From the Guidelines
The Trendelenburg position should be used judiciously in laparoscopic surgery, with the goal of minimizing its duration and degree of tilt, as recommended by the most recent guidelines 1.
Physiological Effects
The Trendelenburg position can cause significant physiological effects, including:
- Increased intracranial and intraocular pressure
- Decreased lung compliance
- Reduced functional residual capacity
- Potential cardiovascular changes, such as increased central venous pressure These effects are generally well-tolerated in healthy patients but may require careful monitoring in those with cardiopulmonary disease, obesity, or increased intracranial pressure.
Recommendations for Use
To minimize the risks associated with the Trendelenburg position, the following recommendations are made:
- Reduce the Trendelenburg position time as much as possible 1
- Keep intraoperative pneumoperitoneum pressure and CO2 ventilation at the lowest possible levels without compromising the surgical field exposure 1
- Avoid long dissecting times on the same spot by electrocautery or ultrasonic scalpels to reduce the surgical smoke 1
- Use a closed suction system and create suitable surgical incisions for the introduction of leak-free trocars 1
Clinical Considerations
Anesthesiologists should be aware of the potential physiological effects of the Trendelenburg position and take steps to mitigate them, including:
- Careful monitoring of patients with cardiopulmonary disease, obesity, or increased intracranial pressure
- Appropriate ventilation strategies and hemodynamic management during the procedure
- Consideration of alternative positioning strategies, such as the reverse Trendelenburg position, in certain cases. The use of the Trendelenburg position in laparoscopic surgery is supported by earlier guidelines, which recommend its use to improve surgical exposure and facilitate dissection in the pelvic area 1.
From the Research
Trendelenburg Position in Laparoscopic Surgery
The Trendelenburg position is commonly used in laparoscopic surgery to optimize visualization and access to the pelvis. However, this position can result in complications in many organ systems.
- The Trendelenburg position may cause rare, potentially life-threatening complications of the respiratory and cardiovascular systems 2.
- Case reports of visual field loss and cognitive aberrations following Trendelenburg positioning have been published 2.
- Few intervention studies have been performed evaluating attenuation of changes in intraocular pressure and haemodynamics 2.
Hemodynamic Changes
Hemodynamic changes due to the Trendelenburg position and pneumoperitoneum during laparoscopic surgery have been investigated.
- The Trendelenburg position in awake and anesthetized patients increased pulmonary arterial pressures, central venous pressure, and pulmonary capillary wedge pressure 3.
- These pressures increased further at the start of CO2-insufflation, decreased towards the end of the laparoscopy, and reached pre-insufflation levels after deflation of pneumoperitoneum 3.
- The mean arterial pressure increased at the beginning of laparoscopy in comparison with the pre-laparoscopic values 3.
Postoperative Complications
The influence of the steep Trendelenburg position on postoperative complications has been evaluated.
- A meta-analysis suggests that the steep Trendelenburg position does not seem to affect postoperative complications and can be considered safe with regard to the risk of venous thromboembolism, cardiac, and cerebrovascular complications 4.
- However, proper individualized preventive measures should still be implemented during all surgeries, including robot-assisted pelvic surgery, to warrant patient safety 4.
Ventilation Modes
The hemodynamic outcome of different ventilation modes in laparoscopic surgery with exaggerated Trendelenburg has been compared.
- Pressure-controlled volume guaranteed mode caused less hemodynamic perturbations and allowed better intraoperative hemodynamic control in exaggerated Trendelenburg position in laparoscopic surgery 5.
- The use of positive end-expiratory pressure (PEEP) of 15 cm H2O during robot-assisted laparoscopic prostatectomy maintained ventilation in the dorsal parts of the lungs and improved lung mechanics 6.