Abstract
Background and Objectives:
One of the responsibilities of the anesthesiologist is to maintain the physiologic anatomic position during surgery. Postoperative positional peripheral nerve injury (PPPNI) inevitably may occur during robot-assisted laparoscopic radical prostatectomy (RARP) in steep-Trendelenburg-lithotomy positioning. The primary aim of the study was to identify incidence and risk factors for the development of PPPNI in the RARP and the secondary aim was to identify the most common types and duration of PPPNI.
Methods:
After ethics committee and patients approval, patients who underwent RARP in past 7 years were retrospectively evaluated. Patients with known peripheral neuropathy were excluded. Patient demographics, American Society of Anesthesiologists (ASA) score, body mass index (BMI), Charlson comorbidity index (CCI), operative time (OT), and Trendelenburg time (TT) were obtained from the records. Patients were asked if they had PPPNI and other descriptive questions.
Results:
A total of 868 patients were included in the study. The mean age, BMI, ASA risk score, and CCI were 63.44 ± 6.68 years, 27.46 ± 2.75 kg/m2, 1.76 ± 0.62, and 2.41 ± 0.89, respectively. PPPNI rate was 5.6% (49 patients). The mean OT, TT and recovery time were 168.83 ± 52.1 minutes, 110.74 ± 46.33 minutes, and 6.5 ± 2.81 months, respectively. The BMI, OT, and TT values of patients with PPPNI were significantly higher than those of patients without PPPNI (P < .01). The cutoff values were 29, 212, and 157 minutes, respectively. Of the 49 patients with PPPNI, 55.1% had upper extremity injuries (pain 51.9%), 51% had lower extremity injuries (motor deficit 58.3%), and 6.1% had injuries to both. Six patients claimed PPPNI.
Conclusion:
The RARP is associated with an elevated risk of PPPNIs, particularly in cases of prolonged OT, TT, and high BMI.
Keywords: Position during surgery, Postoperative positional peripheral nerve injury, Robot assisted laparoscopic radical prostatectomy, Responsibilities of the anaesthesiologist, Steep-Trendelenburg and Lithotomy positioning
INTRODUCTION
The first and most important step in the surgical process is to position the patient for a good surgical view, depending on the type of surgery being performed. In the operating theatre, standard positions can be given quickly by a team of anesthesiologists and surgeons. However, there may be some risks to the patient from the position given on the operating table.1 To minimize these risks, the use of extreme positions that do not correspond to the neutral anatomical position should be avoided, even if they facilitate the surgeon’s work. It should be also remembered that patients are under anesthetic effect during surgery and cannot express any discomfort. In addition it is recommended that the anatomical position of the patient should be checked periodically during the operation.1–6
However, some highly-specialized procedures require nonroutine positions. Robot-assisted laparoscopic radical prostatectomy (RARP) is one such procedure. RARP provides anatomically easier access to the prostate, which is located deep behind the pubic symphysis, during surgery and provides better oncological, surgical and functional outcomes and has replaced open radical prostatectomy as a minimally invasive surgical procedure. However, low lithotomy with steep-Trendelenburg (30–45°F) position (sT-L) are required for robot placement, best surgical view and most appropriate surgery. But some serious complications related to this position, although rare, have been reported.
The most important of complication is the position-dependent varying degree of motor and sensory peripheral nerve damage in the upper and lower extremities.
For postoperative positional peripheral nerve injury (PPPNI), which has a multifactorial etiology, the combination of stretch and compression is the key factor during surgery under general anesthesia with sT-L position.7 PPPNI may develop as a result of the weakening or paralysis of the distal branches of the peripheral nerve and may manifest immediately following the recovery from anesthesia or may occur several days after the surgical procedure. The incidence has been reported in various sources with varying percentages, from 0.02% to 21%.8 It constitutes a significant cause of morbidity in social, health, and medico-legal terms.8
This is a major concern in the field of anesthesiology as PPPNI means that the safety of patients undergoing surgery cannot be ensured. The American Society of Anesthesiologists (ASA) Closed Claims Database reported that nerve injuries constituted 22% of malpractice claims between 1990 and 2007.8,9
Factors such as position, type and duration of surgery, duration of position, patient’s age, weight, and comorbidities (diabetes mellitus, hypertension ext.) have been reported to increase the risk of PPPNI.1–6,8,10,11
The primary aims of this study was to identify the incidence and risk factors for the development of PPPNI in the RARP and the secondary aims was to identify the most common types and duration of PPPNI.
