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Lateral interbody fusion and posterior percutaneous pedicle screw (LIF-PPS) fixation has been performed in two-stage positioning. The aim of this study was to investigate the surgical outcomes of simultaneous single-position LIF-PPS fixation using O-arm-based navigation. Overall, 102 consecutive subjects underwent indirect decompression surgery for spondylolisthesis with LIF-PPS fixation. Fifty-one subjects underwent surgery with repositioning, and 51 in the right lateral decubitus position. We compared these two groups in terms of the surgery time, occupancy time in the operating room, intraoperative blood loss, Japanese Orthopaedic Association (JOA) score, local lordosis acquisition in postoperative radiographs, and accuracy of screw insertion using postoperative CT scans. In the single-position group, surgery time, occupancy time of the operating room, and estimated blood loss were 93.3 ± 19.3 min (vs. the repositioning group: 121.0 ± 37.1 min; p

Background : Magnetic resonance imaging is essential investigation method for central nervous system lesions. Closed space and loud noise inside magnetic resonance machine can cause sense of fear in children, so it is common practice to use sedation or general anesthesia in children undergoing magnetic resonance imaging. For safe general anesthesia management endotracheal intubation or laryngeal mask airway placement are recommended. However not all magnetic resonance imaging offices are supplied with compatible equipment and often general anesthesia is provided on spontaneous breathing through natural airways. In emergency medicine lateral position can prevent upper airway complications such as obstruction, aspiration, cough and laryngospasm. The aim of our study was to compare incidence of upper airway complications in children in supine and lateral position undergoing head magnetic resonance imaging under general anesthesia. Materials and methods : Forty-one children undergoing elective head magnetic resonance imaging under general anesthesia were randomized into 2 groups: “Supine” and “Lateral”. Children under general anesthesia were left breathing spontaneously in supine or right lateral decubitus position with slight head and neck extension. Vital signs monitoring included ECG, SpO2, blood pressure and sidestream capnography. Episodes of desaturation, obstruction, apnea, need for airway manipulations such as Guedel airway or laryngeal mask airway placement, suctioning and manual ventilation were registered. Results : Incidence of upper airway complications and need for airway manipulations were significantly lower in “Lateral” group. Number of patients with no complications was significantly higher in “Lateral” group. Mean number of any complication per one patient in “Lateral” and “Supine” groups was 0.1 and 2.4 respectively. Number needed to treat of lateral position for total absence of complications was 1.3 and risk reduction of having any complication was 75.8%. Conclusion : Lateral position is simple maneuver that allows to decrease number of upper airway complications, upper airway manipulations and to increase safety of children undergoing head magnetic resonance imaging under general anesthesia on spontaneous breathing through natural airways.

Background: Abdominal pain during pregnancy can be caused by many conditions related to diseases of abdomen, urinary system, gynecological and obstetric problems. One of the important conditions causing non obstetrical pain during pregnancy is renal colic. Ureteral jet is the phenomenon that seen when the dense urine from the ureter is expelled into the more dilute urine in the urinary bladder.Aim of Study: Was to ass ureteric jet by color Doppler ultrasound in pregnant women.Subjects and Methods: Total number of 75 pregnant patients with singleton pregnancy referred to our Radiology Department from Obstetrics and Gynecology Department, in their second and third trimester, presented with suspected urinary tract infections or hydronephrosis were included in our prospective study.Renal and bladder grey scale and bladder color Doppler ultrasonography were performed; patient should be full bladder. Ureteral jet angle was also measured as the angle between the direction of the ureteral jet and intraureteral ridge. Patterns of the ureteric jet were also recorded. Doppler ultrasound of the bladder area was performed in a transverse plane while patient supine includes both ureteric orifices to visualize the bilateral ureteral jets and measures the angle. Number of ureteral jets was also recorded for a period of one minute to three minutes. Study was done also in the right and left lateral decubitus position and number of ureteral jets was also recorded for a period of one or three minutes. Right ureteral jets were recorded in left lateral decubitus position whereas left ureteral jets were recorded in the right lateral decubitus position. Renal Ultrasound was done to detect back pressure changes and its severity.Results: We used Statistical Package for Social Sciences (SPSS) software version 10 for data assessment. Mean age of patients was 23±4 years. Average gestation age was 26.02± 2.56 weeks with minimum and maximum gestation age 21 and 33 weeks respectively. Mean number of ureteral jets seen in supine position at right side was 1.91±1.71 with minimum and maximum number of jets 0 and 4 respectively. Most frequent number of jets was “0” and seen in 36 cases (48%) of the patients.Back pressure changes diagnosed in 52 patients (69%) was unilateral in 41/52 patients (78%) and bilateral in 11/52 cases (22%). Right kidney back pressure changes were seen in 35 patients and left side 6 cases. Mean ± SD ureteral jet angle was significantly greater in affected units with back pressure (67.9±16.5 degrees) than in non affected units (42.8± 12.2 degrees, p

