Prolonged Steep Trendelenburg Positioning During Robotic Prostatectomy

Hazards include:

• Cephalad sliding with pressure on the shoulder supports, which can stretch the brachial plexus and injure the acromion or clavicle area.
• Tucked arms with pronated hands, which can compress the ulnar or median nerve and strain the brachial plexus.
• Airway and facial edema from prolonged head-down positioning and pneumoperitoneum, reflected by rising peak airway pressures and visible swelling.
• Pressure injury, alopecia, and eye injury if the face or globes are compressed.
• Hemodynamic compromise: a blood pressure of 98/54 mmHg in the setting of anesthesia and positioning deserves evaluation before adding more head-down tilt.

Do not increase to 35° automatically. The requested exposure benefit does not justify ignoring unresolved positioning and airway concerns. Pause, inform the surgeon and anesthesia, reduce the Trendelenburg angle if clinically safe, and reposition. Check that the shoulder supports bear weight on the padded acromion area rather than the neck, that the arms are neutral with no pronation or hyperextension, and that the head, eyes, and IV tubing are secure.

With the circulating nurse absent, ask the surgeon to pause and request another team member to summon the circulating nurse. Maintain the sterile field while the repositioning is coordinated. Check:

• That the patient has not slid cephalad and that shoulder supports are padded and not pressing into the neck.
• That arms are tucked in a neutral position, palms facing the body, with no pressure at the elbow or wrist.
• That the head is neutral, eyes are taped and free of pressure, and the endotracheal tube is not tractioned.
• That the IV lines and monitoring cables are not taut.
• That all pressure points and dependent areas are padded, including the heels, sacrum, and iliac crests.

Use a clear team statement: "I need to pause before we increase the angle. The patient has slid up against the supports, the hands are pronated, and airway pressures are rising." Document the position, devices, duration, repositioning, and who was notified. Hand off to PACU the prolonged Trendelenburg time, facial edema, airway pressures, fluids, and pressure areas, especially given his sleep apnea.

Before transfer, confirm that the patient is hemodynamically stable and that the airway plan is clear. Use enough staff and a transfer device; do not allow the patient to be pulled by the arms or shoulders. Account for the edema and sleep apnea: keep the head elevated as ordered, monitor oxygenation and respiratory status, and have suction and airway equipment available. Inspect and document skin condition at the shoulders, heels, sacrum, and other pressure points.

The handoff should include the 4-hour steep Trendelenburg interval, pneumoperitoneum pressure, blood pressure trend, fluid balance, facial and airway edema, peak airway pressures, positioning devices used, and any intraoperative repositioning. This lets the PACU team anticipate airway swelling, hypoxemia, or pressure injury rather than discovering them later.