Running head: INTEGRATIVE LITERATURE REVIEW 1

Integrative Literature Review

Rebecca Nappi

Bon Secours Memorial College of Nursing

Nursing Research

NUR 4222

Christine Turner

July 14, 2018

“I Pledge”
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Integrative Literature Review

Abstract

Purpose:

Background:

Method:

Limitations:

Results and Findings:

Implications

Recommendations:
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The purpose for this integrative literature review is to synthesis the available data on gel

pad placement vs a disposable non-slip pad material on the operating room table to prevent

patient movement, thus preventing skin integrity injuries. Steep Trendelenburg positioning is

required for gynecological surgery, specifically robotically performed laparoscopy. The

advancement of minimally invasive surgery and robotic surgery forces surgeons to require

Trendelenburg positioning for visualization of the pelvic area (Nakayama et al., 2014). This head

down position presents many difficult patient safety challenges for the operating room team. This

researcher has four years of firsthand experience with positioning patients in Trendelenburg for

laparoscopic surgery and the problems that arise when a patient moves even a few inches on the

operating room table during a procedure. This review focused on the two major positioning

materials available currently, a re-usable gel pad and a disposable non-slip pad. A disposable

non-slip pad is really more of a category of options with the egg crate foam mattress cover being

the traditional option until recently (Barber, 2016). The PICO question that spurred this study; In

female patients undergoing robotically assisted gynecological surgery, how does the use of a

reusable gel pad compare to a disposable non-slip pad affect the patient’s movement and skin

integrity during the surgery?

Design and Methods

A thorough search of studies relating to Trendelenburg positioning for surgery was the

first step taken to conduct this review of literature pertaining to the above PICO question. Google

scholar was utilized primarily with additional searches in PubMed and EBSCO host. Five studies

were chosen based on time published (ten years or less), quality of information as determined by

this researcher and author’s qualifications. The main words used in these search engines were,

Trendelenburg, lithotomy, surgery positioning, non-slip material, patient positioning injuries.

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Only studies available in English were used in this review. It was important that each study

selected focus on gynecological surgery or at least lithotomy positioning to be relevant. The

focus of each study used in this study needed to be patient safety and not financial benefits or

cost reduction.

Findings and Results

Although, more research is needed it appears after this review of available data that the

gel-pad is inferior to other materials for keeping the patient from slipping when placed in

Trendelenburg position (Nakayama et al., 2014). Bed sheets, foam pads, bean bags and shoulder

braces were alternatives to the gel-pad and each of these revealed to be better options for patients

between 100lbs and 250lbs. Patients over 250lbs were not included in any of the chosen research

studies for this review. The data available for obese patients being placed in Trendelenburg is

limited. The studies chosen for this review all had a common theme of multiple factors played a

role in patient movement and skin integrity concerns. It is not only the operating room table

material but rather body mass index of patient, length of surgery, degree of Trendelenburg, type

of operating room table, patient’s medical history and Velcro placement and integrity. All

traditional operating room tables have Velcro to hold the mattress to the frame. This simple and

commonly overlooked detail has a lot to do with patient movement during surgery (Griffin,

Donovan, & Hollister, 2010). A simulation study using mannequins revealed that bed sheets, egg

crate foam and bean bag positioners are all superior to the gel pad in keeping a patient from

moving (Nakayama et al., 2014). A literature analysis of 14 studies was conducted and found

that, “the risk of positioning injuries is underappreciated” (Zillioux & Krupski, 2016, p. 69). A

prospective randomized pilot study was conducted on 43 women undergoing gynecological

laparoscopic surgery being placed in Trendelenburg and the results found that compared to a
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disposable memory foam overly on the operating room table the bean bag with shoulder braces

was superior (Farag, Rosen, & Ascher-Walsh, 2018). The shoulder braces require too much

training and perfect placement as well as the increased potential for nerve injury to make this a

standard across the industry.

Discussion and Implications

The take away from this review of the data is that patient movement during surgery is a

real concern and the gel pad although reusable making it inexpensive should not be looked at as

the industry standard when there are other options that keep patients safer.
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References

Barber, J. (2016). Preventing Patient Sliding In Steep Trendelenburg . Retrieved from

https://www.marlinmedical.com.au/images/Preventing_Patient_Sliding_in_Steep_Trende

lenburg_-_UMHS.pdf

Farag, S., Rosen, L., & Ascher-Walsh, C. (2018). Comparison of the Memory Foam Pad Versus

the Bean Bag with Shoulder Braces in Preventing Patient Displacement during

Gynecologic Laparoscopic Surgery. The Journal of Minimally Invasive Gynecology, 25,

153-157. https://doi.org/ https://doi.org/10.1016/j.jmig.2017.09.009

Griffin, J., Donovan, A., & Hollister, N. (2010). Caught in the Slips . British Medical Journal.

https://doi.org/ 10.1136/bcr.08.2009.2186

Nakayama, J., Gerling, G., Horst, K., Fitz, V., Cantrell, L., & Modesitt, S. (2014). A Simulation

Study of the Factors Influencing the Risk of Intraoperative Slipping. Clinical Ovarian

and Other Gynecologic Cancer, 7, 24-28.

https://doi.org/https://doi.org/10.1016/j.cogc.2014.12.001

Zillioux, J., & Krupski, T. (2016). Patient positioning during minimally invasive surgery: what is

current best practice? Dovepress, 2017:4, 69-76. https://doi.org/

https://doi.org/10.2147/RSRR.S115239