Multilevel lateral interbody fusion is an acceptable surgical technique in patients with severe degenerative adult spinal deformity (ASD). The current standard-of-care in spine surgery includes the use of patient reported outcome measures (PROMs) to assess post-operative improvement. Objective activity data during the peri-operative period may provide supplementary information for patients recovering from ASD surgery. In this report, we use smartphone-based activity data as an objective outcome measure for a patient who underwent a two-stage operation for ASD corrective surgery: lateral osteotomy and lumbar interbody fusion with posterior column release. An 82-year-old male presented with intractable back pain secondary to severe thoracolumbar scoliotic deformity (Lenke 5BN). Pre-operative images demonstrated the presence of bridging osteophytes over the left lateral aspect of L2-5 disc spaces and over the apex of the lumbar curvature, with significant neuroforaminal stenosis. Surgical correction was completed in two stages: (1) left-sided lateral osteotomy using anterior-to-psoas approach (ATP) in a right lateral decubitus position, and (2) multilevel Ponte osteotomies and instrumented fusion from T10-pelvis. Post-operative radiography showed correction to scoliotic deformity and sagittal misalignment. The patient had developed seroma and wound dehiscence, which was evacuated on post-operative day 11. At 14-month follow-up, the patient reported significant improvement in pain symptoms, corroborated by patient reported outcome measures. To further quantify and assess patient recovery, smartphone-based patient activity data was collected and analyzed to serve as a proxy for the patient's functional improvement. The patient's walking steps-per-day was compared pre- and post-operatively. The patient's pre-operative baseline was 223 steps/day; the patient's activity during immediate post-operative recovery dropped to 179 steps/day; the patient returned to baseline activity levels approximately 3 months after surgery, reaching an average of 216 steps/day. In conclusion, we found that lateral osteotomy through an ATP approach is a powerful tool to restore normal spine alignment and can be successfully performed using anatomic landmarks. Additionally, smartphone-based mobility data can assess pre-operative activity level and allow for remote patient monitoring beyond routine follow-up schedule.

We report our experience with needlescopic splenectomy (NS) for the surgical treatment of idiopathic thrombocytopenic purpura using a 3-mm needlescope with three ports. One patient was male and two were females, and their mean age was 58 years. The patient was placed in the right lateral decubitus position. The first 12-mm port was introduced through the lateral margin of the left rectus abdominis muscle, and the other two 3-mm ports were inserted in the left upper quadrant. NS was performed by a standard technique under the observation of 3.3-mm needlescope. The surgical procedure was successfully completed in all the patients. The mean duration of surgery, intra-operative bleeding volume and post-operative hospital stay were 176 min, 70 ml and 4.7 days, respectively. There were no particular peri-operative complications in spite of dense adhesions or simultaneous laparoscopic procedures. Our method is safe and feasible with low morbidity and without impairing cosmetic benefits.

