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We sought to measure the coronal alignment of the lumbar spine of patients in the right lateral decubitus position on a hinged Jackson operating table with the following 3 table positions: neutral and right and left 20-degree flexion.We analyzed the data of 23 patients who underwent OLIF. Spinal alignment was quantified using the coronal Cobb angle from L1 to S1, measured on anterior-posterior radiographs obtained preoperatively, after induction of anesthesia, with patients in the right lateral decubitus position, for the following 3 positions of the Jackson hinged operating table: neutral, right 20-degree flexion, and left 20-degree flexion. The Cobb angle at each position, the change in the Cobb angle, and the effective range of motion (%) were obtained from neutral to right and left 20-degree flexion. Alignment was compared between the 3 positions, and the range of motion was compared between men and women.The Cobb angle was different in all 3 positions of the table (P0.0001): -7.0 ± 8.7°, neutral; 2.8 ± 7.6°, right 20-degree flexion; and -14.7 ± 7.8°, left 20-degree flexion. The change in Cobb angle and the effective range of motion were greater in women (10.9 ± 2.8° and 55%) than in men (6.7 ± 5.8° and 34%) from the neutral to right 20-degree flexion position (P = 0.0298).The coronal alignment of the lumbar spine of patients in the right lateral decubitus position on a flat operating table (neutral position) was convex. The right 20-degree flexion position of the hinged operating table yielded less coronal plane lumbar spine deformity, with greater deformity in women.

Patient positioning in colonoscopy has been proposed as a simple and inexpensive technique to increase luminal distention and improve navigation through the large bowel. We sought to determine if the right lateral (RL) starting position compared to the standard left lateral (LL) starting position could improve outcomes in colonoscopy. We conducted a randomized controlled trial of 185 patients who were undergoing an elective colonoscopy. Patients were randomized to either a right lateral decubitus starting position or a left lateral decubitus starting position and the primary outcome measure was cecal intubation time. Secondary outcome measures included cecal intubation rate, patient discomfort, and sedation dosage. All colonoscopists who had successfully completed a colonoscopy skills improvement course were included in the trial. A sample size was calculated prior to the start of the study and outcomes were analyzed using univariate and multiple regression analyses. A total of 94 patients were randomized to RL starting position and 91 patients were randomized to LL starting position. No difference was found in time to cecal intubation comparing the RL starting position (542.6 s, SD 360.7 s) to LL starting position (497.85 s, SD 288.3 s) (p = 0.354). Variables associated with prolonged cecal intubation time included female gender, General Surgery specialty, less than 5 years of endoscopist experience, a high patient discomfort score, amount of water used, and number of position changes required to reach the cecum. There was no difference in any of the secondary outcome measures aside from the amount of midazolam used, with more midazolam used for patients starting in the right lateral decubitus position. This study failed to show an association between cecal intubation time and patient position comparing right and left lateral starting position.

Herein, we assess the safety and feasibility of dual-incision laparoscopic spleen-preserving distal pancreatectomy (DILSPDP) through lateral approach with reduced trocars for benign and low-grade malignancy in pancreas tail. We compare DILSPDP with surgical outcomes of conventional laparoscopic spleen-preserving distal pancreatectomy (LSPDP). Patients with benign pancreas tail mass that had been scheduled for LSPDP were selected to undergo DILSPDP. These patients had spleen-preserving distal pancreatectomy with the dissection in lateral-to-medial fashion using a multichannel trocar in the right lateral decubitus position of patient. We compared the demographics and operative outcomes of DILSPDP with those of conventional LSPDP which was performed with dissection in medial-to-lateral fashion using four or five trocars in supine position. Twenty two cases of DILSPDP and 26 cases of conventional LSPDP were reviewed. There was no difference in terms of demographic features including diagnosis or tumor size, although the location of the tumor was fundamentally different between the two groups. Significantly shorter operative times and reduced blood loss were observed in DILSPDP group (p = 0.004 and 0.011, respectively) and the preservation of splenic vessels was more successful with DILSPDP than conventional surgery (95.5% vs. 65.4%, p = 0.013). DILSPDP appears to be a feasible method of spleen-preserving distal pancreatectomy for benign or low-malignancy of pancreas tail and is accompanied by advantages in terms of splenic vessel preservation and reduced parietal trauma.

Background The sleeping position plays an important role in overall health in both healthy individuals and heart failure (HF) patients, which complain of increasing dyspnea when adopting left lateral decubitus position (LLDP) that improves when turning over to the right lateral decubitus position (RLDP). Several theories have been proposed to explain this preference of HF patients; however, the underlying mechanisms remain unclear. Method We evaluated consecutive dilated cardiomyopathy (DCMP) patients with regard to whether they had a sleeping position preference and analyzed early and late left ventricular filling velocities, tissue Doppler recordings, tricuspid annular plane systolic excursion (TAPSE), and left ventricular outflow tract time-velocity integral (LVOT-TVI). Baseline echocardiographic parameters were obtained first by LLDP, followed by the supine position (SP) and finally RLDP in each position for 10 minutes to ensure a stabilized hemodynamic milieu. Results A total of 26 DCMP patients were included in this study and a 78 echocardiographic examination performed. We detected that many HF patients preferred the right lateral decubitus sleeping position (RLDSP, 54%) and avoided from the left lateral decubitus sleeping position (LLDSP, 40%); the echocardiographic LVOT TVI and TAPSE parameters were statistically higher in RLDP compared to SP and LLDP. Conclusion The echocardiographic LVOT TVI and TAPSE values as functional parameters of left and right ventricular function change with body position, and these hemodynamic changes may explain why HF patients willingly adopt RLDSP.

