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A Planning Playbook for Opening a New Orthopedic ASC
The ASC market continues its rapid growth. In 2023, roughly 116 new ASCs opened in the U.S., many of which were orthopedic-specific in nature....
ADD-ON HELP Attachments should be easy for your staff to manipulate while positioning patients.Today's patient positioning attachments turn any surgical surface into a specialty table and give surgeons the visualization and access they need for successful case outcomes. If you're looking to upgrade the centerpieces of your ORs, now's the time to take another look at all you can bring to the table.
Positioning pluses
Leg holders, arm boards, shoulder positioners and "beach chair" attachments ready conventional tables for complex procedures. Look for devices that hold patients' legs or arms securely in place, that can be flipped to accommodate right and left configurations, and with low-profile designs that keep valuable space in the sterile field free of impediments. The best devices for orthopedic procedures are easily adjustable, so surgeons can achieve the desired level of traction without help from an assistant, who's then freed up to perform other more valuable clinical tasks. Eliminating the need to hold a patient's leg or arm in place for the duration of a procedure also improves the ergonomic safety of your surgical team.
A growing number of surgery centers are deciding to add total joints, but might not have the space or financial resources to invest in a joint-specific table. Specially designed attachments help place patients in the supine position, allowing for an anterior approach to the hip that spares muscles around the joint. That approach lets patients ambulate more quickly after surgery and readies them for same-day discharge.
In the lateral position, the patient's spine must be properly aligned, the hips placed at 90 degrees and the shoulder, hips and face protected from skin and nerve damage — all while providing surgeons with unimpeded access to the surgical site.
When placing patients in the Trendelenburg position for robotic, colorectal and gynecologic procedures, keeping them stable as they lie inverted is critical to preventing skin injuries and nerve damage that can occur if they slide down the table's surface during conventional laparoscopy or port trauma if they move only a matter of inches during robotic surgery (see "The Trouble With Trendelenburg").
Luckily, several positioning attachments offer solutions to these potential problems. One inflatable device is unfolded onto the surgical surface and its integrated straps attach securely to the table's rails. The patient is transferred onto the device, with her arms to the side. Staff members mold the positioner around her body then deflate it, forming a vacuum-like seal around the contours of her sides and shoulders to keep them padded and securely in place on the table's surface throughout the procedure. The same technology is available for patients positioned laterally. Another option involves placing a shape-conforming single-use pad on the table's surface that molds to the contours of the patient's body, padding her shoulders and hips. The pad keeps the patient from sliding and, hopefully, eliminates the need to reposition her mid-procedure.
SNUG Devices should keep appendages securely in place and protect patients from positioning-related injuries.Accessory advice
Ask surgeons and staff for input when shopping the options for each type of case you host, from abdominal surgery to orthopedic procedures performed on the shoulder, knee and hip. What are the positioning needs? Also have the surgeons and staff members who will use the attachments trial them to ensure the devices are light enough to maneuver without much effort. Do the attachments feel sturdy once they're in place? Will they be easy to adjust while under the patient's full weight? Are they easily attached and detached from the table?
Patients are bigger and heavier than ever, so consider using attachments that add to the standard width of conventional tables. In addition, make sure all straps are large enough to fit snugly around the legs, arms and torsos of the heaviest patient you have the potential to host.
The attachments you buy must be compatible with the tables you're using. Some devices are advertised as "universal" solutions, but have your staff confirm that that's truly the case. They should attach and detach each option from the tables in your ORs and practice positioning a member of the surgical team to see how easy it will be to maneuver patients before and during actual procedures.
Attachments used during orthopedic cases should be made of radiolucent materials that allow for intraoperative imaging. Also look for devices and attachments that provide clear access to the patient and surgical site. Attachments should be ergonomic, provide excellent stability and be engineered to support today's heavier patients. Ideally, they should have a flexible design that allows for on-the-fly positioning changes.
Also keep your staff's safety in mind. Powered options ease mid-procedure positioning and limit risk of injury to members of the surgical team. Although newer designs are constructed with lightweight materials, specially designed carts that ease the moving and storing of the equipment are, in my mind, well worth the investment.
INJURY PREVENTION
The Trouble With Trendelenburg
Placing patients in the Trendelenburg position is wrought with potential complications. Patients might slide toward the head of the bed, resulting in skin burns along the back, nerve damage near the shoulders and, during robotic surgery, internal injuries caused by the static arms of the robot.
Injuries to the brachial plexus are common perioperative neuropathy, and are more likely to occur in patients placed in steep 40-degree Trendelenburg during robot-assisted procedures performed on the uterus, prostate or bladder. Avoiding the use of shoulder braces limits the injury risk, although Advances in Anesthesia (osmag.net/RPgJz4) researchers say mattresses and pads designed to prevent patients from slipping aren't adequate solutions. They suggest the use of padded shoulder braces and a headrest designed to distribute the body's weight evenly across the shoulders and the base of the neck. They also say you should select properly fitted and well-padded leg positioners to avoid injuries caused by low perfusion pressure that results from the legs remaining above the heart for long stretches during surgery.
Research published in the AORN Journal (osmag.net/HHa7pN) has a different take on protecting patients during robotic-assisted laparoscopic prostatectomy, which requires patients to be placed in the low-lithotomy position with stirrups to maneuver them properly under the robot and in steep Trendelenburg with arms at their side for most of the procedure to shift the bowel toward the head. "This type of extreme positioning may make it difficult to implement necessary safety measures," they write.
The study says an injury to the brachial plexus occurs in 0.16% of robotic or laparoscopic gynecologic surgery, which requires similar patient positioning. Although a brachial plexus injury is relatively uncommon, it has several negative consequences, ranging from numbness, weakness or loss of sensation or motor control of the arm or hand, to severe pain.
Patients need to be properly supported on the table, but keeping them secure with shoulder braces is "not recommended," according to the authors of the AORN Journal study. Instead, they note, it's preferred to use adequate amounts of appropriately placed padding and other methods to prevent sliding and to minimize the degree of Trendelenburg position.
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