What are the complications of Trendelenburg procedure?

October 2, 2025 •

4 min read

First described in the 19th century by German surgeon Friedrich Trendelenburg, the Trendelenburg procedure involves placing a patient in a head-down tilt to improve surgical access. However, while effective, it is associated with a range of potential complications that surgical teams must manage carefully to ensure patient safety.

Quick Summary

The Trendelenburg procedure, while useful for surgical access, carries risks including increased intracranial and intraocular pressure, respiratory distress, and nerve damage from prolonged or steep positioning. Careful monitoring, protective padding, and minimizing duration are essential preventative measures to avoid adverse patient outcomes.

Key Points

Cardiovascular Risk: The head-down tilt increases blood pressure and venous return, posing a risk to patients with pre-existing heart conditions.
Respiratory Challenges: Increased pressure on the diaphragm from abdominal organs can reduce lung volume and lead to airway edema, causing breathing difficulties.
Nerve Damage: Pressure and stretching of nerves, particularly the brachial plexus, can occur, emphasizing the need for proper padding and positioning.
Ocular Issues: Increased intraocular pressure can lead to serious complications like ischemic optic neuropathy and retinal detachment, especially in prolonged procedures.
Skin and Tissue Injury: Patient sliding during the procedure can cause skin shear injuries, pressure ulcers, or, in rare cases, compartment syndrome.
Prevention is Key: Minimizing the angle and duration of the tilt, using proper restraints, and frequent monitoring are crucial for mitigating complications.

Understanding the Trendelenburg Procedure

The Trendelenburg position is a surgical and medical position where the patient is laid flat on their back (supine) with the feet higher than the head. This tilt is primarily used in pelvic and abdominal surgeries to utilize gravity to shift the abdominal organs toward the head, thus improving the surgeon's view of the pelvic cavity. It is also historically used in managing certain medical conditions like hypotension, though this application has been re-evaluated due to potential risks. While the procedure is valuable in its clinical applications, awareness and understanding of its potential complications are vital for both medical professionals and patients.

Cardiovascular Complications

The changes in blood flow caused by the head-down tilt can place significant stress on the cardiovascular system. Healthy individuals may tolerate this shift well, but patients with pre-existing conditions are at higher risk. Some potential issues include:

Increased Cardiac Workload: The pooling of blood in the upper body increases venous return to the heart, which can raise the heart's workload. In patients with cardiac disease, this can lead to hemodynamic compromise.
Pulseless Electrical Activity (PEA): In extremely rare but severe cases, the weight of the abdominal organs can compress the heart, causing it to beat without effectively pumping blood. This can result in cardiac arrest.
Transient Blood Pressure Changes: Upon returning to a flat position after a prolonged tilt, a patient may experience a sudden drop in blood pressure, which can have serious consequences for a weakened individual.

Respiratory Complications

Positioning the body with the head down shifts the abdominal contents, impacting respiratory mechanics and gas exchange. The steeper and longer the procedure, the higher the risk of respiratory issues:

Decreased Lung Volume and Compliance: The pressure from the abdominal organs against the diaphragm reduces the lungs' ability to expand fully, decreasing lung volume and compliance.
Airway Edema: Prolonged positioning can cause swelling (edema) in the face, tongue, and upper airway. This can lead to significant breathing problems, particularly when removing the breathing tube (extubation) after surgery.
Increased Risk of Aspiration: For patients with an unprotected airway, the position increases the risk of passive regurgitation, where gastric contents enter the lungs.

Neurological Complications

Increased pressure and nerve compression are significant neurological risks associated with the Trendelenburg position.

Brachial Plexus and Peripheral Nerve Injuries

Historically, shoulder braces were used to prevent patients from sliding. However, these braces could cause direct compression or stretching of the brachial plexus nerves, which supply the arm and hand. Modern practice avoids these braces in favor of alternative securing methods.

Increased Intracranial Pressure (ICP)

The head-down tilt promotes pooling of blood and cerebrospinal fluid in the head, which can increase ICP. This is especially dangerous for patients with pre-existing neurological conditions like head injuries or intracranial hypertension. In some cases, prolonged steep positioning has led to cerebral edema and subsequent neurological complications.

