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Trendelenburg position
Trendelenburg position
Trendelenburg position
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Medical mannequin placed in the Trendelenburg position
subject is lying on their back with legs higher than their body
Trendelenburg position

In the Trendelenburg position (/ˈtrɛndələnbɜːrɡ/), the body is lain supine, or flat on the back on a 15–30 degree incline with the feet elevated above the head.[1] The reverse Trendelenburg position, similarly, places the body supine on an incline but with the head now being elevated.

The Trendelenburg position is used in surgery, especially of the abdomen and genitourinary system. It allows better access to the pelvic organs as gravity pulls the intra-abdominal organs away from the pelvis. Evidence does not support its use in hypovolaemic shock, with concerns for negative effects on the lungs and brain.[2]

The position was named for the German surgeon Friedrich Trendelenburg (1844–1924).[3]

Current uses

[edit]
subject is lying on their back with legs lower than their body
Reverse Trendelenburg
  • The Trendelenburg position can be used to treat a venous air embolism by placing the right ventricular outflow tract inferior to the right ventricular cavity, causing the air to migrate superiorly into a position within the right ventricle from which air is less likely to embolise.[4]

Most recently, the reverse Trendelenburg position has been used in minimally invasive glaucoma surgery, also known as MIGS. This position is commonly used for a superior sitting surgeon that uses a combination of downward patient tilt, of approximately 30 to 35 degrees, microscope tilt towards themselves at the same angle and an intraoperative goniolens or prisms that allows them to visualise the inferior trabecular meshwork. Some joysticking of the globe may be required with an appropriate goniolens to bring the meshwork into view.[citation needed]

  • The Trendelenburg position along with the Valsalva maneuver, termed as modified-Valsalva maneuver, can also be used for the cardioversion of supraventricular tachycardia.[5]
  • The Trendelenburg position is helpful in surgical reduction of an abdominal hernia.[6]
  • The Trendelenburg position is also used when placing a central venous catheter in the internal jugular or subclavian vein. The Trendelenburg position uses gravity to assist in the filling and distension of the upper central veins, as well as the external jugular vein. It plays no role in the placement of a femoral central venous catheter.[7]
  • The Trendelenburg position can also be used in respiratory patients to create better perfusion.[8]
  • The Trendelenburg position has occasionally been used to produce symptomatic relief from septum posticum cysts of the subarachnoid space in the spinal cord, but does not bring about any long-term benefits.[9]
  • The Trendelenburg position may be used for drainage images during endoscopic retrograde cholangiopancreatography.[10]
  • The Trendelenburg position is reasonable in those with a cord prolapse who are unable to achieve a knee-to-chest position.[11] It is a temporary measure until a cesarean section can be performed.[11]
  • If a patient in a Fowler's position or semi-Fowlers position has sunk too far down into the bed, they may temporarily be put in a Trendelenburg position while staff reposition them. This does not have a direct therapeutic action but rather provides a mechanical advantage[12]

Controversial uses

[edit]
subject is lying on their back with legs raised and knees over another person's shoulders
A historic depiction of the Trendelenburg position
  • People with hypotension (low blood pressure) have historically been placed in the Trendelenburg position in hopes of increasing blood flow to the brain. A 2005 review found the "Literature on the position was scarce, lacked strength, and seemed to be guided by 'expert opinion.'"[13] A 2008 meta-analysis found adverse consequences to the use of the Trendelenburg position and recommended it be avoided.[14] However, the passive leg raising test is a useful clinical guide to fluid resuscitation and can be used for effective autotransfusion.[15] The Trendelenburg position used to be the standard first aid position for shock.[16]
  • The Trendelenburg position can also be used in the treatment of scuba divers with decompression sickness or arterial gas embolism.[17] Many experienced divers still believe this position is appropriate, but current scuba first aid professionals no longer advocate elevating the feet higher than the head. The Trendelenburg position in this case increases regurgitation and airway problems, causes the brain to swell, increases breathing difficulty, and has not been proven to be of any value.[18] "Supine is fine" is a good, general rule for victims of submersion injuries unless they have fluid in the airway or are breathing, in which case they should be positioned in the recovery position.[19]

See also

[edit]

