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of the fixation. • Cannula systems. Surgeons want cannula systems that are easy to use and that allow for smooth instrument passing and mobility once the tools enter the joint. This is surgeon-dependent, based on their experience and preferred technique, but in general, surgeons need to place portals in locations that allow them to approach pathology cor- rectly and make repairs efficiently and effectively. Patient positioning also plays a key role in those abilities, especially during shoulder repairs. During rotator cuff repairs, I prefer to have patients placed in the beach chair position so that the spine is in line and bony prominences are well-padded. • Pump pressure. It's important to have good visualization, which is achieved with minimal pressure from the arthroscopy pump in order to keep the joint open and maintain a safe, but low blood pressure. During shoulder arthroscopy, I run the irrigation pump's pressure very low — around 30 or 35 mmHg for the whole case — to help lessen post-op pain and swelling. Automatic irrigation pumps that sense when distention pressure is dropping -— including recognizing when burrs and shavers are in use — and adjust pressure accordingly are helpful. Surgeons must avoid flooding the soft tissue around joints when pumping in fluid, which tends to run down fascial planes. The higher the pump pressure during shoulder surgery, for example, the greater the chance fluid will flow into the chest wall or neck. Although those risks are small, surgeons still want to keep the pressure as low as pos- sible in order to avoid potential adverse events. There's a fine line between managing the pump pressure and main- taining the patient's blood pressure. It's dangerous if the patient's blood pressure drops too low — that's something I'm constantly moni- toring and gauging during arthroscopy procedures — especially in the beach chair position. Surgeons must have a great rapport with anes- thesia providers, who want to keep the patient's blood pressure as 1 0 6 O U T P A T I E N T S U R G E R Y M A G A Z I N E O N L I N E | M A R C H 2 0 1 5