotic surgeries with extended operative times. A surgical checklist was developed with the goal of addressing these issues and maximizing patient safety. Extended operative times during robotic surgery increase patient risk for position-related complications and other adverse events. These cases also raise concerns for surgical, anesthesia, and nursing staff which are less common in shorter, non-robotic operations. Key elements of the checklist were designed to coordinate operative staff in verifying patient safety while addressing the unique concerns within each specialty. As robotic surgery is increasingly utilized, operations with long surgical times may become more common due to increased case complexity and surgeons overcoming the learning curve. A standardized surgical checklist, conducted three to four hours after the start of surgery, may enhance perioperative patient safety and quality of care.

Preventing perioperative peripheral nerve injuries

Peripheral nerve injuries are largely preventable injuries that can result from incorrect patient positioning during surgery. Patients who are diabetic, are extremely thin or obese, use tobacco, or undergo surgery lasting more than four hours are at increased risk for developing these injuries. When peripheral nerve injuries occur, patients may experience numbness, burning, or tingling and may have difficulty getting out of bed, walking, gripping objects, or raising their arms. These symptoms can interrupt activities of daily living and impede recovery. Signs and symptoms of peripheral nerve injury may appear within 24 to 48 hours of surgery or may take as long as a week to appear. Careful attention to body alignment and proper padding of bony prominences when positioning patients for surgery is necessary to prevent peripheral nerve injury. The use of a preoperative assessment tool to identify at-risk patients, collaboration between physical therapy and OR staff members regarding patient positioning, and neurophysiological monitoring can help prevent peripheral nerve injuries.