Trendelenburg Position - an overview (2023)

The Trendelenburg position produces an increased venous return and central venous pressure which may produce deleterious effects in those with coronary artery disease or ventricular dysfunction.


Related terms:

  • Air Embolism
  • Pelvis
  • Pneumoperitoneum
  • Incision
  • Abdomen
  • Dissection
  • Carbon Dioxide
  • Supine Position
  • Hypotension
View all Topics

In Vitro Fertilization and Other Assisted Reproductive Technology

David H. Chestnut MD, in Chestnut's Obstetric Anesthesia, 2020

Pneumoperitoneum and the Trendelenburg Position

Carbon dioxide is the gas most commonly used to establish pneumoperitoneum. The high blood solubility of carbon dioxide facilitates absorption from the peritoneal cavity after laparoscopic surgery and may represent a life-saving property of the gas in the rare but potentially catastrophic event of gas embolization. For example, rapid intravenous injection of 5 to 10 mL/kg of carbon dioxide produces only transient (< 1 minute) hypotension in anesthetized dogs (Fig. 15.13),83 whereas intravascular administration of a similar volume of a less soluble gas (e.g., helium, oxygen, nitrogen) is usually fatal.

Signs of embolization of large quantities of carbon dioxide (or any other gas) in anesthetized patients may include hypocapnia, hypotension, hypoxemia, ST-segment and T-wave changes, arrhythmias, and audible changes in heart sounds.84 Initial treatment of carbon dioxide embolism should include release of the pneumoperitoneum and pharmacologic support of the circulation. If initial resuscitation efforts are unsuccessful, aspiration of gas from the right atrium (using a multi-orifice central venous catheter) should be considered. Although the use of the left lateral recumbent position (Durant's maneuver), with or without head-down positioning, has been suggested to facilitate removal of the postulated air lock from the right side of the heart,85 laboratory evidence suggests that this maneuver may have a detrimental effect on cardiac function after venous gas embolism.86

Nearly as soluble in blood as carbon dioxide, nitrous oxide is associated with less peritoneal and diaphragmatic irritation87 and has been suggested for the establishment of pneumoperitoneum in awake patients undergoing laparoscopy. A major disadvantage of nitrous oxide is its ability to support combustion, which could increase the possibility of an explosion if the surgeon uses electrocautery.

GIFT and ZIFT procedures are often performed with the patient in the Trendelenburg position to facilitate visualization of the fallopian tubes and other pelvic structures. Positioning strategies to prevent the patient from moving cephalad on the operating table and to prevent brachial plexus damage should be used. The adduction of the patient's arms against her trunk has been suggested to reduce the risk for brachial plexus injury, but the efficacy of this precaution is unproven.

Both pneumoperitoneum and the Trendelenburg position produce physiologic changes. Hemodynamic effects of moderate pneumoperitoneum (< 20 mm Hg) in a patient in the Trendelenburg position include increased mean arterial and central venous pressures, increased systemic vascular resistance, and decreased stroke volume and cardiac output.88 Heart rate usually does not change, but in some patients pneumoperitoneum may elicit sinus bradycardia, heart block, or even cardiac arrest. Finally, pneumoperitoneum aggravates the respiratory effects of the Trendelenburg position (e.g., reduced chest wall compliance, increased venous admixture). Overall, most healthy patients easily tolerate the cardiovascular and pulmonary effects of intra-abdominal pressures lower than 20 mm Hg.

Patient Positioning

James Duke MD, MBA, in Anesthesia Secrets (Fourth Edition), 2011

7 What are the physiologic effects and risks associated with the Trendelenburg position?

Head down, or Trendelenburg position, further increases translocation of blood to the central compartment. Intracranial and intraocular pressure increase in the Trendelenburg position secondary to decreased cerebral venous drainage. Adverse outcomes in healthy patients have not been noted, although the Trendelenburg position is clearly contraindicated in patients with increased intracranial pressure. Lengthy procedures may result in significant facial and upper airway edema. The likelihood of postextubation airway obstruction should be considered, and the ability of the patient to breathe around the endotracheal tube with the cuff deflated is reassuring, although it does not completely ensure that postextubation airway obstruction will not occur. After prolonged surgery in the Trendelenburg position, particularly when there has been substantial intravenous fluid administration, it may be prudent to leave the patient intubated with the upper torso elevated, allowing time for fluid redistribution to take place. Decreases in pulmonary compliance and functional residual and vital capacity also occur in the Trendelenburg position. Peak airway pressures during mechanical ventilation are also noted. Shoulder braces used to keep the patient from sliding off the surgical table have been associated with brachial plexus injuries.