References

[edit]
[edit]
Revisions and contributorsEdit on WikipediaRead on Wikipedia

Trendelenburg position

View on Grokipedia
from Grokipedia
The Trendelenburg position is a positioning technique used in medical and surgical settings, in which the individual lies on a bed or table that is tilted such that the head is lower than the feet, typically at an angle of 15 to 30 degrees, with the serving as the highest point of the trunk. This configuration aims to shift toward the upper body to enhance venous return and . Named after the German surgeon Friedrich Trendelenburg (1844–1924), the position was first described in the late 19th century as a method to improve visualization during pelvic surgeries by allowing the abdominal viscera to fall away from the operative field through gravity. Trendelenburg, a prominent figure in Berlin's surgical community, introduced this innovation amid advancements in aseptic techniques and operative positioning, though its origins may trace back to earlier anatomical practices in antiquity. Over time, it has evolved into a standard in perioperative care, with variations like steep Trendelenburg (30–40 degrees) employed in modern minimally invasive procedures. Common indications include facilitating lower abdominal, gynecological, genitourinary, and colorectal surgeries to optimize surgical access; aiding insertion by distending neck veins; and temporarily supporting in hypotensive or hypovolemic states, such as during or . A 2024 systematic review confirmed that the position significantly increases and other hemodynamic parameters in adults, supporting its utility in despite historical debates. However, evidence for its routine use in shock remains mixed, with some studies indicating limited or transient benefits compared to alternatives like passive leg raising. Physiologically, the head-down tilt promotes cephalad blood redistribution, potentially raising short-term, but it can also elevate intracranial and while reducing pulmonary compliance and . Complications associated with prolonged or steep applications include respiratory distress, airway , brachial plexus injury, corneal abrasions, and rare instances of ischemic or postoperative visual loss, particularly in obese or ventilated patients. Careful monitoring and limited duration are essential to mitigate these risks.

Definition and History

Definition

The Trendelenburg position is a variation of the supine position in which the patient lies flat on their back with the head of the bed or table tilted downward, positioning the head 15 to 30 degrees below the horizontal plane relative to the feet. This tilt is typically achieved by elevating the foot of the bed or operating table while keeping the patient's body aligned and supported. The primary mechanical purpose of this positioning is to utilize gravity to shift abdominal contents cephalad, away from the pelvic region, thereby improving visibility and access during procedures, or to facilitate enhanced venous return toward the central circulation. It is named after the 19th-century German surgeon , who popularized the technique. The Trendelenburg position differs from the standard , which maintains a flat, horizontal alignment without any tilt, and from the reverse Trendelenburg position, in which the head is elevated above the feet to achieve the opposite gravitational effect.

Historical Development

The Trendelenburg position, a head-down tilt of the body, originated in 19th-century surgical practice as a means to enhance visibility during pelvic and abdominal operations by utilizing gravity to displace abdominal organs cephalad. It was first formally described in 1885 by Willy Meyer, a surgical assistant to the German surgeon Friedrich Adolf Trendelenburg (1844–1924), who had been experimenting with elevated pelvic positioning in the early 1880s to facilitate access in procedures such as repairs and other gynecological surgeries. Although Trendelenburg himself detailed the technique more extensively in subsequent publications, including a 1890 description of its application in positions, the nomenclature "Trendelenburg position" became standardized in medical literature by the early , honoring his foundational contributions. Initially confined to operative settings, the position leveraged the of to shift bowel contents away from the surgical field, marking a practical in an era before modern retractors and techniques were available. Trendelenburg's work built on earlier rudimentary tilting methods but introduced a systematic approach, often involving custom table modifications to achieve a 25–30 degree incline, which improved outcomes in challenging pelvic exposures. By the early 20th century, the Trendelenburg position expanded beyond surgery into emergency care, particularly during , where it was adopted for managing to purportedly augment venous return and . This broader application persisted into the mid-20th century, influenced by wartime experiences and initial anecdotal successes, but faced growing scrutiny from evidence-based studies in the that demonstrated its limited efficacy in improving circulation, prompting a reevaluation of its routine use outside surgical contexts.

Procedure and Variations

Implementation

To implement the Trendelenburg position in clinical settings, the patient is first positioned on an adjustable or bed, ensuring the body is flat and aligned with arms at the sides or secured as needed. The table is then tilted by elevating the foot end and lowering the head end to achieve an angle of 15 to 30 degrees, with the feet positioned higher than the head. To secure the patient against gravitational sliding, a padded footboard is used at the feet; additional restraints, such as wide fabric straps across the hips or thighs, may be applied. Anti-slip measures, including gel pads or specialized foam sheets with high-friction surfaces, are placed beneath the patient from shoulders to calves to minimize shear and enhance stability. Shoulder braces are not recommended due to the risk of . The following outlines the key steps for safe implementation:
  • Verify the table's functionality and secure all attachments before transferring the patient.
  • Transfer and position the patient , padding pressure points (e.g., heels, ) and tucking arms to avoid extension.
  • Apply anti-slip along the and limbs.
  • Gradually tilt the table to the target angle while observing for immediate shifting.
  • Confirm securement with footboard and other restraints, adjusting as needed to maintain neutral alignment.
Required equipment includes a fully adjustable with tilt capability, footboards, or foam anti-slip pads, and restraint straps. Throughout the procedure, such as , , and are monitored continuously using standard equipment, airway patency is checked to prevent obstruction, and the position is typically maintained for under 4 hours with hourly assessments to verify stability and padding integrity. Steep variations may involve angles exceeding 30 degrees for enhanced exposure.