Summary Introduction We assessed the feasibility of blind orotracheal intubation in children using the Air-QILA as a conduit in supine position and the glottic view grading by fiberoptic bronchoscope (FOB) through it both in supine and lateral positions. Methods After ethical approval and consent, 60 children were enrolled in the study. In the operating room, after attaching standard monitors to all children, anesthesia was induced with sevoflurane (2–8%) in oxygen (100%). Once the children became sedated, an i.v. access was established and injection glycopyrrolate (10 μg·kg−1), fentanyl (2 μg·kg−1), and atracurium (0.5 mg·kg−1) were administered. After 3 min, the Air-QILA was placed in supine position and glottic view was assessed by using FOB, in supine and right lateral decubitus position. In all children, gradings of glottic view in two different positions were noted. After that all children were turned supine, and orotracheal intubation was done blindly through the Air-QILA. The success rate, insertion time of the Air-QILA, and endotracheal intubation were noted. Results The Air-QILA placement was successful in 57 children in first attempt and three children required second attempt. However, blind endotracheal intubations through the Air-QILA were successful in 38 children in first attempt and 12 children required second attempt. In the remaining 10 children, where blind endotracheal intubation through the Air-QILA remained unsuccessful, conventional laryngoscopy was performed. In supine and lateral positions, Grade 1 glottic view was seen in 41 and 38 of total 60 patients, respectively. Turning of all children from supine to lateral decubitus position resulted in the deterioration of grading of glottic view in eight children and improvement in two children (P = 0.001 ). Conclusion The Air-QILA is an easy to place supraglottic airway device with excellent airway seal and low airway morbidity. It may be useful as a conduit for blind orotracheal intubation in supine position and can be used as an effective alternative to FOB in low resource settings.

Background To investigate postural effects on intraocular pressure (IOP) and ocular perfusion pressure (OPP) in patients with non-arteritic ischemic optic neuropathy (NAION). Methods IOP and blood pressure (BP) were measured in 20 patients with unilateral NAION 10 min after changing to each of the following positions sequentially: sitting, supine, right lateral decubitus position (LDP), supine, left LDP, and supine. IOP was measured using a rebound tonometer and OPP was calculated using formulas based on mean BP. The dependent LDP (DLDP) was defined as the position when the eye of interest (affected or unaffected eye) was placed on the dependent side in the LDP. Results IOPs were significantly higher (P = 0.020) and OPPs were significantly lower (P = 0.041) in the affected eye compare with the unaffected eye, with the affected eye in DLDP. Compared with the mean IOP of the unaffected eyes, the mean IOP of the affected eyes increased significantly (+2.9 ± 4.4 versus +0.7 ± 3.1 mmHg, respectively; P = 0.003) and the mean OPP decreased significantly (−6.7 ± 9.4 versus −4.9 ± 8.0 mmHg, respectively; P = 0.022) after changing positions from supine to DLDP. In addition, changing position from supine to DLDP showed significantly larger absolute changes in IOP (4.13 ± 3.19 mmHg versus 2.51 ± 1.92 mmHg, respectively; P = 0.004) and OPP (9.86 ± 5.69 mmHg versus 7.50 ± 5.49 mmHg, respectively; P = 0.009) in the affected eye compared with the unaffected eye. In the affected eye, there was a significant positive correlation between absolute change in IOP and OPP when changing position from supine to DLDP (Rho = 0.512, P = 0.021). Conclusions A postural change from supine to DLDP caused significant fluctuations in IOP and OPP of the affected eye, and may significantly increase IOP and decrease OPP. Posture-induced IOP changes may be a predisposing factor for NAION development. Electronic supplementary material The online version of this article (doi:10.1186/s12886-017-0441-3) contains supplementary material, which is available to authorized users.

Laparoscopic resection of gastric subepithelial lesions (SELs) located on the posterior wall of the gastric fundus is technically difficult and time-consuming. To facilitate access, we propose performing the laparoscopic procedure with patients in a right lateral decubitus position, rather than the standard supine position. The aim of our study was to compare operative and clinical outcomes for laparoscopic SEL resection performed in either the right lateral decubitus or the traditional supine position.The analysis was based on the data of 62 patients who underwent laparoscopic resection of SELs of the gastric fundus at Chonnam National University Hospital: 30 patients in the supine position (SUP) group and 32 in the right lateral decubitus position (RLD) group. All surgeries were performed by a single surgeon. Between-group comparisons were evaluated by Student's t, chi-squared, or Fisher's least squared tests, as appropriate for the data set.Compared with the SUP group, the RLD had shorter operative time (103 minutes versus 52 minutes, P .001), less intraoperative blood loss (71 mL versus 31 mL, P .001), and lower C-reactive protein levels on postoperative days 1 and 2 (P .005). Time to first flatus and length of hospital stay were comparable between groups.Laparoscopic gastric wedge resection for SELs on the gastric fundus in the right lateral decubitus position is feasible and safe, and provides operative advantages over the supine position.

Objective: It was the aim of this study to investigate the effects of the right lateral decubitus, left lateral decubitus and supine lying position on P-wave dispersion (PWD) in patients with heart failure (HF). Subjects and Methods: Seventeen patients with HF whose ejection fraction was Results: After the right lateral decubitus position, there was a statistically significant reduction in the longest P-wave duration (100.0 ± 14.5 and 84.7 ± 16.2 ms; p = 0.001) and a significant decrease in PWD (41.7 ± 8.0 and 24.1 ± 7.1 ms; p < 0.0001). After the left lateral decubitus position, there was no significant change between the baseline PWD values (41.7 ± 8.0 and 40.2 ± 9.7 ms; p = 0.606). After the supine position, there was no significant change between the baseline PWD values (41.7 ± 8.0 and 39.7 ± 9.4 ms; p = 0.427). Conclusion: Our study revealed that patients' PWDs and maximum P-wave durations were lower in the right lateral decubitus lying position than in other positions. The clinical implication of this study needs to be further explored.

PURPOSE Evaluation of data obtained during diurnal intraocular pressure (IOP) measurements by means of the Goldmann Applanation tonometer in sitting and lateral decubitus positions. PATIENTS AND METHODS Retrospective cohort study of 41 consecutive untreated subjects (82 eyes) with ocular hypertension or suspicious discs. The IOP was measured by Goldmann Applanation tonometer in sitting position at 9 AM, 12 AM, 3 PM, and 6 PM; and in right lateral decubitus position around 12:15 PM. RESULTS In the right eye (RE) mean peak IOP was 22.19±4.68 mm Hg. In the left eye (LE) peak mean IOP was 22.19±3.8 mm Hg. In 91.5% of the eyes, the IOP increased in the lateral decubitus position. The average change in the RE was an increment of 4.22±2.67 mm Hg (P

We report a case of a 51-year-old male who developed frequent nonsustained episodes of monomorphic ventricular tachycardia after being diagnosed with bioprosthetic aortic valve endocarditis and treated with intravenous antibiotics. A peripherally inserted central venous catheter (PICC) had been placed without complication less than 24 hours prior to the episodes. Ventricular tachycardia (VT) occurred during the night, while sleeping, when he assumed a right lateral decubitus position with abduction of the right arm and placement of the forearm under his head. VT occurred repeatedly when such position was assumed again upon request, and it would terminate immediately when sitting upright. The PICC was repositioned in the superior vena cava without further VT. He was discharged home the same day and underwent successful aortic valve replacement 2 months later. Position-dependent VT related to PICC requires careful history taking and PICC repositioning to make the diagnosis. X-ray in different patient positions during PICC placement can be considered to evaluate for ventricular migration.

