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Springer Medizin Verlag Heidelberg

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Planning: Dr. Fritz Kraemer, Heidelberg Project management: Willi Bischoff, Heidelberg Copy editing: Susan Peters, Hamburg

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Foreword

The success of an operation depends not only on careful clarification of the indications, selection of the right time for operating and technically neat operating techniques, but also on correct preoperative preparation and positioning of the patient. But this aspect in particular is frequently neglected, particularly by young surgeons, because technical details of the operation assume far greater attention, underestimating the contribution made by optimum positioning to a time-saving operation which runs as perfectly as possible. How easy is it for an operation to develop complications out of all proportion because the surgeon forgot certain »minor matters« during preparations! Anyone who has witnessed this themselves will appreciate just how important exact preoperative planning and preparation is before an operation takes place.

It is therefore our great pleasure to present a work put together with the assistance of renowned expert co-authors about safe positioning techniques which are of great use to operating procedures and which cover the various different surgical disciplines.

Like no other surgical discipline, accident surgery clearly demonstrates the results of the dramatic rate of progress in medical development: 4 new, gentler osteosynthesis techniques and new implants with a huge expansion in the range of possible operations

4 introduction of navigation and new imaging procedures such as Iso-C3D imaging 4 introduction of new operating tables with improved fluoroscopic properties 4 new procedures for dealing with wound infections (vacuum sealing, new antiseptics).

The many new procedures in operative surgery - and also in the other medical disciplines - make it necessary to take stock of an effective approach to operation preparation. New techniques demand an increasingly intensive approach to dealing with new materials: completely new instruments and devices, developed for example for minimally invasive surgery, or concealed surgical proce dures with direct visualisation techniques. Special instruments are only used for one specific purpose; a surgical needle today has its own anatomy. In addition, these aspects are joined by stricter safety conditions, increased demands made by patients, with the threat of legal consequences if something should go wrong in terms of »nihil nocere« ...

We have therefore made an attempt to illustrate a procedure which has proven successful over many years at the Medical University Hannover. This does not mean that there are not other appropriate or even better suited procedures for specific situations, which would ideally supplement the procedure described here. We felt it was important to describe safe, practical positioning techniques to simplify each specific operation.

At this point we would like to extend our thanks to the years of intensive, trusting cooperation with Ms. Schroder, Ms. Conrad, Dr. Kraemer and Mr. Bischoff from Springer Verlag. Thanks also go to Susan Peters for her external copy editing.

Many thanks also to all the colleagues in the positioning and surgical teams in the various departments, to the MHH photo department, models Martina Pruser and Ute Gerber and to Maquet GmbH & Co.KG

Special thanks to Dr. Lutz Mahlke and Dr. Axel Ganss-len for their suggestions and corrections over the last few months, and naturally also to our families who have provided us with vital support day by day.

Rastatt/Hannover, October 2005

Dirk Aschemann

Prof. Dr. Christian Krettek

Many special thanks to my parents and, for all their personal sacrifices, to my wife Cornelia and our twins Lisa and Nils.

Hildesheim, October 2005 Dirk Aschemann

Contents

I General section

1 Psychological management of children. . . 3

R. Sümpelmann

1.1 Special aspects of childhood 4

1.2 Psychological and medication preparation. . . 5

1.3 Transport to the operating suite 5

1.4 Transfer of the patient and transport to the anaesthesia preparation room 5

References 6

2 Hygienic aspects 7

W. Kasperczyk

2.1 Perioperative hygiene in accident surgery . . . 8

2.2 Guidelines for formulating hygiene measures 8

2.3 Concrete measures 8

2.3.1 Clothing in the operating suite 9

2.3.2 Cleaning and disinfecting hands 9

2.4 Preoperative patient preparation 10

References 11

3 Legal aspects 13

B. Debong

3.1 Legal principles 14

3.2 Interdisciplinary cooperation in positioning the patient 14

3.2.1 Preoperative phase 14

3.2.2 Positioning for the operation 15

3.2.3 Positioning on the operating table 15

3.2.4 Changes in position 15

3.2.5 Postoperative phase 15

3.3 Cooperation between doctors and nurses in positioning the patient 15

3.4 Burden of proof 16

3.5 Documentation of patient positioning 16

4 Use of X-rays in the operating suite 19

General aspects and X-ray Ordinance, radiation generation and radiation protection 19 H. Kreienfeld, H. Klimpel, V. Böttcher

