|
 
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| REVIEW ARTICLE |
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| Year : 2021 | Volume
: 8
| Issue : 1 | Page : 9-12 |
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Perennial relevance of anonymous surgical position portrayed in Susruta in concurrence to contemporary lithotomy position
Gaurav Soni
Department of Rachana Sharir, North Eastern Institute of Ayurveda and Homoeopathy, Shillong, Meghalaya, India
| Date of Submission | 24-Aug-2021 |
| Date of Decision | 11-Sep-2021 |
| Date of Acceptance | 12-Oct-2021 |
| Date of Web Publication | 26-Nov-2021 |
Correspondence Address:
Dr. Gaurav Soni
Department of Rachana Sharir, North Eastern Institute of Ayurveda and Homoeopathy, Shillong - 793 018, Meghalaya
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/AYUHOM.AYUHOM_43_21
Compendium of Susruta is the real treasure of clinical/surgical/para-surgical information, the more you explore it the more you are going to get. Similarly, a vivid portrayal of surgical positions, which is one of the prerequisites of the operative process, gives an insight into the anatomical and surgical understanding of Susruta. Anonymous positions portrayed during the surgery of hemorrhoids, fistula-in-ano, urology, etc., have remarkable similarities with the modern-day lithotomy position. Positions though described are basic, still cannot be disregarded as they are still commendable in the current era with some modifications. The lithotomy position described by him is still very much in practice, especially for gynecological and anorectal procedures. Hereby, an effort is done to evaluate and appreciate the historical and perennial relevance of the surgical positions described in the compendium of Susruta in current surgical methodology to assess their efficacy under conventional as well as contemporary provisions.
Keywords: Lithotomy position, preoperative requisite, surgical positions, Susruta
How to cite this article:
Soni G. Perennial relevance of anonymous surgical position portrayed in Susruta in concurrence to contemporary lithotomy position. AYUHOM 2021;8:9-12 |
How to cite this URL:
Soni G. Perennial relevance of anonymous surgical position portrayed in Susruta in concurrence to contemporary lithotomy position. AYUHOM [serial online] 2021 [cited 2023 Mar 31];8:9-12. Available from: http://www.ayuhom.com/text.asp?2021/8/1/9/331323 |
| Introduction | |  |
Among the diverse pioneers of Susruta associated with the development of surgery and anatomy, the description of surgical positions is least attributed.[1],[2] Susruta was a highly skilled master and has illustrated every detail related to anatomy and surgery in his compendium; starting from the basic anatomical description of bones, organs, etc., the training on mannequins', the utility of instruments, preparation of patient (preoperative), operative procedure, postoperative measures, and surgical ethics.[3],[4],[5],[6],[7] Preparation of the patient both at the level of substantial and psychological along with specified positioning comprises the preoperative requisites.[8] The prime objective for placing a patient in a precise position is to give the best access to the certain anatomical locations/operative site along with stabilizing the patient to avert inadvertent movement and injury.[9]
In the present era, there is a list of requisites to decide the position of a patient in a particular surgical modus operandi such as the type and length of the surgical procedure, exposure of the operative site, the type of anesthesia, the patient's age, height, weight, nutritional status, level of mobility, comorbidities, the patient's overall condition, etc.[10] The discovery of anesthesia was a game-changer for surgery as the unconscious patient is least to make any movement thus excluding the probability of injury to least but same was not in the era of Susruta, surgery was conducted only as a last resort as it was highly risky and painful due to unavailability of proper anesthesia (some alcoholic preparations along with cannabis were used instead);[11] which tends the patients to make accidental movement causing injury which may be moderate to severe or even fatal.
Objective
To evaluate and appreciate the historical and perennial relevance of the surgical positions described as preoperative requisite in the compendium of Susruta in current surgical methodology. Anonymous position portrayed during the surgery of hemorrhoids, fistula-in-ano, urology, etc.; which has remarkable similarity with the modern-day lithotomy position is to be assessed for its effectiveness under conventional as well as contemporary provisions.
| Materials and Methods | | |
Literal material utilized from classical texts like a compendium of Susruta along with the commentaries of Dalhana and Dr. Ghanekar related to the surgical procedures; online open access journals especially web of Science, PubMed, and Scopus enlisted were data mined for the word surgical positions, Susruta, lithotomy positions, web pages of reputed scientific organizations related with surgery, and preoperative nursing, contemporary literature concerned to surgical methods and procedures in particular to positions.