TRACHEAL COMPRESSION in patients with a right-sided aortic arch and Kommerell’s diverticulum (classically defined as a bulbous configuration of the origin of an aberrant left subclavian artery in the setting of a right-sided aortic arch) previously has been described. In reported cases, clinically significant tracheal compression was noted preoperatively or soon after induction of anesthesia but prior to any change in the position of the patient. There has not been a case report in a patient with a right-sided aortic arch and Kommerell’s diverticulum in whom tracheal compression and/or obstruction was related only to surgical positioning and was otherwise absent. This case report describes a patient with a right-sided aortic arch and Kommerell’s diverticulum without any clinically significant symptoms during normal daily activities, exercise, or while sleeping in supine, lateral, or prone positions. Following tracheal intubation under general anesthesia in the supine position, no tracheal compression or difficulty with mechanical ventilation was encountered. However, complete tracheal obstruction was manifested in the right lateral decubitus position after placement of an axillary roll. This compression was relieved completely when the axillary roll was removed and the patient was returned to the supine position.

The aim of this study was to examine whether shoulder rotation increases the length of the posterior longitudinal ligament (PLL) in the lateral decubitus position.Thirty-four adult male volunteers were placed in the right or left lateral decubitus and flexion position on a horizontal operating table. Thoracic spinal ultrasonography was performed using the paramedian oblique sagittal plane to obtain the optimal ultrasound view for the PLL on the dependent side. The lengths of the PLL were measured at the T6/7 and T9/10 interspaces before and after ipsilateral 30-degree shoulder rotation.In the right lateral decubitus position, the ipsilateral shoulder rotation increased the mean (SD) of the PLL from 7.4 (2.8) to 8.4 (2.6) mm (P = 0.006) at the T6/7 level and from 8.4 (2.9) to 10.6 (2.8) mm (P0.0001) at the T9/10 level. Similarly, in the left lateral decubitus position, the ipsilateral shoulder rotation increased the mean (SD) of the PLL from 8.0 (2.6) to 9.1 (2.6) mm (P = 0.001) at the T6/7 level and from 9.3 (2.8) to 11.8 (3.1) mm (P0.0001) at the T9/10 level.Shoulder rotation significantly increased the dimension of the acoustic target window for paramedian thoracic epidural access in the lateral decubitus position at both T6/7 and T9/10 levels. Further clinical studies are needed to investigate the effect of shoulder rotation on thoracic epidural access.

To determine if the retroperitoneal oblique corridor will be affected by right lateral decubitus position.Forty volunteers were randomly enrolled and MRI scan was performed from L1 to L5 in supine and right lateral decubitus positions, respectively. In images across the center of each disc, O was defined as the center of a disc and A (supine) or A' (right lateral decubitus) was located in left lateral border of the aorta or the iliac artery; B (supine) or B' (right lateral decubitus) was on the anterior medial border of the psoas. The distance of AB and A'B' (Recorded as A-Ps and A-Pr, respectively) at each level was recorded and compared to each other. The relationships between A-Pr, sex, BMI and relative psoas cross-sectional area (PCSA) at each level were also evaluated.A-Pr was significantly smaller than A-Ps at L1/2, L2/3 and L3/4 (All p 0.05); there was no significantly difference of A-Pr between all levels (p = 0.105), but L1/2 seemed to be larger than L3/4, followed by L2/3 and L4/5; A-Pr at each level was not affected by sex (All p 0.05); linear relationships were found between A-Pr, BMI and PCSA at L1/2 and L3/4.ROC at L1/2, L2/3 and L3/4 will significantly decrease from supine to right lateral decubitus position and the reason may be due to the relaxed psoas deformation. Using MRI images in supine position for pre-operatively ROC evaluation is not accurate. Spine surgeon should also be more cautious when OLIF is performed at L4/5 where ROC is the smallest. Patients from Asia and those with strong psoas major at L1/2 and L3/4 are also associated with relatively narrow ROC.

Situs inversus is an extremely rare autosomal recessive disease with left-right inversion of internal organs. It carries technical difficulties in diagnostic or therapeutic procedures. There have been a few case reports on stone extraction by ERCP in situs inversus patients. ERCP techniques in situs inversus can be classified into conventional method and mirror image method. In mirror image method, the procedure is performed with the patient in the right lateral decubitus position and the endoscopist on the patient's left side. Until now, there is no consensus about which method is better. Herein, we report an unusual case of choledocholithiasis in a patient with situs inversus who underwent ERCP for stone extraction by both conventional method and mirror image method.

This report suggests that single-access laparoscopic splenectomy may be an opportunity to further refine minimally invasive approaches for general surgical disease., Background: Laparoscopic splenectomy has been performed in a standard fashion with 4 to 5 trocars since the early 1990s. Single access laparoscopy has recently gained interest, but single access laparoscopic splenectomy has not been reported to date. It has the possible benefits of less pain, faster recovery, better cosmesis, with theoretically similar costs to that of traditional trocars. Methods: A case is presented and the surgical technique of single access laparoscopic splenectomy is detailed. Results: The patient is an otherwise healthy 24-year-old male with medically refractory idiopathic thrombocytopenic purpura and a platelet count of 15 000. A splenectomy was performed using a single incision laparoscopic technique. The patient was placed in a right lateral decubitus position, and a 2.5-cm left upper quadrant incision was made. A multi-instrument flexible single incision port was used that held 3 trocars. A standard splenectomy was performed through this port. A linear stapler was used to transect the splenic hilum. The procedure time was just over 2 hours. The patient did well, was happy with his incision, and was discharged with a platelet count of 108 000. Conclusions: Single access laparoscopic splenectomy is feasible in select patients and may provide a less painful, better cosmetic result.

