A patient is scheduled for a laparoscopic cholecystectomy. Which position will likely be used during the procedure?

Reverse Trendelenburg. A laparoscopic cholecystectomy (gallbladder removal) is an upper abdominal procedure. The patient is placed supine with Reverse Trendelenburg (head-up tilt) to allow the abdominal organs to shift inferiorly by gravity, improving visualization of the gallbladder and hepatic structures.

An axillary roll is used in the lateral position. Where should it be placed?

Under the chest wall, just caudal to the axilla. The axillary roll is placed under the chest wall, just BELOW (caudal to) the axilla of the dependent (down) side. It is NOT placed in the axilla itself. Its purpose is to relieve pressure on the brachial plexus and axillary vessels by lifting the thorax off the table.

Which nerve is most commonly at risk for injury during lithotomy positioning?

Common peroneal nerve. The common peroneal nerve wraps around the fibular head at the lateral knee and is vulnerable to compression from stirrup posts in lithotomy position. Injury causes foot drop. Proper padding and correct stirrup placement are essential to prevent this injury.

When should the surgical patient be positioned?

After anesthesia induction but before prepping and draping. The patient is positioned AFTER anesthesia induction and BEFORE prepping and draping. After induction, the patient is relaxed and cannot report discomfort, making it the appropriate time for positioning. The anesthesiologist must control the head and airway during all position changes.

Key Takeaways

Supine (dorsal recumbent) is the most common surgical position — patient lies face-up on the table
Prone position (face-down) is used for spinal, posterior fossa, and rectal surgeries
Trendelenburg (head-down tilt) improves visualization of lower abdominal/pelvic structures
Reverse Trendelenburg (head-up tilt) is used for head, neck, and upper abdominal procedures
Lithotomy (legs elevated in stirrups) is used for gynecological, urological, and perineal procedures
Lateral (side-lying) position is used for kidney, hip, and thoracic procedures
The surgical technologist assists with positioning AFTER anesthesia induction and BEFORE prepping/draping
Padding all bony prominences and ensuring proper body alignment prevent nerve injury and pressure ulcers
The safety strap should be placed 2 inches above the knees and snug but not restrictive

Patient Positioning & Safety

Correct patient positioning is essential for surgical access, anesthesia management, and patient safety. Improper positioning can lead to nerve injuries, pressure ulcers, compartment syndrome, and circulatory compromise.

Common Surgical Positions

Position	Description	Common Procedures	Key Risks
Supine	Flat on back, face up	Abdominal, cardiac, breast, extremity	Brachial plexus injury, pressure on heels/sacrum
Prone	Face down	Spinal, posterior fossa, rectal	Airway compromise, eye injury, pressure on chest
Trendelenburg	Supine with head tilted down 15-30°	Lower abdominal, pelvic, laparoscopic	Increased ICP, respiratory compromise
Reverse Trendelenburg	Supine with head tilted up	Head/neck, thyroid, upper abdominal	Hypotension, air embolism risk
Lithotomy	Supine with legs elevated in stirrups	GYN, urological, perineal	Peroneal nerve injury, compartment syndrome
Lateral	Side-lying (right or left)	Kidney, hip, thoracic	Brachial plexus injury, pressure on dependent side
Jackknife (Kraske)	Prone with table flexed at hips	Rectal, coccygeal	Hypotension, respiratory compromise
Fowler's/Beach Chair	Seated or semi-seated	Shoulder arthroscopy, posterior fossa	Hypotension, air embolism

Positioning Safety Principles

Padding Requirements

All bony prominences must be padded: heels, sacrum, elbows, shoulders, knees
Gel pads, foam, or pillows are placed under pressure points
The axillary roll (used in lateral position) prevents brachial plexus compression — it goes under the chest wall, NOT in the axilla
Eyes must be protected in prone position (check every 15-30 minutes for pressure)

Nerve Injury Prevention

The most commonly injured nerves during surgery are related to positioning:

Nerve	Common Cause	Deficit
Brachial plexus	Arm abduction > 90°, shoulder bracing	Arm weakness, numbness
Ulnar nerve	Pressure on olecranon (elbow)	"Claw hand," finger numbness
Common peroneal	Pressure at fibular head (lithotomy)	Foot drop
Radial nerve	Pressure on lateral arm	Wrist drop
Sciatic nerve	Improper lithotomy positioning	Leg weakness, numbness

Key Safety Rules

Position the patient after anesthesia induction (patient is relaxed, cannot report discomfort)
Positioning is a team effort — requires coordination among surgeon, anesthesiologist, surgical technologist, and circulating nurse
The anesthesiologist controls the head and airway during all position changes
The safety strap is placed approximately 2 inches above the knees, snug but allowing one finger underneath
Arms should be tucked at sides (protected with draw sheet) or on armboards with < 90° abduction
All moves should be slow and coordinated with a count ("On three...")
Never drag the patient — always lift

CST Certified Surgical Technologist Exam

1Introduction: CST Exam Overview

2Chapter 1: Perioperative Care — Preoperative Preparation

3Chapter 2: Perioperative Care — Intraoperative Procedures

4Chapter 3: Postoperative Procedures & Ancillary Duties

5Chapter 4: Basic Science

6Chapter 5: Exam Strategy & Practice