MATERIALS AND METHODS
In our study, following the approval of the ethics committee (B0.10.1.TKH.4.34.H.GP.0.01/487) and patient consent, a retrospective review of patients who underwent a RARP procedure in our hospital within seven years was planned. Patients with a postoperative period of less than six months, patients with a known history of muscular dystrophy, peripheral neuropathy, lumbar-cervical discopathy, orthopedic surgery and trauma, patients who underwent retroperitoneal lymph node dissection, and patients who underwent conversion to laparotomy during surgery were excluded from the evaluation. Also patients who were admitted to the postoperative Intensive Care Unit for any reason intraoperatively or with a preoperative indication were excluded from the evaluation. The remaining patients were scheduled to be included in the study.
PPPNI was defined as a condition characterized by weakness, paresthesia and/or numbness, or pain related to peripheral neurological or muscular structures.
The patients who met the study criteria were contacted via telephone to ascertain whether they had developed PPPNI, if so, in which extremity, in what form (weakness, or numbness, or pain), for how long their symptoms persisted, whether they sought medical attention for these complaints, the treatment provided by the physician, if any, and whether PPPNI persisted despite the treatment. The answers to the questions were recorded in the data set.
Additionally the following data were obtained from the patient files and recorded: age, body mass index (BMI), ASA score, Charlson Comorbidity Index (CCI), operative time (OT), and Trendelenburg time (TT). The ASA score assesses the patient’s overall condition and is used to determine the appropriate level of care. The CCI is a scoring system in which 10-year survival is evaluated with age and 16 different comorbidities present in the patient. Mortality risk increases as the score increases. The period between the induction of anesthesia and the patient's awakening from anesthesia is referred to as the “operative time.” The term “Trendelenburg time” is used to refer to the time spent in the Trendelenburg position.
In the operating room, all patients were positioned on a soft sponge mattress. The induction and maintenance of anesthesia were performed using the standard anesthetic technique, with bispectral index (BIS) monitoring employed to ensure depth of anesthesia. The temperature of the operating room and the patient were monitored, and heating was instigated as necessary.
In the operating theatre, the steep Trendelenburg position (30–45°) is maintained with the arms fixed in adduction on both sides of the body in accordance with neutral anatomical posture (fingers protected from bed hinges), in a nonslip manner. Additionally, soft gel shoulder supports are utilized, and the feet are fixed in a low lithotomy position (hip abduction <30°; hip flexion >45°) with the use of compression stockings and pneumatics (Figure 1). The position is established by the operating theatre staff, anesthesiologist and urologist in accordance with their respective areas of expertise. In the operating room, intra-abdominal pressure remains below 15 mmHg throughout the pneumoperitoneum period.
Figure 1.
Patient position before RARP operation. Steep Trendelenburg position (30–45°) with low lithotomy position (hip abduction <30°; hip flexion >45°).
In accordance with standard procedure, normal saline (1 m/kg/hour) and 6% HES 200/05 (1 ml/kg/hour) infusions are administered intraoperatively, with urine output monitored. A crystalloid solution of 2,000 ml is administered for rehydration until 24 hours postoperatively.
The primary objective of this study was to ascertain the incidence and risk factors associated with the development of PPPNI in the surgical treatment of prostate cancer by the RARP technique. The secondary outcomes were to identify the most common types and duration of PPPNI.
Statistical Methods
Statistical analysis was performed by using the IBM SPSS Statistics 22.0 (IBM SPSS, Turkey). The normality of continuous variables was investigated by Shapiro-Wilk’s test. Descriptive statistics were presented using mean and standard deviation for normally distributed variables and median (and minimum-maximum) for the non-normally distributed variables. For comparison of two normally distributed groups Student’s t test was used. Nonparametric statistical methods were used for values with skewed distribution. For comparison of two non-normally distributed groups Mann–Whitney U test was used. The χ2 or Fisher Exact test (where available) was used for categorical variables and expressed as observation counts (and percentages). To identify correlation of two normally distributed continuous variables, Pearson correlation coefficient, two non-normally distributed continuous variables, Spearman ρ correlation coefficient was calculated. Statistical significance was accepted when two-sided P value was lower than .05.
