What position should a patient be in for robotic surgery?

September 21, 2025 •

5 min read

According to studies on robotic-assisted surgery, optimal patient positioning is a foundational element for a successful outcome, particularly for gynecologic, urologic, and colorectal procedures. Understanding what position should a patient be in for robotic surgery reveals the meticulous planning involved in these advanced operations.

Quick Summary

The specific position for a patient undergoing robotic surgery is highly dependent on the surgical site and procedure, often involving variations of the Trendelenburg, lithotomy, or lateral decubitus positions. This careful setup, which utilizes specialized equipment like padded stirrups and anti-slip mats, is crucial for maximizing surgical access and visibility while preventing potential nerve damage and other patient injuries.

Key Points

Position depends on procedure: The specific patient position, such as Trendelenburg, lithotomy, or lateral decubitus, is determined by the location of the surgery to provide the best access for the robotic arms.
Gravity aids visibility: For pelvic and lower abdominal surgery, the head-down Trendelenburg position uses gravity to move organs out of the way, creating a better view for the surgeon.
Lithotomy provides dual access: Combining the lithotomy position with Trendelenburg is common for procedures requiring access to both the abdomen and the perineum.
Safety is paramount: Preventing patient slippage and nerve compression is a top priority, achieved through the use of anti-slip gel pads, careful padding, and avoiding restrictive shoulder braces.
Teamwork is essential: The entire surgical team, including nurses and anesthesiologists, is responsible for ensuring the patient is positioned correctly and safely before the robot is docked for the procedure.
Time in position matters: The duration and angle of extreme positioning are minimized whenever possible to reduce physiological stress and the risk of nerve or pressure injuries.

Understanding the Principles of Patient Positioning for Robotic Procedures

Patient positioning for robotic-assisted surgery is a complex and crucial process that goes far beyond simply placing a patient on an operating table. Because the robotic system's arms are fixed in place once docked, the patient's position cannot be easily altered during the procedure. This necessitates extreme precision in the initial setup, with the entire surgical team—including the surgeon, anesthesiologist, and nurses—collaborating closely. The position chosen directly impacts the surgeon's ability to access the operative field, ensures the robotic arms have adequate range of motion, and, most importantly, protects the patient from injury throughout the duration of the surgery.

The Most Common Positions in Robotic Surgery

The position a patient is placed in for robotic surgery is not universal; rather, it is tailored to the specific type of procedure being performed. The three most common positions are Trendelenburg, lithotomy, and lateral decubitus, often used in combination or with modifications.

The Trendelenburg Position

The Trendelenburg position is a critical component for many robotic surgeries involving the pelvis and lower abdomen, such as prostatectomies and hysterectomies. In this position, the operating table is tilted head-down, typically at a steep angle of 25 to 45 degrees.

Why it's used: The head-down tilt uses gravity to move the abdominal organs (like the intestines) out of the pelvis, providing the surgeon with an unobstructed view of the surgical site. This is particularly advantageous for minimizing blood loss and improving precision in the confined space of the pelvis.
Associated risks: The steep angle creates a risk of the patient sliding down the table. This can cause severe complications, including nerve damage (brachial plexus injury) and corneal abrasions, if not properly secured. Careful padding and specialized positioning aids are essential to mitigate these risks.

The Lithotomy Position

The lithotomy position is frequently combined with the Trendelenburg position for pelvic and urologic procedures. It involves placing the patient on their back with their hips and knees flexed and their legs and feet supported in specialized stirrups.

Why it's used: This position provides simultaneous access to both the abdomen and the perineum, which is necessary for procedures that require both internal and external access. For instance, in a robotic-assisted prostatectomy, it allows for the use of a uterine manipulator and other instruments.
Associated risks: Prolonged lithotomy positioning can increase the risk of nerve injuries, particularly to the common peroneal nerve, which runs near the fibular head. It can also increase the risk of compartment syndrome if perfusion to the lower limbs is compromised.

The Lateral Decubitus Position

For robotic surgeries involving the chest, kidneys, or spleen, the patient may be placed in the lateral decubitus position. In this position, the patient lies on their side, with padding placed strategically to support the head, arms, and pressure points.

Why it's used: This position provides the best access to the flank area and allows gravity to assist in displacing organs away from the surgical target, much like the Trendelenburg position does for the pelvis.
Associated risks: Risks include nerve compression injuries, especially to the brachial plexus or peroneal nerve, and pressure-related skin damage. The patient must be securely anchored to the table to prevent shifting during the procedure.

Ensuring Patient Safety During Robotic Surgery Positioning

Patient safety is a paramount concern during any surgical procedure, but the unique demands of robotic surgery require specific protocols. Preventing patient slippage and nerve damage are primary objectives.

