1. Don't do it out of habit. Trendelenburg positioning — especially steep
positioning — often happens because it's what surgeons have been
trained to do. The general rule should be, don't do it automatically or out
of habit. Think about it first. Ask whether it's going to be beneficial. And
ask whether steep positioning would add anything that regular
Trendelenburg (less than 30 degrees) wouldn't. Traditionally, when peo-
ple want to do something in Trendelenburg, they automatically go to
steep, figuring the more, the better. And now they're doing it with both
robotic and laparoscopic cases, both of which can last longer and there-
by increase the odds of complications.
2. Know your anatomy. Trendelenburg is all about exposure — being
able to get the bowel out of the way and see the pelvis. But the bigger
parts of the bowel – the rectum and the sigmoid, which always seem
to be in the way — are independent of gravity. No matter what you do
to the patient, that part of the intestine doesn't move. I think some
surgeons have the false notion that steep Trendelenburg is going to
make a difference with that fixed anatomy, but it won't.
3. Consider whether regular Trendelenburg is steep enough. There
always comes a point where giving more Trendelenburg is not going
to be helpful. If you've tilted the table 20 degrees and you still can't
get the bowel out of the way, will 40 degrees improve the situation?
The answer is probably no. Surgeons sometimes lose perspective on
that.
4. Consider the patient. Ventilating patients, especially obese patients,
in Trendelenburg is challenging, because the gut is pushing against the
diaphragm and it becomes very difficult for people to breathe. What's
the patient's BMI? Has he had any respiratory or ventilation difficul-
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