Lateral Decubitus

Arthroscopic shoulder surgery can be performed using the lateral decubitus or beach-chair position:

Lateral Decubitus position – To achieve the lateral decubitus position for shoulder arthroscopy, the patient is placed laterally(if the left shoulder is operated, the patient will be on their right side) on a standard operating table with the operative shoulder exposed vertically.
Beach-Chair position – To put the patient into the beach chair position the patient is placed on the operating table, a standard or “beach-chair” table, in the supine (sitting) position. The head, neck, and torso are supported in a neutral position by special straps and attachments. The patient is placed into 10 to 15 degrees of Trendelenberg; flexed at the hips to 45 to 60 degrees; and the patient’s knees are flexed to 30 degrees.

One of the most significant advantages of the Lateral Decubitus position is increased visualization and working space within the glenohumeral joint with instrumentation. Specifically, improved access is allowed to the inferior and posterior labrum, inferior capsule, subacromial space, and articular side of the rotator cuff. This is accomplished with lateral and axial traction applied to the operative arm held within a traction device. By positioning the glenoid parallel to the floor, a reference point can be established that assists in identifying relevant surgical anatomy and orienting the operating surgeon. The Lateral Decubitus position also allows the surgeon to operate with his/her arms at his/her side, rather than in an abducted position, as is often required while working in the Beach-Chair position, which allows for increased comfort and decreased fatigue.

Advantages of the Lateral Decubitus Position:

Improved visualization of the glenohumeral joint, obviating the need to create accessory portals that disrupt the rotator cuff.
Increased working space, specifically to the inferior and posterior labrum, inferior capsule, subacromial space, and articular side of the rotator cuff.
Allows surgeon to operate with arms at side for increased comfort and decreased fatigue (as opposed to abducted position).
Bubbles created by electrocautery move laterally, providing a clearer view.
Lower incidence of cerebral desaturation events compared with the beach chair position.

One disadvantage of the beach chair position is that the patient’s head may act as a mechanical barrier for superior and posterior portals, which is not typically a problem in the Lateral Decubitus position. The Lateral Decubitus position allows full access circumferentially around the glenohumeral joint without impedance by the patient’s head. In addition, fogging of the arthroscope lens and collection of bubbles within the subacromial space can obstruct the view during shoulder arthroscopy in the Beach-Chair position, whereas in the Lateral Decubitus position, bubbles generated by electrocautery move laterally, providing a clearer view.

Deliberate hypotensive anaesthesia is commonly used to reduce bleeding during arthroscopic shoulder surgery; however, this may lead to cerebrovascular morbidity, particularly in the Beach-Chair position in which it may be more difficult to monitor the patient’s true cerebral blood pressure due to the upright position of the patient. Murphy et al. reported a significantly higher incidence of cerebral desaturation events during arthroscopic shoulder surgery in the Beach-Chair position compared with the Lateral Decubitus position.

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Lateral Decubitus

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