Dichotic sound discrimination is influenced by either visual or vestibular stimulation. This study investigated the effect of simultaneous gaze and vestibular inputs on dichotic sound discrimination. The subjects (n = 12) closed their eyes or gazed at a red target light placed at a distance of 50 cm from their eyes, and the ITD discrimination test was simultaneously performed in either the supine or in the right lateral decubitus position, in which gravitational linear acceleration causes utricular stimulation in the lower ear. In the ITD discrimination tests, the amplitudes of saw-tooth waves in the supine position with straight gaze were significantly different from those in the lateral decubitus position with downward or upward gaze. The saw-tooth waves in the lateral decubitus position with eye closed significantly shifted toward the upper ear compared to that in the supine position with eye closed. The saw-tooth waves in the lateral decubitus position with upward and with downward gaze shifted significantly toward the upper and lower ears, respectively, as compared to that in the supine position with straight gaze. We concluded that a sound image resulting from dichotic stimulation may be more dominantly influenced by the direction of eccentric gaze than by utricular stimulation that occurs due to gravitational linear acceleration.

t has been reported that cardiac vagal modulation is im- paired in patients with coronary artery disease (CAD), and that the reduction in the cardiac vagal modulation correlates with the angiographic severity of the changes in the coronary arteries. 1,2 In patients with CAD or congestive heart failure (CHF) or both, the short-term heart rate varia- bility (HRV) is significantly lower in those with inducible ventricular tachycardia than in those without clinical or elec- trocardiographic (ECG) evidence of ventricular tachycardia; and the probability of developing sudden death increases substantially when short-term HRV decreases below 50 ms. 3 Background This study compared the effect of 5 recumbent positions on cardiac autonomic nervous modula- tion in patients with coronary artery disease (CAD). Methods and Results Spectral heart rate variability analysis was performed on 33 CAD patients and 17 pa- tients with patent coronary arteries in random order in 5 positions; namely, supine, right lateral decubitus, left lateral decubitus, left prone and right prone positions. In the right lateral decubitus position, the vagal modulation was the highest and the sympathetic modulation was the lowest among the 5 recumbent positions in the control group. In the CAD patients, the vagal modulation in the supine position was significantly lower than that in the other 4 positions. The lower the normalized high-frequency power (nHFP) in the supine position, the larger the percent age increase in nHFP when the position was changed from supine to another recumbent position in both CAD patients and controls. There was no significant change in the respiratory rate when the position was changed from supine to any of the other 4 positions. Conclusions Right lateral decubitus position leads to the highest vagal modulation in the controls, whereas the supine position leads to the lowest vagal modulation in the CAD patients. In addition to the right lateral decubitus position, both the right and left prone positions can be used as a vagal enhancer in patients with CAD as compared with supine, especially for those patients who have severely reduced cardiac vagal modulation while supine. (Circ J 2008; 72: 902 - 908)

A 78-year-old man with a history of aphasia caused by cerebral infarction came to our hospital because of persistent progressive left lower back pain for 1 week, which had radiated through the left buttock and down the left thigh. On clinical examination, he was in the right lateral decubitus position on a bed in a psoas posture with a body temperature of 36.7°C. Laboratory results revealed leucocytosis (9.71×109/L), and elevated lactate dehydrogenase (415 IU/L) and creatine kinase (255 IU/L) levels. Contrast-enhanced CT of the abdomen after plain CT revealed a swollen left psoas muscle that was enhanced homogeneously (figure 1, arrows), indicating tumours in the left psoas. …

Case Report A 72-year-old man was transferred to our emergency department with sigmoid volvulus (Fig. 1A). He had had repeated episodes of abdominal pain for several years. His condition had always been labeled subocclusive crisis and had resolved spontaneously or with conservative treatment. Evaluation of two abdominal radiographs during follow-up revealed, to our surprise, a shift of the hepatic shadow from the right to the left upper quadrant. The time elapsed between the radiographs was 24 hours (Figs. 1B and 1C). The second radiograph was obtained immediately after the patient awakened. He usually slept in the left lateral decubitus position. One day later, abdominal CT (Figs. 1D–1G) performed in both lateral decubitus positions confirmed considerable mobility of the liver in the transverse plane. When the patient was lying in the left lateral decubitus position, the liver rotated clockwise and occupied the entire left hypochondrium. Images with the patient in the right lateral decubitus position showed the liver shifting to its normal anatomic position. No other organ misplacement, intestinal malrotation, or other anomaly was noticed. The patient did not report discomfort while undergoing imaging or after staying in the left lateral decubitus position for several hours.

Objectives. This study attempted to evaluate the effects of supine and lateral recumbent positions on pulmonary venous flow by transesophageal Doppler echocardiography in healthy subjects. Background. Although transesophageal echocardiographic examination is usually performed with the patient lying in the left lateral decubitus or supine position, little attention has been paid to the effects of these positions on pulmonary venous flow. Methods. We performed pulsed Doppler transesophageal echocardiography of the left and right pulmonary veins in 16 normal subjects as they lay in the left and right lateral decubitus and supine positions. Results. Data are reported as mean value ± SD. Adequate recordings were obtained in 12 subjects (75%). In the left pulmonary vein, peak systolic velocity and time-velocity integral of systolic flow increased significantly in the left compared with the right lateral decubitus position (56 ± 12 vs. 44 ± 13 cm/s, p < 0.05, and 15 ± 4 vs. 9 ± 4 cm, p < 0.05, respectively). In the right pulmonary vein, peak systolic velocity and time-velocity integral of systolic flow decreased significantly in the left compared with the right lateral decubitus position (38 ± 10 vs. 48 ± 9 cm/s, p < 0.05, and 9 ± 2 vs. 12 ± 2 cm, p < 0.05, respectively). There were no significant differences between positions in peak diastolic flow velocity, time-velocity integral of diastolic flow or peak velocity of flow reversal at atrial contraction. Conclusions. Pulmonary venous systolic peak velocities and time-velocity integrals of systolic flow Increase when the pulmonary venous recording is from the recumbent subject's lower side. Therefore, the effects of position should be considered in evaluating left ventricular diastolic function by transesophageal Doppler echocardiography.

