A robotic-assisted hysterectomy is a minimally invasive procedure using specialized surgical instruments controlled by a surgeon from a console. This technique offers benefits like smaller incisions and a faster recovery. Successful use requires the patient to be placed in a specific physical orientation on the operating table. This precise positioning is managed by the surgical team to ensure patient safety and the best possible outcome.
Understanding the Need for Specific Positioning
The patient cannot lie flat because the surgeon needs a clear view of the uterus and surrounding pelvic structures. Robotic surgery targets the deep pelvic cavity, a space crowded by intestines and other abdominal organs. To visualize this area, the surgical team uses two techniques: insufflation and gravity.
Insufflation involves filling the abdominal cavity with carbon dioxide gas, creating a working space for instruments and the camera. This gas pressure helps separate the abdominal wall from the organs, but it is insufficient to clear the pelvis entirely. The second requirement is using gravity to pull the bowel and omentum (fatty tissue) out of the way.
This requirement dictates the need for a highly angled setup for optimal visualization. Without this positioning, the surgeon’s view would be obscured by these organs, making precise robotic movements difficult. The positioning must also accommodate the robotic arms, which are docked over the patient, and allow full instrument mobility within the small abdominal incisions.
The Steep Trendelenburg Position
The position used is the Steep Trendelenburg position, often combined with a modified lithotomy position where the legs are placed in padded stirrups. The patient lies on their back, but the operating table is tilted sharply so the head is significantly lower than the feet. This head-down angle is typically set between 30 and 45 degrees, though the exact angle varies based on the patient’s size and the surgeon’s preference.
This degree of tilt is considered “steep” because it is a more extreme angle than used in most other abdominal surgeries. The purpose is mechanical: the sharp incline causes abdominal contents to slide toward the patient’s chest and diaphragm, away from the operative field in the pelvis. This creates an open, clear space around the uterus, offering the surgeon an unparalleled view through the robotic camera system.
From the patient’s perspective, the head is angled downward while the feet are elevated. While the patient is fully anesthetized, the team manages the physiological changes that occur due to this inversion. The position is maintained throughout the operation to ensure the surgeon retains the clear field of view required for the precise movements of the robotic instruments.
Ensuring Patient Security and Monitoring
Due to the extreme angle of the Steep Trendelenburg position, patient security and monitoring are carefully managed by the surgical and anesthesia teams. Preventing the patient from sliding toward the head of the table is a primary concern, as movement could lead to pressure injuries or compromise the port sites. To prevent this, specialized, non-slip padding, such as gel mattresses or “egg-crate” foam, is used beneath the patient to minimize shearing forces.
The patient is secured to the table using various methods, including a specialized beanbag-like mattress that molds around the body or strong straps placed across the chest and hips. Arms are tucked and padded along the patient’s sides to protect sensitive nerves, such as the ulnar nerve, and prevent injury from the downward force of the position.
The anesthesia team closely monitors the patient’s vital signs, paying particular attention to physiological effects of the head-down tilt. This positioning can increase pressure in the head and eyes and affect lung capacity as abdominal organs press upward on the diaphragm. To counteract fluid shifts, the team may restrict intravenous fluids to minimize the risk of facial or airway swelling.
Post-Operative Effects
Minor post-operative effects are common but resolve quickly. These may include shoulder discomfort from the carbon dioxide gas irritating the diaphragm or slight facial swelling.