Introduction Patients with undiagnosed anterior mediastinal tumors commonly undergo surgery for diagnosis and treatment. However, determining the optimal therapeutic strategy is difficult for tumors with substantial invasion, such as lesions touching the aortic arch (AA). Case presentation A 76-year-old man of Asian descent presented to our hospital because chest computed tomography (CT) revealed an anterior mediastinal tumor. This tumor surrounded the left subclavian vein and touched the AA. We suspected the tumor to be malignant. We therefore decided to resect the tumor with preparation for total arch replacement (TAR). The operation was performed in three steps. First, we performed a mediastinal sternotomy. However, the tumor had invaded the subclavian vein, so we resected this vein after adding a transmanubrial approach. However, because of invading the AA we needed next step. Second, we shifted the patient to the right lateral decubitus position. We performed partial resection of the left upper lobe and exfoliated the distal AA. Third, we shifted the patient to the dorsal position and implanted an artificial cardiopulmonary device, after which we performed TAR, and pulmonary artery (PA) trunk plasty with a pericardial patch. The operation was successful, with no major adverse events. Pathologically, the tumor was diagnosed as diffuse large B-cell lymphoma. Discussion If oncologically complete resection is preferable for tumors with substantial invasion, complete resection should be attempted even if the surgery is difficult. Conclusion We performed complete resection of an anterior mediastinal tumor with TAR and PA trunk plasty using a pericardial patch., Highlights • We performed complete resection of a malignant tumor through TAR and PA trunk plasty with a pericardial patch. • Discrimination between ML and thymoma is frequently difficult. • If complete resection is preferable for tumors, the surgery should be attempted even if the surgery is difficult.

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.

Background The oblique lumbar interbody fusion or anterior-to-psoas (OLIF/ATP) technique relies on a corridor anterior to the psoas and posterior to the vasculature for lumbar interbody fusion. This is evaluated preoperatively with CT and/or MRI. To date, there have been no studies examining how intraoperative, lateral decubitus positioning may change the dimensions of this corridor when compared to preoperative imaging. Objective Our objective was to evaluate changes in the intraoperative corridor in the supine and lateral positions utilizing preoperative and intraoperative imaging. Methods We performed a retrospective analysis among patients who have undergone an OLIF/ATP approach at two tertiary care centers from 2016 to 2018 by measuring the distance between the left lateral border of the aorta or iliac vessels and anteromedial border of the psoas muscle from L1-L2 through L4-5 disc spaces. We compared this corridor between supine, preoperative MRI axial and intraoperative CT acquired in the right lateral decubitus position. Results Thirty-three patients, 15 of whom were female, were included in our study. The average age of the patients was 65.4 years and the average BMI was 31 kg/m2. The results revealed a statistically significant increase (p

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.

Purpose To report a novel approach for locally advanced tumors located at the gastroesophageal junction (GEJ) using a laparoscopic abdominal phase and open left thoracotomy with the patient in a single right lateral decubitus position. Background The standard open left thoracoabdominal approach offers excellent exposure and access to the GEJ and lower esophagus. It also involves a single position for the procedure, shortening the operation time. The disadvantages are a large incision, division of the costochondral junction, and a low-level thoracotomy. The laparoscopic-assisted left thoracoabdominal esophagectomy (LLTA) is performed with the patient in the same right lateral decubitus position, but initially rolled away from the operator at 45° allowing laparoscopic gastric mobilization and lymphadenectomy. The patient is then tilted back to the lateral position for the thoracic phase. An anterolateral left thoracotomy is performed through the higher fifth intercostal space allowing a high intrathoracic anastomosis, just below the aortic arch. No disruption of the costochondral junction is made. Methods Consecutive patients selectively treated for locally advanced GEJ tumors with an LLTA approach between 2013 and 2019 were analyzed and compared to national standards (NOGCA). Results This series of 74 consecutive patients had a mean age of 63 years. The median operation time was 235 minutes. The median inpatient stay was 10 days (NOGCA 9 [11–17]). The tumors were predominantly adenocarcinoma (95%) and located at the GEJ (92%). The majority were locally advanced T3 or T4 tumors. Postoperative morbidity was low, Clavien–Dindo (C–D) 0 in 52.7% patients, C–D1 (1.4%), C–D2 (31.1%), C–D3a (5.4%), C–D4a (9.5%), and C–D5 (1.4%). The median number of total lymph nodes (LN) excised was 28 (NOGCA >15); LN % yield ≥18 was 90% (NOGCA 82.5%). Positive nodes were located at the lesser-curve (40%), paraesophageal (32.4%), and subcarinal regions (2.7%). Positive circumferential resection margins ( Conclusion This series demonstrates a novel, safe, and reproducible approach for locally advanced cancer of the GEJ. It offers a better exposure of the hiatus than the right-sided approach and avoids division of the costochondral junction and low thoracotomy seen with the open left thoracoabdominal approach.

