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To increase the friction surface, Ms. Barber used the concavities of the patient's back. Shaped like half moons, these so-called speed bumps fit into the curves of the neck, lumbar spine and lower calves. They're covered with corrugated rubber so they interlock with the ribs of the underlying mattress, giving a cog-wheel effect. "The steeper the tilt, the more firmly they'll hold," says Ms. Barber. "If you correctly place the bolsters, it's virtually impossible for a patient to slip in the maximum tilt of which most tables are capable — about 50 degrees." During a 10-month period in which they performed 503 laparoscop- ic and gynecological cases with patients inclined to steep Trendelenburg at a 30- to 40-degree angle, "no patient slid on the Or bed and there have been no skin shearing or brachial plexus injuries," says Ms. Barber. — Dan O'Connor J a n u a r y 2 0 1 7 • O U T PA T I E N TS U R G E R Y. N E T • 6 7 3. Less can be more. Trendelenburg is all about giving the surgeon better visualization and exposure. But some anatomy, like the rectum and the sigmoid, are independent of gravity, so a 40-degree tilt may be no more beneficial than 20 degrees. Some surgeons think the steeper the tilt, the better the exposure. That's not always the case with fixed anatomy. Fewer degrees of tilt can result in acceptable operative exposure with fewer negative consequences. 4. Respiration. Ventilating patients in Trendelenburg is challenging, because the gut is pushing against the diaphragm, making it difficult for people to breathe, especially obese patients. A complication known as V/Q mismatch is not uncommon. V/Q mismatch is a defect that occurs in the lungs whereby ventilation and perfusion are not evenly matched. The head-down tilt causes so much pressure on the lungs they can't expand enough to oxygenate the blood. If you hear anesthe- sia say, We've got to level back out. I can't ventilate very well, think