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Jackknife prone position for urethral diverticulectomy in women
JACKKNIFE PRONE POSITION FOR URETHRAL DIVERTICULECTOMY RICHARD
B. SASNETI,
WILLIAM
W. MIMS,
ROY WITHERINGTON,
IN WOMEN
M.D. M.D. M.D.
From the Section of Urology, School of Medicine, Augusta,
The Medical Georgia
Almost all descriptions of urethral diverticulectomy in women state that the patient is placed on the operating table in the “usual lithotomy position. “l-* We have used the jackknife prone position for urethral diverticulectomy in 5 women during the past two years and have been pleased with it. By close cooperation between the anesthesiologist and surgeon we have been able to operate on even the largest of these women using a position which we believe gives maximum exposure and facilitates the performance of the operation by allowing the surgeon to work from a standing position.s The essentials of the jackknife prone position are that the pelvis and chest be elevated to allow the abdomen to move without restriction, the back and neck must lie in the same plane to allow the head to be turned to either side, the patient’s arms should rest above the head, the inferior vena cava and femoral vessels must not be compressed, the infraclavicular fossae must be free of pressure points, and the breasts must be displaced laterally. To obtain elevation of the anterior superior iliac spines, an elevating mechanism is attached to the operating table (Fig. 1). If such a device is not available, sandbags topped with cushioning may be used. The height of these sandbags is adjusted by placing varying thicknesses of plywood between the table and sandbags. Care must be taken to use narrow sandbags that will not encroach upon either the femoral vessels, the abdominal wall, or the costal margins. By moving the cushion of the table forward, a space is created for free excursion of the abdomen. By folding
UROLOGY
/ FEBRUARY
1978
/ VOLUME
XI, NUMBER
College
of Georgia
sheets to a 20-inch width and 40-inch length and placing them on top of the cushion centrally, the patient’s chest is elevated to allow free movement of the abdomen. This permits her breasts to be positioned laterally, and it also places the back and neck in essentially the same plane. After placing the patient in the prone position, both arms are rotated downward and then cephalad so that they are resting above the head on armboards. The foot extension piece is then attached at right angles to the lowered end of the table forming a shelf upon which the patient essentially kneels. Appropriate adjustment of the extension piece for each patient allows much of the weight of the patient’s hips and thighs to rest on the ends of the femurs. The feet are then supported on a padded adjustable stool.
FIGURE 1. Patient in position.
2
183
FIGURE 2. Excellent exposure of anterior vaginal toward wall when posterior vaginal wall is retrut& sacrum.
The thighs are strapped to the table in a manner which will avoid compression of the popliteal vessels. The support under the anterior superior iliac spines serves as a fulcrum over which a portion of the weight of the hips acts to flex the back and allow the lumbar curve to flatten. Prior to placing the patient in the prone position, after induction of anesthesia, trocar cystostomy may be performed. In our experience, cystostomy permits early removal of the urethral catheter and facilitates healing of the inflamed urethra. Once in position, and after sterile preparation and draping, the labia are sewn apart using sutures between the labia and the inner surface of the thighs to expose the introitus. From a stand-
184
ing position the surgeon and assistant(s) work looking downward on the operative field a natural stance. A medium-sized Richardson or Deaver retractor is inserted into the vagina and retracted upward, thus creating adequate exposure of the anterior vaginal wall (Fig. 2). A 16 F Foley catheter is inserted into the urethra. The diverticulum is visualized and a vertical or transverse incision made over it. The diverticulum is dissected free and its neck divided at its junction with the urethra. The urethral defect, subvaginal fascia, and vaginal mucosa are each closed with interrupted 3-O chromic catgut or polyglycolic acid sutures. A dry vaginal pack is left in place for twenty-four to forty-eight hours. Follow-up has demonstrated a completely satisfactory result in all patients thus operated on. Augusta, Georgia 30901 (DR. WITHERINGTON) References 1. McNally A: Diverticula of the female urethra, Am. J. Surg. 28: 177 (1935). 2. Young HH: Diverticulum of the female urethra, South. Med. J. 31: 1943 (1938). 3. Cook EN, and Pool TL: Urethral diverticulum in the female, J. Ural. 62: 495 (1949). 4. Davis HJ, and Telinde RW: Urethral diverticula: an assay of 121 cases, ibid. 86: 34 (1958). 5. Davis BL, and Robinson DG: Diverticula of the female urethra: assay of 120 cases, ibid. 164: 856 (1970). 6. Moore TD: Diverticulum of female urethra: an improved technique of surgical excision, ibid. 68: 611 (1952). 7. Spence HM, and Duckett JW: Diverticulum of the female urethra: clinical aspects and presentation of a simple operative technique for cure, ibid. 164: 432 (1970). 8. Benjamin J, Elliot L, Cooper JF, and Biomson L: Urethral diver&urn in adult female: clinical aspects, operative procedure and natholoror, Urolow 3: 1 (1974). 9.*SmithRH, Gramling Zk, and Volpitto PP: The problem of the prone position, Anesthesiology 22: 289 (1961).
