“on table” positioning for optimal access for cancer excision in the lower rectum -凯发官网入口

“on table” positioning for optimal access for cancer excision in the lowerrectumkoutarou maeda, m.d., ph.d., morito maruta, m.d., harunobu sato, m.d., koji masumori, m.d.,hiroyuki aoyama, m.d.department of surgery, fujita health university school of medicine, 1-98 kutsukake, 470-1192 toyoake, aichi, japanpublished online: march 17, 2004abstract. poor visualization and restricted access often make tumor le-sions in the lower rectum difficult to excise, particularly in a narrow malepelvis. the aim of this study was therefore to study whether (and if so towhat extent) different positions of the patient on the operating table mightimprove accessibility. twenty consecutive patients (men and women) un-dergoing laparotomy with surgery of the lower rectum were studied. thegeometric configuration of the pelvis was studied and compared on lateralradiographsobtainedattheoperatingtableineachoffourpositions.com-pared with the conventional lithotomy position, the thighs-flat” positioncaused significant extension movement of the lumbosacral joint. augmen-tation of the lumbar lordosis widened the pelvic view and enabled a morevertical view of the lower rectum (27.5 degrees in lithotomy position, 13.0degrees in the thighs-flat position). insertion of a “lumbar pad“ contrib-uted further to the augmentation (7 degrees). when compared on radio-graphic studies, the thighs-flat position is preferable to the conventionallithotomy position in terms of facilitating low rectal surgery by improvingboth visibility and accessibility to the pelvic cavity.positioning the patient for operations on the rectum is controver-sial[1].thelithotomyorlithotomy-trendelenbergpositionwithorwithout a sacral rest or the supine, prone, or jack-knife positionhave been tried, with these modifications having been widelyadopted for rectal surgery in many institutions [2–9]. lloyd-daviesand lond reported that “the best exposure of the pelvic cavity isobtained when the thighs are extended” [9]. we have reconsideredthe concept and after some modification found that “the thighs-flat” position with or without a “lumbar pad” is a more rationalposition than the traditional lithotomy position because of the vis-ibility and access from the abdomen. to our knowledge, no studieshave compared the various positions in terms of better visibility.this trial therefore aimed to determine the positions that are mostadvantageous from the geometric point of view in the pelvis forbetter visibility of the lower rectum.materials and methodsaltogether, 20 consecutive patients, including 11 men of medianage 56 years (range 36–66 years) and 9 women of median age 59years (range 48–68 years) who were undergoing excision of a rectalcarcinoma/low anterior resection (lar), hartmann’s operation,or abdominoperineal excision (apr) were entered into the study.they were randomly (using sealed envelopes) divided into twogroups (10 patients each) according to the positions studied. fivemale patients were included in a group of 10 patients and 6 malepatients in another group. there was no past history of lumbar orback pain or diseases of the lumbar vertebra in these patients. in-formed consent to participate in the study was obtained from allpatients before the operation.after induction of anesthesia the patient was placed in position.aspeciallydesignedoperatingtablethatallowedautomaticcontrolofthelegsupportswasused.changingtheangleofthelegsupportscould be easily and carefully performed when flexion of the thighswas needed. special care was taken to avoid improper pressure onthe legs.four positions were studied: position i (lithotomy position), po-sition ii (thighs-flat position), position i with a sacral pad, and po-sitioniiwithalumbarpad(fig.1).theanglebetweenthebodyandthe thighs was measured by a graduator and set at 140 degrees forthe lithotomy position and 180 degrees for the thighs-flat position.a cushion pillow was used as a sacral pad or a lumbar pad and wasplaced underneath the second to third sacral vertebrae or thefourth lumbar vertebra, respectively, to elevate the sacrum or toincrease the “swayback.” potential complications related to posi-tioning were studied after the operation.contrast medium was introduced into the rectum. a metal boltwas placed on the skin of a cranial margin of the pubic bone aftereach position was established. three plain radiographs with a lat-eral view of the pelvis were obtained after placing each patient ineachposition.positionsi,iwithasacralpad,andiiwerestudiedinone group; and positions i, ii, and ii with a lumbar pad were stud-ied in another group. geometric measurements of the patients inthe various positions were performed on the radiographs, as dem-onstrated in figure 1. the upper margin of the anal canal was de-fined as the lowest point of the rectum demonstrated by the me-dium to be tapering on the radiograph. the site of the metal boltwas defined as the cranial margin of the pubic bone.angle a was measured with a pelvic tilt to the operating table.correspondence to: koutarou maeda, m.d., ph.d., e-mail: kmaeda@fujita-hu.ac.jpworldjournal ofsurgery© 2004 by the socie ´te ´internationale de chirurgieworld j. surg. 28, 416–419, 2004doi: 10.1007/s00268-003-7305-0