RESULTS
A total of 969 patients who underwent RARP operations under general anesthesia in the previous seven years were identified in our operating theatre, having met the inclusion criteria. A total of 868 patients were included in the study, as 27 of these patients had deceased, 24 patients’ complete data could not be obtained, and 50 patients could not be reached by telephone.
The mean age and BMI of the patients were 63.44 ± 6.68 and 27.46 ± 2.75, respectively. The incidence of PPPNI was determined to be 5.6% (n = 49).
Table 1 presents the demographic data of the patients, the mean results of the other parameters analyzed, the type of PPPNI, and the extremity distribution of the patients with PPPNI.
Table 1.
Demographic Data, the Mean Results of the Other Parameters Analyzed, and the Incidence and Parameters of PPPNI
| Min–Max | Mean ± SD | |
|---|---|---|
| Age (years) | 42–76 | 63.44 ± 6.68 |
| BMI (kg/m2) | 20–40 | 27.46 ± 2.75 |
| Operation time (minutes) | 120–380 | 168.83 ± 52.17 |
| Trendelenburg time (minutes) | 70–310 | 110.74 ± 46.33 |
| Duration of damage (months) | 1–13 | 6.50 ± 2.81 |
| CCI | 2–8 | 2.41 ± 0.89 |
| n | % | |
|---|---|---|
| ASA | ||
| 1 | 345 | 39.7 |
| 2 | 447 | 51.4 |
| 3 | 73 | 8.4 |
| 4 | 3 | 0.3 |
| PPPNI Incidence Rate and Types | n | % |
|---|---|---|
| PPPNI | ||
| Yes | 49 | 12.9 |
| Upper extremities | ||
| Yes | 27 | 55.1 |
| Postoperative pain | 14 | 51.9 |
| Postoperative weakness | 13 | 48.1 |
| Postoperative numbness | 2 | 7.4 |
| Lower extremities | ||
| Yes | 25 | 51.0 |
| Postoperative pain | 12 | 48.0 |
| Postoperative weakness | 14 | 58.3 |
| Postoperative numbness | 1 | 4.0 |
| Upper+Lower extremities | ||
| Yes | 3 | 6.1 |
| Outcome of PPPNI | n | % |
|---|---|---|
| Medical attention | ||
| No | 43 | 87.8 |
| Yes | 6 | 12.2 |
| Treatment | ||
| Gabapentin | 5 | 83.3 |
| Pregabalin | 1 | 16.7 |
| Persisted PPPNI | ||
| No | 46 | 93.9 |
| Yes | 3 | 6.1 |
| Recovery time Mean ± SD; 6.5 ± 2.81 months | ||
PPPNI, postoperative positional peripheric nerve injury; BMI, body mass index; OT, operation time; TT, Trendelenburg time, duration of damage; the period of time for which the damage was sustained; CCI, Charlson Comorbidity Index; ASA, American Society of Anesthesiologists risk score.
Of the patients with positional damage, 6 (12.2%) sought medical attention 4 weeks after surgery (Table 1). They were evaluated by neurologist. After detailed examination and electromyography, 5 (83.3%) patients were treated with Gabapentin, while 1 (16.7%) was treated with Pregabalin. The mean recovery time was 6.5 ± 2.81 months. In 3 patients, numbness symptoms persisted despite medical and physical therapy 12 months after surgery.
There is no difference between groups in the terms of International Society of Urological Pathology (ISUP) grade group pathologic staging or Gleason grade group for the PPPNI. The statistical analysis revealed that the BMI levels, OT and TT of patients with PPPNI were significantly higher than those without PPPNI (P < .01). The analysis revealed no statistically significant correlation between age, CCI and ASA scores and the presence of PPPNI (P > .05) (Table 2).
Table 2.