Common Safety Protocols:

Anti-Slip Materials: Specialized gel pads or high-friction mattresses are placed under the patient to prevent sliding, particularly in the steep Trendelenburg position. Using a gel pad directly against the patient's skin, rather than with a sheet in between, increases friction.
Padding All Pressure Points: All bony prominences, such as the head, elbows, and ankles, are meticulously padded to distribute pressure evenly and prevent nerve compression or skin breakdown. This includes the use of padded boot stirrups in the lithotomy position.
Avoiding Braces and Straps: Modern practice discourages the use of shoulder braces or rigid straps, which can increase the risk of nerve stretch injuries, particularly to the brachial plexus.
Team Communication: The entire surgical team communicates throughout the positioning process and the surgery itself. Nurses monitor the patient for any signs of movement or pressure-related issues, and the anesthesiologist manages the patient's physiological responses to the positioning.
Minimizing Time and Angle: Where possible, the surgical team minimizes both the duration and the degree of extreme positioning, such as steep Trendelenburg, to reduce physiological stress on the patient.

Comparison of Common Robotic Surgery Positions


Feature	Trendelenburg Position	Lithotomy Position	Lateral Decubitus Position
Primary Use	Pelvic and lower abdominal surgery (e.g., prostatectomy, hysterectomy)	Pelvic and urologic surgery (often combined with Trendelenburg)	Chest, kidney, or spleen surgery (e.g., nephrectomy)
Patient Orientation	Head-down, body tilted at a steep angle	Back-lying with legs raised and supported in stirrups	Lying on one side, stabilized with padding
Main Advantage	Uses gravity for optimal surgical exposure of the pelvic region	Provides simultaneous abdominal and perineal access	Optimizes access to flank region for specific procedures
Key Patient Safety Risk	Patient slippage leading to nerve injury and skin damage	Common peroneal nerve injury, compartment syndrome	Nerve compression (e.g., brachial plexus, peroneal)
Primary Support Equipment	Anti-slip gel pads, friction mats	Padded boot stirrups (e.g., Allen stirrups)	Gel pads, pillows, stabilization straps

The Role of Technology in Safe Positioning

While the surgeon operates the robot from a console, the precise and stable positioning of the patient is handled by the entire surgical team and supported by advanced equipment. The inability to make intraoperative adjustments to the patient's position once the robot is docked means that the initial setup is critically important. Newer technologies, such as specialized surgical tables that automatically adjust to maintain an optimal position, are being developed to further enhance patient safety and simplify the setup process. However, even with the most advanced technology, a vigilant and experienced surgical team remains the most important factor in preventing positioning-related complications.

For more detailed information on preventing positioning-related risks in various surgical contexts, the Anesthesia Patient Safety Foundation offers excellent resources.

Conclusion

In conclusion, understanding what position should a patient be in for robotic surgery involves appreciating a complex interplay of procedural requirements, specialized equipment, and robust safety protocols. The precise positioning of the patient in Trendelenburg, lithotomy, or lateral decubitus depends on the surgical target, but the universal goal is to optimize the surgeon's access while rigorously protecting the patient from harm. Through careful padding, anti-slip measures, and coordinated team effort, the risks associated with these positions are mitigated, ensuring that the benefits of robotic surgery can be realized safely and effectively.

Frequently Asked Questions

Patient positioning is critical because once the robotic system is docked, the patient cannot be moved without undocking the robot, which is a time-consuming process. Proper initial positioning ensures optimal surgical access, prevents patient movement, and protects against nerve injuries and other complications.

In robotic surgery, the Trendelenburg position means the patient is placed on their back on a table tilted head-down, often at a steep angle. This uses gravity to move organs out of the way, improving the surgeon's view for pelvic and lower abdominal procedures.

The lithotomy position involves the patient lying on their back with their hips and knees flexed and legs supported by stirrups. It is often combined with Trendelenburg to provide the surgeon with access to both the abdominal and perineal regions, which is necessary for many urologic and gynecologic procedures.

To prevent sliding, special high-friction gel pads or anti-slip mats are placed on the operating table, and the patient's shoulders and hips are secured. Modern techniques rely on friction rather than restrictive straps or braces to prevent injury.

Potential risks of prolonged, extreme positioning include nerve compression injuries (such as to the brachial plexus or common peroneal nerve), skin breakdown from pressure, increased intracranial and intraocular pressure, and in rare cases, compartment syndrome or visual impairment.

No, the position depends on the surgery. While Trendelenburg is common for pelvic procedures, other positions like lateral decubitus (lying on the side) are used for surgeries involving the kidneys or other upper abdominal organs.

Determining the correct patient position is a collaborative effort involving the entire surgical team. The surgeon defines the access requirements, while the anesthesiologist and nurses ensure the patient is safely and securely positioned and monitored throughout the procedure.