Supine Position 
Adrian Sarli 
 
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 supine position is the most widely used 
patient position in abdominal surgery. This position 
is ideal for access to the peritoneal cavity and is the 
position of choice for operations such as exploratory 
laparotomy, bowel resection, cholecystectomy and 
appendectomy. It is widely used in laparoscopic as 
well as open surgery with some slight differences in 
patient positioning. It can also be used for head and 
neck operations such as thyroidectomy, neck 
dissection and tracheostomy, as well as some 
operations on extremities. Each of these operations 
will have slight variations in positioning. 
Despite being one of the most common 
positions used in surgery, supine positioning is not 
without risks. These include the risk of pressure 
injuries, ulnar nerve injuries, brachial plexus injuries, 
and cervical spine injuries. 
Careful positioning and padding is vital to 
minimize these risks. Check that the patient is in the 
proper position prior to starting the case, and then 
make sure that the patient is periodically checked to 
ensure they did not shift. 
It is important to think through each step of 
the planned operation prior to starting to ensure the 
patient is properly positioned to make your job 
easier.  
Supine positioning can be accomplished with 
the following steps: 
● Prepare equipment 
● Transfer patient to OR table 
● Position patient, considering the use of 
positioning adjuncts as needed 
● Recheck patient position frequently during case 
 
Steps: 
1. Transfer patient to operative table. If the patient 
is able to transfer themselves, this is often 
preferred. Otherwise, a slide board can be used. 
Typically 3-4 people will be needed to transfer a 
patient. 
2. Have the patient lie supine on the table with arms 
at their sides while monitoring equipment is 
attached and anesthesia initiated. See Airway 
Management and Endotracheal Intubation 
3. Secure the endotracheal tube well and protect the 
patient’s eyes by taping the eyelids shut. 
4. Position arms: 
Arms can be tucked at the patient’s side. The 
advantage to tucking arms is that this allows the 
surgeon to stand closer to the ipsilateral shoulder. 
This can be helpful in some operations. For example, 
in a laparoscopic appendectomy, the left arm is 
usually tucked, allowing the surgeon and assistant to 
stand on the patient’s left and aim the camera and 
operating instruments towards the right lower 
quadrant. 
 
Proper technique: the arm holder is tucked under the mattress 
at the level of the patient’s forearms with adequate padding. 
The majority of the arm’s weight rests at the patient’s side on 
the mattress, not on the armboard itself. There is no pressure 
on the ulnar groove of the elbow. 
 
Supine Position 
Adrian Sarli 
 
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 positioned in supine position with arms tucked for a 
laparoscopic procedure. The sheet was folded in half 
longitudinally and placed on the bed before the patient lay 
down. Note that arms have been tucked loosely enough to allow 
adequate circulation with thumbs up. The patient is adequately 
secured for the extremes of table tilting that will be required for 
laparoscopic surgery, including a footboard and safety straps. 
Arm holders, like those in the previous picture, can be used as 
an adjunct to protect the patient’s arms and prevent them from 
falling out. 
 
Alternatively, the arms can be extended using 
armboards. This allows the anesthesiologist to obtain 
further IV access if needed and better access to the 
arms. This can also be helpful in obese patients, 
especially when the operating table is narrow. 
Traditionally, this is the positioning used during an 
exploratory laparotomy. 
 
Patient properly positioned in supine position with arms 
extended. Note that arms are at slightly less than 90˚. Ideally, 
the patient is adequately secured to the table with safety straps 
on torso or thighs, and arms are secured to arm boards with 
proper padding. 
 
Head positioning: During head and neck 
operations, a shoulder roll can be placed to extend 
the neck, and a head ring may be used to support the 
patient’s head and relieve the cervical spine 
 
Patient positioned with a shoulder roll and head ring to allow 
for head and neck operations, rigid esophagoscopy, etc.  
 
 
A more extreme extension of the neck allows a direct passage 
from the incisors to the esophagus, as for rigid esophagoscopy. 
It is even more crucial to assure that the head is supported to 
avoid cervical spine injury. See “Pitfalls” below. 
 