Perioperative and Pathological Factors by PPPNI Status
| PPPNI |
|||
|---|---|---|---|
| No (n = 819) |
Yes (n = 49) |
||
| Perioperative Factors | Mean ± SD (median) | Mean ± SD (median) | P Value |
| Age (year) | 62.56 ± 6.83 (63) | 61.76 ± 6.25 (62) | .297a |
| BMI (kg/m2) | 26.74 ± 2.14 (26) | 28.61 ± 3.46 (28) | .001a** |
| Operation time (minutes) | 163.92 ± 47.10 (200) | 201.88 ± 70.09 (218) | .001a** |
| Trendelenburg time (minutes) | 107.36 ± 42.85 (140) | 133.53 ± 60.96 (150) | .005a** |
| CCI | 2.42 ± 0.88 (2) | 2.68 ± 0.76 (3) | .015b |
| ASA | 1.69 ± 0.62 (2) | 1.71 ± 0.68 (2) | .861b |
| Pathological Factors | n (%) | n (%) | |
|---|---|---|---|
| ISUP | .87c | ||
| Grade group 1 | 368 (44.9) | 21 (42.8) | |
| Grade group 2 | 346 (42.2) | 20 (40.8) | |
| Grade group 3 | 65 (7.9) | 5 (10.2) | |
| Grade group 4 | 40 (4.9) | 3 (6.1) | |
| Pathological stage | .77c | ||
| pT2 | 492 (60) | 30 (61.2) | |
| pT3a | 257 (31.3) | 15 (30.6) | |
| pT3b | 70 (8.5) | 4 (8.1) |
aStudent’s t test; bMann–Whitney U test; cPearson χ2 test; **P < .01. ISUP, International Society of Urological Pathology.
In light of these findings, it was deemed appropriate to calculate the cutoff point for BMI, TT, and OT. A receiver operating characteristic (ROC) curve was constructed in order to ascertain the optimal cutoff point in relation to the presence of a PPPNI. In consideration of the presence of a PPPNI, the optimal cutoff point for BMI, OT, and TT was determined to be 29, 252, and 3, respectively (Table 3, Figure 2).
Table 3.
BMI, TT, and OT; Diagnostic Scan and ROC Analysis Results
| Diagnostic Scan |
ROC Curve |
P | ||||||
|---|---|---|---|---|---|---|---|---|
| Cutoff | Sensitivity | Spesifisity | Positive Predictive Value | Negative Predictive Value | Auc | 95% Confidence Interval | ||
| BMI | ≥29 | 49.51 | 81.16 | 49.51 | 81.16 | 0.666 | 0.599–0.733 | .001** |
| OT | ≥212 | 75.73 | 37.68 | 31.20 | 80.62 | 0.582 | 0.518–0.646 | .014* |
| TT | ≥157 | 58.25 | 59.42 | 34.88 | 79.23 | 0.595 | 0.533–0.658 | .004** |
BMI, body mass index; OT, operation time; TT, Trendelenburg time.
Figure 2.
ROC analysis for BMI, OT, and TT level according to PPPNI. PPPNI, postoperative positional peripheric nerve injury; BMI, body mass index; OT, operation time; TT, Trendelenburg time.
There is no statistically significant relationship between age, BMI, OT, TT, CCI, and ASA scores and PPPNI duration time (P > .05) (Table 4).
Table 4.
The Relationship between the Duration of PPPNI and the Descriptive Characteristics of Cases with PPPNI
| PPPNI Duration Time (Months) |
||
|---|---|---|
| r | P | |
| Age (years)a | −0.181 | .217 |
| BMI (kg/m2)a | 0.019 | .902 |
| OT (minutes)a | −0.155 | .294 |
| TT (minutes)a | −0.210 | .153 |
| CCIb | 0.174 | .237 |
| ASAb | −0.149 | .311 |
aPearson correlation analysis; bSpearman’s ρ correlation analysis. PPPNI, postoperative positional peripheric nerve injury; BMI, body mass index; OT, operation time; TT, Trendelenburg time, duration of damage; the period of time for which the damage was sustained; CCI, Charlson Comorbidity Index; ASA, American Society of Anesthesiologists risk score.
