Lithotomy position

AORN Journal,  Feb, 2008  by Bonnie Denholm

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QUESTION: Recently, the nurses at our facility have been discussing the risks of injury associated with the lithotomy position. What are the general considerations and primary risks associated with the lithotomy position?

ANSWER: AORN's "Recommended practices for positioning the patient in the perioperative practice setting" addresses patient safety considerations and patient injury risks for common positions. (1) For patients in the lithotomy position, perioperative RNs should take the following patient safety precautions.

* Place the stirrups at an even height.

* Position the patient's buttocks so that the sacrum is securely supported on the bed surface and even with the lower break of the OR procedure bed. (2)

* Lift the patient's legs slowly and simultaneously into the leg holders to prevent lumbosacral strain. (3)

* Place the patient's arms on padded arm boards that are extended less than 90 degrees from the long axis of the procedure bed. Position the patient's palms up and secure the arms gently. (3,4) The patient's the arms should only be tucked at the his or her side if tucking is surgically necessary. If the patient's arms need to be tucked, pad the patient's elbows and position his or her palms to face in toward the body. Protect the hands and fingers by enclosing them in foam protectors when tucking the arms so that when the foot of the procedure bed is repositioned, no injury occurs. (3)

* Place the patient's heels in the lowest possible position. (5)

* Provide support over the largest possible surface area of the leg. (5)

* Protect the patient's legs to ensure that they do not rest against the stirrup posts. (4)

* Avoid shearing forces when moving the patient to the break in the procedure bed during repositioning.

* Confirm proper positioning of the patient's buttocks before surgery is initiated. (2)

* Slowly remove the patient's legs from the leg holders with the knees together to protect the patient's hip rotation and body alignment. Slowly, return one leg at a time to the OR procedure bed to maintain hemodynamic status. (3)

The circulating nurse should collaborate with the rest of the perioperative team to ensure that the patient is in the lithotomy position for the shortest time possible. (5) Continuous surveillance is important to ensure that scrubbed personnel are not leaning against the patient's thighs during the procedure. (4,6)

Primary risks associated with the lithotomy position include the potential for pressure injury, nerve injury, and compartment syndrome. The patient's heels are at risk for pressure ulcers at the heel support sites, and the patient's legs are at risk for pressure injuries if the legs rest against the leg supports or stirrup posts. (4,5)

Nerve injury causing foot drop or lateral lower-extremity paresthesia can result if the patient's fibular neck rests against the vertical post of the stirrup. This can cause injury to the peroneal nerve, which runs along the lateral aspect of the patient's knee. The obturator, saphenous, sciatic, posterior tibial, and femoral nerves also are vulnerable for injury in the lithotomy position. (2-4,7)

Compartment syndrome occurs as a result of arterial compression that progresses to poor tissue perfusion, potential cell death, and fluid leaking into a closed compartment (8,9) (ie, a partitioned-off portion of a larger bound space (10)). The compartments of the extremities are

   bound deeply by bones and intermuscular septa and superficially by
   deep fascia and generally are not in communication with the other
   compartments, and thus infection or increased pathologic pressure
   may be limited to one compartment. (10(p417))

Lower extremity compartment syndrome is not a common complication but has been reported to occur more frequently in the lithotomy position (eg, one in 8,720 procedures) than in other positions, (11) especially during prolonged procedures (eg, longer than four hours). (4,11,12) The acute angles at the hips and knees may cause the major vessels to be compromised and may cause compression of the calf muscles and the popliteal fossa, especially when knee crutch stirrups are used. (2,3,6,12,13)

The patient also is at risk for circulatory and respiratory complications that may result from being placed in the lithotomy position. The increased risk of blood pooling in the patient's calf muscles during the procedure increases the risk of deep vein thrombus. When the patient's legs are removed from the leg supports at the end of the procedure, blood rapidly returns to the patient's peripheral circulation and may cause an overall hypovolemic state. Procedures performed in the lithotomy position often require the head to be tilted down (eg, Trendelenburg position), which increases the risk for pulmonary congestion and respiratory compromise and also further reduces limb perfusion. (2,6,8) For more information about general positioning considerations, see AORN's "Recommended practices for positioning the patient in the perioperative practice setting." (1)