View chapterPurchase book

(Video) Trendelenburg position | Anatomical Positions | Explained Practically | Learn conceptually

Read full chapter



In AORN Journal (2018-), 2020


In collaboration with the surgeon, determine whether the Trendelenburg position is the most appropriate for the patient and the procedure.

Assess factors related to the procedure, including the

type and length,

ability of the patient to tolerate the position,

amount of surgical exposure required,

ability of the anesthesia professional to access the patient,

positioning devices required, and

potential changes in position.1

Patients may be placed in the Trendelenburg position for surgical procedures involving the abdomen or when needing improved access to the pelvic organs.2

Use a standardized tool to assess the patient’s risk for pressure injury development.3


In , 2008

(Video) Trendelenburg position

Positioning the patient

The modified lithotomy Trendelenburg position is used to facilitate synchronous combined excision of the rectum. The patient is catheterised, a soft sandbag or ‘wedge’ is placed under the buttocks and a tray is placed under the perineum and attached to the end of the table. A plastic sheet is inserted between the buttocks and the sandbag so that the towels will slide easily over the perineal tray and under the buttocks without a member of the theatre staff having to lift the patient and without the surgeon becoming contaminated during the towelling procedure. At this stage the patient should not be placed in the steep Trendelenburg tilt unless restraining supports have been fitted to the shoulders, for fear that he or she may slip cephalad. The optimum position will depend upon the size of the buttocks, the presence of hip disease or kyphoscoliosis and the build of the individual. In order not to compromise access by the abdominal surgeon, approximately 60–80° of hip flexion is used, with 40° of abduction at the hip and 100° of knee flexion (Figure 39.3). The position of the legs should be supervised by the surgeon and the Allan stirrups adjusted accordingly. Pneumatic leg bags are then placed around the calves and the skin preparation applied to the abdominal wall and perineum.

The first towel to be applied should be the one under the buttocks and over the perineal tray. Two leg bags are then placed over the lower limbs, to cover the penis and scrotum in the male. The leg bags and perineal towels are then sutured to the skin. The side towels and upper sheet are then placed around the abdomen and secured to the abdominal wall with a transparent adhesive drape. A covering sheet with two separate openings (for the abdomen and perineum) is placed over the existing towels and the Mayo table. Two side towels are attached to the Mayo table so as to exclude the anaesthetist from the sterile area.

For a synchronous combined proctocolectomy, one assistant and a scrub nurse are sufficient for the colectomy, but another surgeon and scrub nurse are needed for synchronous combined excision of the rectum.

View chapterPurchase book

Read full chapter



James G. Adams MD, in Emergency Medicine, 2013

Trendelenburg Position

Hypotensive patients are often placed in the Trendelenburg position while resuscitative efforts, such as establishing intravenous access and administering fluids, are initiated. The Trendelenburg position was thought to increase venous return and thereby augment cardiac output. This assumption is incorrect because of the capacitance of the venous circulation. The Trendelenburg position does not promote venous return or increase cardiac output. Hypotensive patients should not be put in the Trendelenburg position. This position serves only to increase the risk for aspiration.

Critical Care After Bariatric Surgery

R. Rajendram, ... V.R. Preedy, in Metabolism and Pathophysiology of Bariatric Surgery, 2017


Positioning patients in the reverse Trendelenburg position can optimize respiratory function. However, lying in one position for prolonged periods increases the risk of pressure sore formation. Pressure ulcers result from prolonged pressure on soft tissue or compression of the skin between a bony prominence or hard surface (e.g., bed sides). Pressure-induced injury ranges from nonblanching, erythematous (but intact) skin to deep ulcers down to the bone. The risk of pressure sores in critically ill patients is reduced by repositioning patients regularly [39]. When positioning patients, it is important not to occlude blood flow, which could increase the risk of VTE.

