Special section

D. Aschemann, C. Krettek, A. Becker, A. Gänsslen, T. Hüfner, D. Kendoff, T. Kofidis, J. Leonhardt, L. Mahlke, G. Scheumann, U. Schmidt, B. Ure

(Illustrations and picture processing: D. Aschemann, W. Mayrhofer, A. Lang, P. Lang, K. Adam; Models: M. Prüser, U. Gerber)

11.1 Median thoracotomy (sternotomy) - 134 11.1.1 Supine position - 134

11.2 Bilateral thoracotomy - 36

11.2.1 Supine position - 136

11.3 Lateral thoracotomy - 138

11.3.1 Lateral position - 138

11.3.2 Modified lateral position - 140

11.4 Anterolateral thoracotomy - 142

11.4.1 Supine position - 142

11.5 Others - 144

11.5.1 Modified supine position - 144

11.5.2 Supine position - 146

D Figs. 11.1-11.4. Indications

Sternotomy for coronary surgery (ACVB, OBCAP), valve surgery (mitral/ aortic valve replacement), HTX and type A dissection.

Preparations

4 Arm positioning devices 4 Padded arm protection

Positioning

4 Standard operating table position 1, position 2 or universal operating table

4 Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices 4 Normal positioning of the operating table in the theatre 4 When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure 4 Position both arms at the body with arm protection, forearm slings, clips or other positioning aids 4 Radial artery removal: position the arm in supination position with 90° abduction on the arm positioning device. An arm protection can be adapted on this side to make it easier to move the arm back to the body again later on

4 Apply the neutral electrode and connect to the HF surgery device 4 Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection 4 Position the operating lights 4 Connect the water mat/patient warming system

D Figs. 11.5-11.7. Indications

Bilateral access for double lung transplantation (DLuTX). Preparations

4 Arm positioning devices 4 Padded arm protection 4 Padded cushions

Positioning

4 Standard operating table position 1, position 2 or universal operating table 4 Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices 4 Normal positioning of the operating table in the theatre 4 When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure 4 Place a padded cushion under the thoracic vertebrae along the body axis

(to raise the thorax) 4 Position both arms at the body with arm protection, forearm slings, clips or other positioning aids 4 Apply the neutral electrode and connect to the HF surgery device 4 Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection 4 Position the operating lights 4 Connect the water mat/patient warming system

D Figs. 11.8-11.10. Indications

Lateral access for lung transplantation (LuTX), lung segment resection and lobectomy.

Thoracoscopy for lung biopsy, pleural biopsy, pleural effusion, pericardial effusion, partial pleurectomy, resection of peripheral pulmonary nodules and tangential parenchyma resection.

Preparations

4 Arm positioning devices

4 Gel ring, gel cushion, Goepel leg holder, body support, radial adjusting clamps, padded cushions (normal and flat) and wedge cushions or tunnel cushions, body belts

Positioning

4 Standard operating table position 1 or universal operating table 4 Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices 4 Normal positioning of the operating table in the theatre 4 When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure 4 Fit the radial adjusting clamp to the rail of the head plate, position the

Goepel leg holder and place a gel padded mat on the operating table 4 Spread out the arm on the side not being operated in max. 90° abduction 4 Move the patient onto the healthy side, with the back near the edge of the operating table

4 Open the operating table step by step by lowering the pelvic and back plate (operating table in roof position) 4 Raise the head plate and position the head on a padded cushion with gel ring to leave the ear free 4 Position and fix the arms

4 Move the lower arm forwards so that the weight of the upper body does not lie directly on the shoulder 4 Fit the body supports to the side rails and support the body at the level of the sacrum and symphysis 4 1st possibility: position the legs with the padded cushions (normal and flat) and possibly wedge cushions 4 Fix the lower leg and the positioning aids with the body belts 4 2nd possibility: position the legs with the tunnel cushion 4 Apply the neutral electrode and connect to the HF surgery device 4 Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection 4 Position the operating lights 4 Connect the water mat/patient warming system

D Figs. 11.11-11.13. Indications

Lateral access for descending aorta replacement and thoracoabdominal aorta replacement.

Preparations

4 Arm positioning devices

4 Gel ring, gel cushion, Goepel leg holder, body support, radial adjusting clamps, padded cushions (normal and flat) and wedge cushions or tunnel cushions, body belts

Positioning

4 Standard operating table position 1 or universal operating table 4 Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices 4 Normal positioning of the operating table in the theatre 4 When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure 4 Fit the radial adjusting clamp to the side rail of the head plate, position the

Goepel leg holder and place a gel padded mat on the operating table 4 Spread out the arm on the side not being operated in max. 90° abduction 4 Move the patient onto the healthy side, with the back near the edge of the operating table

4 Open the operating table step by step by lowering the pelvic and back plate (operating table in roof position) 4 Raise the head plate and position the head on a padded cushion with gel ring to leave the ear free 4 Position and fix the arms

4 Move the lower arm forwards so that the weight of the upper body does not lie directly on the shoulder 4 Thorax 90° position, pelvis 45° position

