Lateral - Jack KNife

DESCRIPTION:

While in lateral decubitus, the patient is bent from the hips so that both the thorax and thighs are lower than the hips to stretch the flank and widen intercostals to facilitate a thoracotomy incision.

USED for:

Surgical access to the hemithorax, kidney, retroperitoneal space.

   
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POSITIONING STEPS:

  1. A bean bag covered with a draw sheet, may or may not be used, to assist in lateral stabilization of the patient on the table.

  2. Operating bed remains flat and patient is anesthetized and intubated in the supine position, and the ETT is securely fastened.

  3. Patient is then turned, with a minimal assist of four persons, onto his or her side after induction and pulled towards the edge of the table,  while maintaining careful stabilization of the ETT.  Care should also be maintained to preserve cervical spine, and body alignment.

  4. Legs are either bent or maintained in the long axis of the body, but in most cases, the lower leg is padded with egg crate and flexed at the knee to prevent rolling and aid in stabilization.   The upper leg remains in extension over the padded lower leg.

  5. At least 2 pillows are placed between the legs to aid in spinal alignment, and to remove pressure from the lower leg and bony prominences (which can help prevent circulatory compromise and injury to the peroneal nerve).

  6. Additional padding is placed at the knees and under ankles to provide support, and prevent nerve injuries and foot drop.

  7. An axillary roll is placed so there are 2-3 fingerbreadths between the roll and the axilla anterolaterally, and extending to the area beneath the scapula posterolaterally, to relieve pressure from the neurovascular structures, preventing brachial plexus nerve injury, to preserve blood flow to the dependent arm, and allow for better chest excursion.

  8. The head is positioned neutrally within c-spine alignment using foam donuts, pillows, blankets or a combination thereof.  This is done to prevent instability or stretching of the neck, brachial plexus or nerve injuries, and to maintain a patent airway. 

  9. Careful attention is placed to prevent ear, nose, and eye compressions.  Consider using a foam donut directly under the head.  The chin should be 2-3 fingerbreadths from the torso.

  10. The arms are padded and positioned at less than 90°, with lower arm palm up on a padded double arm board, with blankets or pillows between the arms to provide padding and support, while the upper arm is supported at shoulder height, with the palm down, to prevent nerve stretch or compression.  (See: Lateral Arm Positions)

  11. The patient is secured to the table and stabilized with the bean bag vacuumed into a supportive shape, with tape or Velcro across the hip between the iliac crest and the head of the femur (so not to cause aseptic necrosis of the femur head).  Tape can also be placed across the thorax, caudad to the axilla (but not across costal margins, so as not to decrease chest expansion).  Tape or Velcro straps are used over padded calves and arms to protect extremities from falling off of the operating table.

  12. Break the table from the middle hinge at the hips, bringing both the thorax and thighs lower than the hips.  Once the flank is satisfactorily stretched, adjust the chassis of the bed to allow the thorax to be horizontal while still maintaining the jackknife.  Caution should be taken to not allow the lower portion of the bed to hit the floor.

 


EQUIPMENT:

POTENTIAL COMPLICATIONS: 

 


LATERAL ARM POSITIONS: POSITIONING VARIATIONS: