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Value of Low Lithotomy Position in Urologic Surgery
THE JOURNAL OF UROLOGY
Vol. 85, No. 4 April 1961 Copyright © 1961 by The Williams & Wilkins Co.
Printed in U.S.A.
VALUE OF LOW LITHOTOMY POSITION IN UROLOGIC SURGERY HENRY M. WEYRAUCH AND GLEN SHOLS From the Presbyterian Hospital and 1l1edical Center, San Francisco, Cal. Our purpose is to present the advantages and application of a position which has not come into general use but is widely adaptable for many operations. The term "low lithotomy" seems to most accurately describe this position. It has been in occasional use for many years. In the early nineteen hundreds, Dr. Hugh Hampton Young placed patients in this position for transvesical repair of vesicovaginal fistula. With the development of retropubic prostatectomy, it has come into use in Germany. More recently a modification has been described in the Mexican literature which is recommended for all types of abdominal operations, especially infraumbilical laparotomies. INDICATIONS
In urologic surgery, the low lithotomy position is indicated if access to the urethra, genitalia or rectum is desirable during operations on the prostate, bladder and lower portions of the ureters. In augmenting accessory procedures, it does not compromise exposure of the pelvic organs. CONTRAINDICATIONS
The position cannot be used for patients who have fusion of one or both hips. It is undesirable for patients with vascular disease of the lower extremities in whom limitation of the blood supply might prove dangerous. Nor is the position suited for perineal exposure of the prostate since the exaggerated lithotomy position is essential for exposure of the deep perineum. TECHNIQUE
Place the patient in the dorsal decubitus position, abduct the legs and support them in knee rests at a level not above that of the abdomen. If the knees are higher, they interfere with access to the operative field. Spread the patient's legs widely apart to allow room for the surgeon and/or the second assistant during the operation (fig. 1). Place a sand bag beneath the sacrum to elevate the bony pelvis. This hyperextends the lumbosacral joint and permits all possible access to deep pelvic structures (fig. 2). Read at annual meeting of Western Section of American Urological Association, Inc., Vancouver, B. C., Canada, June 20-23, 1960. 624
Preparation of legs. Wrap the patient's legs with elastic bandages, starting at the feet and continuing above the knees (fig. 1). Place foam rubber padding beneath the knees to prevent pressure on the popliteal space. Also protect the calves and heels from the stirrups. Quickly locate points of undue pressure by placing the hand under the knees, calves and heels. The proper position is readily accomplished by the use of adjustable knee and foot supports. The object is to distribute the weight of the legs over as large an area as possible, avoiding pressure at any point where it might lead to ischemia or to damage to nerves. In Lagarde's modification of this position, which he recommended for abdominal operations the patient's legs are widely abducted on a wooden board, cut in the form of a Y (fig. 3). "\Vhile avoiding possible pressure on nerves and blood vessels the large Y board extends outward from the foot of the operating table and limits maneuverability in the operating room. The Y position shares the advantages of the low lithotomy position in permitting access to the genitalia and rectum and by strategic placement of the second assistant allows more operating space for the surgeon and first assistant. Preparation of operative field. To return to consideration of the low lithotomy position, the next step is to prepare the operative field. Disinfect the skin of the abdomen from the xyphoid down to and including the external genitalia and perineum. In fern.ale patients include preparation of the vagina. When it is desirable to have access to the rectum, as for elevating the prostate, gloves are changed or a plastic shield with a rectal prolongation is used to maintain sterility. After draping the area of the abdominal incision and contiguous genitalia, place leggings over the legs and finally a large abdominal sheet over the patient. Allow one opening for the entire operative field-from the umbilicus above to the perineum below. Drape the genitalia and perineum apart from the operative field when access is not required. Location of surgical team. Following preliminary
VALUE OF LOW LITHOTOMY POSITION
Frn. 1. Low lithotomy position. Patient's knees level with abdomen; legs spread widely apart; adjustable knee and foot supports.