4 Fit the body supports to the side rails and support the body at the level of the sacrum and symphysis 4 Fit the body support to the rail of the head plate (at the back of the patient)

and support on the upper scapula so that the point of the scapula is free 4 1st possibility: position the legs with the padded cushions (normal and flat) and possibly wedge cushions 4 Fix the lower leg and the positioning aids with the body belts 4 2nd possibility: position the legs with the tunnel cushion 4 Position the upper leg in external rotation

4 Apply the neutral electrode and connection to the HF surgery device 4 Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection 4 Position the operating lights 4 Connect the water mat/patient warming system

D Fig. 11.11. Modified lateral position for thoracoabdominal access
D Fig. 11.12. Support for the shoulder and for the pelvis tilted approx. 30-40° backwards
D Fig. 11.13. Positioning with freely moving leg

D Figs. 11.14,11.15. Indications

Anterolateral access for MIDCAB and minimally invasive ASD. Preparations

4 Arm positioning devices 4 Padded arm protection 4 Small wedge cushion

Positioning

4 Standard operating table position 1, position 2 or universal operating table

4 Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices 4 Normal positioning of the operating table in the theatre 4 When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure 4 Minimally invasive ASD: position the wedge cushion under the right shoulder/thorax

4 MIDCAB: position the wedge cushion under the left shoulder/thorax 4 Position both arms at the body with arm protection, forearm slings, clips or other positioning aids 4 Apply the neutral electrode and connect to the HF surgery device 4 Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection 4 Position the operating lights 4 Connect the water mat/patient warming system

D Fig. 11.14. Supine position with wedge cushion under the right shoulder/thoracic side

11.5.1 Modified supine position

Indications

Mediastinoscopy.

Preparations

4 Arm positioning devices 4 Padded arm protection 4 Gel ring, possibly flat padded cushion

Positioning

4 Standard operating table position 1, position 2 or universal operating table top

4 Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices 4 Crosswise positioning of the operating table in the theatre 4 When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure 4 Possibly pad the shoulders with a flat padded cushion 4 Tilt the operating table in the Trendelenburg position, raise the back plate by 20-30°, lower the leg plates and the head section 4 Position the head on a gel ring, possibly slightly turned to the left and reclined

4 Position the left infusion arm on the anaesthetist's side on the arm positioning device

4 Position the right arm at the body with arm protection, forearm slings, clips or other positioning aids 4 Apply the neutral electrode and connect to the HF surgery device 4 Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection 4 Position the operating lights 4 Patient warming system

Fig. 11.16. Supine position with raised back plate and lowered head plate

D Figs. 11.18-11.20. Indications

AICD (defibrillator) and pacemaker. Preparations

4 Arm positioning devices

4 Padded arm protection

4 C-arm and monitor trolley, X-ray protection

Positioning

4 Standard operating table position 1 or universal operating table with X-ray protection

4 Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices 4 Normal positioning of the operating table in the theatre 4 When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure 4 Position both arms at the body with arm protection, forearm slings, clips or other positioning aids 4 Apply the neutral electrode and connect to the HF surgery device 4 Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection 4 Position the operating lights 4 Patient warming system

12.1.1 Supine position - 150

12.2 Upper extremities - 152

12.2.1 Supine position - 152

12.3 Lower extremities - 154

12.3.1 Supine position - 154

12.1.1 Supine position

O Figs. 12.1-12.4. Indications

Operation to the carotis: carotid patch, carotid shunt, carotid TEA; tumour operations to vessels (glomus tumour).

Preparations

4 Arm positioning devices 4 Padded arm protection 4 Gel ring

Positioning

4 Standard operating table position 1, position 2 or universal operating table

4 Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices 4 Normal positioning of the operating table in the theatre 4 When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure 4 Possibly pad the shoulders with a flat padded cushion 4 Tilt the operating table in the Trendelenburg position, raise the back plate by 20-30°, lower the leg plates and the head section by hand 4 Position the head on a gel ring, possibly slightly turned to the side and reclined

4 Position both arms at the body with arm protection, forearm slings, clips or other positioning aids or the infusion arm in the supination position with max. 90° abduction on an arm positioning device 4 Apply the neutral electrode and connect to the HF surgery device 4 Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection 4 Position the operating lights 4 Patient warming system

D Fig. 12.1. Supine position with raised back plate and lowered head plate

D Fig. 12.2. Supine position with raised back plate, adapted connection bar, fastening piece and one-piece horseshoe-shaped headrest

a gel ring a one-piece horseshoe-shaped headrest

O Figs. 12.5, 12.6. Indications

Embolectomies of the upper extremities; shunt placement, (Cimino shunt), shunt revisions; shunt connections, e.g. axillofemoral bypass.