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 and study aims A 72-year-old man with complete situs inversus presented with early gastric cancer on the lesser curvature wall of the antrum of the stomach. Endoscopic submucosal dissection (ESD) was selected as a treatment. When the patient was positioned in the left decubitus position, the lesion was hidden by blood and gastric fluid because it was located on the gravitational side. Therefore, we decided to perform ESD with the patient in the right lateral decubitus position and use an inverted overtube, which provided a good endoscopic view without the need to rearrange the endoscopist, assistants, or endoscopic system. ESD was safe and feasible using the inverted overtube.

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.

A 53-year-old woman presented at the emergency department with stab wounds on the epigastrium and left posterior chest with a retained knife. The patient was in a right lateral decubitus position and this posed a greater risk to performing an effective physical examination. In a situation like this, the standard Advanced Trauma Life Support (ATLS) approach may be limited with errors in physical examination and monitoring of the patient. Management of this care process and treatment in this position proved challenging. Keywords: lateral decubitus physical exam, lateral decubitus injury, ATLS lateral decubitus approach

Air embolism is an uncommon, but potentially life-threatening event for which prompt diagnosis and management can result in significantly improved patient outcomes. Most air emboli are iatrogenic. Arterial air emboli may occur as a complication from lung biopsy, arterial catheterization or cardiopulmonary bypass. Immediate management includes placing the patient on high-flow oxygen and in the right lateral decubitus position. Venous air emboli may occur during pressurized venous infusions, or catheter manipulation. Immediate management includes placement of the patient on high-flow oxygen and in the left lateral decubitus and/or Trendelenburg position. Hyperbaric oxygen therapy is the definitive treatment which may decrease the size of air emboli by facilitating gas reabsorption, while also improving tissue oxygenation and reducing ischemic reperfusion injury.

Background Platypnea-orthodeoxia syndrome is a rare syndrome characterized by dyspnea and hypoxia when the patient is sitting or standing. Here we report a case of platypnea-orthodeoxia syndrome caused by a right hemidiaphragmatic elevation with giant liver cyst that triggered a right-to-left shunt through the patent foramen ovale. This case report is the first presentation of a case secondary to hemidiaphragmatic elevation with giant liver cyst. In addition to this, a malposition of the pacemaker lead could be associated with platypnea-orthodeoxia syndrome in this case. Case presentation A 91-year-old Japanese woman presented to our hospital with hypoxia of unknown origin. Severe hypoxia and cyanosis were observed only in the right lateral decubitus position. A chest X-ray and computed tomography scan revealed right hemidiaphragmatic elevation, which was probably compressing the right atrium. A transesophageal echocardiogram showed a compressed right atrium and shunt blood flow in both directions: from the left to the right atrium and vice versa. The shunt flow was exacerbated by postural changes from the left to the right lateral decubitus. A transesophageal echocardiogram also confirmed compression of the right atrium due to giant liver cyst and a malposition of the pacemaker lead abnormally placed in the left atrium through patent foramen ovale. We concluded that the cause of hypoxia was platypnea-orthodeoxia syndrome with right-to-left interatrial shunt through patent foramen ovale. Surgical closure of patent foramen ovale was not performed due to the age of our patient, surgical difficulties, and failure to obtain informed consent. For these reasons she was discharged after receiving medical advice about her posture. Conclusions Platypnea-orthodeoxia syndrome is rare and difficult to diagnose. The present case suggests that hypoxia due to postural changes should be considered a differential diagnosis of platypnea-orthodeoxia syndrome.

