The importance of surgical tables is sometimes overlooked, causing many general surgeons to operate on tables that, in all honesty, aren't optimal choices for patient positioning or staff ergonomics. Working with versatile tables and effective positioning devices can improve case efficiencies, surgeons' visualization of the abdominal cavity and patient safety. Focus on these factors to ensure your laparoscopic cases are performed on the best possible surface.

1 Engage surgeons
Tables are major capital expenditures and durable equipment. Once a table has been installed, you're not likely to replace it for a long time. And unlike other, more specialized equipment, there is sometimes a disconnect or gap in the purchasing decision between what surgeons would find useful and what your facility is willing to spring for. It's entirely possible we surgeons are to blame. When it comes to purchasing equipment, we pick our battles. We'll stand up and fight for the instruments we want, but we're often willing to concede on the table.

While patient positioning might not always get the careful and continuous attention it demands, it's only recently that surgical industry observers — even those of us standing at the table — have even begun to take the ergonomic concerns of the surgeon seriously.

The positioning, posture and repetitive stresses of laparoscopy are hard on the surgeon's body. Clinical studies, including those by Adrian Park, MD, the chair of general surgery at the University of Maryland Medical Center, have shown the effects (see "General Surgeons Suffering"). Plus, after 25 years in practice, my malfunctioning joints are proof of it.

The combination of the long instruments we use, the table on which the patient is lying, how we're standing and how long we're standing for all have an impact on our long-term physical well-being. You're likely constantly on the search for intraoperative improvements with respect to patients. Don't forget to examine ergonomic options designed to help surgeons, who can perform better surgery when they're able to comfortably manipulate instruments.

2 Prioritize positioning
Patient positioning in general surgery has become more complex since the rise of minimally invasive techniques and robot-assisted procedures. We once simply laid the patient flat on his back and made an incision into his abdomen, or perhaps placed her legs into stirrups for the lithotomy position. Now, preparations for abdominal surgery may include tilting the entire patient from the head or the feet (the Trendelenburg or reverse Trendelenburg positions), or placing him completely on his side, in the lateral decubitus position.

Even as the complexity of patient positioning increases, keep positioning's basic principles in mind before every case by protecting patients against perioperative musculoskeletal and skin injuries, and by understanding that every position has a physiological effect on the anesthetized and immobilized patient.

Make sure a patient's extremities are placed properly during some of the extreme positions required to give surgeons better access to the abdominal cavity. Does your staff always tuck patients' arms securely by their sides, so an arm doesn't fall out of position and hang off the table, undetected by staff for the remainder of the procedure because it's concealed beneath the drape? You likely focus on all the other safety preparations your staff takes for a case, but are your patients placed on the table and positioned by nurses who might not be aware of which position is needed for a particular procedure? Are patients placed into position without full consideration of how the position and the devices used during the procedure might affect the parts of the body aside from the surgical site?

Above all, proper patient positioning is a function of continual care. Your entire surgical team, led by the surgeon, must ensure that the patient remains properly positioned throughout the entirety of surgery.

Your surgical team should regularly inspect the positioning of a patient, but that's sometimes easier said than done. During a procedure the surgeon is focused on the surgical site, the circulator is running from the field to the back table to the computer and the anesthesia provider is concentrating on vital signs, breathing rates and airway patency. Will someone notice a draped arm that has fallen off the table? They'd better, or your patient may wake with nerve palsy or other positioning injuries.

To avoid avoidable mishaps related to patient positioning, include an assessment of proper positioning in your pre-op safety checklist, along with marking the surgical site, verifying the case and taking a time out. Take the initiative and institute a process for maintaining safety during a case, including a consistent focus on proper patient positioning for all the members of your team.

During the majority of cases, everything turns out fine, but once in a while a compromised outcome occurs: nerve damage or pressure injuries. Make patient safety a priority, not an afterthought, by taking issues of padding and positioning seriously.

3 Shop the surfaces
It's amazing how many of us surgeons just put up with whichever table is installed in the OR, however inefficient it is, but perhaps it's inevitable. We've been working with one-size-fits-all tables and positioning for a long time, and may not realize other options exist. But they do.

If you're in the market to replace or upgrade a table, work with your surgeons to include their input into the purchasing decisions. When you're checking out tables at conference exhibit halls or in other facilities' ORs, think about all the types of cases your facility hosts and which surfaces would work best in actual practice. Don't just stand next to a table and measure its height against yours. Raise and lower the table to the levels you'll require for a variety of laparoscopic cases. Tilt it at the head and foot, and from side to side. Does it go low enough for ergonomic comfort? Keep in mind that surgeons, like patients, come in all shapes and sizes. Can the table you're considering be positioned and repositioned with minimal complexity to accommodate the tallest and shortest of the bunch? Some tables offer voice-activated controls or wireless remotes to make repositioning during surgery even easier.

If your patient population includes a large percentage of obese patients, invest in tables with a heavier weight limit and wider tabletop. The laparoscopic devices and robotic equipment that get built around the table can be cumbersome, so also consider how well the table will accommodate them in your OR. Position a member of your staff on the tables you use to hear how it feels from a non-anesthetized, conscious individual. And make sure patients can be safely secured to the table to prevent falls when you've tilted the surface. Not all tables are equipped for securing patients, so you may have to purchase the necessary accessories along with patient positioning devices.

4 Assess the attachments
Positioning devices are also an area where you might often settle for what has long been used, even though materials advances have created better alternatives. Patient positioning demands the appropriate padding of bony prominences. But laying an arm down on a board, wrapping it with a foam sheet and taping it down, or using beanbags out of which the air has been vacuumed to prop up a patient on his side, are primitive options. Specialized positioning products that employ gel, memory foam and anatomical designs are safer, more effective and more comfortable.

Beneath the surface
The point of a table's support and positioning is to allow for efficient access during surgery. But you must properly assess the support and positioning of patients, otherwise they — or, in time, your surgeons — may be exposed to safety risks. A table's limitations and abilities can play a huge role in case outcomes. Giving some serious consideration to the central role your table plays in the OR can help protect patients, staff and surgeons, and improve results in all of your abdominal cases.