View chapterPurchase book

Read full chapter

(Video) Patient Positioning in Steep Trendelenburg: TrenGuard™ Restraint [Demonstration]


Central Venous Catheterization and Pressure Monitoring

Lyle E. Kirson DDS, Jacob Friedman MD, in Anesthesia Secrets (Fourth Edition), 2011

7 Describe the external jugular vein approach

When the patient is in a Trendelenburg position, the external jugular vein frequently can be visualized where it crosses the sternocleidomastoid muscle. The needle is advanced in a direction paralleling the vessel and is introduced into the vein approximately two finger widths below the inferior border of the mandible. Difficulty may arise in advancing the catheter or guidewire into the central circulation from the external jugular vein approach because the patient's anatomy frequently directs the catheter into the subclavian rather than the innominate vein. It is also frequently difficult to pass the guidewire or catheter past the clavicle.

View chapterPurchase book

Read full chapter


Operative Therapy for Ulcerative Colitis

Katerina Wells, ... Matthew Mutch, in Shackelford's Surgery of the Alimentary Tract, 2 Volume Set (Eighth Edition), 2019

Transanal Mucosectomy: Operative Technique

The table is positioned in the Trendelenburg position, and the hips are placed in flexion to adequately expose the anus. A self-retaining anal retractor is used to evert the anus and expose the dentate line. A circumferential incision is made through the mucosa at the dentate line, and the more proximal submucosal plane is infiltrated with a solution of 1 : 100,000 epinephrine. The mucosa is dissected off the underlying rectal wall with scissors or cautery, with the dissection continued to a level above the anorectal ring, at which point the rectal wall is incised and the proctectomy is completed. The specimen is either transabdominally or transanally removed, and the apex of the pouch is delivered to the level of the sphincter. Prior to delivering the pouch into the anal canal, four or more full-thickness sutures incorporating the anal mucosa and internal sphincter are placed at regular intervals around the circumference of the canal to begin the anastomosis. A ring or atraumatic clamp is passed through the anal canal into the pelvis to grasp the pouch in proper orientation (small bowel mesenteric edge to the patient's right, body of pouch in curve of sacrum) and deliver it to the distal canal. The previously placed sutures are passed through the full thickness of the pouch wall to secure the pouch into place. Finally, the anastomosis is completed with interrupted, full-thickness sutures such that no defects are identified. The spacing between each suture and the total number of sutures is at the surgeon's discretion (Fig. 162.16).

View chapterPurchase book

Read full chapter



Operations for Morbid Obesity

David S. Tichansky, Alec C. Beekley, in Shackelford's Surgery of the Alimentary Tract (Seventh Edition), 2013

3 Creation of the Gastric Pouch

Placement of the patient in reverse Trendelenburg position facilitates exposure to the supramesocolic abdomen. Dissection is begun at the phrenoesophageal ligament using the surgeon's choice of energy source. Dissection at this location helps identify the presence of a hiatal hernia, which should be reduced and possibly repaired prior to pouch creation, and facilitates identifying the proper aiming point and passage for linear staplers. The energy source can then be used to divide the typically transparent area in the gastrohepatic ligament over the caudate lobe of the liver. This helps the surgeon identify the right crus, esophagogastric junction, left gastric vascular trunk, body of the pancreas, and posterior wall of the stomach. On occasion, it may be necessary to divide the avascular adhesions of the posterior wall of the stomach to the anterior body of the pancreas to free up the lesser sac posterior to the stomach. The lesser curvature vascular arcade approximately 3 to 6cm below the esophagogastric junction is then divided with the energy source. Care should be taken to preserve the left gastric trunk arising from superior to the body of the pancreas. All tubes and monitors are confirmed to be removed from the stomach before stapling (Figure 64-1).