Recent research has revealed that patients with neurodegenerative disease sleep longer in the supine position, while healthy controls prefer sleeping in the lateral decubitus position. Thus, sleeping in the lateral position seems to be protective against neurodegeneration. It has also been suggested that a protective role of this body position could be associated with better cerebral venous drainage in this body position, which results in more active glymphatic system of the brain (the system responsible for clearance of the cerebral tissue from waste products, e.g. amyloid-β). Since no published evidence exists regarding venous outflow from the cranial cavity in the lateral decubitus position, we performed a pilot sonographic study of the internal jugular veins in 3 young healthy volunteers and 2 patients presenting with abnormal jugular valves. In all healthy volunteers both internal jugular veins were opened in the supine position and collapsed in the sitting one. In the right lateral decubitus position the right internal jugular vein was opened, while the left one was partially collapsed; and-vice versa-in the left lateral decubitus position the right internal jugular vein was partially collapsed and the left one opened. In patients with abnormal jugular valves both internal jugular veins were opened in both lateral decubitus body positions. We hypothesize that in the lateral decubitus body position, because of decreased flow resistance in the extracranial veins, cerebral venous outflow is optimal, which in turn optimizes the activity of the glymphatic system. Therefore, people intuitively prefer this body position during sleep, while other positions are associated with a higher risk of neurodegenerative disorders. Yet, it should be emphasized that our results need to be interpreted with caution, since only a few individuals have been assessed and this discovery should be confirmed in more patients and healthy controls, and by precise quantitative measurements.

The patient with a left adrenal mass (Figs. 1.1 and 1.2) is intubated and then placed into the right lateral decubitus position with all pressure points padded. Both arms are partially extended into a comfortable “hugging” configuration with the right arm placed on a padded arm board and the left arm positioned on pillows or an elevated arm board. An axillary roll is placed just caudal to the right axilla to prevent brachial plexus palsy. We generally position the patient so he or she is reclining slightly more supine than in full decubitus position. The left flank is exposed, and the right lower ribs should be placed overlying the “break” in the operating table; this ensures that, when the table is flexed, the space between costal margin and iliac crest widens, allowing more working room for the laparoscopic instruments. Conceptually, the patient is positioned so that the upper pole of the kidney is placed on top of the break in the bed.

Background Ankylosing spondylitis (AS) is a seronegative spondyloarthropathy within the spectrum of rheumatologic diseases. The systemic inflammation that characterizes AS leads to bone resorption and reformation. Pathologic remodeling may include kyphosis, osteoporosis, and multi-segment auto-fusion. Cervical fractures account for 53-78% of spinal trauma seen with AS. Surgical planning is often challenging owing to spinal deformity, medical comorbidities, the cervicothoracic foci of injury, and gross instability of these fracture. Case description A 55-year-old male with AS was presented with a three-column injury at the C6 level. The C6 vertebra was fractured, minimally displaced, and there was a focal kyphotic deformity. Attempted posterior fixation 2 days after presentation was aborted; the patient could not tolerate prone positioning, and there were further technical limitations to a posterior approach. Cervicothoracic fixation from C2 to T2 was then performed using the right lateral decubitus position employing the Mayfield head holder, a beanbag, and spinal neuronavigation. Conclusion In this study, we presented a unique approach to posterior fixation of an unstable cervicothoracic fracture in a patient with AS utilizing the lateral position and neural navigation under intraoperative physiological monitoring.

To analyze the effect of maternal rest in the left and right lateral decubitus positions and resting alone on the amniotic fluid index (AFI).Sixty-nine women with singleton pregnancies and an AFI of 6 to 24 cm at 36 to 40 weeks' gestation were included in this randomized controlled trial. The women were randomized into 2 intervention groups. After initial AFI measurements, group 1 (n = 35) rested in the left lateral position for 15 minutes and then rested in the right lateral position for another 15 minutes. Group 2 (n = 34) rested in the right lateral position for 15 minutes and then rested in the left lateral position for another 15 minutes. To compare differences between groups, AFIs were measured at the end of each 15-minute period while the participants were kept on their backs in a semirecumbent position.The demographic data, gestational ages, and initial AFI values did not differ between groups (P.05). In group 1, the initial mean AFI ± SD of 12.25 ± 3.81 increased significantly during the first 15 minutes to 15.17 ± 4.27 and decreased significantly during the second 15 minutes to 13.30 ± 4.29 (P.001); however, the 30-minute AFI was still significantly higher than the initial value (P = .008). In group 2, the initial AFI change during the first 15 minutes, from 12.83 ± 3.99 to 12.72 ± 3.87, was not significant (P.05); however, it increased significantly to 15.63 ± 4.14 during the second 15 minutes (P.001). The 30-minute AFI was still significantly higher than the initial value (P.001).Maternal rest in the right lateral decubitus position does not seem to either increase or decrease the AFI, and resting alone does not increase the AFI in the short term.

