Patient positioning during minimally invasive surgery: what is current best practice?

INTRODUCTION: Positioning injuries are a known surgical complication and can result in significant patient morbidity. Studies have shown a small but significant number of neurovascular injuries associated with minimally invasive surgery, due to both patient and case-specific factors. We sought to review the available literature in regards to pathophysiological and practical recommendations. METHODS: A literature search was conducted and categorized by level of evidence, with emphasis on prospective studies. The result comprised 14 studies, which were summarized and analyzed with respect to our study objectives. RESULTS: While incidence of positioning injury has been identified in up to one-third of prospective populations, its true prevalence after surgery is likely 2%–5%. The mechanism is thought to be intraneural disruption from stretching or pressure, which results in decreased perfusion. On a larger scale, this vascular compromise can lead to ischemia and rhabdomyolysis. Prevention hinges on addressing patient modifiable factors such as body mass index, judicious positioning with appropriate devices, and intraoperative team awareness consisting of recurrent extremity checks and time management. CONCLUSION: The risk for positioning injuries is underappreciated. Surgeons who perform minimally invasive surgery should discuss the potential for these complications with their patients, and operative teams should take steps to minimize risk factors.