Minimizing Trendelenburg Position for Laparoscopic Gynecologic Surgery [6L]

INTRODUCTION: Trendelenburg position is needed for adequate exposure of pelvic anatomy during gynecologic surgery. Steep Trendelenburg can be associated with anesthetic challenges, physiologic changes and rare complications that increase risk. The degree of Trendelenburg for optimal exposure has not been described. METHODS: A single surgeon at our institution routinely placed patients in the minimal amount of Trendelenburg necessary to expose the anatomy measuring the degree with a smart phone app and documenting in the operative reports. All of the robotic cases from November 1, 2011 through July 31, 2018 performed by the surgeon were identified and operative notes and charts from each case were reviewed. RESULTS: Results: 338 out of 380 cases were identified that had degree of Trendelenburg dictated. Mean Trendelenburg was 15.4 degrees (range from 7 to 31) with a median of 15. 85% of cases (287/338) were completed 18 degrees or less of Trendelenburg. Addition of Modifier 22 to the case was associated with higher mean Trendelenburg from 15.2 (n= 255; range 7-31) to 16.0 (n=83; range 9-30) (p=0.05). BMI >30 was associated with higher mean Trendelenburg from 15.0 (n=218; range 7-25) to 16.3 (n=120; range 9-31) (p=0.001). Surgeries that included hysterectomy (mean Trendelenburg 15.4, n=309, range 7-31) showed no difference compared with other gynecologic procedures (mean Trendelenburg of 15.3; n=29, range 10-30) (p=0.9). CONCLUSION: Traditional “steep” Trendelenburg is not always needed to adequately expose anatomy for surgery. BMI and case difficulty were associated with requiring steeper Trendelenburg.