Preparations

4 Arm positioning devices 4 Large arm table

Positioning

4 Standard operating table position 1, position 2 or universal operating table

4 Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices 4 Crosswise positioning of the operating table top in the theatre 4 When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure 4 Remove the arm positioning device on the operating side and attach the large arm rest to the side rail of the back plate 4 Position the patient near to the edge of the table

4 Standard supine position, position the infusion arm on the arm positioning device

4 Apply the neutral electrode and connect to the HF surgery device 4 Arrange self-adhesive covers for preoperative skin disinfection 4 Position the operating lights 4 Patient warming system

Fig. 12.5. Supine position with arm in abduction. The back plate can be adjusted during the operation without jeopardising the stability of the large arm table

12.3.1 Supine position

O Figs. 12.7-12.9. Indications

Angioplasty procedures, e.g. profundaplasty, patch graft; shunts, e.g. Y-shunt; aneurysms, e.g. abdominal aortic aneurysm, embolectomies to the lower extremities; prosthesis connections, e.g. axillofemoral bypass.

Preparations

4 Arm positioning devices Positioning

4 Standard operating table position 1, position 2 or universal operating table

4 Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices 4 Normal positioning of the operating table in the theatre 4 When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure 4 Spread out and pad both arms on the arm positioning devices 4 Apply the neutral electrode and connect to the HF surgery device 4 Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection 4 Position the operating lights 4 Patient warming system

Fig. 12.7. Supine position for Y-shunt operation with arms in abduction

D Fig. 12.8. Maximum 90° abduction and supination position of the arms

D Fig. 12.9. Head positioned on a double wedge cushion

D Fig. 12.8. Maximum 90° abduction and supination position of the arms

D Fig. 12.9. Head positioned on a double wedge cushion

13.1.1 Supine position - 158

13.1.2 Supine position, neurosurgical headrest - 160

13.2 Open laparotomy - 162

13.2.1 Supine position (median and transverse laparotomy, incision right or left parallel to the costal margin) - 162

13.2.2 Lithotomy position - 164

13.3 Laparoscopic operations - 166

13.3.1 Supine position - 166

13.4 Heidelberger position (position for Kraske access) - 168 13.4.1 Modified prone position - 168

13.5 Lateral position - 170

13.5.1 Modified lateral position - 170

13.1 Neck

13.1.1 Supine position

O Figs. 13.1, 13.2. Indications

Operations to the thyroid/parathyroid: thyroid operations (e.g. hemithyroidec-tomy), thyroid operations of tumours with systematic lymphadenectomy (e.g. total thyroidectomy).

Operations to the oesophagus: operations to the oesophagus (e.g. anastomotic connection with stomach pull-up, resection of Zenker's diverticula).

Operations to cysts and embryonal duplications of the oesophagus: e.g. medial or lateral cysts in the neck, cervical oesophagus duplication.

Preparations

4 Arm positioning devices 4 Gel ring

4 Padded arm protection Positioning

4 Standard operating table position 1, position 2 or universal operating table

4 Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices 4 Normal positioning of the operating table in the theatre 4 When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure 4 Possibly pad the shoulders with a flat padded cushion 4 Tilt the operating table in the Trendelenburg position, raise the back plate by 20-30°, lower the leg plates and head section (by hand) 4 Position the head on a gel ring, possibly slightly turned to the side and reclined

4 Position both arms at the body with arm protection, forearm slings, clips or other positioning aids or the infusion arm in supination position with 90° abduction on the arm positioning device 4 Apply the neutral electrode and connect to the HF surgery device 4 Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection 4 Position the operating lights 4 Patient warming system

13.1.2 Supine position, neurosurgical headrest

O Figs. 13.3, 13.4. Indications

Operations to the thyroid: thyroid operations for tumours with systematic lymphadenectomy, e.g. total thyroidectomy and systematic lymphadenectomy of compartments 2, 3 and 4 (mediastinum via sternotomy).

Operations to cysts and embryonal duplications of the oesophagus: cysts and embryonal duplications of the oesophagus (e.g. medial or lateral cysts in the neck, cervical oesophagus duplication).

Preparations

4 Arm positioning devices 4 Padded arm protection

4 Neurosurgical headrest, wedge cushions, block cushions, knee half roll Positioning

4 Standard operating table position 1, position 2, universal operating table or beach-chair operating table 4 Anaesthetic preparation and induction in supine position with 2 adapted arm positioning devices 4 Normal positioning of the operating table in the theatre 4 When positioning the patient, take appropriate measures to prevent decubitus at areas which are subjected to pressure 4 Fasten and pre-position the neurosurgical headrest to the head part of the operating table

4 Tilt the operating table in the Trendelenburg position, move the patient towards the head end until the shoulders are flush with the upper edge of the operating table

4 Lift the legs and fix the wedge and block cushion under the buttocks and thighs

4 Lift the back plate by 20-30°, possibly lower the leg plates 4 Position and fix the head in the neurosurgical headrest, possibly slightly turned to the side and reclined 4 Position both arms at the body with arm protection, forearm slings, clips or other positioning aids or the infusion arm in supination position with 90° abduction on the arm positioning device 4 Apply the neutral electrode to the upper arm and connect to the HF surgery device

4 Arrange absorbent drapes or self-adhesive covers for preoperative skin disinfection 4 Position the operating lights 4 Patient warming system

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