4.1 Radiation protection in the operating suite . . 20

4.1.1 Introduction 20

4.1.2 Legal principles for the use of X-rays in medicine 21

4.1.2.1 X-ray Ordinance, Atomic Energy Law,

Euratom Directives, ICRP recommendations . . 21

4.1.2.2 Use of X-rays on people 22

4.1.2.3 Radiation protection manager, radiation protection officer 24

4.1.2.4 Obligations when operating an X-ray machine 24

4.1.2.5 Occupational exposure to radiation, personal dosimetry 25

4.1.2.6 Helpers 27

4.1.2.7 Information and instruction procedures . . . . 27

4.1.2.8 Records 29

4.1.2.9 Quality assurance according to the X-ray Ordinance 29

4.1.3 Generating X-rays 30

4.1.4 The image receiver system for surgical image intensifiers 32

4.1.5 The main components in surgical image intensifiers 32

4.1.6 Technical minimum requirements for examinations with surgical image intensifiers 32

4.1.7 Application-related radiation protection in the operating suite 32

4.1.8 Correct positioning of the image receiver system 34

4.1.9 Correct use of the automatic dose output control (ADR) 34

4.2 Surgical image intensifier systems 35

4.2.1 Expert inspection 36

4.2.2 X-ray radiation 36

4.2.3 Radiation protection 36

4.2.4 Structure and technique of a surgical image intensifier 37

4.2.5 Application 38

4.2.6 Use of the surgical image intensifier 38

4.2.7 Tips and tricks for daily routine 38

References 39

5 High-frequency surgery 41

V Hausmann

5.1 General aspects 42

5.1.1 How it works/Definition 42

5.1.2 Incision 43

5.1.3 Coagulation 44

5.1.4 Influences on the surgical effect 45

5.2 Neutral electrode 46

5.2.2 Safety systems 46

5.2.3 The neutral electrode, which, where, how? . . . 46

5.2.4 Burns under the neutral electrode? 47

5.3 Rules for safe use 48

5.3.1 General 48

5.3.2 Use of high-frequency surgery in minimally invasive surgery 48

5.3.3 Other information 49

Glossary 50

References 54

6 New technologies 55

D. Kendoff, L. Mahlke, T. Hüfner, C. Krettek, C. Priscoglio

6.1 Navigation 56

6.1.1 Equipment, arrangement and modalities . . . . 56

6.1.2 Iso-C3D general 57

6.1.3 Iso-C3D navigation 58

6.2 AWIGS/VIWAS - New systems for image-

guided surgery 60

6.2.1 Introduction 60

6.2.2 Overview of the system components 60

6.2.3.1 Use and benefits of the system 60

6.2.4 VIWAS 65

6.2.4.1 VIWAS in combination with an angiography system 65

6.2.4.2 VIWAS in combination with a sliding gantry . . 66

6.2.5 Prospects 66

References 66

7 Technical equipment 67

7.1 Operating table 68

7.1.1 Introduction 68

7.1.2 Historical development 68

7.1.3 Classification criteria according to technical design 73

7.1.3.1 Operating table systems 73

7.1.3.2 Mobile operating tables 75

7.1.4 Classification criteria according to purpose . . 78

7.1.5 Classification criteria according to the school of surgery 78

7.1.6 Production, production control and safety . . . 78

7.2 Positioning accessories and aids 79

7.2.1.1 Pads with viscoelastic foam core 79

7.2.2 Operating table accessories 82

7.2.3 Extension table accessories 86

7.2.4 Special devices 88

7.2.5 Vacuum mats 88

7.2.6 Patient warming system 90

8 Standard positioning 91

D. Aschemann, A. Gansslen

8.1 Introduction 92

8.2 Preparation of the operating table 92

8.2.1 Universal operating table Alphamaquet

1150.30 with water and gel mat for trauma surgery 92

8.3 Supine position 93