Introduction The lateral approach is the standard for laparoscopic splenectomy. However, when the modified Hassab's operation is performed laparoscopically, the patient is placed in the supine position and then the right semi-lateral or lateral decubitus position. Based on our experience with laparoscopic adrenalectomy and splenectomy, we laparoscopically performed the modified Hassab's operation with the patient in the right lateral decubitus position. Materials and Surgical Technique Indications for the modified Hassab's operation for patients with portal hypertension in our institute include both gastric varices and hypersplenism resistant to endoscopic or radiologic procedures. We performed splenectomy and devascularization of the greater curvature and then dissected adhesions between the stomach, pancreas, and gastrohepatic ligament. With the patient in the right lateral decubitus position, the lesser curvature could be identified from both the ventral and dorsal sides. Discussion For the modified Hassab's operation, as in laparoscopic gastrectomy, many operators select the supine position for lesser curvature devascularization and gastric vessel ligation. However, after sufficient adhesion dissection around the stomach, anatomical structures can be identified in the right lateral decubitus position. For this approach, gravity is not an issue on the dorsal side, and the lesser curvature can be observed from both the ventral and dorsal sides with the patient in the right lateral decubitus position. Laparoscopically performing the modified Hassab's operation with the patient in the right lateral decubitus position is a feasible method.

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.

We report a case of simultaneous anterior and posterior interosseous nerve syndrome in association with shoulder arthroscopy. Shoulder arthroscopy was performed in a 45-year-old male patient with left shoulder instability. In the right lateral decubitus position, under general anesthesia, traction was applied with elbow extension for 2 hours. One week after surgery, the patient revisited the clinic for weakness of the flexor of the thumb, index finger, and extensor of the fingers. Recovery was not achieved after four months of observation. Therefore, nerve exploration was performed in the anterior and posterior interosseous nerve and hourglass-like fascicular constriction was detected in the posterior interosseous nerve. The area of constriction was removed and epineural neurorrhaphy was performed. Three months after exploration, the extension function of the fingers was recovered. Recovery was achieved gradually, and, five months after nerve exploration, the symptoms were completely recovered. Simultaneous anterior and posterior interosseous nerve syndrome following shoulder arthroscopy is rare. However, it could occur due to the traction and position of the patient. Thus, the operator should be careful of traction and position of the patient.

Surgical positioning is accompanied by numerous anesthetic considerations, particularly its potential effects on the cardiovascular, respiratory, and nervous systems. Clinical studies have shown that lateral positioning does not affect hemodynamics; however, with the addition of trunk flexion, there is a decrease in cardiac output, which may be secondary to caval compression. In this report, we describe a unique case of hypotension that arose in a patient positioned only in the right lateral decubitus position with flexion and that was exacerbated by an abnormally narrow inferior vena cava.

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.

In comparison to open surgery, VATS lung resections are technically challenging operations as the operative field is transformed from a three dimensional multi-angle wide view to a two dimensional screen. Therefore careful pre-operative and intra-operative planning is required to complete the procedure safely and successfully. All our patients undergo a Computed Tomography (CT) which is essential for pre-operative planning. The Multiplanar Reconstruction (MPR) mode displays images in the Coronal and Sagittal view. The sagittal view can be rotated by 90 degrees to bring the lung apex to the left side. This corresponds to the patient's position in the right lateral decubitus position (for left sided resections) but not in the left lateral decubitus position for right sided resections. Therefore, the standard sagittal view in the MPR mode is not adequate for operative planning for right sided lung resections.

