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Proper Patient Positioning Guidelines: Lithotomy Position

The lithotomy position is a specialized patient positioning method commonly utilized in various medical procedures, including during surgeries involving the lower abdomen or pelvic region and during certain stages of labor. Proper patient positioning is crucial to ensure surgical access, patient safety, and comfort. This article provides detailed guidelines on the correct positioning of the head and neck, arms and upper body, and legs and lower body in the lithotomy position, along with considerations to prevent potential complications. 

Patient Positioning in Lithotomy: Head and Neck 

Proper alignment and support of the head and neck are essential in the lithotomy position to maintain airway patency and prevent cervical spine strain or injury. The patient's head should rest in a neutral position, aligned with the spine, to ensure comfort and safety throughout the procedure. 

Maintaining a neutral alignment involves positioning the head so that the neck is neither excessively flexed nor extended, thereby preserving spinal integrity and reducing the risk of muscle strain. Supportive padding, such as a head positioner, should be utilized to support the head and distribute pressure evenly, which helps prevent pressure ulcers and discomfort. 

Airway management is critical, especially under general anesthesia. It is important to ensure that airway devices, such as endotracheal tubes, are secured without tension or kinking, and continuous monitoring is vital to maintain airway patency. In patients with known or suspected cervical spine injuries, cervical spine precautions should be taken by maintaining immobilization and taking extra care to prevent further injury. 

Additionally, protecting the eyes from pressure or trauma is necessary by ensuring they are free from compression against any surfaces. This comprehensive approach to head and neck positioning helps in minimizing potential risks and enhances patient safety during procedures requiring the lithotomy position. 

Patient Positioning in Lithotomy: Arms and Upper Body

The arms and upper body require meticulous positioning to prevent nerve injuries, avoid vascular compromise, and maintain patient comfort. Proper positioning also ensures that intravenous lines and monitoring equipment remain accessible and secure. 

Arms can be positioned in one of two ways: tucked alongside the body or placed on padded armboards. When tucked, the arms should be wrapped gently with palms facing inward, ensuring they are not compressed by the body or equipment. The arms should be extended less than 90 degrees from the body to minimize the risk of stretching the brachial plexus. 

Adequate padding at pressure points, particularly the elbows and wrists, is essential to prevent compression of nerves such as the ulnar nerve. It is important to avoid overextension by not abducting or extending the arms beyond 90 degrees, thereby reducing the risk of nerve injuries. 

Securing the arms gently with soft straps can prevent accidental movement while avoiding tight restraints that could impair circulation. The arms should be positioned to allow unobstructed access to intravenous lines, blood pressure cuffs, and other monitoring devices, ensuring that all equipment remains functional and accessible throughout the procedure. 

Patient Positioning in Lithotomy: Legs and Lower Body

The positioning of the legs is the defining characteristic of the lithotomy position, involving elevation and support to provide optimal surgical access while minimizing risks. 

Leg elevation and support must be conducted with care. Both legs should always be raised and lowered simultaneously to prevent hip dislocation or lumbar spine torsion. Appropriate stirrups should be used to support the legs securely and distribute weight evenly. Boot-type stirrups support the foot and calf, reducing pressure on the popliteal fossa and peroneal nerve. 

Hip flexion and abduction vary depending on the type of lithotomy position required: 

• Low Lithotomy: Hips are flexed at 40 to 60 degrees for procedures requiring minimal access. 
• Standard Lithotomy: Hips are flexed at 80 to 100 degrees, common for gynecological surgeries. 
• High Lithotomy: Hips are flexed at 110 to 120 degrees, allowing deeper pelvic access. 
• Exaggerated Lithotomy: Hips are flexed at 130 to 150 degrees for extensive surgical requirements. 

Padding and attention to pressure points are crucial. The lateral aspect of the knees should be padded to protect the peroneal nerve from compression against stirrups. Adequate padding over the femoral epicondyles and tibial condyles helps reduce pressure and prevent nerve injuries. The sacral area should be cushioned with a supportive surface to alleviate pressure on the sacrum, reducing the risk of pressure sores. 

Preventing nerve injuries involves avoiding excessive pressure on the fibular head to prevent peroneal nerve damage, which can lead to foot drop. Limiting extreme hip flexion reduces stretching of the femoral nerve, minimizing the risk of femoral nerve injury. 

Circulatory considerations are also important. Elevated legs increase venous return; therefore, patients with cardiovascular issues should be monitored closely. Prolonged lithotomy positioning can lead to acute compartment syndrome, so the duration should be limited, and patients should be monitored for signs like swelling or severe pain. 

Adjustments may be necessary based on patient-specific factors. For patients with obesity, modified positioning may be required due to increased body mass and the heightened risk of pressure injuries. For those with joint limitations, leg positions should be adjusted to prevent discomfort or injury. 

Postoperative care includes lowering the legs slowly and simultaneously after the procedure to prevent hypotension and circulatory instability. It is essential to assess for signs of nerve injury or circulatory compromise after repositioning to ensure patient safety. 

Preventing Injuries and Facilitating Positive Outcomes 

The lithotomy position is integral to facilitating access during surgeries involving the pelvic region, lower abdomen, and during childbirth. Proper patient positioning is essential to minimize risks such as nerve injuries, pressure ulcers, musculoskeletal strain, and vascular complications. Using adequate padding and specialized equipment, remaining vigilant for potential complications, and tailoring the positioning to individual patient needs will enhance safety, promote comfort, and facilitate surgical outcomes. 

More Resources for Lithotomy and Other Surgical Positions  

AliMed has a wide range of reusable and disposable surgical positioning products to aid with proper patient positioning while helping reduce pressure, shear, and nerve injuries during supine procedures.     
 
Explore our interactive Lithotomy Patient Positioning Page or browse our comprehensive guide for more patient positioning products and resources for supine and other common surgical positions, including lateral, prone, fowler’s, supine, Trendelenburg, reverse Trendelenburg, and spinal.