The Prone Position During Surgery and its Complications: A Systematic Review and Evidence-Based Guidelines

Abstract

Surgery in the prone position is often a necessity when access to posterior anatomic structures is required. However, many complications are known to be associated with this type of surgery, as physiologic changes occur with increased pressure to anterior structures. While several studies have discussed postoperative vision loss, much fewer studies with lower levels of evidence have addressed other complications. A systematic literature review was conducted using 2 different databases, and 53 papers were regarded as appropriate for inclusion. Qualitative and quantitative analysis was performed. Thirteen complications were identified. Postoperative vision loss and cardiovascular complications, including hypovolemia and cardiac arrest, had the most number of studies and highest level of evidence. Careful planning for optimal positioning, padding, timing, as well as increased vigilance are evidence-based recommendations where operative prone positioning is required.

Guideline Implementation: Positioning the Patient

“…The prone position is required for procedures that require access to dorsal aspects of the body, including the rectum, sacrum, and the spine. The patient placed in the prone position is at risk of many complications, including increased intra‐abdominal pressure, increased bleeding, abdominal compartment syndrome, limb compartment syndrome, nerve injuries, pressure injuries, cardiovascular compromise, thrombosis and stroke, hepatic dysfunction, ocular injuries, oropharyngeal swelling, airway maintenance device dislodgement, and air embolism 16 …”

“…The injuries may be caused by gravitational effects on the anatomical structures and pressure created at the points of contact between the body and the surfaces under the patient, such as the head positioner and the mattress on the OR bed 16 . To decrease the risk of the patient developing any of these complications, the surgical team should keep the patient in the prone position for the shortest amount of time possible.…”

“…The patient placed in the prone position is at risk of many complications, including increased intra-abdominal pressure, increased bleeding, abdominal compartment syndrome, limb compartment syndrome, nerve injuries, pressure injuries, cardiovascular compromise, thrombosis and stroke, hepatic dysfunction, ocular injuries, oropharyngeal swelling, airway maintenance device dislodgement, and air embolism. 16 The injuries may be caused by gravitational effects on the anatomical structures and pressure created at the points of contact between the body and the surfaces under the patient, such as the head positioner and the mattress on the OR bed. 16 To decrease the risk of the patient developing any of these complications, the surgical team should keep the patient in the prone position for the shortest amount of time possible.…”

“…16 The injuries may be caused by gravitational effects on the anatomical structures and pressure created at the points of contact between the body and the surfaces under the patient, such as the head positioner and the mattress on the OR bed. 16 To decrease the risk of the patient developing any of these complications, the surgical team should keep the patient in the prone position for the shortest amount of time possible. This is an intervention that is not generally under the control of the surgical team, but the time factor should be discussed before the procedure to assist in determining whether any repositioning or other corrective interventions can be accomplished to help prevent a positioning injury.…”

Another approach for prone positioning under general anaesthesia

“…[5] Intensive precautions and application of different modalities for prone positioning in surgical patients with known cervical pathology have been advocated. [6]…”