In general, 45- or 60-mm linear stapler loads are used to create the gastric pouch. Most authors are reporting use of 3.5- to 4.8-mm staple heights, and current data demonstrate that use of staple line reinforcement reduces staple line leaks and postoperative complications.20 With use of 60-mm stapler loads, the pouch can usually be completed in three to five stapler fires, resulting in a 15- to 30-mL pouch totally divided from the gastric remnant. The manner and sequence in which the gastric pouch is completed varies based on the technique being used to perform the gastrojejunostomy. For example, if the gastrojejunostomy is being completed with an end-to-end anastomotic (EEA) circular stapler with transoral passage of the anvil, the pouch can be completed in its entirety as the initial steps. If the EEA anvil is being introduced through the abdominal wall for transgastric passage, the anvil may be placed initially with the anvil spike presented through the anterior gastric wall followed by completion of the gastric pouch around it, or an initial transverse staple line may be fired with transgastric passage of the anvil through the end of the staple line. Recently, authors have described a technique whereby the initial staple lines of the pouch are created, followed by completion of a totally linear stapled gastrojejunostomy, and the pouch itself is only completed after the anastomosis has been created.21

The pouch can be sized by introducing a transoral Baker tube with a 30-mL balloon and retracting the inflated balloon to the esophagogastric junction. Alternatively, a transoral flexible dilator or bougie, typically 34 French (34F) in size, can be introduced transorally to help size the pouch for uniformity from patient to patient and can also help prevent inadvertent division of the superior stomach with a linear stapler. The use of a bougie is not necessary and is entirely at the discretion of the surgeon. Some surgeons prefer not to use these devices to prevent inadvertent inclusion of these objects in the staple lines. As the surgeon gains more experience with laparoscopic gastric bypass, gastric pouches with fairly consistent size from patient to patient can be created based on visual cues alone.

View chapterPurchase book

Read full chapter


Abdominal Wall Hernias

Jonathan E. Schoeff MD, in The Mont Reid Surgical Handbook (Sixth Edition), 2008



Position the patient in steep Trendelenburg position, use adequate sedation, and place ice on hernia. Taxis (process of reducing hernia) requires paradoxical traction on the hernia sac while applying gentle pressure at the neck of the hernia to reduce the contents. This is thought to decrease edema of intestinal contents and also decrease the volume of sac contents being reduced at any one time.


Significant tenderness, induration, erythema, or leukocytosis suggest possible strangulation and should prompt urgent surgical exploration; if these signs/symptoms are present, no reduction should be attempted.

View chapterPurchase book

Read full chapter

(Video) Trendelenburg & Reverse Trendelenburg - The Freedom Bed™️



How long can you keep a patient in Trendelenburg? ›

The risks associated with the Trendelen-burg position increase the steeper patients are angled and the longer they remain in the position. If a procedure is taking longer than three hours, consider flattening the patient out for a few minutes to give their body a break from the physical stressors of the position.

What are the disadvantages of Trendelenburg position? ›

Trendelenburg should be avoided until larger studies are conducted as it may increase a patient's risk for hemodynamic compromise, elevated intracranial pressure, and impaired lung mechanics. Specific patient populations should not be placed in Trendelenburg including those with: Decreased RVEF. Pulmonary disorders.

What are the types of Trendelenburg position? ›

In the Trendelenburg position, the body is lain supine, or flat on the back on a 15–30 degree incline with the feet elevated above the head. The reverse Trendelenburg position, similarly, places the body supine on an incline but with the head now being elevated.

What are pressure points for Trendelenburg position? ›

Pressure point areas in the Trendelenburg and reverse Trendelenburg position include the occiput, scapula, olecranon, sacrum, ischial tuberosities and calcaneus (Figure 2 and Figure 3). The supine position is one of the most frequently used positions during surgery.

Why would you put someone in Trendelenburg position? ›

Currently, the Trendelenburg position is often used in lower abdominal surgeries, including colorectal, gynecological, and genitourinary procedures. In this position, gravity pulls the intra-abdominal organs away from the pelvis, allowing for better surgical access to the pelvic organs.

When would you put a patient in Trendelenburg? ›

Patients may be placed in the Trendelenburg position for surgical procedures involving the abdomen or when needing improved access to the pelvic organs. Use a standardized tool to assess the patient's risk for pressure injury development.

Does Trendelenburg decrease heart rate? ›

CVP increased significantly during Trendelenburg, while heart rate remained unchanged (Table 3).

Does Trendelenburg decrease cardiac output? ›

surgery patients from the Trendelenburg position back to the horizontal position caused a significant decrease in cardiac output (P < 0.05), a non-significant decrease in MAP and a non-significant increase in heart rate (Table 2).