Aim: The aim of this work was to report the technique and result of thoracoscopic repair for a newborn with congenital diaphragmatic hernia (CDH) under high-frequency oscillatory ventilation (HFOV) in the neonatal intensive care unit (NICU). Methods: Ventilation was supported by HFOV. The patient was placed in the right lateral decubitus position. Thoracoscopic surgery was performed through three 5-mm trocars. Carbon dioxide insufflation was maintained in the thoracic cavity at a pressure of 6–8 mm Hg. The hernia defect was repaired by using interrupted sutures with extracorporeal knots. Results: The operation lasted 60 minutes. The intraoperative course was uneventful. Normal vital signs and PO2 value were maintained throughout the operation. The patient had a normal chest X-ray 1 month after discharge. Conclusion: Thoracoscopic repair of CDH in the NICU during HFOV is feasible and safe.

Background The gastroesophageal junction was commonly approached surgically through a thoracoabdominal incision. With the advent of improved retraction devices, this has been abandoned because the upper midline incision has provided adequate exposure with decreased morbidity. However, exposure of the gastroesophageal junction remains a challenge in the setting of surgical complications associated with repeat surgeries and abscess formation. Methods Patients were placed in the right lateral decubitus position. An incision was made 2 cm below the tip of the scapula to a point in the midline equidistant from the xiphoid process to the umbilicus. The chest was entered at the eighth intercostal space. The abdominal cavity was entered by dividing the diaphragm peripherally from its lateral attachments to the ribs. Results We have used this approach on 4 patients. All patients were discharged home tolerating oral diets. The average postoperative stay was 10 days. No complications related to the incision were reported. At the 6-month follow-up evaluation all patients continued to tolerate a regular diet without difficulties. Conclusions The technique described allows for excellent exposure of the upper gastrointestinal tract in a subset of patients with complex upper gastrointestinal complications.

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. …

Introduction: Robot-assisted laparoscopic donor nephrectomy (RALDN) is an emerging minimally invasive technique for procuring living renal allografts for transplantation. As an alternative to traditional laparoscopy, robotics provides optical magnification and instrument articulation, which can be used in intricate dissection of the vessels and obtaining maximum length for the graft. We provide a reproducible 12-step instruction on our standard left RALDN and results of our initial experience. Methods: The patient is placed in the right lateral decubitus position and the robotic ports are placed. The 12 steps of our standard left RALDN include medial reflection of the descending colon, complete mobilization of the spleen, exposure of the gonadal and renal vein, ligation of the adrenal, gonadal, and lumbar vein, mobilization of the kidney laterally and posteriorly, dissection of the adrenal off the upper pole/superior mobilization, dissection of the renal hilum, medial rotation of the kidney and p...

A 22-year-old man presented with fever of 1-month duration. He was a known case of dextrocardia and situs inversus from childhood. Physical examination revealed a systolic ejection murmur at the right sternal border and right precordium, cyanosis and clubbing, an ejection systolic murmur at the second right intercostal space, and a holosystolic murmur at the right apex. On transthoracic echocardiography, the left atrium was located on the right side of the right atrium. All the images were obtained from the right precordium, with the patient lying in the right lateral decubitus position.

We report a 10-year-old male patient (30 kg, 140 cm, ASA I) who underwent left latissimus dorsi muscle transfer (free flap) surgery under general anesthesia (GA) because of biceps brachii muscle motor weakness and atrophy occurring after oral (OPV) and inactive polio (IPV) vaccination (Figure 1). A decision was made to perform thoracic PVBs (TPVBs) bilaterally after surgery for postoperative pain management. With the patient in the right lateral decubitus position, a 10 MHz high-frequency linear transducer (GE LOGIQ book XP, GE Healthcare, Milwaukee, WI) was placed approximately 2-2.5 cm lateral to the tips of the spinous processes. Sonography demonstrated the consecutive transverse processes and pleura in between. The two level TPVBs was performed using the out-of-plane technique, aiming to block the dermatomes between T2 and T8 on the left side. After negative aspiration, a total of 20 ml of 0.125% bupivacaine was divided equally and deposited in paravertebral spaces of T3-T4 and T6-T7 while observing the pleura being moved downwards (Figure 2). Then, with the patient in the left lateral decubitus position, the same technique was used to perform a level T1 TPVBs to provide analgesia for levels C6-T2. Ten ml of 0.25% bupivacaine was injected and a 20-gauge catheter was placed to provide vasodilation of the free flap vascular anastomosis in addition to effective pain control. The catheter was then connected to an

