Strategies for Safer Trendelenburg and Lithotomy Positioning in the OR

The recommended limit for manual lifting per the National Institute for Occupational Safety and Health (NIOSH) is 35 pounds. Yet perioperative professionals routinely find themselves lifting more – exertion necessary for positioning patients in surgical settings.   

The inherent risks of such movement are exacerbated by everyday OR realities. Operating rooms and related spaces are often constrained and small, leading to bending and twisting that can compromise posture (lifting just 35 pounds at waist height can cause lumbar disc strain if posture is not ergonomically neutral). Add limited staff and subsequent hurry, also pervasive, and it’s easy to see why patient handling-related injuries (including repetitive strain injuries) are a leading cause of OR staff workers’ compensation claims.

Trendelenburg and lithotomy positions are particularly ripe for caregiver injury. Used in pelvic and gynecological procedures, both require high levels of attention and exertion. Trendelenburg and lithotomy also pose unique pitfalls for patients (who, it should be noted, are typically sedated or under anesthesia). Risks for both parties increase as patient BMI rises.   The good news: Several emerging, evidence-based safe patient handling tools go a long way toward safer positioning – if meaningfully incorporated into operating room culture and protocol. But first, a closer look at the two complex surgical positions at hand

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RISKS OF TRENDELENBURG AND LITHOTOMY POSITIONING

A supine position that raises feet higher than the head to improve access to pelvic organs, Trendelenburg requires significant vigilance and physical effort among OR nurses and staff. This is especially true for steep Trendelenburg, in which the head-down angle reaches 30 to 45 degrees.

Much lifting and adjusting is needed to bring a sedated or anesthetized patient from neutral to Trendelenburg and then back to neutral once a procedure is complete. Falling and sliding are common, even when foam, gel pads, and other preventative measures are employed. Shearing, tissue strain, and a host of other patient risks (brachial plexus injuries, for example) can stem from resulting friction. Trendelenburg poses other inherent risks, too, including risk of nerve compression. Altogether, these necessitate frequent on-the-fly repositioning and micro-positioning that set the stage for caregiver exertion and therefore caregiver injury.

In lithotomy position, patients lay on their back with legs raised, separated, and situated in stirrups or knee cradles. Hips and knees are flexed at 90-degree angles.

Transferring sedated or anesthetized patients into stirrups and providing lower extremity support are leading causes of most lithotomy-related OR nurse injuries. This position is difficult to achieve, requiring team effort. Strained backs, shoulders, and wrists among medical staff are not uncommon.

Patient risks here are also noteworthy. Asynchronous movement during lithotomy positioning can lead to patient joint or soft tissue injury. Prolonged lithotomy can compress major nerves (peroneal, femoral, sciatic). It is therefore critical to get patients into lithotomy position quickly and keep them there for the shortest possible duration of time – setting the stage for hurry that can also compound injury odds.

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BARIATRIC AND HIGHER BMI RISKS

Another complicating factor in Trendelenburg and lithotomy positioning, and positioning overall: The higher a patient’s BMI, the greater the injury risk for all parties.

For staff, rates of back, shoulder, and neck injuries increase alongside patient weight. Pulling a 250-pound patient can require more than 100 pounds of push-pull force if nothing is used to reduce friction. Even common and seemingly small surgical adjustments (tucking an arm, folding a leg, tilting the surgical table, managing unpredicted movements) become substantial risks amidst high BMI.

A few additional factors further exacerbate injury risk in these scenarios. Some OR tables are not rated for higher weight capacities, for example, or lack the width needed to provide stable support. Standard stirrups sometimes fail to accommodate larger leg circumference or are unable to distribute pressure evenly. These challenges are becoming more pervasive as average patient weight continues to rise and as advances in medicine and surgical technologies set the stage for busier operating rooms in years ahead.  

AIR ASSISTED TECHNOLOGY IN THE OR

Air-assisted technology pushes air between a patient and the surface beneath them, reducing friction and thereby decreasing force required for patient movement by 80 to 90%. In one biomechanical study simulating a lateral patient transfer, force required to reposition a patient dropped from 100 pounds to less than 20 pounds (a total well below the NIOSH safe lifting limit recommendation of 35 pounds or less).

This is a game-changer for lateral transfers, boosting, and repositioning overall, but especially for nuanced positioning and related effort required by Trendelenburg and lithotomy. Beyond reducing necessary exertion, air-assisted devices decrease necessary spinal compression forces by more 70 percent when compared to manual transfer effort.

Air-assisted devices have notable benefits for patients, as well:

• More controlled repositioning. Because it makes movement smoother and easier, use of air-assisted devicesimproves patient comfort as well as alignment and nerve protection during positioning.
  
