Lateral Patient Positioning for Shoulder Arthroscopy

1. Pad and Secure Patient

• Compression devices are placed on the lower extremities to prevent venous thromboembolism. Prior to positioning an examination of the operating arm should be done to assess the range of motion and stability in all directions.¹⁸
• Then the patient is turned on their nonoperative side on a beanbag.
• Sufficient padding should be applied under their head (circular pad) and neck to maintain in the neutral position during the procedure.
• An axillary roll is placed 3 fingerbreadths below axillary space to prevent the strain on the brachial plexus, cervical spine and to allow for adequate blood flow to the nonoperative arm.
• Next, the surgical team raises and secures the sides of the beanbag around the patient, ensuring a sheet layer is placed between the beanbag and the patient. In order to secure the beanbag in place and maintain stability intraoperatively the suctioning is applied and vacuum seal created. The surgical team should check the beanbag's position to ensure it allows the surgeon access to the shoulder by aligning the upper edge of the beanbag with the axilla of the nonoperative arm. In some cases, a ‘sloppy lateral’ position, where the patient’s torso leans backward by about 20° to 30°, is preferred.¹⁸
• Both knees should be bent, and a pillow should be placed under the lower knee and between the thighs and shins to protect the fibular head and prevent compression to the neurovascular structures. Once the patient is properly placed a belt and surgical tape are used to secure the patient onto the bed in the lateral position to prevent movement during the procedure.¹⁸

2. Draping and Lateral Positioner Setup

• 1015 U-drapes (3M) are used for the original draping around the operative arm.
• The lateral positioner (Arthrex) is attached to the side of the bed the patient is facing such that the operative arm comes across the patient body.
• After positioner setup, the patient is then draped with 1 rectangular drape over their body and 2 additional U-drapes, 1 with a pouch to collect arthroscopic fluids, that are finally covered with Ioban drapes around the perimeter to prevent water leaking underneath.
• The anesthesia team should verify the positioning and stability of the patient’s head before securing the operative arm in the traction device.²⁶
• The patient’s hand is made into a fist and secured in the hand holder by Velcro straps. The hand holder is then clipped to the sterile portion of the lateral positioner and 12.5 pounds of counterweight is applied to start, which can be increased to as much as 15 pounds.
• Ensure that only the minimum traction needed to visualize the joint is applied to reduce stress on vital neurovascular structures.²⁶
• The axillary pad is then strapped to the end of the positioner and approximately 20 pounds of traction is applied to increase glenohumeral joint space.
  

3. Standard Shoulder Arthroscopy Setup

• Once the patient is properly positioned, the surgical team marks the anticipated portal sites using bony landmarks such as the acromion, clavicle, acromioclavicular joint, and coracoid process. In the LD position, the standard posterior portal is typically placed 2 cm inferior and 1–2 cm medial to the posterolateral corner of the acromion. After the posterior portal is established, insert the arthroscope and establish the subsequent portals under direct visualization.²⁶
• Standart anterior portal passes between the pectoralis major and deltoid muscles and is typically established using an outside-in technique. Care must be taken to ensure all anterior portals are lateral to the coracoid process  to minimize the risk of neurovascular injury.²⁶
• Anteroinferior portal (5 o’clock) is located a little inferior to the coracoid and is commonly done through an inside-out technique.²⁶
• Accessory portals can be placed depending on the nature of the procedure.²⁶
• Standard arthroscopy setup follows, including a shoulder arthroscopy set with tubes, a shaver, Bovie tip with Colorado tip, water, cannula and outflow devices.