There is a lack of consensus as to whether there is a difference in the amount of gastroesophageal reflux when lying with the right versus the left side down. In an attempt to answer this question we conducted a two-part study. The first consisted of a questionnaire distributed to 103 gastroenterologists with a special interest in the esophagus. The second was a randomized study in 20 normal subjects given a high-fat meal to induce reflux. Postprandial reflux was monitored by esophageal pH testing for 4 h after random assignment to either the left or right lateral decubitus position (left or right side down) on different days. Of the 87 gastroenterologists responding to our survey, 45 were uncertain as to which position was associated with worse reflux. Among the 42 who did specify, 27 (64%) favored the right lateral decubitus position as associated with more reflux symptoms. The direct comparison of the two positions demonstrated that the total amount of reflux time was significantly (p < 0.05) greater with subjects in the right decubitus position (231 min) than in the left (117 min). Although total episodes of reflux were greater when lying on the right side (227), compared with the left (198), the difference was not significant. In addition, average overall acid clearance was significantly (p < 0.001) prolonged with right side down (0.77 +/- 0.14 min/episode) compared with left side down (0.29 +/- 0.08 min/episode).

and three interactive table-mounted instrument manipulators. Details of this system have been previously described.1 Starting September 18, 1999, 18 patients with single-vessel coronary disease involving the left anterior descending coronary artery underwent beating-heart minimally invasive coronary artery bypass grafting with telerobotic assistance after approval by the university’s institutional ethics committee. Totally robotic, closed-chest procedures were completed in 6 male patients and are the subject of this report. After establishment of general anesthesia with a doublelumen endotracheal tube, each patient was placed in a 45° right lateral decubitus position. The left arm was abducted to permit the insertion of three 5-mm access ports, while avoiding external robotic arm collisions. The left internal thoracic artery (LITA) was identified and dissected as a pedicle from the first to sixth ribs with voice-activated robotic and video assistance using the Harmonic Scalpel (Ethicon EndoSurgery, Inc, Somerville, NJ). During the procedure, warm carbon dioxide gas was insufflated into the pleural cavity up to a pressure of 5 to 10 mm Hg. The left anterior descending coronary artery (LAD) was stabilized with a prototype articulating endoscopic stabilizer (Fig 1). A specially designed sternal elevator was used in 3 of the patients to increase anteroposterior intrathoracic working space. A 5-mm 0° endoscope and assistant instruments were passed through working ports. The patients were then systemically heparinized and the LAD prepared for anastomosis. The LITA Significant advances have been made in computer-assisted robotic coronary surgery in the past 2 years. Although limited success has been achieved with totally endoscopic, robotassisted bypass on the arrested heart, the ultimate objective is to perform a beating-heart procedure. To date, technical limitations have prevented this goal from being accomplished. We describe our initial clinical experience using robotic instrumentation and voice-controlled camera guidance (Zeus; Computer Motion Inc, Goleta, Calif) in performing closedchest, beating-heart coronary artery bypasses. Patients and methods. The Zeus endoscopic instrument control system is a supervised online robotic system consisting of three components: a surgeon’s console, a computer controller, CLOSED-CHEST CORONARY ARTERY BYPASS GRAFTING ON THE BEATING HEART WITH THE USE OF A COMPUTER-ENHANCED SURGICAL ROBOTIC SYSTEM

When compared with open splenectomy, laparoscopic splenectomy was associated with fewer complications, however, with more hemorrhagic complications. Furthermore, the mean operative time for laparoscopy was significantly longer than for the open procedure. Vessel sealing systems are represented as decreasing operative time and blood loss in several surgical procedures. The aim of this study is to evaluate the blood loss and operating time of laparoscopic splenectomy with a vessel sealing system. We evaluated 19 laparoscopic splenectomies with a vessel sealing device, particularly focusing on operative blood loss and operating time. Patients were operated in the right lateral decubitus position usually with three ports. In all cases, dissection of the spleen and sealing of hilar vessels and short gastric vessels were performed with a vessel sealing system. No clips, sutures, or monopolar-bipolar diathermy were used. Mean operative blood loss was 88 ml (range 20-400 ml) and mean operative time was 107 minutes (range 45-230 minutes). Both results were better than those of most series of laparoscopic splenectomy performed with endostaplers or endoclips. Laparoscopic splenectomy with a vessel sealing system is safe for all vascular controls in laparoscopic splenectomy and can lead to less blood loss. This technique removes the disadvantage of longer operating times for laparoscopic as compared to open splenectomy.

Magnetic resonance imaging (MRI) provides superior visualization of the prostate, its substructure, surrounding tissues, and, most important, focal lesions or cancer. The purpose of our canine study was to demonstrate the feasibility of a low-field (0.35 T) transperineal system that enables precise MR image guidance of prostate interventions. The canines were placed in the right lateral decubitus position. Template reconstruction, trajectory planning, contouring were based on T2-weighted FSE images. For image guidance and target confirmation, fast gradient spoiled-echo (FSPGR) sequence was used. MR compatible coaxial needles were manually inserted through the perineum to the base of the prostate. After satisfactory position was confirmed, brachytherapy catheters were placed through the coaxial needles. The mean deviation of the needle displacements was 2.9 mm with a median value of 2.7 mm. 97% of the errors were less than 4.0 mm. The needle placement accuracy was modelled by the Rayleigh distribution with a sigma value of 2.3 mm. Visual confirmation of needle placements was demonstrated on pathology tissue slices. The time needed for each step was: anaesthesia - 15 min, setup and positioning - 15 min, initial imaging - 15 min, template registration, projection - 15 min, contouring, trajectory planning, insertion of 12 needles - 60 min Based on our canine experiences our method seems to be a promising approach for performing feasible, accurate, reliable and high-quality prostate MR guidance within a reasonable time span.