FrG. 2. Elevation of bony pelvis with sand bag facilitates exposure of deep pelvic organs.
procedures, such as cystoscopy and vasectomy while the surgeon stands between the patient's legs, the surgeon proceeds to the side of the table, the first assistant stands opposite and the second assistant between the patient's legs (fig. 4). Place the instrument table over the knee of the patient on the side of the surgeon, with the instrument nurse and supply table adjacent. Either arm of the patient may be used for administering intravenous fluids. USE OF LOW LITHOTOMY POSITION FOR SPECIFIC OPERATIVE PROCEDURES
Suprapubic and retropubic prostatectomy. The advantages of the low lithotomy position in these types of open prostatectomy arc:
625
Preliminary cystoscopy and vasectomy can be conveniently performed without redraping or changing the position of the patient. The prostate may be elevated by digital rectal pressure at any time during operation. This can be applied by either the second assistant or the surgeon. The urethral catheter is easily introduced after the prostate is removed, the bag inflated, traction applied and irrigation performed by the second assistant out of the operative field of the surgeon and first assistant. If continuous traction is to be maintained, as after blind suprapubic prostatectomy, a wire anchor can be applied over the genitalia and traction regulated while the amount of bleeding is observed in the bladder. The position is suited to transurethral fulguration of bleeding vessels after the suprapubic or retropubic operation. This procedure has been sporadically revived since first advocated by McCarthy in 1941. Radical retropubic prostatectomy. The advantages are those described for conservative retropubic prostatectomy. In addition, the position facilitates drawing the vcsical neck to the membranous urethra with stay sutures brought out the perineum by using Vest's modification of radical perinea! prostatectomy. Total cystectomy. One of the advantages of the position in total cystectomy is in digital identification of the rectum when there is difficulty in freeing the bladder and posterior aspect of the prostate late in the operation. Further advantages are in bringing out drains through the perineum and in performing combined abdominoperineal cystectomy. Partial cystectomy. The value in partial cystectomy is in placing ureteral catheters up one or both ureters when their identification is desirable. This is more easily accomplished cystoscopieally than after suprapubic entry to the bladder. The position also makes it possible to delineate by transurethral fulguration the margin of normal bladder to be excised and to devitalize superficial portions of the tumor before opening the bladder, This minimizes the danger of spreading viable neoplastic cells, which is one of numerous drawbacks to segmental resection. Ureterosigmoidal anastomosis. Whether ureterosigmoidal anastomosis is performed as a separate procedure or combined with total cystectomy, the low lithotomy position is advantageous when ureteral catheters are used as splints-whether
626
HENRY M. WEYRAUCH AND GLEN SHOLS
FIG.
3. Lagarde's position. Patient's legs abducted on a wooden board Aoesth eti st
0
Frn. 4. Low lithotomy position. Location of surgical team they are introduced through rectal tubes placed upward from below (Weyrauch) or introduced through the rectum from above (Prentiss). In our experience ureteral catheters are helpful in
maintaining patency of the anastomosis during the early postoperative period when edema may cause complete or partial ureteral obstruction. OperationR on the lower portions of the ureters.
627
VALUE OF LOW LITHOTOMY POSITION
Fm. 5. Low lithotomy position facilitates placement of sutures in retropubic suspension of vesical neck. The low lithotomy position has wide application for operations on the lower ureter, particularly when a splinting catheter is left in place. It avoids the necessity for use of a T tube or ureterotomy drainage above the site of any plastic procedure, which so often promotes ureteral stricture. For calculi of the lower ureter, the position permits an attempt at cystoscopic removal before proceeding to immediate ureterotomy. In the rare case when an ureteral calculus cannot be located at open operation, the bladder can be inspected cystoscopically to determine whether the calculus was expressed into the bladder during exposure of the ureter. In plastic revision of the ureterovesical junction and in uretero-cysto-neostomy, splinting catheters can be introduced cystoscopically and tied to a Foley catheter while the bladder is still open. This avoids the danger of dislocating a splint while retrieving it with a cystoscope after operation. Suprapubic repair of vesicovaginal fistula. In this operation ureteral catheters can be placed cystoscopically more easily than through a cystotomy. Another advantage is that the fistula can be elevated into the operative field by transvaginal pressure. Retropubic suspension of the vesical neck. The chief value in this opera.tion in women is that the surgeon himself can exert manual pressure through the vagina to elevate and fix the vesical neck while placing the suspension sutures. More precision is lent by a bimanual technique because one can judge the proper position of the sutures and the depth to which they are laid (fig. 5). An angulated needle holder facilitates taking the more inaccessible sutures. Operations for 11rinary incontinence. The posi-
tion is helpful in the Cooney and Horton procedure (1951) in which fascial strips from the rectus fascia are placed through a tunnel beneath the bulbocavernosus muscle as close to the urogenital diaphragm as possible. Perineal repair of rupture of bulbomembranous urethra. The advantage of the low lithotomy position is that it allows simultaneous approach to both ends of the divided urethra-retrograde instrumentation through a cystotomy and access from the anterior urethra with urethral or inter-· locking sounds. This permits rapid identification and precise suture of the divided ends. In using the low lithotomy position for this operation, better exposure of the perineum is obtained elevating the patient's knees to a higher than usual level to permit better exposure of the bulbomembranous portion of the urethra. The same technique is applicable to opcratiom for impermeable stricture of the bulbomernbranous urethra. As previously mentioned, the low lithotomy position is only useful for exposure of superficial perineal structures. The extreme lithotomy position is required for exposure of the deep perineum. SUMMARY The value of the low lithotomy position for specific urologic operations is presented. The position permits simultaneous access to the urethra, genitalia and rectum during operations on the prostate, bladder and lower portions of the ureters. In augmenting accessory procedures, it does not compromise exposure of the pelvic organs. special advantage is to provide more operating space for the surgeon and first assistant, as the second assistant stands at the foot of the table. 2201
Webster
St.,
San
Francisco
15,
Cal.
(H.M. W.) REFERENCES LAGARDE, PoR Lum ANDRES: Porsicion en "Y" des las Pacientes en Intervenciones Abdominales. Ginecologia Y Obstetricia de Mexico, 9: 40-43, 1954. McCARTHY, J. F.: A critique of present methods in the surgery of the prostate gland. J. Urol., 45: 428-431, 1941.
PRENTISS, RoBERT: Personal communication. WEYRAUCH, H. M.: Landmarks in the d8velopment of uretero-intestinal anastomosis. Ann. Roya.! College Surg. Eng., 18: 343-365, 19,56. WEYRAUCH, H. M. AND MELODY, G. F.: MarshallMarchetti operation for prolapse of vesical neck. Surg., Gynec. & Obst., 110: 115-116, 1960.
Vol. 85, No. 4 April 1961 Copyright © 1961 by The Williams & Wilkins Co.
Printed in U.S.A.
VALUE OF LOW LITHOTOMY POSITION IN UROLOGIC SURGERY HENRY M. WEYRAUCH AND GLEN SHOLS From the Presbyterian Hospital and 1l1edical Center, San Francisco, Cal. Our purpose is to present the advantages and application of a position which has not come into general use but is widely adaptable for many operations. The term "low lithotomy" seems to most accurately describe this position. It has been in occasional use for many years. In the early nineteen hundreds, Dr. Hugh Hampton Young placed patients in this position for transvesical repair of vesicovaginal fistula. With the development of retropubic prostatectomy, it has come into use in Germany. More recently a modification has been described in the Mexican literature which is recommended for all types of abdominal operations, especially infraumbilical laparotomies. INDICATIONS
In urologic surgery, the low lithotomy position is indicated if access to the urethra, genitalia or rectum is desirable during operations on the prostate, bladder and lower portions of the ureters. In augmenting accessory procedures, it does not compromise exposure of the pelvic organs. CONTRAINDICATIONS
The position cannot be used for patients who have fusion of one or both hips. It is undesirable for patients with vascular disease of the lower extremities in whom limitation of the blood supply might prove dangerous. Nor is the position suited for perineal exposure of the prostate since the exaggerated lithotomy position is essential for exposure of the deep perineum. TECHNIQUE
Place the patient in the dorsal decubitus position, abduct the legs and support them in knee rests at a level not above that of the abdomen. If the knees are higher, they interfere with access to the operative field. Spread the patient's legs widely apart to allow room for the surgeon and/or the second assistant during the operation (fig. 1). Place a sand bag beneath the sacrum to elevate the bony pelvis. This hyperextends the lumbosacral joint and permits all possible access to deep pelvic structures (fig. 2). Read at annual meeting of Western Section of American Urological Association, Inc., Vancouver, B. C., Canada, June 20-23, 1960. 624
