Beach chair position: is it really feasible in laparoscopic procedures?

To the Editor:—In the November 2007 issue of ANESTHESIOLOGY, Valenza et al. described how they used the application of positive end-expiratory pressure and the beach chair position to counteract the respiratory derangements in morbidly obese patients undergoing laparoscopic gastric surgery. The authors state that although both the beach chair position and the addition of positive end-expiratory pressure each similarly improved lung volumes, oxygenation, and respiratory mechanics at baseline, it was only the combination of both positive end-expiratory pressure and the beach chair position that improved oxygenation during pneumoperitoneum. Because it is often the practice of surgeons to ask their anesthesiology colleagues to place the patients in some degree of Trendelenburg to “facilitate” the exposure during laparoscopic surgeries, we are forced to question how feasible it would be to use the beach chair position in any laparoscopic procedure, let alone in morbidly obese patients. Moreover, in certain types of laparoscopic surgeries (prostatectomies, and some gynecologic surgeries), extreme Trendelenburg is requested, thus making the use of beach chair position even more impractical. A number of variables contribute to the respiratory derangements in all anesthetized patients; notable among them are the general anesthetic, paralytics, pneumoperitoneum, and positioning. The authors describe performing recruitment maneuvers (three consecutive inspiratory holds of 5 s at 45 cm H2O airway pressure) in both positions, with and without pneumoperitoneum, to improve respiratory derangements. Although it is not always possible to consistently maintain improved oxygenation for a prolonged period of time after performing the recruitment maneuvers, it is quite more practical to perform these maneuvers as opposed to attempting to use the beach chair position when performing laparoscopic procedures.