What is the opposite of Trendelenburg? ›

Other: Reverse Trendelenburg position. The Reverse Trendelenburg position is a position in which patients' hip and knee are not flexed but the head and chest are elevated at 30° than the abdomen and legs.

What muscles are weak in Trendelenburg? ›

A trendelenburg gait is an abnormal gait resulting from a defective hip abductor mechanism. The primary musculature involved is the gluteal musculature, including the gluteus medius and gluteus minimus muscles. The weakness of these muscles causes drooping of the pelvis to the contralateral side while walking.

Which nerve is Trendelenburg? ›

Many times, the muscle weakness that causes the Trendelenburg gait starts with damage to the superior gluteal nerve, which originates in the pelvis and ends in the gluteus minimus muscle. When this nerve is damaged, it's hard for the affected side to support the weight of the body.

Is Trendelenburg position good for hypotension? ›

One intervention commonly used to manage severe hypotension is Trendelenburg positioning, defined as a position in which the head is low and the body and legs are on an inclined or raised plane.

How do you assess Trendelenburg? ›

The patient is asked to stand on one leg for 30 seconds without leaning to one side the patient can hold onto something if balance is an issue. The therapist observes the patient to see if the pelvis stays level during the single-leg stance.

Does Trendelenburg decrease blood pressure? ›

Background: Little evidence indicates that changing a patient's body position to the Trendelenburg (head lower than feet) or the modified Trendelenburg (only the legs elevated) position significantly improves blood pressure or low cardiac output.

What is the best position for low BP? ›

The Trendelenburg position (TP) is defined as “a position in which the head is low and the body and legs are on an inclined or raised plane” [2] and is traditionally being used to manage hypotension and hypovolemic shock.

What are the cardiovascular changes in Trendelenburg position? ›

Anesthesia and the Trendelenburg position increased the CVP, PCWP and pulmonary arterial pressures and decreased cardiac output. Pneumoperitoneum increased these pressures further mostly in the beginning of the laparoscopy, and cardiac output decreased towards the end of the laparoscopy.

Does Trendelenburg increase intracranial pressure? ›

The concomitance of pneumoperitoneum and the Trendelenburg position can increase ICP as estimated with non-invasive methods.

Why is the Trendelenburg position contraindicated? ›

The Trendelenburg position is probably not indicated or may have harmful effects in: Resuscitation of patients who are hypotensive. Patients in whom mechanical ventilation is difficult, or patients with decreased vital capacity. Patients who have increased intracranial pressure.

Why do you have to adjust the bed to your waist level? ›

Adjust bed height to approximately waist height to allow you to stand comfortably with your back straight. Lower the bed rails to get as close to the patient as possible to help decrease the stress on your back.

What happens if you have weak hip abductors? ›

Hip abductor weakness can lead to overuse injuries like patellofemoral pain syndrome (pain behind the kneecap) and iliotibial band syndrome (ITBS). It's not clear whether hip abduction weakness is a cause of or a result of knee problems. Findings about the relationship between hip abduction and knee issues are mixed.

What causes weak hip abductors? ›

Underuse of the muscles or sitting down for extended periods can cause weak hip flexors. Conditions such as and osteoarthritis can also cause weakness in this muscle group.

How do you fix a dropped hip? ›

Four Simple Exercises to Correct Your Hip Drop
  1. Hip Hitches – 3 sets of 15 each side.
  2. Isometric Glute Med Hold – 3 sets of 30 second holds each side.
  3. Resistance Band Crab Walk – 3 sets of 30 seconds each direction.
  4. Glute Med & Psoas Drill – 3 sets of 10 each side.

What are the best exercises to correct Trendelenburg gait? ›

Physical therapy and exercise
  1. lying on your side and extending your leg straight out.
  2. lying on the floor and moving one leg up, over the other, and back in the opposite direction.
  3. stepping sideways and up onto an elevated surface, then back down again.

Can Trendelenburg gait be fixed? ›

Note 2: research has shown the importance of strengthening not only the gluteus medius but also the quadriceps and the hamstrings. Increases in the strength of the muscles will result in a reduction of the degree of Trendelenburg gait.