DISCUSSION
In our study, the incidence of PPPNI in patients undergoing RARP was found to be 5.6% (n = 49). We determined that prolonged OT, TT, and elevated BMI were associated with an increased risk of PPPNI. No correlation was identified between age, ASA score and CCI and PPPNI. The most prevalent form of PPPNI was pain in the upper extremity (55.1%), while the occurrence in both extremities was 6.1%. The mean recovery time was 6.5 ± 2.81 days.
The incidence rates of PPPNI have been reported in a variety of percentage in the literature, ranging from 1.3% to 10.8%, 0.6% to 10%, 0.02% to 21%.8,12,13 This discrepancy may be attributed to the fact that numerous parameters vary between studies, including the positioning during surgery, the surgical team's experience, and the surgical time. Furthermore, precise figures may be unattainable due to factors such as the lack of documentation of certain mild cases or PPPNI occurring in the postoperative period and not being linked to the procedure.
It has been reported that the prolonged application of the steep Trendelenburg position during urological robotic surgery is associated with an increased risk of postoperative morbidity.14–16 The most significant risk factors for the development of PPPNI during a steep Trendelenburg position have been identified as the duration of the surgical procedure and the position of the patient on the operating table.14,15,17
Furthermore, prolonged operation time may also be associated with an increased risk of damage, even when the anatomically appropriate position is maintained.1,4,14,15,17 In particular, the lithotomy position for a period exceeding two hours has been linked to an elevated risk of nerve injury.14 A prolonged fixed position may result in damage to the pressure points that come into contact with the operating table, which may be temporary or permanent in natüre.1,3,4 However, the anesthetist does not typically impose constraints on the duration of the operation or the angle of inclination during the procedure. Furthermore, in the absence of an acute medical emergency, it is not possible to alter the position of the patient once the robot has been docked during the surgical procedure. Therefore it has been recommended that adequate surgical positioning be ensured with available and appropriate equipment (such as dry viscoelastic polymer mattress covers and gel pads) and devices to assist in performing the procedure.1,3,6
Additionally, the anesthesia -surgical procedure duration has been identified as a distinct risk factor. As prolonged immobilization and pressure exposure cause anoxia, tissue necrosis and ultimately skin damage.5,8,12,13,18,19 It can be posited that one hour of surgery may increase the patient's risk of developing this type of injury by 1.07. Moreover, it has been demonstrated that surgeries exceeding two hours may favor the occurrence of pressure injury by affecting the oxygenation of compressed tissues.5
Another significant intraoperative risk factor has been identified as the type and depth of anesthesia. This impacts the extent of nervous system depression, the inhibition of pain receptors and the relaxation of muscles, thereby preventing the patient's defensive mechanisms from protecting against pressure, which can result in pressure injury and an increased risk of pain.5
Furthermore, there is evidence to suggest that the use of pneumoperitoneum in conjunction with deep Trendelenburg positioning during RARP may result in significant circulatory and respiratory complications.8,14
The point in the surgical learning curve represents a significant determinant of the overall duration of the surgical procedure. However, regardless of the proficiency and experience of the surgical team, the complexity of the RARP operation, the induction of anesthesia, the necessity for invasive monitoring, the positioning of the patient, the placement of the robot, and the subsequent emergence from anesthesia will inevitably result in a certain duration of operation. In fact, it is not feasible to perform the surgical procedure in less than a certain time. The cases included in this study were performed by the same surgical and anesthetic teams, who had intermediate to advanced experience.
