Approach to Positioning the Patient and the Surgeon 
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:  
You probably did not get much training in 
positioning the patient, and even less on positioning 
yourself. But this is a discipline you cannot ignore: 
an operation goes better when the patient, the 
surgeon, and the operative team are positioned well. 
Visibility is better, the hand is steadier, the operation 
goes more smoothly, and everything just seems to 
“work.”  
An excellent surgeon will set up the table 
height, the patient position, the lights, and the 
assistants without seeming to expend any effort at all. 
Others might not even realize that this setup has 
occurred. And then the operation “just” goes well, 
without any problems. But be assured, a lot of 
thought and preparation has gone into this seemingly 
effortless process. Remember, a complex skill is 
nothing more than a series of simple skills performed 
simultaneously or in close sequence.  
In this chapter we want to break down the 
complex skill of “setting up an operation” into its 
simple steps:  
 
Choosing a position 
Look for the easiest and safest position that 
will allow you to accomplish your goal. For example, 
when operating on a perianal abscess, does the 
patient really need to be in prone jack-knife position, 
or can you see what you need to in the much safer, 
and quicker to achieve, lithotomy position?  
 
 
Supine > Lithotomy > Lateral decubitus > Prone 
 
 
In general, the farther you get to the right in 
the above equation,  
● the longer and more complex the setup 
● the longer the time anesthesia needs to put to 
sleep and awaken the patient,  
● the longer the turnover time between cases, and 
● the more danger to the patient from positional 
injury.  
 
Putting the patient in position 
If there is anything unusual about the 
operation, be present in the room during the 
positioning of the patient. This is especially true if 
the patient is unstable. While there, don’t make a 
nuisance of yourself or tell the professionals how to 
do their jobs. But do clarify where the incision will 
be, where you will stand, and other details that will 
help in the positioning. If you will be tilting and 
rotating the patient into extreme positions, use a 
beanbag or other ways to restrain the patient, and 
prepare these before the patient gets on the table. 
Once the patient is positioned, do a quick and 
silent “time out” and ask yourself these questions 
before the team starts to prepare and drape and you 
go off to scrub.  
 
● Does the position look “natural?” Can you 
imagine yourself lying like that for several 
hours? Or are the shoulders or hips abducted 
excessively? Is the neck hyperextended or 
excessively rotated? Do the wrists, elbows, knees 
and ankles look comfortable?  
● Is the head well supported? Or is it being 
supported only by the extended neck? If the head 
“bounces” when you press gently on the 
forehead, it is being held up by the cervical spine! 
Put another folded sheet underneath it, or under 
the headring that is holding it.  
 
Pushing gently downward on the patient’s head after 
extension of the neck with a head ring and shoulder roll. If the 
head moves further, it is supported by the cervical spine and 
 
Approach to Positioning the Patient and the Surgeon 
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  
 
not the head ring. The head ring should be raised to avoid this 
situation.  
 
● Is there pressure on nerves anywhere? Consider 
the peroneal nerve over the fibular head, the ulnar 
nerve in the ulnar groove, the radial nerve at the 
mid-humerus, and the sciatic nerve lateral to the 
ischial tuberosity.  
● Is there pressure on other structures anywhere? 
Consider the eyeballs, the nose, lips and ears, the 
breasts, the testicles, tension on the foley 
catheter. 
● When you flex the bed, or raise the head or foot 
board, what will be the effect on the patient? Are 
there fingers or other appendages near any 
mechanical joints where they could be pinched or 
amputated?  
● How far could you rotate or angulate the bed 
before the patient is in danger of sliding out of 
position? Are there restraints to prevent sliding? 
Make a mental note of how far you dare go, it 
will be harder to visualize this when the patient 
is under drapes. 
● Is there room for you or your assistant to stand 
where you need to? Would you have more space 
if the table was moved away from anesthesia, or 
rotated 90 degrees?  
● Are the laparoscopic / endoscopic monitors in the 
position that you and your assistant need them to 
be in?  
● Are the overhead lights in position? Is your 
headlight on your head?  
● Are the settings on the cautery adequate?  
● Are the devices you may need, such as implants, 
hardware, or staplers, available? What about any 
equipment you’d use if things went wrong and 
you had to implement your backup plan? (You 
have a backup plan for every situation, right?) 
 
Illumination 
Most of the time, the OR lights are mounted 
to the ceiling directly above the patient, two shafts 
connected by an “elbow” that rotates 360 degrees and 
allows movement up and down. Before you scrub, 
adjust the two “elbows” so they are facing away from 
each other. Having the elbows pointing away from 
each other allows you to adjust each light 
independently as the situation demands.  
 
These lights may be shining where the surgeon wants them, but 
it will be difficult to make any adjustments.  
 
If you are using a floor lamp, put it in the 
position you would like before you scrub. If it is to 
be positioned directly behind you, show that position 
to the circulator and then slide it backwards before 
you go scrub, so that the circulator can easily return 
it to that place once you are in position.  
If you are using a headlight, hold up your 
hands in a place that is directly in front of your face, 
at about elbow level. Position the beam so that it 
shines directly on your two thumbnails. Remember 
that neck and back pain increase as the headlight gets 
heavier, so consider investing in a lightweight 
system.  
 
