Hysterectomy Trendelenburg position: Less may be more



LAS VEGAS – Significantly reducing the degree of Trendelenburg position during robotic-assisted hysterectomy did not increase operative time and cut blood loss in half in a small retrospective analysis.

Surgeons spent an average of 66.5 minutes (range, 38-110 minutes) at the console when patients were placed in a minimum Trendelenburg position, compared with 79 minutes (range, 30-180 minutes) with a steep Trendelenburg position.

The difference in this primary outcome failed to achieve statistical significance (P = .105); however, the use of a minimum Trendelenburg position significantly reduced the average estimated blood loss from 101.3 mL to 50 mL (P = .007), Dr. Kelli Sasada reported at the 41st AAGL Global Congress.

A minimum degree of Trendelenburg position can be as effective as a steep Trendelenburg position in achieving adequate surgical exposure, thereby allowing safe completion of hysterectomy without increasing operative time, she said.

A steep Trendelenburg position, defined as at least 20 degrees in the anesthesia literature, improves the view of the surgical area during pelvic surgery by taking advantage of gravity to retract the bowels. It is common practice to use this approach during robotic-assisted hysterectomy because the patient’s position cannot conveniently be adjusted once the robot is docked, Dr. Sasada explained.

A steep Trendelenburg position, however, is often fraught with complications that can be severe and permanent, such as neural and retinal injuries, the patient moving or sliding off the table, ventilation concerns including airway access for the anesthesia provider, poor cardiopulmonary status, and alopecia, she added.

To explore the minimum degree of Trendelenburg necessary to complete the surgery safely, Dr. Sasada and her associate, Dr. Linda Mihalov, at Virginia Mason Medical Center in Seattle, took advantage of a new iPad app called clinometer HD (by plaincode) among 50 women undergoing da Vinci robotic-assisted benign total laparoscopic hysterectomy with or without bilateral salpingo-oophorectomy. Patients were secured in the dorsal lithotomy position, the abdomen was entered laparoscopically, and a brief survey was conducted to assess the size, position, and accessibility of the pelvic organs. The degree of Trendelenburg was determined by the surgeon and the iPad clinometer HD placed on the bed rail to measure the table tilt. The robot was then docked parallel to the patient’s side, and the surgery completed.

A steep Trendelenburg, defined as 30 degrees, was used in 38 women, and a minimum degree of Trendelenburg averaging 16.6 degrees (range, 13.8-19 degrees) used in 12 women, said Dr. Sasada, now with United Hospital System, St. Catherine’s Medical Center in Pleasant Prairie, Wis.

The average uterine weight was not significantly different between the steep and minimum Trendelenburg groups (215.4 g vs. 173.6 g; P = .21).

Body mass index also was similar at 28.5 kg/m2 vs. 25 kg/m2 (P = .071), with a wide range in both groups, she said.

There was one case of intraoperative bleeding (500 cc) and no postoperative complications in the steep Trendelenburg group, and one case of postoperative urinary retention and no intraoperative complications in the minimum Trendelenburg group.

During a discussion of the study, Dr. Sasada said it’s possible that the lower blood loss with the minimum Trendelenburg position could be due to chance, but that both surgeries were completed with the same four incisions and without bowel prep.

Dr. Sasada currently uses a minimum Trendelenburg position and an iPad when performing robotic-assisted hysterectomy and other pelvic surgeries, but not in all cases, as some OR beds have built-in clinometers. The advantage of the iPad technology is that it offers "ease of use in the OR by anesthesia or nursing staff, and reproducibility between OR beds," she said in an interview.

Dr. Sasada and Dr. Mihalov reported no relevant financial disclosures.

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