In a survey study on anesthesiologists’ practice of the steep Trendelenburg position in the USA, Souki et al reported that the second most common complication associated with this position was brachial plexus injury. There were notable discrepancies among the participants with regard to the protective measures employed, the documentation maintained, the positioning techniques utilized, and the fluid management strategies applied in the context of the steep Trendelenburg position. Two-thirds of the participants indicated that patients typically position their arms laterally, while one-third of them still utilize shoulder braces. Notably, only one-sixth of them reported that the use of shoulder braces was avoided. However, a common thread runs through these reports: they highlight a lack of institutional policies. In order to mitigate the risk, it has been advised that the duration of the steep Trendelenburg position be limited as much as possible and that effective communication be established with the surgical team. Furthermore, written protocols should be developed to determine the appropriate course of action during the position, and training should be provided within the institution to ensure continuity.14
In a case series, Devarajan et al emphasized that the arms should be adducted and tucked to the patient's side, and that shoulder braces should be avoided in order to reduce the risk of brachial plexopathy during the steep Trendelenburg position.20
Despite the existence of differing practice habits, it is important for anesthesiologists to be aware of the potential adverse effects that may arise from the steep Trendelenburg position.14 In order to mitigate the risk of positional complications and brachial plexus neuropathy associated with the steep Trendelenburg position, the practice recommendation of the ASA is that the abduction of the arms should not exceed 90°, that shoulder belts should not be used, and that frequent position control and marking on a checklist is essential.21,22
Additionally, patient-related risk factors, including demographic differences, BMI, ASA classification, and CCI, may contribute to the elevated risk of postoperative positional injury (PPI).8,12,13
While numerous studies have indicated that a high BMI is a risk factor for PPPNI, others have reported no association or even suggested that being underweight may be a risk factor.8,13,23,24
In individuals with obesity, the accumulation of adipose tissue compresses the blood vessels and the accompanying nerve structures, which results in a reduction in tissue perfusion and may ultimately lead to damage to the nerves.5,23 Conversely, low weight may render the vascular structures and accompanying nerve tissues in the patient unprotected and closer to the surface, rendering them more vulnerable to factors such as stretching and compression, which may result in nerve damage.5 It appears that being underweight may increase the risk of PPPNI and pressure injury in the lower extremity in the lithotomy position.24
Nevertheless, given that RARP is a cancer surgery, it is not feasible to await the patient's attainment of the optimal body weight prior to the procedure.
In our study, most patients were classified as ASA 1 or 2. As the number of ASA 3 patients was low and there were only 3 ASA 4 patient. Therefore we did not find ASA among the factors increasing the risk.
Furthermore, the CCI scores of our patients exhibited minimal variation and were relatively low. As patients with advanced comorbidities were not included in the RARP operation in our center, therefore, we think that we did not find CCI among the factors that increase the risk.
In our study, the development of PPPNI was predominantly observed in the upper extremities. Cornelius et al reported a higher incidence of PPPNI in the lower extremities, while another study identified brachial plexus injury as the most common.12,14 A review of the literature revealed that intraoperative peripheral nerve injury was most commonly observed in the Trendelenburg position in the upper extremities and in the lithotomy position in the lower extremities.25,26 We suggest that these different results are attributable to the different positions and the way in which they are given.
The degree and severity of sensory and motor damage are significant factors in peripheral nerve damage. The clinical picture may range from mild dysesthesia to more severe symptoms such as numbness, pain, and loss of strength, which can significantly impact an individual’s ability to perform daily activities. Fortunately, most symptoms associated with peripheral nerve damage are transient.
Given that PPPNI continues to occur, as evidenced by this study, despite rigorous attempts at positioning and padding interventions, it is probable that there are as yet unidentified causes of PPPNI, which we currently consider to be multifactorial.
It is also crucial to emphasize that when PPPNI is developed, it is vital to diagnose and record it promptly, administer and treat it in a predetermined and standardized manner, and document it as a case study.
Patients who will undergo RARP must be informed in detail about the risk of nerve damage and must provide consent while being fully apprised of the potential risks and complications that may develop preoperatively. It is also important to be aware that this situation, which depends on the patient’s position, could potentially lead to a malpractice lawsuit, which is a significant issue globally.8,9
Retrospective single centre natüre and not evaluating some other events affecting intraoperative hemodynamics (hypoxia, hypotension and significant blood loss ext.) are the main limitations of this study.
CONCLUSION
The risk of PPPNI should not be forgotten especially in operations requiring extreme positioning such as RARP. We recommend that a common procedure should be established by the surgeon, staff and anesthesia team for positioning, the team should be regularly informed about this issue, the best surgical view position should be in accordance with the anatomical position as much as possible, pressure points and the shoulder should be supported with soft pads, the patient's position should be checked periodically during the operation, the patient and his/her relatives should be informed preoperatively about the complications that may occur related to the position and the planned procedures to be performed for treatment if they occur, these issues should be clearly written in the written consent document and the consent should be signed.