Preparation of legs. Wrap the patient's legs with elastic bandages, starting at the feet and continuing above the knees (fig. 1). Place foam rubber padding beneath the knees to prevent pressure on the popliteal space. Also protect the calves and heels from the stirrups. Quickly locate points of undue pressure by placing the hand under the knees, calves and heels. The proper position is readily accomplished by the use of adjustable knee and foot supports. The object is to distribute the weight of the legs over as large an area as possible, avoiding pressure at any point where it might lead to ischemia or to damage to nerves. In Lagarde's modification of this position, which he recommended for abdominal operations the patient's legs are widely abducted on a wooden board, cut in the form of a Y (fig. 3). "\Vhile avoiding possible pressure on nerves and blood vessels the large Y board extends outward from the foot of the operating table and limits maneuverability in the operating room. The Y position shares the advantages of the low lithotomy position in permitting access to the genitalia and rectum and by strategic placement of the second assistant allows more operating space for the surgeon and first assistant. Preparation of operative field. To return to consideration of the low lithotomy position, the next step is to prepare the operative field. Disinfect the skin of the abdomen from the xyphoid down to and including the external genitalia and perineum. In fern.ale patients include preparation of the vagina. When it is desirable to have access to the rectum, as for elevating the prostate, gloves are changed or a plastic shield with a rectal prolongation is used to maintain sterility. After draping the area of the abdominal incision and contiguous genitalia, place leggings over the legs and finally a large abdominal sheet over the patient. Allow one opening for the entire operative field-from the umbilicus above to the perineum below. Drape the genitalia and perineum apart from the operative field when access is not required. Location of surgical team. Following preliminary
VALUE OF LOW LITHOTOMY POSITION
Frn. 1. Low lithotomy position. Patient's knees level with abdomen; legs spread widely apart; adjustable knee and foot supports.
FrG. 2. Elevation of bony pelvis with sand bag facilitates exposure of deep pelvic organs.
procedures, such as cystoscopy and vasectomy while the surgeon stands between the patient's legs, the surgeon proceeds to the side of the table, the first assistant stands opposite and the second assistant between the patient's legs (fig. 4). Place the instrument table over the knee of the patient on the side of the surgeon, with the instrument nurse and supply table adjacent. Either arm of the patient may be used for administering intravenous fluids. USE OF LOW LITHOTOMY POSITION FOR SPECIFIC OPERATIVE PROCEDURES
Suprapubic and retropubic prostatectomy. The advantages of the low lithotomy position in these types of open prostatectomy arc:
625
Preliminary cystoscopy and vasectomy can be conveniently performed without redraping or changing the position of the patient. The prostate may be elevated by digital rectal pressure at any time during operation. This can be applied by either the second assistant or the surgeon. The urethral catheter is easily introduced after the prostate is removed, the bag inflated, traction applied and irrigation performed by the second assistant out of the operative field of the surgeon and first assistant. If continuous traction is to be maintained, as after blind suprapubic prostatectomy, a wire anchor can be applied over the genitalia and traction regulated while the amount of bleeding is observed in the bladder. The position is suited to transurethral fulguration of bleeding vessels after the suprapubic or retropubic operation. This procedure has been sporadically revived since first advocated by McCarthy in 1941. Radical retropubic prostatectomy. The advantages are those described for conservative retropubic prostatectomy. In addition, the position facilitates drawing the vcsical neck to the membranous urethra with stay sutures brought out the perineum by using Vest's modification of radical perinea! prostatectomy. Total cystectomy. One of the advantages of the position in total cystectomy is in digital identification of the rectum when there is difficulty in freeing the bladder and posterior aspect of the prostate late in the operation. Further advantages are in bringing out drains through the perineum and in performing combined abdominoperineal cystectomy. Partial cystectomy. The value in partial cystectomy is in placing ureteral catheters up one or both ureters when their identification is desirable. This is more easily accomplished cystoscopieally than after suprapubic entry to the bladder. The position also makes it possible to delineate by transurethral fulguration the margin of normal bladder to be excised and to devitalize superficial portions of the tumor before opening the bladder, This minimizes the danger of spreading viable neoplastic cells, which is one of numerous drawbacks to segmental resection. Ureterosigmoidal anastomosis. Whether ureterosigmoidal anastomosis is performed as a separate procedure or combined with total cystectomy, the low lithotomy position is advantageous when ureteral catheters are used as splints-whether
626
HENRY M. WEYRAUCH AND GLEN SHOLS
FIG.