UROLOGY
/
FEBRUARY
1978
/
VOLUME
XI, NUMBER
2
B. SASNETI,
WILLIAM
W. MIMS,
ROY WITHERINGTON,
IN WOMEN
M.D. M.D. M.D.
From the Section of Urology, School of Medicine, Augusta,
The Medical Georgia
Almost all descriptions of urethral diverticulectomy in women state that the patient is placed on the operating table in the “usual lithotomy position. “l-* We have used the jackknife prone position for urethral diverticulectomy in 5 women during the past two years and have been pleased with it. By close cooperation between the anesthesiologist and surgeon we have been able to operate on even the largest of these women using a position which we believe gives maximum exposure and facilitates the performance of the operation by allowing the surgeon to work from a standing position.s The essentials of the jackknife prone position are that the pelvis and chest be elevated to allow the abdomen to move without restriction, the back and neck must lie in the same plane to allow the head to be turned to either side, the patient’s arms should rest above the head, the inferior vena cava and femoral vessels must not be compressed, the infraclavicular fossae must be free of pressure points, and the breasts must be displaced laterally. To obtain elevation of the anterior superior iliac spines, an elevating mechanism is attached to the operating table (Fig. 1). If such a device is not available, sandbags topped with cushioning may be used. The height of these sandbags is adjusted by placing varying thicknesses of plywood between the table and sandbags. Care must be taken to use narrow sandbags that will not encroach upon either the femoral vessels, the abdominal wall, or the costal margins. By moving the cushion of the table forward, a space is created for free excursion of the abdomen. By folding
UROLOGY
/ FEBRUARY
1978
/ VOLUME
XI, NUMBER
College
of Georgia
sheets to a 20-inch width and 40-inch length and placing them on top of the cushion centrally, the patient’s chest is elevated to allow free movement of the abdomen. This permits her breasts to be positioned laterally, and it also places the back and neck in essentially the same plane. After placing the patient in the prone position, both arms are rotated downward and then cephalad so that they are resting above the head on armboards. The foot extension piece is then attached at right angles to the lowered end of the table forming a shelf upon which the patient essentially kneels. Appropriate adjustment of the extension piece for each patient allows much of the weight of the patient’s hips and thighs to rest on the ends of the femurs. The feet are then supported on a padded adjustable stool.
FIGURE 1. Patient in position.
2
183
FIGURE 2. Excellent exposure of anterior vaginal toward wall when posterior vaginal wall is retrut& sacrum.
The thighs are strapped to the table in a manner which will avoid compression of the popliteal vessels. The support under the anterior superior iliac spines serves as a fulcrum over which a portion of the weight of the hips acts to flex the back and allow the lumbar curve to flatten. Prior to placing the patient in the prone position, after induction of anesthesia, trocar cystostomy may be performed. In our experience, cystostomy permits early removal of the urethral catheter and facilitates healing of the inflamed urethra. Once in position, and after sterile preparation and draping, the labia are sewn apart using sutures between the labia and the inner surface of the thighs to expose the introitus. From a stand-
184
ing position the surgeon and assistant(s) work looking downward on the operative field a natural stance. A medium-sized Richardson or Deaver retractor is inserted into the vagina and retracted upward, thus creating adequate exposure of the anterior vaginal wall (Fig. 2). A 16 F Foley catheter is inserted into the urethra. The diverticulum is visualized and a vertical or transverse incision made over it. The diverticulum is dissected free and its neck divided at its junction with the urethra. The urethral defect, subvaginal fascia, and vaginal mucosa are each closed with interrupted 3-O chromic catgut or polyglycolic acid sutures. A dry vaginal pack is left in place for twenty-four to forty-eight hours. Follow-up has demonstrated a completely satisfactory result in all patients thus operated on. Augusta, Georgia 30901 (DR. WITHERINGTON) References 1. McNally A: Diverticula of the female urethra, Am. J. Surg. 28: 177 (1935). 2. Young HH: Diverticulum of the female urethra, South. Med. J. 31: 1943 (1938). 3. Cook EN, and Pool TL: Urethral diverticulum in the female, J. Ural. 62: 495 (1949). 4. Davis HJ, and Telinde RW: Urethral diverticula: an assay of 121 cases, ibid. 86: 34 (1958). 5. Davis BL, and Robinson DG: Diverticula of the female urethra: assay of 120 cases, ibid. 164: 856 (1970). 6. Moore TD: Diverticulum of female urethra: an improved technique of surgical excision, ibid. 68: 611 (1952). 7. Spence HM, and Duckett JW: Diverticulum of the female urethra: clinical aspects and presentation of a simple operative technique for cure, ibid. 164: 432 (1970). 8. Benjamin J, Elliot L, Cooper JF, and Biomson L: Urethral diver&urn in adult female: clinical aspects, operative procedure and natholoror, Urolow 3: 1 (1974). 9.*SmithRH, Gramling Zk, and Volpitto PP: The problem of the prone position, Anesthesiology 22: 289 (1961).
UROLOGY
/
FEBRUARY
1978
/
VOLUME
XI, NUMBER
2