After the congregation of concerned literature, first of all, the preoperative preparations especially position portrayed while various surgical procedures of Susruta were critically studied and analyzed to explain them in contemporary terms; then, they are compared and evaluated in terms of contemporary surgical positions. The lithotomy position portrayed in many surgical procedures by Susruta is evaluated in both conventional and contemporary terms to evaluate its perennial efficacy in gynecological examination and surgery.
Positions portrayed in Susruta Samhita
Susruta has scientifically prearranged a three-phased process for any surgery, i.e., Purvakarma (preoperative), Pradhankarma (operative), and Paschatkarma (postoperative); contemporary known as the preoperative, operative, and postoperative procedures.[12] He has elaborately described the preoperative measures starting from the type of food intake, mental conditioning, and the position in which the surgery will take place.[13] Different associates were also assigned the roles beforehand, especially some of them holding the patient to avert any inadvertent movement due to panic or pain during surgery. The aim for placing a patient in a specific position was to give the best access to the operative site, which is stated in the different illustrations where no specific posture is recommended.[14] In ailments concerning to perineum or pelvis region such as hemorrhoids, Fistula-in-ano, and urology, specific arrangements of body parts have been portrayed executing surgical positions.[15],[16] Some of the surgical positions portrayed in the compendium of Susruta are summarized in [Table 1]. | Table 1: Summarizing the anonymous positions portrayed in different surgical procedures in Susruta in contemporary terminology
Click here to view |
Proper positioning aims to maintain the anatomical alignment of the patient's body, along with sufficient exposure of the region to be operated. Supine, prone, lithotomy, sitting, and lateral are the five fundamental types of positions used in clinical/surgical practice.[23] Commonly 4–5 persons are required to safely position a patient requiring the anesthetist at the cranial end and two other on either side along with the surgeon.[24] Improper positioning while the procedure/examination can lead to injuries and complications such as musculoskeletal pain, joint dislocation, nerve damage, and respiratory compromise.[25]
Lithotomy position
This is the most common position is used to facilitate gynecological, urologic, and anorectal examination and surgeries. The targeted region in these kinds of surgeries is the perineum (area between anus and genitals) which is achieved by placing the patient in a supine position along with abduction of lower limbs with flexion of knees and especially legs supported/strapped with the foot of the table. Several modifications of lithotomy positions such as low, standard, high, hemi, and exaggerated can also be portrayed as per the degree of elevation of the lower body.[26]
| Discussion | | |
The positions described by Susruta are the most preliminary ones and are the result of facilitating the operating area. We should always keep in mind the period in which Susruta has intervened the procedures. Some of the general arrangements have to be done due to the absence of anesthesia, an artificial source of light, and other sophisticated requisite equipment like:
- For better visualization procedures were conducted in the morning, placing the area under surgery toward the sun, i.e. East; compensating for the absence of spotlight
- Patients were placed on the lap of assistants mostly supine, facilitating the absence of moveable tables (vertical or horizontal) which can be adjusted as per the requirement
- Placing the cloth or blankets below the part which needs to be uplifted, facilitating a better view of the area
- Strapping or holding of upper and lower limbs to avert any inadvertent movement due to panic or pain; which may cause.
As mentioned earlier the unique arrangement of body parts of the patient in the surgery of pelvic region/anal region, where exposure of perineum is mandatory for proper facilitation, a highly specialized position is to be portrayed. Keeping in mind, the general considerations as discussed above, the following points may be noted in addition:
- The perineal region should be placed toward the sunlight for better observation
- The superior body parts (upper trunk) should be placed in the lap of the subordinate in the supine position; for vertical or horizontal movement if required
- Uplift the pelvis region, with the help of placing some clothes or blankets below the buttocks, for a better approach
- Strap up the lower limbs and hold the arms hold properly to avoid any injury due to fright, as the patient is conscious.
Apart from the above-mentioned benefits of the described position, another positive note can be taken, as when the surgeon is performing the procedure in the perineal area, he cannot keep eye on a patient so the assistant holding the patient can keep the watch on any complications/unwanted symptoms and may timely inform the surgeon to intervene the situation or even to stop the procedure and console the patient.