How to stand 
Consider the figure below, the so-called 
“Neutral Posture.” This position, as described in the 
field of Ergonomics, places muscles at their resting 
length, neither contracted nor stretched. It applies the 
least pressure on nerves, tendons, joints, muscles, 
and spinal discs. The ears are centered over the 
shoulders, over the hips, over the knees, over the 
ankles. This is the position that you can stand in 
comfortably for the most time.  
Approach to Positioning the Patient and the Surgeon 
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  
 
  
Left: Classic Neutral Posture, the position at which most of the 
muscles in the body are at their resting length. Right: Neutral 
Posture adapted for surgery. The forearms are advanced 
forward and the neck is flexed no more than 15 degrees.  
 
For open surgery, start in the Neutral Posture 
and slide your forearms forward while maintaining 
them in a horizontal supported position. Bend your 
head forward to see what you are doing. Ideally your 
neck will flex no more than 15 degrees.  
You will find that over a long surgery your 
body position “declines,” as described further below. 
Counter this by positioning, and repositioning, the 
patient so that you are as close to the Neutral Posture 
as possible throughout the surgery. As the surgery 
progresses, reposition the patient in order to move 
yourself closer to the Neutral Posture. 
 
Poor posture: operating in this position for a long time will 
result in pain in the neck, shoulders, and lower back. The hands 
may be steady at first, but as back and shoulder muscles fatigue, 
the hands will become increasingly unsteady.  
 
For video-assisted surgery you will position 
the monitor so that it is at or just below eye level, and 
your instruments such that your shoulders are 
relaxed, your arms are as close to vertical, and your 
forearms are as close to horizontal as possible. It is 
quite acceptable to rotate the patient into extreme 
positions in order to accomplish this, as described 
further in the Chapter “Principles of Laparoscopy- 
Port Positioning and Placement.”  
 
Positioning the patient for open surgery 
Steady fingers depend on firm support of the 
hand, wrist, forearm and elbow. These will be 
supported by the whole body. The shoulders should 
be in a natural position. The upper arms should be 
close to vertical. The forearms should be horizontal; 
adjust by raising the table so that the level you are 
operating on is level with your elbows. If you are 
seated, the seat and the table can both be adjusted to 
achieve this level. If possible, your entire arm should 
be resting on a solid surface from the tip of the elbow 
Approach to Positioning the Patient and the Surgeon 
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  
 
all the way to the metacarpals. The wrist should be 
straight, rather than flexed, if possible.  
 
The steadiest hand needs forearm support all the way from the 
elbow to the metacarpophalangeal joint. 
 
 
Position the table at the height of your elbows so that you can 
support as much of your forearm and hand as possible.  
 
As the surgery progresses, you will find that 
your position changes. Possibly you move deeper 
into a body cavity, or possibly you are drawn to one 
side of the field. Remember to reposition your body 
and the table so that your head is not rotated, your 
neck is flexed forward as little as possible, and your 
forearms are well supported and as close to level as 
possible.  
 
When this operation began, the table was at the correct height 
for opening the abdomen. But now the work is deeper: the 
patient should be repositioned.  
 
Approach to Positioning the Patient and the Surgeon 
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 table has been raised and rotated towards the surgeon, who 
is now closer to the Neutral Posture.  
 
Often you will be resting your forearm and 
wrist on part of the patient.  
● Operating in the groin or pubis, steady your arm 
on the patient’s thighs. Operating in the neck, 
steady your arm on the patient’s chest.  
● Operating on the wrist or hand, use the width of 
the armboard to support yourself: adjust the table 
height and position yourself so that as much of 
your forearm as possible is steadied by it. If you 
are seated, keep your torso upright and flex your 
neck no more than 15 degrees.  
● Standing at the head of the bed operating on the 
scalp or brain, use a table or other device to 
steady your forearm, especially for long or 
delicate operations.  
 
This need to have your arm resting on 
something steady will be one of the factors that 
determines where you stand. Consider for example a 
surgeon performing an open operation on the 
ascending colon. When standing on the patient’s 
right, the surgeon has to bend at the waist a bit and 
raise the elbows and shoulders in order to work in the 
depths of the right abdomen.  
 
The surgeon standing on the same side as the intra-abdominal 
pathology has to bend at an awkward angle.  
 
On the other hand, standing to the patient’s 
left, the surgeon’s arms can rest on the chest or upper 
abdomen. The surgeon reaches over into the right 
side of the abdominal cavity in a natural way, 
maintaining an upright posture.  
 
Approach to Positioning the Patient and the Surgeon 
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  
 
 
After moving to the other side of the table and raising and 
rotating it, the surgeon can now stand more comfortably while 
operating inside the abdomen.  
 
Sometimes you are not able to rest your 
forearm all the way back to the elbow. Examples 
include operating on the head, shoulder, or sole of the 
foot. If this is the case, is even more important to 
have the rest of your body relaxed. Make sure that 
you are operating at the level of your elbows, and that 
you are standing up straight with your shoulders 
relaxed and your neck not bent more than 10-15 
degrees. Consider sitting down or tilting the table to 
see better. If your work is delicate, bring in another 
table or instrument stand to steady your forearm and 
wrist.  
 
Richard Davis MD FACS FCS(ECSA) 
AIC Kijabe Hospital  
Kenya 
 
