Lateral Decubitus Position 
Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
  
The lateral decubitus position is used for 
operating on the patient’s flank, in operations 
including 
nephrectomy 
or 
pyelolithotomy, 
thoracotomy, or reduction and fixation of an 
acetabular or hip fracture. Alternatively, operations 
on the back such as tumor excision can be done in 
this position to avoid the risks of full prone position.  
 
This position takes time to set up, so it should 
not be used in patients who are hemodynamically 
unstable. For example, in an unstable trauma patient 
with ongoing bleeding from a chest tube, an 
anterolateral thoracotomy in the supine position is 
much more appropriate.  
 
For operations on the kidney through a flank 
incision, the patient is positioned on the operating 
table such that the space between the iliac crest and 
the lateral costal margin can be expanded by 
hyperextending the table. This is sometimes called 
“breaking the table” because both the upper and 
lower parts of the table move downwards. We 
recommend that you “break the table” before draping 
rather than afterwards. By doing this, you can watch 
the patient and see how much their torso is being 
flexed. Stop before the position starts to look 
unnatural, to avoid injuries including lumbar spine 
fracture.  
 
Hyperextending the bed causes the patient’s torso to be 
hyperextended in the direction shown by the two arrows. Make 
sure this is not too far. Watch the patient while “breaking the 
bed” and stop before the extension becomes excessive, to avoid 
thoracolumbar spine injury. Source: Primary Surgery Vol. 1 : 
Non 
Trauma 
https://global-help.org/products/primary-
surgery/ Accessed 8 May 2022 
 
 
There are risks of positional injury in this 
position, especially to the brachial plexus on the side 
that faces downwards. This risk is decreased by using 
a shoulder roll, but the surgeon must be diligent to 
make sure that the roll is placed, and remains, in the 
right place.  
 
Placing a patient in lateral decubitus position 
proceeds in the following steps:  
● Equipment is prepared 
● General anesthesia is induced in the supine 
position 
● Patient is slid towards the side that is to face 
up and then that side is rotated upwards 
● Axillary roll is placed and lower arm is 
extended 
● The head is supported so that the neck is 
straight 
● The beanbag, if available, is positioned and 
deflated 
● The upper arm holder is placed 
● The upper leg is flexed and padded 
● A thorough inspection of the entire body is 
performed.  
  
Steps: 
1. Prepare the sandbag on the operating table 
before the patient lies on it. If a sandbag is not 
available, prepare four rolled up bedsheets. You 
will place these to the side of the patient’s chest 
and abdomen so that they stay in the lateral 
position. 
 
The sandbag is laid on the table and covered with a sheet before 
the patient lies on the table. The apex of the inset (Red dot) 
should be directly under the axilla. 
 
Lateral Decubitus Position 
Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Make an axillary roll by rolling up sheets until they are about 
15cm thick. Alternatively, a 1L IV bag can be wrapped in a 
sheet. If you do not have a beanbag, make 5 of these rolls; one 
will be the axillary roll and the other four will support the chest 
and abdomen on either side of the patient.  
 
2. The patient lies on a sheet on the sandbag, on the 
operating table. General anesthesia is induced. 
The endotracheal tube is well secured and the 
eyelids are taped shut. 
 
The endotracheal tube is doubly secured in place and the eyes 
are taped shut.  
 
3. Get enough people to move all parts of the 
patient at the same time. Prepare the team to 
position the patient by telling them in advance 
the steps below.  
4. Abduct the arm on the side that will be facing 
down to 90 degrees and place an armboard 
under it. Have an assistant hold the arm that will 
be facing up, keep this arm at the patient’s side 
for now.  
5. Slide the patient and the sheet they are lying on 
towards the side that is to face upwards. Stop 
when their side is a little past middle of the table. 
 
Slide the patient and the sheet they are on towards the side 
which is to face upwards (in this case, the patient’s right.) The 
Red line indicates the edge of the bed. 
 
6. Rotate the patient upwards into the lateral 
decubitus position. They will now be centered 
on the table. Anesthesia leads this step while 
supporting the patient’s head and protecting the 
endotracheal tube from dislodgement. During 
subsequent maneuvers, they continue to support 
the head until it is positioned as below.  
Lateral Decubitus Position 
Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
The patient and the sheet they are lying on are rotated 90 
degrees so that they are again in the middle of the bed.  
 
7. Two assistants raise the patient’s chest while 
you slide the axillary roll into position. Be aware 
that there may be a groove between the 
operating table’s cushions, that the axillary roll 
will settle into. If this is the case, have the team 
move the patient towards the head or foot to get 
the axillary roll out of this groove.  
 
The patient’s torso is elevated by several members of the team 
while another places the axillary roll, just caudal to the bulge 
of the shoulder (Red arrow.) The lower arm, abducted before 
the patient was rolled, rests on its armboard.  
 
 
The axillary roll (Red arrow) seen from the patient’s back. The 
roll has slid into a groove between two cushions on the 
operating table. The scapula is pushed medially and dorsally as 
a result of pressure on the shoulder. This condition should be 
corrected by repositioning the axilla so it is no longer over this 
groove, or by using a thicker axillary roll. 
 