Footnotes
Funding sources: none.
Conflict of interests: none.
Disclosure: none.
Contributor Information
Şenay Göksu, Anaesthesiology and Reanimation Department, Health Science University, Umraniye Training and Research Hospital, Istanbul, Turkey. (Drs. Göksu and Bakan).
Gülşah Karaören, Anaesthesiology and Reanimation Department, Das Alice-Hospital Darmstadt, Darmstadt, Germany. (Dr. Karaören).
Ahmet Tahra, Department of Urology, Health Science University, Umraniye Training and Research Hospital, Istanbul, Turkey. (Drs. Tahra, İnkaya, and Küçük).
Abdurrahman İnkaya, Department of Urology, Health Science University, Umraniye Training and Research Hospital, Istanbul, Turkey. (Drs. Tahra, İnkaya, and Küçük).
Eyüp Veli Küçük, Department of Urology, Health Science University, Umraniye Training and Research Hospital, Istanbul, Turkey. (Drs. Tahra, İnkaya, and Küçük).
Nurten Bakan, Anaesthesiology and Reanimation Department, Health Science University, Umraniye Training and Research Hospital, Istanbul, Turkey. (Drs. Göksu and Bakan).
References:
- 1.Nascimento FCLD, Rodrigues MCS. Risk for surgical positioning injuries: scale validation in a rehabilitation hospital. Rev Lat Am Enfermagem. 2020;28:e3261. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Menezes S, Rodrigues R, Tranquada R, Müller S, Gama K, Manso T. Lesões decorrentes do posicionamento para cirurgia: incidência e fatores de risco [Injuries resulting from positioning for surgery: incidence and risk factors]. Acta Med Port. 2013;26(1):12–16. [PubMed] [Google Scholar]
- 3.Lopes CM, Haas VJ, Dantas RA, Oliveira CG, Galvão CM. Assessment scale of risk for surgical positioning injuries. Rev Lat Am Enfermagem. 2016;24:e2704. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Burlingame BL. Guideline implementation: positioning the patient. Aorn J. 2017;106(3):227–237. [DOI] [PubMed] [Google Scholar]
- 5.Peixoto CA, Ferreira MBG, Felix MMDS, Pires PDS, Barichello E, Barbosa MH. Risk assessment for perioperative pressure injuries. Rev Lat Am Enfermagem. 2019;27:e3117. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.de Oliveira KF, Nascimento KG, Nicolussi AC, Chavaglia SRR, de Araújo CA, Barbosa MH. Support surfaces in the prevention of pressure ulcers in surgical patients: an integrative review. Int J Nurs Pract. 2017;23(4):e12553. [DOI] [PubMed] [Google Scholar]
- 7.Grant I, Brovman EY, Kang D, Greenberg P, Saba R, Urman RD. A medicolegal analysis of positioning-related perioperative peripheral nerve injuries occurring between 1996 and 2015. J Clin Anesth. 2019;58:84–90. [DOI] [PubMed] [Google Scholar]
- 8.Zarandona Del Campo A, Herreros Marias N, Torvisco Macias A, et al. Factors associated with peripheral nerve injury after pelvic laparoscopy: the importance of surgical positioning. J Nurs Res. 2023;31(1):e259. [DOI] [PubMed] [Google Scholar]
- 9.Welch MB. Patient positioning for surgery and anesthesia in adults. UpToDate. Available at: https://www.uptodate.com/contents/patient-positioning-for-surgery-and-anesthesia-in-adults. Accessed on February 23, 2025. [Google Scholar]
- 10.Abdalmageed OS, Bedaiwy MA, Falcone T. Nerve injuries in gynecologic laparoscopy. J Minim Invasive Gynecol. 2017;24(1):16–27. [DOI] [PubMed] [Google Scholar]
- 11.Güzelküçük Ü, Skempes D, Kumnerddee W. Common peroneal nerve palsy caused by compression stockings after surgery. Am J Phys Med Rehabil. 2014;93(7):609–611. [DOI] [PubMed] [Google Scholar]
- 12.Cornelius J, Mudlagk J, Afferi L, et al. Postoperative peripheral neuropathies associated with patient positioning during robot-assisted laparoscopic radical prostatectomy (RARP): a systematic review of the literature. Prostate. 2021;81(7):361–367. [DOI] [PubMed] [Google Scholar]
