During a hysterectomy, you lie on your back with your legs raised in stirrups, a setup known as the dorsal lithotomy position. If your surgery is laparoscopic or robotic rather than open, the operating table is then tilted so your head drops below your pelvis, sometimes at a steep angle. The combination of these two positions and how long you stay in them varies by the type of hysterectomy, and that variation matters more than most patients realize.
Why Your Body Is Angled During Surgery
For an open abdominal hysterectomy, the position is straightforward: you lie flat on your back (supine), and the surgeon works through an incision in your abdomen. The table may be tilted slightly head-down, but nothing dramatic. Vaginal hysterectomies use lithotomy position, meaning your legs are supported in stirrups with your hips flexed, giving the surgeon access through the vaginal canal. Again, the tilt is minimal.
Laparoscopic and robotic hysterectomies are where positioning gets more involved. The surgeon operates through small incisions using instruments and a camera, but the uterus sits deep in the pelvis, surrounded by the bladder in front and the bowel behind. To get a clear view, the surgical team tilts you into the Trendelenburg position, where your head is lower than your feet. This lets gravity pull your intestines toward your upper abdomen and away from the surgical field. For robotic-assisted procedures, the tilt can be quite steep, ranging from about 25 to 45 degrees depending on the case and the surgeon’s preference.1European Journal of Obstetrics & Gynecology and Reproductive Biology. Patient positioning for robot-assisted laparoscopic benign gynecologic surgery: A review That steeper angle creates better surgical exposure but puts more physiological stress on your body, which is why the anesthesia team monitors you closely throughout.
What Happens to Your Heart and Blood Pressure
Being tilted head-down shifts blood toward your chest and head, essentially giving your heart a sudden volume load it was not expecting. Your blood pressure rises, particularly the mean arterial pressure, and the pressures inside your chest, including in your pulmonary arteries and central veins, increase as well.2PubMed. Hemodynamic changes due to Trendelenburg positioning and pneumoperitoneum during laparoscopic hysterectomy On top of that, the surgeon inflates your abdomen with carbon dioxide gas to create working space, and that added abdominal pressure pushes your diaphragm upward and further compresses the blood vessels, compounding the cardiovascular effects.
Your heart rate tends to slow down in response. One study of women undergoing robotic surgery found roughly a 20 percent decrease in heart rate within five minutes of being placed in steep Trendelenburg, and that slower rate persisted through much of the operation.3European Journal of Obstetrics & Gynecology and Reproductive Biology. Steep Trendelenburg position during robotic sacrocolpopexy and heart rate variability These changes tend to stabilize over the course of the procedure. Once the table is leveled and the gas is released, pressures return to where they started.4IntechOpen. Cardiovascular Changes during Robot-Assisted Pelvic Surgery For most healthy patients, the cardiovascular shifts are manageable and temporary, but they are the reason your anesthesiologist continuously watches your heart rhythm, blood pressure, and oxygen levels during the case.
How the Position Affects Breathing
Lying head-down with a gas-filled abdomen makes breathing harder, even though a ventilator is doing the work for you under general anesthesia. Your abdominal organs press upward against your diaphragm, reducing how much your lungs can expand. The ventilator has to push harder to deliver each breath, and the pressures it generates inside your airways climb. In a study of patients with a BMI of 40 or above undergoing robotic hysterectomy, mean airway pressures during steep Trendelenburg reached levels that required careful ventilator management to avoid lung strain.5PubMed Central. The effect of steep head-down tilt on respiratory status in endometrial cancer patients with obesity during robot-assisted hysterectomy
An interesting finding from research on robotic hysterectomy in women across a wide range of body sizes is that the breathing stress during surgery appears to be driven more by the positioning and the gas inflation than by the patient’s weight alone. Once women of all BMI categories were in steep Trendelenburg with a pneumoperitoneum, their peak airway pressures and lung compliance measurements converged to similar values, regardless of whether they were in the normal weight range or had a BMI above 50.6PubMed Central. Saturation of respiratory strain during robotic hysterectomy in obese women with endometrial cancer That convergence suggests the position itself imposes a kind of ceiling on ventilatory strain, which is reassuring for patients who worry that their size disqualifies them from a minimally invasive approach. Pulmonary complications in that study occurred in under 5 percent of patients, with no cases of lung injury from the ventilator pressures involved.