For the left retroperitoneal approach to L5-S1, place the patient in the right lateral decubitus position held by either the inflatable “beanbag” or appropriate towel padding. Take care to prevent any degree of left hip flexion, which could permit the thigh to interfere with the exposure.

This article will review the recumbent positions of patients with chronic congestive heart failure. The time for the right lateral decubitus position was two-fold longer than that for the supine and left lateral decubitus positions. Sympathetic nervous modulation was most attenuated and parasympathetic tone was most augmented in the right lateral decubitus position. The underlying mechanisms why heart failure patients prefer this position will be discussed. In conclusion, the right lateral decubitus position preferred by patients with chronic congestive heart failure may be a self-protecting mechanism to augment cardiac output and to attenuate the imbalance of cardiac autonomic nervous activity.

Most patients with chronic heart failure feel uncomfortable in left lateral decubitus position (LLD). They suffer from trepopnea. In LLD position cardiac sympathetic activity and preload are increased. Cardiac output is decrased. The right lateral decubitus position (RLD) can help to avoid discomfort in heart failure. RLD position may be a self-protective strategy of patients with heart failure to gain preferable hemodynamic parameters.

Study Objectives To compare the effects of left and right lateral decubitus positions on percentage of REM sleep and on respiratory events in obstructive sleep apnea (OSA) patients.

The Wagnerian leitmotif in this book on OSA is sleep position. OSA is a serious, highly prevalent disease with major health implications (chapters “Introduction” and “OSAS: The Magnitude of the Problem”). In the beginning of the book, the finding is highlighted that mild OSA in the majority of cases is positional (chapters “The Contribution of Head Position to the Apnea/Hypopnea Index in Patients with Position-Dependent Obstructive Sleep Apnea”, “Influence of Sleep Position on the Transition of Mild to Moderate and Severe OSA” and “Positional Therapy: Left Lateral Decubitus Position Versus Right Lateral Decubitus Position”). With progression of the disease from mild via moderate to eventually severe OSA, positional OSA progresses into non-positional severe OSA. In later chapters the observation is made that patients with insufficient response to therapy, such as can happen in palatal surgery, maxillomandibular advancement or bariatric surgery, severe non-positional OSA can reverse to less severe positional OSA (chapters “Positional OSA in the Morbidly Obese and the Effect of Weight Loss on OSA Severity”, “Positional Therapy and Tongue Base Surgery”, “Residual POSA After Maxillomandibular Advancement in Patients with Severe OSA”, “Impact of Upper Airway Surgery on Positional Change During Sleep” and “Comparison of Positional Therapy to CPAP in Patients with Positional Obstructive Sleep Apnea”). The circle is complete.

Introduction: Laparoscopic adrenalectomy is the gold standard for resection of adrenal tumors. Limitations include adherence to adjacent tissues, loss of tissue planes, and risk of conversion to laparotomy.1,2 A hand-assisted technique may prevent conversion.3 There is limited description of this technique for laparoscopic adrenalectomy.1,4 The aim of this video is to describe this technique in a case of bilateral adrenalectomy for pheochromocytoma. Case: A 69-year-old woman with a history of hypertension developed new-onset supraventricular tachycardia in the setting of malignant hypertension. Biochemical workup revealed elevated urinary metanephrines (13,310 µg/24 hours) and normetanephrines (10,139 µg/24 hours). CT scan revealed 8.2×7 cm left adrenal and 4×3.5 cm right adrenal masses. She had no family history of endocrinopathies. She consented for laparoscopic bilateral adrenalectomy. She was positioned in right lateral decubitus position for the left adrenalectomy. The abdomen was entered wi...