- 13.Bjøro B, Mykkeltveit I, Rustøen T, Candas Altinbas B, Røise O, Bentsen SB. Intraoperative peripheral nerve injury related to lithotomy positioning with steep Trendelenburg in patients undergoing robotic-assisted laparoscopic surgery - a systematic review. J Adv Nurs. 2020;76(2):490–503. [DOI] [PubMed] [Google Scholar]
- 14.Souki FG, Rodriguez-Blanco YF, Polu SR, Eber S, Candiotti KA. Survey of anesthesiologists’ practices related to steep Trendelenburg positioning in the USA. BMC Anesthesiol. 2018;18(1):117. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Maerz DA, Beck LN, Sim AJ, Gainsburg DM. Complications of robotic-assisted laparoscopic surgery distant from the surgical site. Br J Anaesth. 2017;118(4):492–503. [DOI] [PubMed] [Google Scholar]
- 16.Adams CL, Sheeder J, Arruda J, Guntupalli SR, Davidson SA, Behbakht K. Prolonged steep Trendelenburg positioning increases the risk of postoperative morbidity in patients undergoing robotic surgery for presumed gynecologic malignancy. Gynecol Oncol. 2015;137:54. [Google Scholar]
- 17.Sukhu T, Krupski TL. Patient positioning and prevention of injuries in patients undergoing laparoscopic and robot-assisted urologic procedures. Curr Urol Rep. 2014;15(4):398. [DOI] [PubMed] [Google Scholar]
- 18.Spruce L. Back to basics: preventing perioperative pressure injuries. Aorn J. 2017;105(1):92–99. [DOI] [PubMed] [Google Scholar]
- 19.Baccaglini W, Medina L, Azhar RA, Sotelo RJ. Complications of robotic surgery in urological diseases: are we using standardized methodology to report complications? Curr Opin Urol. 2019;29(1):19–24. [DOI] [PubMed] [Google Scholar]
- 20.Devarajan J, Byrd JB, Gong MC, et al. Upper and middle trunk brachial plexopathy after robotic prostatectomy. Anesth Analg. 2012;115(4):867–870. [DOI] [PubMed] [Google Scholar]
- 21.American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies. Practice advisory for the prevention of perioperative peripheral neuropathies: an updated report by the American Society of Anesthesiologists Task Force on prevention of perioperative peripheral neuropathies. Anesthesiology. 2011;114(4):741–754. [DOI] [PubMed] [Google Scholar]
- 22.Practice Advisory for the Prevention of Perioperative Peripheral Neuropathies 2018. An updated report by the American Society of Anesthesiologists Task Force on prevention of perioperative peripheral neuropathies. Anesthesiology. 2018;128(1):11–26. [DOI] [PubMed] [Google Scholar]
- 23.Velchuru VR, Domajnko B, deSouza A, et al. Obesity increases the risk of postoperative peripheral neuropathy after minimally invasive colon and rectal surgery. Dis Colon Rectum. 2014;57(2):187–193. [DOI] [PubMed] [Google Scholar]
- 24.Al-Temimi MH, Chandrasekaran B, Phelan MJ, et al. Incidence, risk factors, and trends of motor peripheral nerve injury after colorectal surgery: analysis of the national surgical quality improvement program database. Dis Colon Rectum. 2017;60(3):318–325. [DOI] [PubMed] [Google Scholar]
- 25.Bentsen SB, Eide GE, Wiig S, Rustøen T, Heen C, Bjøro B. Patient positioning on the operating table and patient safety: a systematic review and meta-analysis. J Adv Nurs. 2024. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Das D, Propst K, Wechter ME, Kho RM. Evaluation of positioning devices for optimization of outcomes in laparoscopic and robotic-assisted gynecologic surgery. J Minim Invasive Gynecol. 2019;26(2):244–252.e1. [DOI] [PubMed] [Google Scholar]