8. Assure that the lower arm rests well on the 
armboard. Check that there is no pressure on the 
ulnar groove at the elbow.  
9. Have assistants on both sides push the sides of 
the beanbag against the downward side of the 
chest and abdomen. Apply negative pressure to 
the beanbag, sealing it in this position. 
Alternatively, place the four rolls that you made 
previously, one on each side of the chest and one 
on each side of the abdomen. “Wedge” these 
into place so they are supporting the torso. 
When you let go, the patient should not roll 
forwards or backwards.  
Lateral Decubitus Position 
Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
The patient is confirmed to be in straight lateral decubitus (not 
“slumped” ventrally or dorsally) and then the edges of the 
beanbag are raised so that they support the patient in this 
position. Several team members are needed at this stage, to 
support the edges of the beanbag all around the patient’s torso. 
 
 
Once the position is adequate, the sandbag is deflated by 
applying suction to the pinch-valve. Once this step is 
accomplished, the sandbag will support the patient in position.  
 
10. Support the head definitively, with a head ring 
directly under it, held up by enough folded 
bedsheets until the neck is straight.  
 
The patient’s head is supported with a head ring. The head ring 
is placed on top of folded sheets, which are added or removed 
to adjust the height of the head until the cervicothoracic spine 
is straight.  
 
11. Support the upper arm with the shoulder flexed 
and abducted 90 degrees. This is sometimes 
called “airplaning” the arm. If you have a device 
that clamps to the bedrail, use it. Otherwise, use 
a small table with adjustable height such as a 
Mayo stand, with a pad on it. Check the ulnar 
groove very carefully and make sure that the 
pressure of the forearm is spread evenly across 
the pad. There should be no place where the 
cushion or the edge of the table presses into the 
forearm or upper arm. Secure the upper arm 
loosely; if you have followed all the steps above, 
you should not need a tight restraint to hold it in 
place.  
Lateral Decubitus Position 
Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
An upper armboard is attached to the bed frame and adjusted 
so that it maintains the superior arm extended anteriorly. The 
height of the board applies even, uniform pressure throughout 
the forearm, up to the midpoint of the upper arm. Assure no 
excessive pressure on the ulnar groove (Red dot) or the upper 
arm where it meets the armboard (Blue dot.) .  
 
 
If a dedicated armboard is not available, a Mayo stand or other 
table with adjustable height, covered with a cushion, can be 
used. Again, adjust the height so that the arm is at a neutral and 
horizontal position and its weight is distributed evenly on the 
cushion.  
 
12. Flex the upper leg and place a pillow or several 
folded sheets between the thighs and knees. 
Check the ankles and make sure they are not 
flexed too far. The upper foot should be resting 
lightly on the operating table. Tape over the leg 
loosely to hold it in this position. Some surgeons 
prefer to flex the lower leg, this is acceptable as 
well. In either case, it is important to be careful 
that pressure points are well padded and the 
joints are in a natural position and not under any 
stress.  
 
Keep the inferior leg straight and flex the superior one. Apply 
padding such as a pillow or folded sheets between the legs. Be 
sure the ankle and foot are supported, not hanging free. Here, 
the foot is supported by the sandbag. The hip should also be 
secured with tape to further prevent the patient from rolling 
dorsally or ventrally. (In this case the hip and thigh were part 
of the operative field so this was not possible.)  
 
13. Look over all of the patient from head to toes, 
checking any pressure points. Genitalia should 
not be squeezed between the thighs, pulled or 
pinched. The urinary catheter should not be 
under tension. The axillary roll should still be in 
proper position. 
14. Pay special attention to the head and face. The 
neck should be straight. The head should be 
supported by the headring under the temporal 
and occipital bones and the lower jaw. There 
Lateral Decubitus Position 
Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
should be absolutely no pressure on the lips, 
nose or eyes. The eyelids should still be taped 
shut. Lift up the head to verify that the ear is not 
“folded  over” and that it is not under undue 
pressure.   
 
Examine the face carefully to make sure that there is no 
pressure on the globe; even a small amount of pressure over a 
long time could cause eye damage or blindness.  
 
 
Gently lift the head to make sure that the ear is lying flat and 
there is no excessive pressure on it.  
 
Pitfalls:  
● Injury to the face from pressure on sensitive 
structures such as the eyes, ear, nose, or mouth. 
Carefully check the face after the patient’s 
position is finalized. The anesthetist should 
check this area frequently during the surgery, as 
the patient’s position can shift.  
● Migration of the endotracheal tube after 
positioning the patient: auscultate the chest and 
make sure breath sounds are still equal after 
positioning. For thoracotomy and single lung 
ventilation, anesthesia will place the double-
lumen endotracheal tube while the patient is 
supine, then repeat  bronchoscopy to recheck the 
position of their tube once positioning is 
complete.  
● Pressure injury resulting in bruising and 
ecchymosis from excess pressure on the hips, 
knees, ankles, and side of the head, especially if 
the patient is frail or the operation is prolonged. 
Be very careful that all supporting structures are 
soft.  
● Thoracolumbar spine injury from sideways 
over-flexion, when attempting to widen the 
space between the iliac crest and the costal 
margin for flank incision. Always hyperextend 
the bed before you drape the patient, so you can 
see how far the hyperextension goes. The 
patient’s position should look comfortable and 
natural to you.  
● Brachial plexus injury due to incorrectly applied 
axillary roll: be sure the shoulder is supported 
by the roll; the shoulder should not be 
supporting the entire torso. 
● Nerve injury due to pressure, especially to the 
ulnar nerve at the elbow or the peroneal nerve at 
the fibular head.  
 
Richard Davis MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
 
