The majority of patients are positioned supine with an inflatable bag beneath the shoulders (Figures 24-3A,5). This permits extension of the neck in a controlled fashion, but allows the extension to be removed easily during tracheal anastomosis, when cervical flexion is desired. Extreme cervical extension is to be strictly avoided. The patient is usually positioned with slight flexion at the hips and at the knees so that positioning the neck and upper sternum appropriately for the surgeon, often with the sternum approximately horizontal, will not result in a reverse Trendelenburg position with blood pooling in the lower extremities. If access to both arms is desired for intravenous and arterial lines, then these may be abducted on arm boards at an approximately 30o angle. The arm board is placed carefully so that the surgeon may stand against the table above the arm without encountering the board itself (Figure 24-3 C). With intravenous support poles placed at the ends of either one or both of the arm boards, as well as poles in the usual position at the head of the table, it is possible to drape the patient so that access may be had by the surgical team, above and below the arm board, but yet leave the arm accessible to the anesthesia team. Limitation of abduction to 30o also protects the brachial plexus.

In a patient with an upper- or midtracheal tumor of uncertain extent, or in a patient with an extensive stenosis that may have been complicated by prior unsuccessful surgical procedures, intrathoracic mobilization may be required. It is occasionally judicious to position such a patient as described with the addition of a roll support, placed longitudinally beneath the upper back to the right of the midline (Figures 24-4A,5). With the right shoulder partly abducted and the elbow partly flexed, the right chest is

figure 24-3 A, Position of patient for anterior tracheal resection. Note the flexed table, inflated bag beneath upper shoulders, horizontal neck and sternum, extended neck, and head support. Details are in the text. B, Photograph of a patient in the position described in A. C, View of the operative arrangement from above. The wavy lines indicate the borders of sterile draping, supported by poles (black dotsj at head of the table and for arm board access. The stippled area designates the usual operative field. The acute angle of the arm board allows easy access to the field by the surgeon.

included in the operative field to the level of the posterior axillary line. A midline sternal incision may be extended laterally, if necessary, beneath the right breast, elevating the pectoral muscles and entering the right hemithorax through the fourth interspace (see Chapter 23, "Surgical Approaches"). The resultant "trapdoor" offers exposure to the entire trachea from cricoid to carina and even provides access to the posterior aspect of the carina. After positioning and draping the patient for this approach, the operating table may be side-tilted to level the sternum so that the initial part of the operation is done as if the patient were simply supine on the table (see Figure 24-4B). A midline posterior support provides a possibility of opening the left side as well (with suitable draping in advance) for left hilar mobilization, if that possibility is anticipated (Figure 24-4C).

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