The positioning of the patient during the operation is an important aspect of safe treatment, along with preoperative preparation and postoperative monitoring. Numerous complications such as nerve damage, pressure points, or electrical current marks are a result of incorrect positioning. Correct positioning is the joint responsibility of the operating room nurses, the anesthesia team and ultimately the surgeon. Only a few hospitals have special positioning nurses, whose routinely acquired knowledge might avoid many complications. With shorter turnaround times on the one hand and longer operating times on the other (cancer surgery, pelvic floor surgery), correct positioning is becoming more and more important.
Abdominal procedures are still the most common ones in gynecology in most hospitals, although laparoscopic and vaginal procedures are impinging on their predominance.
Abdominal access. Open abdominal procedures can be performed with the patient in simple supine position with the legs extended. In English-speaking countries, abdominal hysterectomies and cesarean sections are usually performed in this way, with the legs abducted temporarily before surgery for disinfection and insertion of a bladder catheter. The arms are placed on arm rests on both sides to provide optimal access for the anesthetists. The risk of hyper-extension of the shoulder should be noted. In German-speaking countries, the possibility of vaginal access is regarded as important during abdominal operations and cesarean section. Alternatively, the legs can be placed in leg supports, which are lowered relatively far after disinfection and catheter insertion, or the legs can remain extended but with the hips abducted. In both cases, it is possible for a second assistant to be positioned between the legs. When leg supports are used, it is important to ensure correct positioning and padding. The foot, knee and contralateral shoulder should form one axis. There must be no contact with the head of the fibula. The surgeon must personally check this. When the legs are extended, pads should be used to ensure positioning without areas of tension and pressure. During long operations, the patient′s temperature can be controlled with heat pads and convection heaters. Correct insulation of the patient from the operating table warrants particular attention. Excessively “wet” disinfection should be avoided and the patient must never lie on anything damp that might conduct electricity. Fluid can collect in the sacral area, particularly during vaginal disinfection, unless towels are used to ensure dryness.
Abdominovaginal access. Many procedures in gynecology can require abdominovaginal access, whether planned or unplanned. The simplest positioning for this is achieved by using mobile leg supports. Both areas are disinfected beforehand. The same important positioning principles apply as in purely abdominal surgery: adequate electrical insulation from the operating table, arms outstretched, adequate padding of the legs, and straight foot–knee–contralateral shoulder axis.