Eye Pressure and Facial Swelling
One of the less obvious effects of being tilted head-down is what happens to your eyes. Fluid and blood pool toward your head, and the pressure inside your eyeballs rises progressively the longer you stay in the position. Research on patients in steep Trendelenburg shows a significant increase in intraocular pressure after just one hour, with further increases through the second hour.7Journal of Minimally Invasive Gynecology. Intraocular Pressure and Steep Trendelenburg During Minimally Invasive Gynecologic Surgery: Is There a Risk? The pressure stays elevated even briefly after the patient is returned to a flat position, though it does come back down.
The optic nerve sheath, which surrounds the nerve connecting your eye to your brain, also swells measurably during steep Trendelenburg. A randomized trial comparing women undergoing robotic hysterectomy in steep Trendelenburg with women having open hysterectomy while flat found significantly greater optic nerve sheath widening in the robotic group. The changes reversed after the procedure, and no patients developed complications from increased pressure around the brain.8PubMed Central. Evaluation of optic nerve sheath diameter in patients undergoing robotic hysterectomy in steep Trendelenburg position compared to open abdominal hysterectomy in supine position: A randomized controlled trial For most patients, the eye pressure changes are temporary and harmless. But if you have glaucoma or other conditions that already elevate your baseline eye pressure, this is something to discuss with your surgical team beforehand so they can plan accordingly, potentially limiting the degree of tilt or the duration.
Facial and airway swelling is a related concern. After several hours head-down, your face, eyelids, and tongue can become noticeably puffy. Anesthesiologists watch for this because severe swelling in the tongue or throat could make it harder to safely remove the breathing tube at the end of surgery. In practice, this is managed by keeping the Trendelenburg time as short as possible and checking for swelling before extubation.
Protecting Your Nerves During Surgery
The combination of lithotomy and Trendelenburg creates specific pressure points and stretch forces on the nerves in both your legs and arms. These positioning-related nerve injuries are uncommon, but they happen often enough that prevention is a major focus of the operating room setup.
In the legs, the most vulnerable nerve is the common peroneal nerve, which wraps around the bony head of the fibula just below the outer side of the knee. Compression there, often from a poorly placed stirrup, can cause numbness along the outer calf and the top of the foot, or even difficulty lifting the foot (a condition called foot drop). The sciatic nerve can be stretched if the hip is flexed beyond about 90 degrees, and the femoral nerve can be compressed against the groin if the hip is pushed into extreme outward rotation or abduction.9Clinical Journal of Nursing Care and Practice. Strategies to Prevent Lower-Extremity Positioning Injuries During Long-Duration Surgery in the Lithotomy Position: Our Techniques and Clinical Outcomes Following Genital Gender-Affirming Surgeries Modern stirrup systems (often called “Allen stirrups” or boot-type supports) distribute pressure more evenly than the older candy-cane stirrups, and surgical teams are trained to keep hip and knee angles within safe limits.
The arms are vulnerable too, especially the brachial plexus, the bundle of nerves that runs from your neck through your shoulder and into your arm. When you are tilted head-down, gravity pulls your body toward the head of the bed, and if your shoulders catch on a brace or your arm slides out of position, the nerves can be stretched or compressed between the collarbone and first rib. The safest approach is to tuck both arms at your sides, wrapped snugly with padding. When arms must be extended on arm boards, they should not be angled out more than 90 degrees from the body, and shoulder braces should not be used.10Journal of Minimally Invasive Gynecology. Laparoscopic positioning and nerve injuries Older practices of using braces to keep patients from sliding have been linked to brachial plexus injuries and are now widely discouraged.11PubMed. Brachial plexus neuropathies after advanced laparoscopic surgery
Keeping You From Sliding Off the Table
If your body slides headward while you are tilted, every protective positioning measure is undone. Your arms shift, your legs move in the stirrups, and nerves that were in safe positions suddenly are not. The steeper the Trendelenburg angle, the stronger the gravitational pull toward the head of the bed, and with robotic procedures sometimes lasting several hours, even small amounts of drift add up.
