Critical biomechanical and clinical insights concerning tissue protection when positioning patients in the operating room: A scoping review

Abstract

An optimal position of the patient during operation may require a compromise between the best position for surgical access and the position a patient and his or her tissues can tolerate without sustaining injury. This scoping review analysed the existing, contemporary evidence regarding surgical positioning-related tissue damage risks, from both biomechanical and clinical perspectives, focusing on the challenges in preventing tissue damage in the constraining operating room environment, which does not allow repositioning and limits the use of dynamic or thick and soft support surfaces. Deep and multidisciplinary aetiological understanding is required for effective prevention of intraoperatively acquired tissue damage, primarily including pressure ulcers (injuries) and neural injuries. Lack of such understanding typically leads to misconceptions and increased risk to patients. This article therefore provides a comprehensive aetiological description concerning the types of potential tissue damage, vulnerable anatomical locations, the risk factors specific to the operative setting (eg, the effects of anaesthetics and instruments), the complex interactions between the tissue damage risk and the pathophysiology of the surgery itself (eg, the inflammatory response to the surgical incisions), risk assessments for surgical patients and their limitations, and available (including emerging) technologies for positioning. The present multidisciplinary and integrated approach, which holistically joins the bioengineering and clinical perspectives, is unique to this work and has not been taken before. Close collaboration between bioengineers and clinicians, such as demonstrated here, is required to revisit the design of operating tables, support surfaces for surgery, surgical instruments for patient stabilisation, and for surgical access. Each type of equipment and its combined use should be evaluated and improved where needed with regard to the two major threats to tissue health in the operative setting: pressure ulcers and neural damage.

Keywords: neural damage; pressure injury; pressure ulcer; surgery.

© 2020 Medicalhelplines.com Inc and John Wiley & Sons Ltd.

Figures

FIGURE 1

Diagrams of the common surgical positions discussed here and the typical pressure points associated with each of these positions (marked as red circles)

FIGURE 2

Intraoperatively acquired pressure ulcers/injuries developed during supine surgery

FIGURE 3

Examples of interface pressure mapping during supine and planed surgical positions, acquired on operation tables with surgical pads. High‐pressure sites are coloured red. These high‐pressure “hotspots” are shown near the sacrum for both the female (left frames) and male (right frames) patients. The respective high sacral pressure regions have been magnified for clarity for both subjects (bottom frames)

FIGURE 4

The risk to occipital scalp tissue health when using a donut‐shaped gel (shown in the top frame) or foam head positioner, visualised by means of a three‐dimensional anatomically realistic computer model of the human head (graphics adopted from 100 ). The model incorporates the facial soft tissue structures, the scalp tissues, and the skull/cervical spine (A). High tissue distortion regions are coloured red. The donut‐shaped head positioner is found to allow the head weight forces to transfer through a relatively narrow ring of scalp tissues, thus increasing the risk of developing occipital pressure ulcers (conforming to the ring shape of the donut positioner) during supine surgery (B)

FIGURE 5

Intraoperatively acquired forehead pressure ulcers: (A) The location and shape of the injury is typical in patients who were operated in a prone position. (B) Computer modelling of an adult head in a prone surgical position. The model, which incorporates soft facial tissues, as well as the skull and cervical spine structure, confirms that the forehead is susceptible to intraoperatively acquired pressure ulcers in a prone surgical position and allows us to assess the biomechanical efficacy of interventions, for example, the specific surgical pad mounted on the operation table and use of positioners and prophylactic dressings