The contemporary lithotomy position has a great similarity with the position above discussed, which is also suggested for inspections as well as performing surgery of gynecological, pelvic, and anorectal regions. The perineum is the area to be exposed for the said purpose and the lithotomy position does it successfully. Due to modernization and availability of better types of equipment, anesthesia, etc., several modifications can be seen in the continuance of position which not only comforts the patient but also curtails the probability of injury or nerve compression.[27],[28]
- In lithotomy position, the patient lies supine with the legs elevated, abducted, and supported in stirrups
- Padded arm boards protect the arms to prevent any injury while the vertical movement of the table
- Stirrups are fixed to the table but are adjustable as per the patient's legs to avoid pressure at the knee and lumbar region of the spine
- Padding of legs prevents nerve injuries due to compression from stirrup itself or any external pressure
- To prevent the back strain (lumber), padding may be placed under the sacrum.
| Conclusion | | |
The compendium of Susruta considered a pioneer work in the history of surgery, establishes the basic techniques of training and practicing. Surgical positions, one of the prerequisites of the preoperative process give insights into the anatomical and surgical understanding of Susruta. Positions though described are basic ones owing to the facilities available at the time of Susruta but cannot be overlooked as they are still worthy enough in the current era after some modifications. The lithotomy position described by him is still very much in practice, especially for gynecological and anorectal procedures. In ending remarks, it can be claimed that along with various landmark surgeries Susruta should also be credited for pioneering the principle and utility of surgical positions.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Singh V. Sushruta: The father of surgery. Natl J Maxillofac Surg 2017;8:1-3.  [ PUBMED] [Full text] |
| 2. | Loukas M, Lanteri A, Ferrauiola J, Tubbs RS, Maharaja G, Shoja MM, et al. Anatomy in ancient India: A focus on the Susruta Samhita. J Anat 2010;217:646-50. |
| 3. | Kumar A, Kumar BN. The Principles of Surgical Practice: Sushruta Samhita and its Importance to Present Day Surgery. J Surg Open Access 2020;6. dx.doi.org/10.16966/2470-0991.207. |
| 4. | Deepa B, Pushpalatha K. Contributions of sushruta to anatomy. Anat J Afr 2014;3:362-5. |
| 5. | |
| 6. | Shrivastav PP, Khandare K. A critical review on Sushruta's surgical ethics. J Indian Sys Med 2020;8:10-3. |
| 7. | Soni G, Lahange S, Bhatnagar V, Bhatnagar S, Hershwani I, A Study of AsthiSharir In Context of Various Types of Asthi Described In Ayurvedic Samhitas, JOA, XII-4, 2018;105-12. |
| 8. | |
| 9. | Armstrong M, Moore RA. Anatomy, patient positioning. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021. |
| 10. | |
| 11. | Bhattacharya S. Sushrutha – Our proud heritage. Indian J Plast Surg 2009;42:223-5. [ PUBMED] [Full text] |
| 12. | Puthumana PP. Through the mists of time: Sushrutha, an enigma revisited. Indian J Plast Surg 2009;42:219-23. [ PUBMED] [Full text] |
| 13. | Sai Prasanna K, Prasad PV. Surgical concepts of sushrutha samhita. Int J Recent Sci Res 2017;8:17299-302. |
| 14. | |
| 15. | Kembhavi SA, Sharma M, Toshikhane H. Review of arsha as per sushruta samhita – Classification and principles of management. Ayurveda Integr Med Sci 2020;5:68-4. |
| 16. | Das S. Shusruta of India: Pioneer in vesicolithotomy. Urology 1984;23:317-9. |
| 17. | |
| 18. | |
| 19. | |
| 20. | |
| 21. | |
| 22. | |
| 23. | |
| 24. | |
| 25. | Fleisch MC, Bremerich D, Schulte-Mattler W, Tannen A, Teichmann AT, Bader W, et al. The prevention of positioning injuries during gynecologic operations. Guideline of DGGG (S1-Level, AWMF Registry No.015/077, February 2015). Geburtshilfe Frauenheilkd 2015;75:792-807. |
| 26. | |
| 27. | |
| 28. | |
[Table 1]
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