Variations

The standard Trendelenburg position, involving a 15- to 30-degree head-down tilt, has several modifications to address particular clinical requirements while maintaining the core principle of body inclination. These variations adjust the angle or orientation to optimize positioning without fully inverting the patient. Steep Trendelenburg refers to an intensified version where the head is lowered at 30 to 45 degrees relative to the feet, providing greater gravitational shift for improved visibility in targeted areas. This adaptation is commonly employed to enhance pelvic access during laparoscopic surgery by maximizing the downward slope. Modified Trendelenburg, also known as passive leg raising, elevates the legs 10 to 45 degrees while keeping the and head horizontal on the bed. This configuration avoids the full body tilt of the standard position, allowing for selective lower body elevation to support circulation in scenarios like . Reverse Trendelenburg inverts the inclination by raising the head 15 to 30 degrees above the feet, with the body remaining . Though related as a positional counterpart, it facilitates access to upper body regions during procedures involving the or .

Physiological Effects

Cardiovascular Effects

The Trendelenburg position facilitates an initial increase in venous return to the heart by gravitational redistribution of from the lower extremities toward the central circulation, thereby enhancing cardiac preload. This central shift typically involves a small effect, displacing approximately 100 mL of blood, which is modest and primarily beneficial in short-term hypovolemic scenarios but insufficient for substantial volume in shock states. As a result of the augmented preload, and rise transiently, often by 10-15% in responsive patients, supporting improved during the initial phase of positioning. However, these elevations are short-lived, with most parameters returning to baseline within about 10 minutes as compensatory mechanisms engage. The position may induce a brief rise in due to the increased , particularly in hypovolemic patients, but this is followed by activation, which triggers reflex and reduced cardiac contractility, potentially leading to if the position is maintained. Studies from the 1980s and later confirm no sustained hemodynamic benefits in shock, as the limited volume fails to meaningfully counteract severe or improve overall .

Respiratory and Neurological Effects

The Trendelenburg position induces significant respiratory changes primarily through the cephalad displacement of abdominal contents, which compresses the diaphragm and restricts its . This mechanical interference reduces lung volumes, notably decreasing (FRC) by approximately 12% (range 6-21%) in anesthetized patients. The resultant cranial shift of the diaphragm promotes formation, particularly in dependent regions, and exacerbates ventilation-perfusion (V/Q) mismatch by altering efficiency during laparoscopic procedures combined with . These alterations can lead to impaired pulmonary mechanics, including reduced compliance and increased , heightening the risk of as evidenced by elevated arterial CO2 tension in patients under steep Trendelenburg during robotic-assisted surgery. Brief reference to elevated from the position may indirectly contribute to these effects by influencing overall , though primary impacts stem from diaphragmatic compression. Neurologically, the Trendelenburg position elevates (ICP) by increasing , which impedes cerebral venous drainage through the jugular veins. In steep tilts (e.g., 30°), this can raise ICP from baseline levels of about 8.8 mmHg to 13.3 mmHg, with greater increases reported in prolonged or combined scenarios with . The mechanism involves hydrostatic pressure gradients that enhance venous congestion in the , potentially compromising cerebral if autoregulation is impaired. Additionally, the position causes venous congestion in the , leading to increased (IOP), often rising by an average of 13 mmHg at the peak of steep Trendelenburg during minimally invasive procedures. This elevation poses risks to ocular health, including potential postoperative visual disturbances, particularly in patients with preexisting or prolonged exposure.

Clinical Applications

Surgical Uses

The Trendelenburg position serves as a foundational technique in various surgical contexts, particularly for procedures involving the lower , , and . It is routinely applied during operations such as hysterectomies and prostatectomies, where the head-down tilt exploits to retract abdominal viscera cephalad, thereby optimizing exposure of the pelvic organs and reducing interference from bowel contents. This gravitational displacement enhances surgical precision and maneuverability, allowing for clearer visualization and safer dissection in these anatomically challenging regions. In laparoscopic surgeries, the Trendelenburg position further supports operative efficiency by promoting the stability of the and facilitating superior instrument access to pelvic structures. The tilt helps maintain intra-abdominal against gravitational forces, preventing collapse of the surgical workspace while shifting viscera away from the operative field to improve ergonomic handling of laparoscopic tools. Steep angles, often 25–45 degrees, are commonly employed in gynecologic and urologic laparoscopic interventions to achieve these benefits without compromising procedural flow. Additionally, the position plays a critical role in central venous catheter insertion, especially via the internal jugular approach, by distending neck veins through increased venous return and thereby enlarging their visibility for needle guidance. The 2020 guidelines from the recommend its use when clinically feasible to minimize procedural risks, such as , during these vascular access procedures.