OBJECTIVES To compare differential renal perfusion in various body positions in healthy volunteers, to help postulate factors responsible for recurrent unilateral stone formation. METHODS Ten volunteers with normal renal function and no history of urinary disease were evaluated with diuretic renography using mercaptoacetyl-triglycine. Scintigraphy was performed 1 week apart in each of three typical sleep positions (supine, left lateral decubitus, right lateral decubitus), and renal perfusion was measured. RESULTS Symmetric renal perfusion was noted in all volunteers in the supine position. Subjects positioned in the left lateral decubitus position had a mean renal perfusion of 61.3% in the dependent (left) kidney, compared with 38.7% in the nondependent (right) kidney (P

The aim of this study was to investigate the nonlinear characteristics of heart rate variability (HRV) for three recumbent positions: the supine, left lateral and right lateral decubitus positions. Recently, using a linear analyses method (for time and frequency domains), the effect of the right lateral decubitus position on vagal modulation has been found to increase parasympathetic activity and decrease sympathetic modulation. Little is known about the nonlinear dynamics of HRV for the three recumbent positions. Therefore, we studied the correlation dimension (CD), the largest Lyapunov exponent (LLE), the sample entropy (SampEn), the approximate entropy (ApEn) and the exponent alpha of the 1/falpha power spectrum as nonlinear characteristics of HRV. In response to the right lateral decubitus position, the CD, LLE, SampEn and ApEn increased significantly in both coronary artery disease (CAD) and control groups. In the linear analyses, the normalized high-frequency power (nHF) increased in the right lateral decubitus position. The CD, LLE, ApEn and SampEn correlated positively to the nHF. The alpha exponent did not correlate to either linear measure or CD, but correlated negatively to LLE, ApEn and SampEn. Among the three recumbent positions, it was found that the right lateral decubitus position can increase the complexity of the human physiological system and the vagal modulation of the cardiac autonomic nervous system the most.

A greater QT dispersion in patients with chronic heart failure (CHF) appears to be a non-invasive marker of susceptibility to malignant ventricular arrhythmias. We evaluated whether QT dispersion in CHF patients is modified by the patients' recumbent position. In 12 CHF patients, and age and sex-matched 12 normal subjects, a single 12-lead surface ECG was recorded in each postural position [left lateral decubitus position (L), supine position (S), and right lateral decubitus position (R)]. In normal subjects, the QT dispersion was comparable in the three recumbent positions [L: 47+/-15 (SD) ms, S: 40+/-9 ms, R: 38+/-14 ms, P=NS]. In contrast, in CHF patients, QT dispersion was significantly shorter in R than those in L and S (L: 93+/-42 ms*, S: 81+/-29 ms*, R: 63+/-24 ms, *P

A 14-year-old boy with a heart murmur was referred to the authors' department because structural heart disease could not be ruled out by standard echocardiographic views. The best apical four-chamber view was obtained with the patient turned to a right lateral decubitus position and the transducer shifted almost to the posterior axillary line. A biplane chest x-ray also showed a counterclockwise heart axis deviation. Magnetic resonance imaging confirmed the suspected congenital absence of the pericardium.

P with chronic congestive heart failure (CHF) have fatigue and dyspnea with exercise intolerance and a poor prognosis. Fluid retention along with peripheral vasoconstriction and reduced skeletal muscle perfusion provide the physiologic basis for the symptoms. Neurohormonal modulation by norepinephrine (NE), atrial natriuretic peptide (ANP), and brain natriuretic peptide (BNP) are heavily involved in the clinical manifestations of patients with CHF. We have recently reported that posture largely affects the autonomic nervous activity in patients with CHF. In the right lateral decubitus position, sympathetic tone decreased, whereas parasympathetic activity increased. In the present study, we hypothesized that neurohormonal environment of patients with CHF is ameliorated in the right lateral decubitus position because these patients prefer the position. • • • The study group consisted of 14 patients (8 men and 6 women, mean age 72 14 years) with CHF due to coronary artery disease (Table 1). Three patients had New York Heart Association functional class II CHF, 10 had class III, and 1 had class IV. The mean left ventricular ejection fraction was 39 18%. No patient had diabetes mellitus. A constant diuretic, digitalis, calcium antagonist, nitrate, angiotensin-converting enzyme inhibitor, and angiotensin II antagonist dosing regimen was continued. However, -blocking therapy had been withdrawn at least 7 days earlier. Eight ageand sex-matched New York Heart Association functional class I patients with normal left ventricular function (5 men, 3 women, mean age 69 13 years) were selected as the control group. In the early morning, each of the 3 positions (left lateral decubitus, supine, right lateral decubitus) was maintained for 1 hour before blood samples were drawn from a peripheral vein through an indwelling catheter. The order of each position was randomized. Plasma NE, ANP, and BNP levels were then measured by radioimmunoassay. All patients provided informed consent to the protocol, which was approved by the human subjects review committee of Takeda Hospital. Data are expressed as mean SD. Comparisons of variables between the 2 groups were conducted by Fisher’s exact test or unpaired Student’s t test. Multiple comparisons were performed by 2-way analysis of variance, followed by the Tukey-Kramer test for each parameter among the 3 recumbent positions of both groups of patients. Results were considered significant at p 0.05. Plasma NE concentrations were higher in patients with CHF than in those with normal LV function (Figure 1A). In addition, plasma NE concentrations were significantly lower in the right lateral decubitus position than those in the left lateral decubitus and supine positions. Plasma ANP and BNP concentrations were also higher in patients with CHF than in those with normal left ventricular function (Figures 1B and 1C). In addition, in patients with CHF, plasma ANP concentrations were higher in the right lateral decubitus position than those in the left lateral decubitus and supine positions, although plasma BNP levels did not significantly differ among the 3 recumbent positions. In patients with normal left ventricular function, there were no significant differences in these From the Departments of Cardiovascular Medicine and Cardiovascular Surgery, Kyoto University, Kyoto; Division of Cardiology, Takeda Hospital, Kyoto; Division of Cardiology, National Cardiovascular Center, Osaka; Department of Medicine, Division of Cardiology, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Osaka; Second Department of Internal Medicine, Kansai Electric Power Hospital, Kanasi; and College of Medical Technology, Kyoto University, Kyoto, Japan. Dr. Fujita’s address is: College of Medical Technology, Kyoto University, 53 Kawaharacho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan. E-mail: mfujita@kuhp.kyoto-u.ac.jp. Manuscript received June 29, 2001; revised manuscript received and accepted September 25, 2001. TABLE 1 Clinical Characteristics of Eight Patients With Normal Left Ventricular Function and 14 Patients With CHF