Ocular Complications

Elevated intraocular pressure is a serious concern, especially during long procedures.

Ischemic Optic Neuropathy (ION): Increased pressure within the eye can compress the optic nerve, leading to vision loss. This risk is compounded by factors like prolonged surgery duration, blood loss, and pre-existing eye conditions such as glaucoma.
Retinal Detachment and Corneal Abrasions: Extreme or prolonged positioning can lead to retinal detachment or abrasions on the cornea.

Dermatological and Musculoskeletal Complications

The mechanics of the position also pose risks to the patient's skin and musculoskeletal system.


Type of Complication	Cause	Mitigation Strategy
Skin Shear Injuries	Sliding down the table due to gravity.	Using protective foam or gel pads and appropriate restraints.
Pressure Injuries	Prolonged pressure on specific body parts, exacerbated by sliding.	Frequent patient position checks and repositioning throughout the procedure.
Compartment Syndrome	Ischemia and reperfusion injury, particularly in the lower limbs, due to impaired blood flow.	Limiting the angle and duration of the tilt; ensuring sufficient fluid management.
Rhabdomyolysis	Severe muscle breakdown due to prolonged ischemia and subsequent reperfusion.	Minimizing time in the position and careful patient monitoring.

The Importance of Prevention and Monitoring

Preventing complications from the Trendelenburg position requires a multi-faceted approach. Surgical teams must carefully consider a patient's individual risk factors, including BMI, pre-existing cardiac or pulmonary disease, and any neurological or ocular conditions. Modern surgical protocols emphasize several preventative measures:

Minimizing Tilt Angle and Duration: Using the least steep angle and shortest duration necessary for the procedure has been shown to reduce complication rates.
Using Advanced Positioning Aids: Modern positioning devices, like beanbag restraints and specialized foam pads, reduce the risk of nerve injury and skin damage compared to older methods.
Regular Monitoring: Continuous monitoring of the patient's vital signs and checking their physical position is crucial.
Controlled Repositioning: Transitioning the patient back to a supine position gradually and carefully helps the body readjust to the change in blood volume.

Conclusion

The Trendelenburg procedure is a valuable tool in modern surgery, especially in laparoscopic and robotic-assisted procedures targeting the pelvis. However, its use is not without risks, which range from manageable physiological changes to potentially severe complications like nerve damage and visual loss. By understanding the potential adverse effects and implementing careful positioning strategies, medical professionals can significantly reduce the dangers associated with this procedure.

For more detailed information on surgical positioning guidelines and patient safety, authoritative resources such as the Association of periOperative Registered Nurses (AORN) are invaluable. AORN: Protect Patients in Steep Trendelenburg

Frequently Asked Questions

The Trendelenburg position is used primarily in surgery, especially for pelvic and lower abdominal procedures, to shift internal organs away from the surgical area using gravity. It was also historically used for managing hypotension.

The position causes a shift of blood towards the head, increasing central blood volume and pressure in the heart and brain. It also puts pressure on the lungs and diaphragm, which can affect breathing.

Using shoulder braces has been linked to an increased risk of brachial plexus nerve injury due to compression. Modern practice favors alternative restraint methods like gel pads and specialized positioning aids.

Yes, although rare, prolonged or steep Trendelenburg positioning can increase intraocular pressure and potentially lead to ischemic optic neuropathy (ION), which can cause permanent vision loss.

No, certain patients are at a higher risk of complications. This includes individuals with pre-existing cardiac or pulmonary conditions, high BMI, glaucoma, or neurological issues like increased intracranial pressure.

Prevention involves a combination of minimizing the degree and duration of the tilt, using appropriate positioning and padding, careful monitoring of the patient throughout the procedure, and being aware of individual risk factors.

The Trendelenburg position is the physical tilt of the patient on the operating table, while the Trendelenburg operation (or procedure) was a historical surgical intervention, notably for varicose veins, that involved ligation at the saphenofemoral junction. However, the term is often used to refer to complications related to the positioning itself in modern contexts.