Surgical teams use anti-slip surfaces placed between you and the operating table to counteract this. A randomized trial comparing three common anti-slip products found meaningful differences in how much patients moved during surgery. One foam-based pad resulted in significantly less total body displacement compared to the other surfaces tested, with differences at some body landmarks measuring several centimeters.12Journal of Minimally Invasive Gynecology. Every Inch Counts: A Prospective Randomized Trial of Anti-Slip Surfaces in Minimally Invasive Gynecologic Surgery A few centimeters may not sound like much, but when the margin between a nerve being protected and a nerve being compressed is measured in similarly small distances, the choice of surface genuinely matters.
Compartment Syndrome in the Legs
A rare but serious complication of prolonged lithotomy positioning is well-leg compartment syndrome. When your legs are elevated in stirrups for a long time, blood flow to the lower legs can be compromised, and pressure builds inside the closed muscle compartments of the calves. If the pressure rises high enough, it can damage muscles and nerves permanently. A study evaluating prevention strategies found that compartment syndrome occurred in about 0.8 percent of control-group patients undergoing lengthy lithotomy procedures but in zero patients when a bundle of preventive measures was used, including intermittent lowering of the legs and compression devices.13PubMed Central. Prevention of well-leg compartment syndrome following lengthy medical operations in the lithotomy position If your surgery is expected to last more than a few hours, the team will typically lower your legs periodically and use sequential compression devices on your calves to keep blood moving.
Shoulder Pain After Laparoscopic Hysterectomy
Many patients are surprised by shoulder pain in the days after a laparoscopic or robotic hysterectomy, and it often has nothing to do with how their shoulders were positioned during surgery. The carbon dioxide gas used to inflate the abdomen irritates the underside of the diaphragm, and the diaphragm shares nerve roots with the shoulder area. Your brain misinterprets signals from the irritated diaphragm as pain coming from the tip of your shoulder. This referred pain can be more uncomfortable than the incision sites themselves and can last up to about 72 hours.14PubMed Central. Pain Characteristics after Total Laparoscopic Hysterectomy
Some research suggests that keeping patients in a mild Trendelenburg position for several hours after surgery could help reduce this shoulder pain by encouraging the residual gas to move away from the diaphragm and be absorbed more quickly through pelvic blood vessels.15PubMed Central. Effect of Trendelenburg positioning on post-operative shoulder pain after gynecological laparoscopy: a randomized clinical trial Walking around soon after surgery also helps your body absorb and clear the remaining gas more quickly.
How Positioning Affects the Surgeon Too
It is worth knowing that your position on the table also determines how comfortably and effectively the surgeon can operate, and surgeon discomfort can translate into longer operating times or less precise movements. A survey of surgeons performing laparoscopic hysterectomy found that roughly nine out of ten reported work-related musculoskeletal symptoms, with problems driven by equipment dimensions, port placement relative to the patient’s body, and limited ability to adjust the workspace.16Semantic Scholar. Save our surgeons: an ergonomics evaluation of laparoscopic hysterectomy Robotic surgery partly addresses this because the surgeon sits at a console rather than standing hunched over the patient, but the patient still needs to be positioned precisely for the robotic arms to reach the surgical field. The height of the table, the degree of Trendelenburg, and the placement of the stirrups are all calibrated not just for your safety but for the surgical team’s ability to work.
What You Can Ask Before Surgery
Most patients never think about their position during surgery because they are asleep for all of it, and the team handles every detail. But there are situations where speaking up beforehand helps. If you have glaucoma or any eye condition involving elevated pressure, tell both your surgeon and your anesthesiologist, because they may limit the steepness or duration of head-down tilt. If you have a history of nerve problems, joint replacements, shoulder injuries, or chronic back pain, mention those as well so the team can pad and position those areas with extra care. If you have a high BMI, the respiratory findings discussed earlier should be reassuring: the evidence indicates that robotic hysterectomy can be performed safely across a wide BMI range, with the ventilatory strain being more about the positioning itself than about body size.6PubMed Central. Saturation of respiratory strain during robotic hysterectomy in obese women with endometrial cancer
You might also ask what type of hysterectomy is planned and roughly how long you can expect to be in the operating room, since positioning risks scale with time. A 45-minute vaginal hysterectomy in lithotomy carries a different risk profile than a four-hour robotic case in steep Trendelenburg. Knowing the approach can help you understand what your body went through if you experience unexpected symptoms like shoulder pain, facial puffiness, or leg tingling in the recovery period.