Prone Position 
Richard Davis, Gregory Sund 
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:  
 
In the prone position, the patient is most 
vulnerable to injury. Great care must be taken by 
both the anesthesia team and the surgical team to 
position the patient safely and to make sure the 
patient remains in position. As with all patient 
positions, the patient can shift under the drapes as the 
surgery progresses, into a position that causes harm, 
while the team remains unaware.  
 
Injury to the eyes including blindness is a 
feared complication of this position. Pressure on one 
or both of the globes is one possible cause. Elevated 
pressure in the ophthalmic vessels is another; it is 
wise to keep the head elevated and to avoid having 
the upper body below the level of the heart for a long 
time. Avoiding hypotension and anemia may also 
decrease the risk.  
 
Loss of the airway is extremely difficult to 
address when the patient is face-down and an 
operation is underway. The best way to prevent this 
problem is to make sure the tube is very secure and 
that it is not dislodged during surgery. 
 
Nerve injury from positioning must be 
avoided. Pay special attention to the ulnar nerve at 
the elbow and the peroneal nerve passing over the 
fibular head. The brachial plexus is also worth 
special attention: make sure the neck, shoulders and 
upper arms are in a position that looks comfortable 
and natural. Patients in prone position can be placed 
with their arms either at their sides or with shoulders 
abducted and forearms “overhead.” In either case, 
this area can shift during surgery and apply pressure, 
leading to a palsy of the brachial plexus.  
 
Pressure from being in one position for a 
prolonged time can cause injury as well. The toes, 
knees, genitalia, breasts, and especially the face can 
be affected. The best way to avoid this kind of injury 
is to methodically examine all these areas once the 
patient is in position and make sure there is no 
excessive pressure or awkward positioning.  
 
Putting a patient in prone position proceeds 
in the following steps:  
● Prepare the equipment: padding for the face 
and body.  
● Induce anesthesia in a separate location 
(trolley / gurney next to the operating table.)  
● Roll the patient into the prone position on the 
operating table. 
● Assure proper positioning of all the devices 
under the patient and verify that ventilation is 
adequate.  
● Perform a final examination of all sensitive 
pressure areas.  
 
 
Steps: 
1. Padding for the face and body are prepared. For 
the face, use either a specially cut foam piece, or 
a piece of cloth shaped into a ring, large enough 
to support the patient’s face without pressing on 
the eyes, nose, and lips. For the body, use large 
rolled sheets or foam pads that will support the 
chest, the pelvis, and the legs.  
 
A cut piece of foam such as this one is preferred. The upper, 
transverse cutout avoids any pressure on the eyes. The lower, 
vertical part of the cutout avoids pressure on the nose or mouth. 
The slit to either side of the mouth portion allows an 
endotracheal tube to pass freely. If such a foam device is not 
available, a “ring” of rolled up cloth can be fashioned to apply 
pressure to only the outside of the face.  
 
Prone Position 
Richard Davis, Gregory Sund 
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 “armored” endotracheal tube is preferred: This tube has 
embedded metal rings and is more resistant to kinking or 
obstruction.  
 
 
Rolls are placed on the operating table in the area where the 
patient’s chest, hips, and lower legs will go. The foam device 
for the face is at the top of the table, covered in plastic and a 
sheet.  
 
2. After induction of anesthesia, the tube is secured 
very well and the eyelids are taped shut.  
 
The endotracheal tube is taped both above and below the 
mouth.  
 
3. A team composed of enough people to safely log-
roll the patient is assembled. One person must 
clearly be in charge, usually the anesthetist, who 
will control the airway as the patient is moved.  
 
The patient on the trolley, next to the prepared operating room 
table. Be sure you have enough help to safely lift the patient. If 
the trolley’s wheels don’t lock, be sure that the staff leans 
against it, to prevent the patient from sliding into the space 
between the two beds.  
 
Prone Position 
Richard Davis, Gregory Sund 
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  
 
 
Prior to rotating the patient, the anesthetist places the foam 
device over the face and then holds it in place as the patient is 
rotated into position. It is also acceptable to have the foam 
device in place and carefully guide the patient’s face into it as 
they are rotated, as shown in other photos here.  
 
4. The patient is carefully turned, with the team 
making sure all parts move simultaneously, into 
prone position. The arms are at the patient’s 
sides. Make sure the shoulder does not flex and 
the fingers are not bent during the move.  
 
 
With the anesthetist controlling the head and commanding the 
team, the patient is rotated with everyone supporting part of the 
body to make sure it all moves together.  
 
 
As the patient continues to be rotated, the team on the operating 
table side (left in this photo) receive and gently guide the patient 
into the face-down position.  
 
 
The patient reaches the prone position.  
 
5. Once the patient is face-down, move the arms 
into position either at the patient’s side or above 
the head. For arms at the side, be sure they are 
loosely held and look to be in a comfortable 
position.  
Prone Position 
Richard Davis, Gregory Sund 
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 arms at the patient’s side, held in place with plastic arm 
holders that allow the arms to rest at the patient’s side. An 
alternative is to fold the arms in a sheet that is tucked under the 
mattress. This technique usually hides the fingers, so make sure 
that they are not being pinched or bent in an awkward position. 
 