8.3.2 Shoulders and arms 93

8.3.3 Back and pelvis 94

8.4 Lithotomy position 96

8.4.1 Head, shoulders and arms 96

8.4.2 Back and pelvis 97

8.5 Beach-chair position 98

8.5.2 Shoulders and arms 99

8.5.3 Back and pelvis 99

8.6 Prone position 99

8.6.1 Head 100

8.6.2 Arms 100

8.6.3 Thorax and pelvis 102

8.6.4 Legs 102

8.7 The lateral position 102

8.7.1 Head 103

8.7.2 Shoulders and arms 103

8.7.3 Thorax and pelvis 104

8.7.4 Legs 104

8.8 Final remarks 105

9 Function workflow in the operating suite 107

D. Aschemann, A. Gansslen, L. Mahlke

9.1 Standard steps in the elective programme . . . 108

9.1.1 Patient reception 108

9.1.2 Selection of the operating table and placing the patient on it 108

9.1.3 Preparation of the patient in the anaesthesia induction room 108

9.1.4 Definitive positioning 108

9.1.5 Preparing the bed and measures at the end of the operation 109

9.2 Preparations in an emergency (under time pressure) 110

9.3 Preparations for open fractures 110

10 Complications 115

M. Bund, F. Logemann, H. Muller-Vahl 10.1 Positioning injuries as seen by the anaesthetist 116

10.1.1 Division of labour between surgeon and anaesthetist 116

10.1.2 Occurrence of positioning injuries 116

10.1.2.1 Frequency 116

10.1.2.2 Kind of injuries 117

10.1.3 Supine position 119

10.1.3.1 Struma position 120

10.1.3.2 Extension table 120

10.1.3.3 Lithotomy position 121

10.1.3.4 Head-down position 121

10.1.4 Lateral position 121

10.1.5 Prone position 122

10.1.6 Sitting/half sitting position 123

10.1.7 Final remarks 123

10.2 Patient positioning under resuscitation conditions 123

10.2.1 Necessary measures 124

10.2.2 Positioning injuries following resuscitation . . 125

10.3 Positioning injuries as seen by the neurologist 125

10.3.1 Introduction 125

10.3.2 Frequency 125

10.3.3 Pathophysiology 125

10.3.4 Symptoms 126

10.3.4.1 Diagnosis and differential diagnosis 126

10.3.4.2 Therapy and progress 126

10.3.5 Special nerve injuries 127

10.3.5.1 Brachial plexus 127

10.3.5.2 Ulnar nerve 127

10.3.5.3 Peroneal nerve 127

10.3.6 Lesions of the lumbosacral plexus and its branches in the lithotomy position 128

10.3.6.1 Pudendal nerve 128

10.3.7 Compartment syndrome following surgical positioning 128

References 128

II 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 Thorax and heart surgery 133

11.1 Median thoracotomy (sternotomy) 134

11.1.1 Supine position 134

11.2 Bilateral thoracotomy 136

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

12 Vascular surgery 149

12.1 Neck 150

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

13 Visceral and transplantation surgery . . . . 157

13.1 Neck 158

13.1.1 Supine position 158

13.1.2 Supine position, neurosurgical head rest . . . . 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 Heidelberg 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

14 Urology 173

14.1 Positioning techniques depending on various surgical indications 174

14.1.1 Supine position 174

14.1.2 Lithotomy position 176

14.1.3 Flank position 178

14.1.4 Modified supine position 180

14.1.5 Prone position 182

15 Spine surgery 185

15.1 Cervical spine 186

15.1.1 Supine position/CRP horseshoe headrest. . . . 186

15.1.2 Supine position/skull clamp 188

15.1.3 Supine position/spine holding unit

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