Issue link: https://beckershealthcare.uberflip.com/i/829284
52 Executive Roundtable the lateral approach as part of a larger deformity operation, in which case the posterior reconstruction is done at a later time/date, and interim standing radiographs can be employed to determine what posterior techniques can be optimally employed to achieve the radiographic goals. CK: I have some general guidelines [for doing the surgery over the course of more than one day]. These include if the patient is over 65 years old, has three levels or more or other co- morbidities such as diabetes or a history of heart disease. I do it in more than one day for the more complicated and extensive procedures where the patient is more frail. This prolongs the recovery for the patient but is generally safer when it is spread over two days. There is a lot of gray area in that distinction. No one has sat down and figured out the best time to split it into one or two days. We have examples of the two extremes — healthy, level-one or level-two patients and then patients with three levels or more. Besides that, the exact switch point is not clear and we do it on a case-by-case basis. Q: In terms of patient positioning, what are the key ele- ments and challenges? CK: The LLIF procedure requires careful patient positioning and optimal intra-operative imaging. The patient has to be secure in true lateral position relative to the floor. If there is rotatory deformity, then the operating table must rotate to accommodate this deformity, whilst still allowing for clear intraoperative radiographic imaging. The major challenge occurs when the C-arm is unduly encumbered by the break in the bed or pedestal of the bed. Therefore, it is imperative that the patient is carefully positioned on the appropriate operating table. RE: The initial challenge was training the operating room team to adjust to a unique process. The success of the operation depends largely on the precision of initial patient positioning and fluoroscopy preparation. The first key to patient positioning is maintaining hip and knee flexion of both lower extremities, and minimizing any table flexion, so that the psoas and lumbar plexus are kept in relatively relaxed condition. Another key aspect of positioning is placing the patient so that the segmental level is addressed for reconstruction and is orthogonally positioned relative to the fluoroscopy beam that has been set up for anteroposterior and lateral views. This minimizes the potential error in reproducing proper view with imaging and increases efficiency for the technician running the fluoroscopy unit. Q: Why and when would you reposition the patient during surgery? RE: The most common reason for repositioning a patient is the need to address more than one level, such as with correction of a deformity, in which there is rotation of the spinal segments. This requires resetting the patient via table control in both rotation and the Trendelenburg [position] to bring the next spinal segment into an orthogonal position for the fluoroscopy beam. The other more obvious need to reposition a patient occurs after the lateral approach is completed, at which point prone positioning is accomplished in order to perform the posterior reconstruction. There is the option in some cases of doing a single position lateral and posterior reconstruction. In this case, both the lat- eral and posterior surgery is done with the patient in the lateral decubitus position, and thus avoiding the transfer to another operative table and the requisite repeat draping of the patient. CK: In healthy patients, we often perform the LLIF procedure and the posterior procedure on the same day. This has been a cumbersome process to placing the patient from the lateral decubitus position to the prone position. Q: What are the potential hazards of patient repositioning and what are the human factors involved, specifically as it relates to the OR staff? CK: In my experience, the repositioning process is cumbersome and labor intensive. Currently, we have about five OR staff members involved in moving the patient to a gurney, the switching out the table for the prone frame. At each step, there is lifting involved, which places staff at increased risk of injury, not to mention the risk of contamination of the sterile field. RE: The primary hazard of repositioning the patient while still in the lateral decubitus position is ensuring that the desired vertebral rotation to neutral position has been accomplished to ensure orthogonal cage delivery. The patient must be se- cured to the table with strong tape at the trunk, pelvis and lower extremities, in order to safely accommodate rotating the table into the desired position. Prone repositioning does not carry any unusual risks, other than those inherent in putting any pa- tient into a prone position. Q: How important are OR logistics in creating a true center of excellence for minimally invasive techniques? CK: A true center of excellence is in constant improvement. We have identified the repositioning step to be a significant weakness in our minimally invasive program, which is why we have been working on developing a simple and efficient strategy that allows the patient to be rolled from the lateral position directly into the prone position. The new Allen® Advance Table L2P™ Platform represents our ongoing efforts to optimize this aspect of minimally invasive surgery. RE: It is quite critical that the OR team is experienced and well-trained in preparing for and utilizing this technique. The efficiency with which the patient is positioned, and with which the surgery is performed, both depend largely on the skill and experience of the entire operative team. n Allen Medical is an industry leader in patient positioning and surgical site access. Our passion is improving patient outcomes and caregiver safety while enhancing our customers' efficiency. We strive to provide innovative solutions to address our customers' most pressing needs. By immersing ourselves in our customers' world, we can better address these needs and the daily challenges of their environment.