 
Arms in “up over head” position, shoulders are not abducted 
beyond 90 degrees and shoulders are not hyperextended. Two 
possible armboard configurations are shown. Either is 
acceptable, as long as the pressure on the forearm is even and 
the ulnar groove in the elbow is not under pressure.  
  
6. Check the position of the chest roll, making sure 
that it supports the upper chest. It must not press 
on the neck or the breasts, and it must not force 
the shoulders into an awkward position.  
 
The roll supporting the chest (yellow plastic) with the arms 
abducted. The roll must be centered over the sternum, pressing 
neither on the neck nor the breasts.  
 
 
The chest roll with the arms at the patient’s side. It does not 
force the shoulders or upper arms too far posteriorly, they 
appear to lie in a comfortable and natural position.  
 
7. Position the roll that is under the hips. It must lie 
under the anterior superior iliac spine. Make sure 
that the foley catheter and the genitalia are not 
pulled, squeezed or pinched, by the roll or by 
anything else.  
Prone Position 
Richard Davis, Gregory Sund 
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 hip roll under the anterior superior iliac spine. Lift up the 
thigh and check on the genitalia and foley catheter.  
 
 
The foley catheter is not under tension. By spreading the thighs 
from posteriorly, you can check on the genitalia and be sure 
they are not pulled, squeezed or pinched.  
 
8. Adjust the roll under the legs. The knees should 
rest on the padding of the bed and the roll should 
support the shins in such a way that the toes are 
just barely resting on the padding of the bed.  
 
The roll under the legs is adjusted so that the weight of the foot 
does not rest on the toes.  
 
9. Check very carefully on the position of the face. 
Make sure that the tape on the eyelids is still in 
place. There must be no pressure on the eyes, 
nose, or lips. Gently check on the entire face by 
pushing the padding supporting it downwards 
gently away from the face. Try to assess where 
the pressure on the face will be. Most of it should 
be at the periphery of the face, on the forehead 
and lateral cheekbones.  
 
 
The face in position supported by the foam block. The 
endotracheal tube passes through the cut in the foam.  
 
Prone Position 
Richard Davis, Gregory Sund 
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  
 
 
Gently examine all of the face by pushing down on the foam and 
assessing the pressure points on the face.  
 
Pitfalls 
● Blindness after surgery in the prone position is a 
devastating complication. Prevent pressure on 
the globes and have the anesthetist frequently 
recheck them. There is some evidence that 
avoiding intraoperative hypotension and anemia 
reduces the risk, and that prolonged time with the 
head below the heart (Trendelenburg’s position) 
increases the risk.  
● Injury to the face from pressure on sensitive 
structures such as the eyes, nose, or mouth. 
Carefully check the face after the patient’s 
position is finalized. The anesthetist should 
recheck the face every hour as the surgery 
progresses.  
● Vascular compression and lower limb ischemia 
from malpositioning of the pelvic roll, or if 
pressure is applied to the femoral artery at the 
groin by a poorly folded sheet or some other 
object in that area.  
 
Mottling of the right foot was noted after the patient was placed 
in prone position. Careful repositioning of the pelvic roll and 
hips led to resolution of the mottling.  
 
● Brachial plexus injury: if the arms are to be 
abducted, make sure they are not past 90 degrees. 
If the patient is tilted upwards or downwards 
(standard or reverse Trendelenburg’s position) 
during surgery, the shoulders can shift.  This may 
occur under the surgical drape and be undetected 
by the team.  
● Migration of the endotracheal tube after 
positioning the patient: auscultate the chest after 
finishing 
positioning 
to 
make 
sure 
the 
endotracheal tube is still located properly. This is 
also something the anesthetist keeps a careful eye 
on as the surgery progresses.  
● Pressure injury resulting in bruising and 
ecchymosis from excess pressure on the knees, 
forehead and over the pelvis, especially if the 
patient is frail or the operation is prolonged. Be 
very careful that all supporting structures are soft.  
● Nerve injury due to pressure, especially in the 
common places where nerves are vulnerable: the 
ulnar nerve in its groove at the elbow or the 
peroneal nerve as it passes over the fibular head.  
● Patient fall: patients are in danger of injury due 
to falls at any time that their position is changed. 
As this maneuver involves a transfer between 
two places, there is particular danger that the 
Prone Position 
Richard Davis, Gregory Sund 
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  
 
patient will fall in between the table and the 
transport gurney. Make sure you have enough 
help. The team that is on the side of the gurney 
should lean into it, pressing it against the 
operating table during the transfer. 
 
 
Richard Davis MD FACS FCS(ECSA) 
AIC Kijabe Hospital  
Kenya 
 
Gregory Sund, MD 
AIC Kijabe Hospital  
Kenya 
 
May 2022 