Foot-board: Movement can be further 
restrained by a padded board that attaches at a right 
angle to the operating table, below the patient’s feet. 
This prevents the patient from sliding towards their 
feet when the operating table is tilted, as shown 
below.  
 
5. After patient positioning on the operative table is 
accomplished, 
the 
table 
can 
be 
tilted 
appropriately for the procedure to be performed. 
Supine Position 
Adrian Sarli 
 
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  
 
 
Trendelenburg position: Tilting the head of the bed 
downwards can be helpful for pelvic procedures or 
laparoscopic appendectomy. 
 
Trendelenburg position. Note the use of shoulder holders to 
prevent the patient from sliding. Source: Jmarchn, CC BY-SA 
3.0 via Wikimedia Commons 
 
Reverse Trendelenburg position: Tilting the head of 
the bed up is helpful for upper abdominal 
laparoscopic procedures. 
 
Reverse Trendelenburg position. Note the use of a footboard to 
prevent the patient from sliding. Source: Saltanat ebli CC0, via 
Wikimedia Commons  
 
Semi-Fowler 
position: 
For 
head 
and 
neck 
procedures, it can sometimes be helpful to position 
the patient in a semi-sitting position with the torso at 
30-45˚. This can improve venous drainage from the 
operating area and potentially minimize bleeding. 
 
Patient in Semi-Fowler, also called “Beach Chair” position. 
Raising the head and torso like this decreases venous distention 
and bleeding. The surgeon must be cautious to avoid venous air 
embolism: in case of any injury to large veins, air can be drawn 
into the venous system when the patient is in this position.  
 
“Side up” (Rotated) positioning can be useful for 
laparoscopic or open operations targeting the right or 
left side of the abdomen, such as cholecystectomy, 
appendectomy, splenectomy and colon procedures. 
Achieving this position involves rotating the bed in 
the sagittal plane, also known as “airplaning.” Some 
beds may not have this capability.  
 
An operating table in Reverse Trendelenburg position with left 
side “airplaned” upwards. This position would be useful for an 
operation in the left upper quadrant of the abdomen, such as an 
open splenectomy.  
 
6. During surgery, ensure that the operative staff 
check the patient’s positioning periodically. 
Supine Position 
Adrian Sarli 
 
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  
 
Patients can slide, and this could cause injuries. 
For example, if the patient is positioned in the 
Reverse Trendelenburg position with arms 
abducted, the patient can slide down and 
hyperextend the arms, causing brachial plexus 
injury. 
 
Pitfalls 
1. When significant patient tilting is involved, such 
as in many laparoscopic cases, ensure patient 
position is checked frequently. When the patient 
is in the Reverse Trendelenburg position, any 
sliding can place the arms at > 90˚ and increase 
the risk of brachial plexus injury. 
2. Make sure that the neck is adequately supported 
to avoid cervical spine injuries. If using a 
shoulder roll, ensure that the patient’s head is 
supported by a small pillow, head ring, or 
positioning gel pad to avoid hyperextending the 
cervical spine.  
 
The patient’s neck has been extended and secured using a head 
ring and shoulder roll as described above. The surgeon now 
pushes gently downward on the patient’s forehead. If the head 
moves further, it is supported by the cervical spine and not the 
head ring. The head ring should be raised to address this 
situation.  
 
3. Ensure the patient is secured so as not to fall off 
the operative table! Limbs can fall off more 
easily than the entire patient, so ensure these are 
especially carefully checked. Be sure to use 
positioning adjuncts such as footboards, shoulder 
holders, safety straps. A deflatable “sandbag,” as 
described in Left Lateral Decubitus Position can 
also be used for the supine position if extreme 
tilting of the table is anticipated.  
4. Avoid allowing air into the venous system at any 
time, which can cause a fatal air embolism. Air 
can be sucked into the internal jugular vein and 
cause an air embolism when the head is elevated 
and venous pressure is low. The risk is greater if 
the patient is taking breaths and generating 
negative thoracic pressure. This is a higher risk 
when using a position such as Semi-Fowler’s or 
Reverse Trendelenburg and operating on the 
venous system. 
 
Adrian Sarli, MD 
University of North Dakota School of Medicine 
North Dakota, USA 
 
December 2022 
 