Recently endoscopy has started to be used for spinal surgery. The benefit of using endoscopy is that it is less invasive, and the small incision results in a shorter hospital stay. In a standard technique for laparoscopic anterior lumbar fusion, the conventional approach for L1/2-L4/5 is retroperitoneal. This approach has a critical point in retracting the iliopsoas muscle because this muscle is bulky at the level of L4/5 and contains a lot of peripheral nerves. We report on a new technique called the “psoas strapping technique,” in which the psoas muscle was retracted by being circled with a nonelastic tape passed through posterior skin. Disc tissue was resected under retraction of the muscle with this technique and a titanium fusion cage was inserted under laparoscopic observation. TECHNIQUE Under general anesthesia, a patient was placed in the right lateral decubitus position. After retroperitoneal insufflation with carbon dioxide to a pressure of 8 mmHg, three trocars were placed in the abdomen. A nonelastic tape was inserted into retroperitoneal space through the portal. An end of the tape was passed below the psoas muscle as close as possible to the lateral side of the vertebral disc, and then passed through the posterior skin. The other end of the tape was inserted into the retroperitoneal space, passed in front of the muscle, and pulled out through the same hole in the posterior skin. Pulling both ends of the tape made it possible to retract the

Patients with coronary artery disease (CAD) have depressed vagal modulation. Because the mortality risk from acute myocardial infarction is lower in patients with higher vagal modulation, methods that can increase vagal modulation are desirable for patients with CAD. The right lateral decubitus position has been found, in young healthy subjects, to lead to the highest vagal modulation among 3 recumbent positions using spectral heart rate variability (HRV) analysis. This study investigated which recumbent position can give rise to the highest vagal modulation in patients with severe CAD. Twenty-seven patients scheduled for coronary artery bypass graft surgery and 17 patients with angiographically normal coronary arteries were studied. Spectral HRV analysis was performed in random order on these patients in 3 recumbent positions: namely, the supine, left lateral decubitus, and right lateral decubitus positions. Normalized high-frequency power was the highest, whereas normalized low-frequency power and low/high-frequency power ratio in the right lateral decubitus position were the lowest, among the 3 recumbent positions in both groups of patients. The lower the normalized high-frequency power in the supine or left lateral decubitus position, the higher the increase in the normalized high-frequency power when the position was changed from supine or left lateral decubitus to right lateral decubitus in patients with severe CAD. Right lateral decubitus position can lead to the highest vagal modulation and the lowest sympathetic modulation among the 3 recumbent positions in patients with severe CAD. Therefore, the right lateral decubitus position can be used as an effective physiologic vagal enhancer in patients with severe CAD.

To investigate the effect of change of body posture from the supine to the lateral decubitus position on intraocular pressure (IOP) in patients with open-angle glaucoma.Prospective, observational case series.Setting. Institutional. Participants. Forty-four eyes of 22 patients with newly diagnosed bilateral open-angle glaucoma. Observation procedures. IOP was measured using the Tono-Pen XL (Reichert Inc) in both eyes 10 minutes after assuming each position: sitting, supine, right lateral decubitus, supine, left lateral decubitus, and supine. By comparing the mean deviation (MD) of Humphrey visual field between both eyes of a patient, eyes were classified into either worse-MD eye or better-MD eye. Main outcome measures. Magnitude of IOP alterations by postural changes and intereye difference of IOP with each posture.The mean ± SD IOP of the dependent eyes (eye on the lower side in the lateral decubitus position) increased after changing from the supine to the right lateral decubitus position (19.1 ± 2.6 mm Hg vs 21.0 ± 2.7 mm Hg; P = .019) or the left lateral decubitus position (18.6 ± 2.9 mm Hg vs 20.6 ± 3.1 mm Hg; P = .002). The mean IOP of the dependent eyes was significantly higher than that of the nondependent eyes in the lateral decubitus positions (right lateral decubitus, +1.2 mm Hg; left lateral decubitus, +1.6 mm Hg; both, P.05). Compared with the better-MD eyes, the worse-MD eyes showed a tendency for greater IOP rise with positional change from the supine to lateral decubitus position (2.3 ± 2.2 mm Hg vs 1.5 ± 2.1 mm Hg; P = .065).The postural change from the supine to lateral decubitus position may increase the IOP of the dependent eyes in patients with open-angle glaucoma.

The goal of the present study is to develop a technique for laparoscopic aortobifemoral bypass. Piglets weighing between 60 and 78 kg were anesthetized with halothane. The lateral retroperitoneal approach was preferred to the more familiar anterior transperitoneal approach and was successfully completed in 19 piglets. The piglets were placed in the right lateral decubitus position. The first port (2 cm) was inserted halfway between the tip of the 12th rib and the iliac crest. Four other trocars were placed in the retroperitoneum after balloon inflation had allowed creation of a space which permitted visualization of the aorta from the left renal artery down to the aorto-iliac junction. After evacuation of the retropneumoperitoneum, the cavity was maintained using an abdominal lift device and a retractor. Using this approach, we performed four aorto-bifemoral bypasses (end-to-end aortic anastomosis) after conventional intravenous heparinization (100 IU/kg) in less than 4 h. Blood loss did not exceed 250 ml and the hematocrit remained stable. Postmortem evaluation of the grafts revealed they were positioned as in a conventional bypass, their limbs having followed in the created retroperitoneal tunnels along the path of the native arteries. No mortality occurred before sacrifice of the animals. We believe that this first performed series of totally retroperitoneal laparoscopic aortobifemoral bypasses in the porcine model is useful in preparation for human application due to the anatomical similarities in the periaortic region.

In eight patients, the ventilation-perfusion (Va/Q) relationships after uncomplicated aortic valve replacement were studied by the multiple inert gas technique. Postoperatively, all patients had a right-to-left intrapulmonary shunt (Qsp/Qt) (range 2.4% to 14.4%) and abnormal distribution of Va/Q patterns to varying degrees. No single mechanism was identified that defined gas exchange in all patients. In three patients, moving from the supine to the right lateral decubitus position resulted in improved oxygenation which occurred because of better matching of Va/Q, not because of a decrease in Qsp/Qt.