  
• Reduced shearing risk. By floating a patient into Trendelenburg or lithotomy instead of dragging them, air-assisted technology reduces risk of shear on the sacrum, the scapula, and the occiput, and damage to skin overall.
  
  
• Improved limb movement control. Air-assist lets teams execute more easily on limb movement including team movements, such as those required to raise both legs into stirrups in lithotomy – always challenging, but now gentler and more readily synchronized.
  
  
• Heightened precision. Because movement is controlled, positioning with air-assisted devices hugely benefits precision – critical in the OR overall and in complex patient positioning especially. More accurate positioning reduces the chance that additional adjustments will be needed, further eliminating injury risk while also improving workflow.  

OR IMPLEMENTATION & PRACTICE CHANGE

So now what? How do we incorporate air-assisted devices into the OR meaningfully, consistently, and effectively?

• Acknowledge barriers. Change in clinical practice, and especially in fast-paced, high-stakes ORs, often encounters resistance. Overcoming it starts by recognizing and acknowledging common objections:
  
  • “We’re too busy to use that. It’s the OR. There’s no time. The next patient is waiting.”
  • “Oh, great – one more thing to manage, keep track of, and keep clean.”
  • “We don’t know how to use it. We weren’t trained on it.”
  • “We’ve always done it this way.”
  • “It’s too much of a hassle to find and set up.”
  • “We’re short staffed”
• Start. Overcoming these barriers starts by educating clinicians on the ways in which air-assisted devices truly offset their challenges and concerns.Clinicians love data. Reinforce that right-fit, evidence-supported air-assisted devices are not extra work but rather pave the way to safer and easier work and stronger outcomes: a 40 to 60% reduction in staff injury, increased patient positioning accuracy, and reduced risk of complication, all while saving time and resources. The goal here isn’t to add more steps, but rather to replace existing steps with smart, safer tools. Communicate this with brevity in mind via short, targeted training sessions during downtime and huddles.
  
• Align. AORN recommends air-assisted devices. The ANA calls for elimination of manual lifting. These recommendations mean air-assisted devices are not strictly a matter of safety, but of compliance, liability, and best practice. When OR practice aligns with national standards, we protect ourselves, our patients, and our healthcare system from avoidable harm – wins all around. Even more, these standards demonstrate that times have changed and technology has improved. Air-assisted devices aren’t some whimsical notion. They are aligned with modern protocol.

• Build. Peer-to-peer influence is shown to be far more effective than a trickle-down from management. It’s key, then, tobuild a team of champions – one or two nurses, techs, surgeons, or aides per shift who can positively and accurately model adoption of these tools. These peers are already in the room. Let them example – and let the ripple effect take hold from there. One OR that identified and trained air-assist device champions concurrently tracked some key metrics. It revealed fewer reports of back strain among staff, fewer patient pressure injuries (especially among patients in steep Trendelenburg), and reductions in positioning time by nearly five minutes per OR patient. It’s important to remember that these improvements didn’t stem from a huge system overhaul. They stemmed from the simple addition and standardization of air-assisted tools that were previously available but underutilized because they hadn’t been woven into OR culture. Once champions were in place, the devices took off.
  
• Make. Last but not least, make it easy to do the right thing. Implement processes to ensure that air-assisted devices are available in the OR, properly stocked, easily accessible, clean, charged, and ready to go – on a rolling basis. They’re not buried in a closet. They’re not on another floor or still in their packaging. Again, safety tools will not be used if they’re hard to find, hard to use, or only sporadically available. Convenience equals compliance.

Evidence and practical thinking back the use of air-assisted devices as first-line interventions in any OR. Beyond protecting individual staff members and patients, these tools preserve team function and case efficiency.
Eager to learn more about integrating air-assisted devices into your OR? Earn one free contact hour by listening to the full on-demand webinar.

Elizabeth Doherty MSN, CRNP, FNP-C

Elizabeth Doherty brings a broad range of clinical expertise to her role as Clinical Education Specialist at HoverTech International. Her background spans long-term care, medical-surgical ICU experience at a large academic hospital, emergency and pediatric emergency nursing in a Level I trauma center, and advanced practice as a Certified Registered Nurse Practitioner.   This diverse foundation allows her to connect with healthcare teams across multiple specialties and understand their unique challenges in patient care and safety.

She is deeply passionate about shaping the future of nursing, supporting frontline nurses, and ensuring they have the knowledge, tools, and confidence to deliver safe, high-quality care.

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1. https://pubmed.ncbi.nlm.nih.gov/11920961/
2. https://pmc.ncbi.nlm.nih.gov/articles/PMC11675142/