Non-Surgical Uses

The Trendelenburg position serves as a temporary intervention in emergency settings for managing or hypovolemic states, where it aims to augment and by shifting blood volume toward the . This application is particularly relevant in prehospital or initial scenarios for patients experiencing shock, though evidence indicates only modest and transient hemodynamic improvements, often limited to durations under 10 minutes to minimize risks like respiratory compromise. By briefly elevating through enhanced venous return, it provides a bridge until definitive treatments such as can be administered. In diagnostic contexts, the Trendelenburg position aids testing, such as during head-up tilt table protocols, where it is applied to counteract symptomatic hypotension and restore hemodynamic stability if presyncope or syncope occurs. Similarly, it facilitates venous imaging by distending central veins, notably the internal jugular, to improve visualization during assessments for or cannulation planning. The position also supports non-invasive procedures like and select studies by optimizing organ positioning for enhanced visualization. During upper gastrointestinal , reverse Trendelenburg is more commonly used for routine cases, though head-down positioning may aid in specific intraoperative scenarios.

Risks and Complications

Common Complications

The Trendelenburg position, particularly when steep and prolonged, is associated with several injuries due to mechanical strain from positioning and body weight distribution. strain occurs when the arms are abducted or extended, leading to stretch or compression of the roots, with symptoms including shoulder , weakness, and ; reported incidence in advanced laparoscopic procedures ranges from 0.16% to as high as 10.8% in robotic-assisted surgeries, especially those exceeding 2 hours. compression, often from leg supports or stirrups in variants, can cause medial and adductor weakness, manifesting postoperatively as transient discomfort in pelvic surgeries. Ocular complications arise from direct pressure, fluid shifts, or elevated intraocular pressure (IOP) exacerbated by head-down tilt. Corneal abrasions result from exposure or rubbing against surgical drapes/masks, with an overall surgical incidence of 0.11%, though higher in Trendelenburg due to facial edema; symptoms include pain, , and , typically resolving with lubrication and patching. Steep tilts (≥30°) can increase IOP by 20-30 mmHg, raising risks for ischemic or postoperative visual loss, particularly in procedures longer than 4 hours. Respiratory distress frequently involves upper airway and facial from venous congestion and redistribution, reported as the most common complication by 39.5% of anesthesiologists in steep Trendelenburg cases. This can narrow the airway, increasing reintubation risk, while aspiration is heightened in obese patients (BMI >30) due to reduced and gastroesophageal reflux facilitation in the head-down posture; those with COPD face amplified challenges from baseline airflow limitation and heightened peak airway pressures. These effects may briefly elevate via impaired venous drainage.

Contraindications and Precautions

The Trendelenburg position is contraindicated in patients with or elevated , as the head-down tilt can exacerbate intracranial hypertension by impeding cerebral venous drainage and increasing cerebral . Similarly, it should be avoided in individuals with or other preexisting ocular conditions, such as , due to the significant rise in that may lead to postoperative visual loss or damage. Patients with severe cardiopulmonary disorders, including uncontrolled or pulmonary conditions like , are at risk of hemodynamic instability and respiratory compromise from increased and reduced . In cases of hypotension or shock, the position may be used as a temporary hemodynamic support, as a 2024 indicates it significantly increases and other parameters in adults, though evidence remains mixed with limited long-term benefits compared to alternatives like passive leg raising, and it may heighten the risk of aspiration by promoting gastroesophageal , particularly in patients with full stomachs or delayed gastric emptying. Obese patients may also face contraindications due to exacerbated difficulties from diaphragmatic compression by abdominal contents. Precautions during Trendelenburg positioning emphasize minimizing duration, especially in steep variants (greater than 25 degrees), to reduce risks of facial and airway that could compromise post-extubation ventilation. Arm positioning requires care to avoid ; arms should be tucked at the sides without abduction, external , or extension, and shoulder braces—if used—must be padded to prevent compression. integrity demands anti-shear measures, such as wide padding under the and heels, to counteract sliding on the table. Continuous monitoring of intracranial and intraocular pressures is advised in at-risk s, with reverse positioning considered if complications arise.

References

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