OBJECTIVES We sought to determine whether patients with congestive heart failure (CHF) avoid the left lateral decubitus (LLD) position during sleep and, if so, whether this avoidance would be more pronounced in those with greater degrees of cardiomegaly. BACKGROUND Anecdotal reports suggest that, in patients with CHF, the LLD position is associated with discomfort due to the enlarged apical heart beat and greater degree of dyspnea (trepopnea) than other positions. It has also been suggested that the LLD position is associated with increased sympathetic nervous activity. METHODS A total of 75 patients with CHF and 75 control subjects underwent nocturnal polysomnography with monitoring of body position. Echocardiography was performed in all patients with CHF to determine left ventricular end-diastolic diameter (LVEDD). A total of 40 patients underwent cardiac catheterization from which pulmonary capillary wedge pressure (PCWP) and cardiac output (CO) were obtained. RESULTS Patients with CHF spent significantly less time in the LLD position than in the right lateral decubitus position. No such difference was observed among control subjects. Among patients with CHF, those with larger LVEDD, higher PCWP, and lower CO spent less time in the LLD position. CONCLUSIONS Patients with CHF avoid the LLD position spontaneously during sleep. This may be a protective strategy to avoid discomfort from the enlarged apical heart beat or further hemodynamic or autonomic compromise.

We correlated the amount of gastric fluid identified by sonography in 143 fasting patients with the presence of duodenal ulcer disease and gastric-outlet obstruction as seen on barium studies. Unselected consecutive patients who were referred for a barium study of the upper gastrointestinal tract were included in a double-blinded prospective study. Sonograms were obtained in the right lateral decubitus position to allow gastric fluid to accumulate in the antrum, where it was quantified by measuring the maximal cross-sectional area of antral fluid in square centimeters. Sonograms revealed no fluid or a small amount (less than 5 cm2) in 87 (61%) of the patients and a large amount of fluid (greater than or equal to 5 cm2) in 56 patients (39%). Barium examinations showed a duodenal ulcer in 26 (46%) of the 56 patients with sonographic evidence of a large amount of gastric fluid compared with 10 patients (11%) in the group with little or no fluid on sonography (p = .001). Sonographic evidence of a large amount of fluid was found in all five patients who had gastric-outlet obstruction on barium examination (p = .02). The detection of a large amount of fluid in the stomach on sonography appears to be a feature of duodenal ulcer disease and gastric-outlet obstruction.

A few cases of the crush syndrome occurring postoperatively have been reported. We present a case of the crush syndrome involving the gluteal compartment secondary to prolonged duration of the patient in the right lateral decubitus position during a urological operation. A review of the literature demonstrates that prompt diagnosis is essential to avoid catastrophic results. The essentials of diagnosis, treatment and prevention are reviewed.

We measured ventilation and static lung volumes in five fit volunteers in the right lateral decubitus position, while they were fully awake and while sedated with diazepam. We also assessed the distributions of ventilation and perfusion in the lungs, using inhalations and intravenous injections of xenon-127. Diazepam, 0.04 mg . kg-1, was administered every three to five minutes as required to induce and maintain a state of sedation which was moderately heavy. Total doses ranged from 0.16 to 0.38 mg . kg-1. Sedation did not alter minute ventilation, but reduced tidal volume, increased breathing frequency and reduced functional residual capacity slightly. Sedation also diminished the normal gradient of ventilation from non-dependent to dependent regions of the lungs. Spontaneous episodes of very small tidal volume breathing during sedation were associated with a marked reduction or cessation of ventilation of the most dependent region of the lungs. There were no sedation-related changes in the distribution of perfusion. These effects of moderately heavy sedation may contribute to the hypoxaemia and impairment of pulmonary gas exchange often present during recovery from general anaesthesia.

Intrapulmonary distribution of ventilation/unit lung volume was studied in 28 volunteers in the sitting, supine, or right lateral decubitus position, either awake or anesthetized-paralyzed and mechanically ventilated. We found significant differences between the awake state and anesthesia-paralysis with mechanical ventilation in 1) intrapulmonary gas distribution, and 2) the vertical gradient of regional functional residual capacities for the subjects in the lateral decubitus position, but not for those in the sitting and supine positions. The effect of increasing the tidal volume on distribution of ventilation was significantly different 1) between the three body positions for a given state, and 2) between the two states for a given body position. The data suggest thoracoabdominal mechanics are different in the three body positions and that anesthesia-paralysis and mechanical ventilation may cause a different pattern of expansion of the respiratory system than spontaneous breathing in the awake state.

This is the first case that demonstrates that the specificity of a SPECT thallium study may be improved by imaging the patient prone instead of supine. Improved specificity is most likely due to better separation of the diaphragm and inferior wall, similar to the improvement seen in planar studies when patients are imaged in the right lateral decubitus position.

• Eight of 67 patients became transiently aphasic after myelography or cisternography with metrizamide. All eight patients had been placed in the left lateral decubitus position for pluridirectional tomography. Immediate EEGs revealed focal left-sided abnormalities in two patients. In one other patient, a computed tomographic scan showed contrast mainly over the left hemisphere. All of the symptoms resolved within 48 hours. In 34 patients who were placed on the right side, no language disturbance was noted. Aphasia after pluridirectional tomography with metrizamide may be due to local irritation of the perisylvian language centers of the dominant hemisphere. The phenomenon is distinct from syndromes of generalized confusion. The complication may be avoided by placing patients in a right lateral decubitus position for pluridirectional tomography.

Distributions of ventilation and perfusion relative to Va/Q were determined in seven young healthy volunteers (24–33 yr) while they were either in the supine or right lateral decubitus position. The subjects were studied first awake and then while anesthetized-paralyzed and breathing 30% oxygen and again while breathing 100% oxygen. In the awake state, no statistically significant differences were observed in the distribution of ventilation and perfusion relative to Va/Q between the supine and right lateral decubitus positions or on changing the inspired oxygen concentrations. After induction of anesthesia-paralysis, Va/Q mismatching increased significantly but only small right-to-left intrapulmonary shunts developed. Ventilating the lungs with 100% oxygen further increased the dispersion of blood flow distribution during anesthesia-paralysis; lung units with low Va/Q or right-to-left intrapulmonary shunts (or both) developed. With induction of anesthesia-paralysis and intubation of the trachea, the anatomic dead space was decreased and the alveolar dead space increased.