Last week we discussed how we get more “head down” rather than “pelvis up” at Trendelenburg position simply by sliding the operating theatre table so that the fulcrum of the operating table comes to lie underneath the pelvis. Not sure about you, but I had anaesthetists complaining many times that the patient was sliding downwards, towards the anaesthetist’s end. Until I started using the beanbag.
I thought I share this little trick that apparently not too many gynaecologists use. When I worked at the ambulance service many years ago, we packed injured patients into beanbags to stabilise their spine and avoid further injury. With laparoscopic surgery I do something similar to hold my patient securely in place during surgery.
A beanbag is a sealed bag containing thousands of tiny plastic beads. The beanbag is normally soft (when inflated) but when the air is withdrawn through suction, a vacuum is created inside the beanbag that forces the plastic beads stick together. As a consequence, the beanbag becomes rock hard. You mould it around the patients body, then vac it. It will form a moulded cast that stabilises the patient and keeps her in a secure position. Any head down is possible without the patient moving head wards.
There are two sizes. I like the wide one, which is 90 cm wide. It is wide enough for most big patients and will allow you to tug the arms in by the patient’s side. There is no way I could put up with arms out at laparoscopic surgery.
I also make sure the beanbag does not slide itself on the operating table. There should not be a sheet between the beanbag and the operating table.
I am also cautious not to wrap the beanbag around the patient’s shoulders.
Especially with big patients the weight on the shoulders in deep head down position can be massive and I would worry about a brachial plexus injury that could happen.
So, how do I position a patient on the operating table?
Once the patient is anaesthetised on the operating table put the legs into adjustable stirrups. Then, bring the patients hips in position so that you have good access. However, the patient must not hang over the edge of the bed as otherwise this can cause back injury if the pelvis is tilted backwards for along time. Then I make sure my patient has a well working drip and all extension lines for i.v. (and if need be arterial) access are working well. Then we bring both arms to the patient’s side and mould the beanbag. The most important part to stabilise is the patient’s hips. You can close the valve and plug the lid to prevent air getting into the bag but I like to keep the suction line on the beanbag throughout the entire surgical case.
Only then I put the diathermy return electrode on. If you put the diathermy pad on too early it can accidentally move during the positioning process, tear off partly and reduce the area of electron return to the diathermy machine, causing a diathermy burn. Then we put on the air-warming device across the patient’s chest. The beanbag itself does not warm the patient. Only then do I prep and drape.
One other advantage of the beanbag is that it distributes the patients’ weight during surgery and reduces the risk of pressure points. After the procedure, the valve is opened, air will suck into the beanbag and it becomes soft again.
Some limitations are worth noting: The beanbag can be punctured and if you are not aware of that the air will leak. In that case you might find your self with a non-vac beanbag during a procedure. Leaks can be repaired with patches. I always keep the suction line on the beanbag throughout the surgical case. Should there be a leak, it will not affect the beanbag because of permanent suction.
I don’t use the beanbag for open surgery. For the possibility of conversion of a laparoscopic procedure to open, I make sure the beanbag does not hang over the side of the operating table. I make sure that the beanbag does not obstruct my access to the side bar of the operating table that can hold a bed-mounted retractor (e.g., Bookwalter retractor).
The beanbag is not sterile and can be reused after cleaning with liquid disinfectant.
Are you a current user of the beanbag? Your comment is welcome.