Does lying down help with low blood pressure? ›

If you feel dizzy or light-headed, sit down or lie down for a few minutes. Or you can sit down and put your head between your knees. This will help your blood pressure go back to normal and help your symptoms go away.

What muscles does Trendelenburg test? ›

Trendelenburg test investigates stability of the hip and particularly the ability of the hip abductors (gluteus medius and gluteus minimus) to stabilize the pelvis on the femur.

How do you know if you have weak hip abductors? ›

When a client is walking on their right leg in the stance phase of the gait cycle and their left hip drops down, this indicates a weakness in the right hip abductors. If hip abductors are weak on both sides, it results in a waddling gait, which is reminiscent of the strut of a Vegas showgirl.

What is a positive result for the Trendelenburg test? ›

The Trendelenburg sign is said to be positive if, when standing on one leg (the 'stance leg'), the pelvis severely drops on the side opposite to the stance leg (the 'swing limb'). The muscle weakness is present on the side of the stance leg.

How often would you change the position of an immobile patient? ›

Changing a patient's position in bed every 2 hours helps keep blood flowing. This helps the skin stay healthy and prevents bedsores. Turning a patient is a good time to check the skin for redness and sores.

How long can elderly be bedridden? ›

The bedridden period can last from 2 weeks up to 6 weeks, depending on the cause of their illness and their companion's age.

What would you do if the patient refuses to change position? ›

If the patient does not want to cooperate, we may encourage, plead, cajole, or even use scare tactics to increase patient adherence. Ultimately, it is the patient's right to refuse. This sometimes is the end of the story… until a lawsuit is filed and the fact the patient was not turned becomes a real sticking point.

Which side do you stand on when ambulating a patient with a weak side? ›

Stand on the client's weaker side and a little behind. Keep one hand ready by the client's waist. Use your other arm to hold the client's upper arm that is closest to you. If the client begins to fall, you are in a good position to support the client and ease them to the floor.

Which muscle is damaged in Trendelenburg? ›

A trendelenburg gait is an abnormal gait resulting from a defective hip abductor mechanism. The primary musculature involved is the gluteal musculature, including the gluteus medius and gluteus minimus muscles. The weakness of these muscles causes drooping of the pelvis to the contralateral side while walking.

Which hip is weak in Trendelenburg gait? ›

The weakness of the involved side causes a contralateral pelvic hip drop during swing phase. This contralateral hip drop might cause the quadratus lumborum, on the stance leg, to bring the pelvis back in neutral. [6] Posterior Lurch Gait.

What nerve is affected in Trendelenburg? ›

Many times, the muscle weakness that causes the Trendelenburg gait starts with damage to the superior gluteal nerve, which originates in the pelvis and ends in the gluteus minimus muscle. When this nerve is damaged, it's hard for the affected side to support the weight of the body.

What position lowers blood pressure? ›

Results: The blood pressure tended to drop in the standing position compared with the sitting, supine and supine with crossed legs. Systolic and diastolic blood pressure was the highest in supine position when compared the other positions.


1. Trendelenburg position #short #medical #types of positions
2. Trulife Elite Trendelenburg Positioning System
(LLC PortexLand)
3. Patient Positioning
(Surgical Tech Tips)
4. Trendelenburg Position for Surgery | Antai Hospital
(RSA Institute - English Channel)
5. Patient Positions - Fundamentals of Nursing - Principles | @LevelUpRN
(Level Up RN)
6. WaffleGrip™ Trendelenburg Positioning System
Top Articles
Latest Posts
Article information

Author: Tyson Zemlak

Last Updated: 02/12/2023

Views: 6067

Rating: 4.2 / 5 (43 voted)

Reviews: 82% of readers found this page helpful

Author information

Name: Tyson Zemlak

Birthday: 1992-03-17

Address: Apt. 662 96191 Quigley Dam, Kubview, MA 42013

Phone: +441678032891

Job: Community-Services Orchestrator

Hobby: Coffee roasting, Calligraphy, Metalworking, Fashion, Vehicle restoration, Shopping, Photography

Introduction: My name is Tyson Zemlak, I am a excited, light, sparkling, super, open, fair, magnificent person who loves writing and wants to share my knowledge and understanding with you.