Surgical Positioning for Tunneled Catheter Removal from Right Neck
For removal of a tunneled catheter from the right side of the neck, position the patient supine with the head turned slightly to the left (contralateral side) to optimize exposure of the right neck and facilitate safe dissection along the tunnel tract.
Optimal Patient Positioning
Place the patient supine on the operating table with adequate lighting and sterile field preparation for the right neck area 1.
Turn the head 15-30 degrees to the left (away from the catheter side) to expose the right neck anatomy, including the exit site and tunnel tract, while avoiding excessive rotation that could distort anatomical landmarks 1.
Consider slight Trendelenburg positioning (10-15 degrees head-down) if there is concern about air embolism during catheter removal, as this increases central venous pressure and reduces the risk of air entrainment through the venous tract 2.
Ensure the right shoulder is positioned flat or with a small roll beneath the scapulae to allow the clavicle to drop posteriorly, improving access to the infraclavicular tunnel portion if the catheter was placed via subclavian or low internal jugular approach 1.
Key Anatomical Considerations
The right internal jugular vein provides the most direct route to the superior vena cava, which is why right-sided catheters are preferred for placement and typically easier to remove 1.
The exit site is typically located in the infraclavicular area or just above the clavicle for right-sided tunneled catheters, with the tunnel tract extending several centimeters before entering the vein 1.
Understanding the catheter's original insertion trajectory (whether via internal jugular or subclavian approach) helps anticipate the tunnel path during removal 1.
Critical Safety Measures During Positioning
Avoid excessive neck extension or rotation beyond 30 degrees, as this can compress vascular structures and make identification of anatomical planes more difficult during dissection 1.
Ensure adequate arm positioning with the right arm either tucked at the side or abducted no more than 90 degrees to prevent interference with the surgical field 2.
Position monitoring equipment and anesthesia access on the left side to keep the right neck and chest area completely accessible 2.
Common Pitfalls to Avoid
Never position the patient with the head turned toward the catheter side (ipsilateral), as this compresses the operative field and makes visualization of the tunnel tract extremely difficult 1.
Avoid steep Trendelenburg positioning beyond 15-20 degrees unless specifically needed for air embolism prevention, as excessive head-down tilt can cause venous engorgement that increases bleeding risk during dissection 2.
Do not attempt removal with the patient sitting or in lateral decubitus position, as these positions increase air embolism risk and provide poor surgical exposure 1.
Special Circumstances
If the catheter is "stuck" or adherent to surrounding tissues, maintain the same supine positioning but ensure fluoroscopy capability is available in the room, as some cases may require imaging guidance or conversion to more extensive surgical exploration 3, 4.
For obese patients or those with short necks, consider placing a small shoulder roll to improve neck extension and catheter tunnel visualization, but avoid hyperextension that could compromise the airway 1.
In patients with known central venous stenosis or thrombosis, the standard supine position with head turned contralaterally remains appropriate, though additional imaging may be needed during the procedure 4, 5.