Dr. Ellison uses the beach chair position almost exclusively. Beach-chair position provides faster and easier patient positioning, reduces risk of neurapraxias because traction is not used. There is reduced distortion of intraarticular capsular anatomy, improved mobility of the patient's arm, and easier conversion to open surgery since repositioning and repreparation is not required.
In the beach-chair position, either general anesthesia or interscalene block can be used. Interscalene block allows the patient to be awake and can assist in controlling the posotion of the head. The knees are flexed to provide counterpressure against the posterior thigh, which will reduce the tendency to slide off the table during surgery. Flexion also decreases tension on the posterior neurovascular structures of the legs. The affected shoulder is brought off the side of the table for access during the procedure.
The head is supported in a neurosurgical headrest and reinforced with coban which is secure without being restrictive. Additional tape reinforces the thorax as necessary. The arm hangs free but support on a Mayo stand as necessary. The patient is draped for routine shoulder surgery.
Once the patient has been positioned, prepared, and draped, the bony anatomical landmarks and proposed portal sites are identified and outlined. Bony sites marked are the anterior, lateral, and posterior outline of the acromion, the acromioclavicular joint, and the coracoid process. The usual portal sites marked are the posterior, anterior, and lateral portals.
As in the knee, a 4-mm, 30-degree oblique arthroscope, with a short bridge that allows fluid inflow and interchangeable cannulas, is used for routine arthroscopy. This arthroscope allows viewing of the entire shoulder joint with manipulation of the arm.
Control of Bleeding During Arthroscopy
Bleeding can be an annoying obstacle during shoulder arthroscopy because the tissue planes penetrated by the arthroscope and instruments are much thicker and more vascular than those in the knee. Also, no tourniquet can be used during shoulder arthroscopy. In addition to using an arthroscopic electrocautery device, an arthroscopy pump for inflow, maintaining a constant fluid flow and pressure minimizes bleeding. The inflow can be through the arthroscopy sheath or a separate inflow cannula for the arthroscopy pump is occasionally placed. Often with "beach-chair" positioning, hypotensive anesthesia is also used. All of these techniques minimize bleeding.