Correspondence  |   June 2008
Beach Chair Position: Is It Really Feasible in Laparoscopic Procedures?
Author Affiliations & Notes
  • Franco Valenza, M.D.
  • *Fondazione Policlinico Ospedale Maggiore, Mangiagalli e Regina Elena–IRCCS, Milano, Italy.
Article Information
Correspondence   |   June 2008
Beach Chair Position: Is It Really Feasible in Laparoscopic Procedures?
Anesthesiology 6 2008, Vol.108, 1153-1154. doi:
Anesthesiology 6 2008, Vol.108, 1153-1154. doi:
In Reply:—
Drs. Singh Heir and Gottumukkala are right: If a surgeon asks for an “extreme Trendelenburg” position, one cannot use the head-up position as a strategy to counteract hypoxemia, unless in an emergency!
The negative effects of the Trendelenburg position have been investigated by others.1–3 Any conclusion taken from our data on the Trendelenburg position is merely speculative, provided we set out to investigate the beach chair position and positive end-expiratory pressure (PEEP).4 Nevertheless, our data allow some speculations on the aspect brought up by Drs. Singh Heir and Gottumukkala in their letter.
In a sedated and paralyzed patient, pleural pressures displace the relaxed diaphragm downward, hence increasing end-expiratory lung volume, while intraabdominal pressure (IAP) acts as a counter pressure on the diaphragm. When the bowels are allowed to slide under gravity in the head-up position, bladder pressure increases, as we have shown (from 17.87 ± 5.45 to 23.92 ± 4.35 cm H2O; P  < 0.01). The increase of bladder pressure in head-up position may thus correspond to a reduction of pressure pushing the diaphragm upward. When we estimated pleural pressure as Ppl = (PEEP + PEEPi) × Ew/(El + Ew)5 in the supine and beach chair positions with and without PEEP, and considered changes of IAP due to the beach chair position (ΔIAP) to obtain an indicative “push-down pressure” (Ppl +ΔIAP), we found that this was positively correlated with end-expiratory lung volume (R  2= 0.857, P  < 0.001, m = 0.67, multiple linear regression analysis). We did not measure IAP changes occurring in the extreme Trendelenburg position. However, we would anticipate that an increase in the forces shifting the diaphragm upward would ensue following the same physical rule. In this condition, PEEP (hence Ppl) may be used as a counterpressure that opposes diaphragm upward shift, thus preserving lung volume.
Recruitment maneuvers proposed by Drs. Singh Heir and Gottumukkala to improve oxygenation have been discussed in our article.4 They are possibly even more important in the extreme Trendelenburg position than in the supine position to open up the lung. However, their effects are short-lived,6 whereas PEEP is known to maintain lung units open, once recruited.
*Fondazione Policlinico Ospedale Maggiore, Mangiagalli e Regina Elena–IRCCS, Milano, Italy.
Oikkonen M, Tallgren M: Changes in respiratory compliance at laparoscopy: Measurements using side stream spirometry. Can J Anaesth 1995; 42:495–7Oikkonen, M Tallgren, M
Odeberg S, Ljungqvist O, Svenberg T, Gannedahl P, Backdahl M, von Rosen A, Sollevi A: Haemodynamic effects of pneumoperitoneum and the influence of posture during anaesthesia for laparoscopic surgery. Acta Anaesthesiol Scand 1994; 38:276–83Odeberg, S Ljungqvist, O Svenberg, T Gannedahl, P Backdahl, M von Rosen, A Sollevi, A
Drummond M: Pressure-volume relationships in the lung during laparoscopy. Br J Anaesth 1978; 50:261–70Drummond, M
Valenza F, Vagginelli F, Tiby A, Francesconi S, Ronzoni G, Guglielmi M, Zappa M, Lattuada E, Gattinoni L: Effects of the beach chair position, positive end-expiratory pressure, and pneumoperitoneum on respiratory function in morbidly obese patients during anesthesia and paralysis. Anesthesiology 2007; 107:725–32Valenza, F Vagginelli, F Tiby, A Francesconi, S Ronzoni, G Guglielmi, M Zappa, M Lattuada, E Gattinoni, L
Gattinoni L, Carlesso E, Cadringher P, Valenza F, Vagginelli F, Chiumello D: Physical and biological triggers of ventilator-induced lung injury and its prevention. Eur Respir J Suppl 2003; 47:15s–25sGattinoni, L Carlesso, E Cadringher, P Valenza, F Vagginelli, F Chiumello, D
Whalen FX, Gajic O, Thomson GB, Kendrick ML, Que FL, Williams BA, Joyner MJ, Hubmayr RD, Warner DO, Sprung J: The effects of the alveolar recruitment maneuver and positive end-expiratory pressure on arterial oxygenation during laparoscopic bariatric surgery. Anesth Analg 2006; 102:298–305Whalen, FX Gajic, O Thomson, GB Kendrick, ML Que, FL Williams, BA Joyner, MJ Hubmayr, RD Warner, DO Sprung, J