3. Lagarde's position. Patient's legs abducted on a wooden board Aoesth eti st
0
Frn. 4. Low lithotomy position. Location of surgical team they are introduced through rectal tubes placed upward from below (Weyrauch) or introduced through the rectum from above (Prentiss). In our experience ureteral catheters are helpful in
maintaining patency of the anastomosis during the early postoperative period when edema may cause complete or partial ureteral obstruction. OperationR on the lower portions of the ureters.
627
VALUE OF LOW LITHOTOMY POSITION
Fm. 5. Low lithotomy position facilitates placement of sutures in retropubic suspension of vesical neck. The low lithotomy position has wide application for operations on the lower ureter, particularly when a splinting catheter is left in place. It avoids the necessity for use of a T tube or ureterotomy drainage above the site of any plastic procedure, which so often promotes ureteral stricture. For calculi of the lower ureter, the position permits an attempt at cystoscopic removal before proceeding to immediate ureterotomy. In the rare case when an ureteral calculus cannot be located at open operation, the bladder can be inspected cystoscopically to determine whether the calculus was expressed into the bladder during exposure of the ureter. In plastic revision of the ureterovesical junction and in uretero-cysto-neostomy, splinting catheters can be introduced cystoscopically and tied to a Foley catheter while the bladder is still open. This avoids the danger of dislocating a splint while retrieving it with a cystoscope after operation. Suprapubic repair of vesicovaginal fistula. In this operation ureteral catheters can be placed cystoscopically more easily than through a cystotomy. Another advantage is that the fistula can be elevated into the operative field by transvaginal pressure. Retropubic suspension of the vesical neck. The chief value in this opera.tion in women is that the surgeon himself can exert manual pressure through the vagina to elevate and fix the vesical neck while placing the suspension sutures. More precision is lent by a bimanual technique because one can judge the proper position of the sutures and the depth to which they are laid (fig. 5). An angulated needle holder facilitates taking the more inaccessible sutures. Operations for 11rinary incontinence. The posi-
tion is helpful in the Cooney and Horton procedure (1951) in which fascial strips from the rectus fascia are placed through a tunnel beneath the bulbocavernosus muscle as close to the urogenital diaphragm as possible. Perineal repair of rupture of bulbomembranous urethra. The advantage of the low lithotomy position is that it allows simultaneous approach to both ends of the divided urethra-retrograde instrumentation through a cystotomy and access from the anterior urethra with urethral or inter-· locking sounds. This permits rapid identification and precise suture of the divided ends. In using the low lithotomy position for this operation, better exposure of the perineum is obtained elevating the patient's knees to a higher than usual level to permit better exposure of the bulbomembranous portion of the urethra. The same technique is applicable to opcratiom for impermeable stricture of the bulbomernbranous urethra. As previously mentioned, the low lithotomy position is only useful for exposure of superficial perineal structures. The extreme lithotomy position is required for exposure of the deep perineum. SUMMARY The value of the low lithotomy position for specific urologic operations is presented. The position permits simultaneous access to the urethra, genitalia and rectum during operations on the prostate, bladder and lower portions of the ureters. In augmenting accessory procedures, it does not compromise exposure of the pelvic organs. special advantage is to provide more operating space for the surgeon and first assistant, as the second assistant stands at the foot of the table. 2201
Webster
St.,
San
Francisco
15,
Cal.
(H.M. W.) REFERENCES LAGARDE, PoR Lum ANDRES: Porsicion en "Y" des las Pacientes en Intervenciones Abdominales. Ginecologia Y Obstetricia de Mexico, 9: 40-43, 1954. McCARTHY, J. F.: A critique of present methods in the surgery of the prostate gland. J. Urol., 45: 428-431, 1941.
PRENTISS, RoBERT: Personal communication. WEYRAUCH, H. M.: Landmarks in the d8velopment of uretero-intestinal anastomosis. Ann. Roya.! College Surg. Eng., 18: 343-365, 19,56. WEYRAUCH, H. M. AND MELODY, G. F.: MarshallMarchetti operation for prolapse of vesical neck. Surg., Gynec. & Obst., 110: 115-116, 1960.