Situation: A 66-year-old man with adenocarcinoma of the lower rectum undergoes abdominoperineal resection with a permanent sigmoid colostomy. He has no other medical conditions. On the second postoperative day, which position is BEST for his comfort and protection of the perineal wound?

Abdominoperineal resection leaves a perineal wound that is painful and at risk of breakdown and infection. A side-lying position keeps pressure off the perineum, and a pressure-relieving cushion is used when he sits. Sitz baths begin once permitted.

Core concept: protecting the perineal wound after abdominoperineal resection

Abdominoperineal resection removes the rectum and anus, leaving a large perineal wound where the anus used to be. This wound sits directly in the midline of the buttocks and is subjected to pressure, moisture, and contamination whenever the patient lies flat or sits directly on it. On the second postoperative day, the wound is still fresh, painful, and highly vulnerable to breakdown and infection.

The side-lying position shifts body weight away from the midline perineum and distributes it across the lateral hip and thigh, which reduces direct pressure on the surgical site and improves air exposure to the wound. Supporting the position with pillows prevents the patient from rolling backward onto the wound and reduces muscle strain that could cause involuntary movement and pain.

The other positions create direct or indirect pressure on the perineal area. Supine places the sacrum and perineum against the mattress, and raising the legs on pillows does not relieve that contact. Sitting upright in a chair places the full weight of the trunk directly on the perineal wound, which is the most harmful option at this stage. High Fowler's position with flexed knees shifts weight toward the sacrum and buttocks and also increases tension across the perineal closure.

Key point! The goal is not only comfort but also wound protection. Any position that loads the sacral-perineal region delays healing and raises the risk of dehiscence or infection.

The evidence from surgical positioning studies supports this principle. A prospective cohort trial evaluating transperineal pelvic drainage combined with lateral positioning after extralevator abdominoperineal resection reported that perineal infection rates can approach 70% without effective intervention, and the lateral position was part of the strategy to promote perineal wound healing ^[1]. A retrospective study from Massachusetts General Hospital found that patient positioning during the perineal portion of the procedure influenced postoperative perineal wound dehiscence and infection, with prone positioning associated with reduced perineal infections compared with supine or lithotomy positioning ^[2]. Another retrospective cohort study also examined the relationship between patient position and postoperative perineal surgical site infection, reinforcing that positioning is a modifiable factor affecting wound outcomes . A systematic review and meta-analysis confirmed that prone positioning during abdominoperineal resection is linked to better outcomes, although the analysis focused on intraoperative positioning rather than postoperative positioning .

These studies address intraoperative positioning, but the underlying principle transfers directly to postoperative nursing care: reducing pressure and contamination on the perineal wound is a central determinant of healing. In the postoperative period, the side-lying position achieves the same protective effect at the bedside that prone positioning achieves in the operating room.

Watch out! Do not confuse the intraoperative prone jackknife position with the postoperative side-lying position. The question asks about the best position for the patient on the second postoperative day, not the position used during surgery. The side-lying position is the practical bedside equivalent that keeps weight off the perineum while allowing the patient to rest comfortably.

When the patient does need to sit, a pressure-relieving cushion or inflatable ring should be placed under the thighs and buttocks so the perineum remains suspended without direct contact. Sitz baths are introduced only after the surgeon confirms that the wound can tolerate moisture and that drainage is controlled. Until then, keeping the perineal area clean, dry, and free of pressure remains the priority.

Position	Effect on perineal wound	Clinical judgment
Side-lying with pillows	Weight shifted to lateral hip and thigh; perineum off the mattress	Best choice for comfort and wound protection
Supine with legs raised	Sacrum and perineum remain in contact with the bed	Does not relieve perineal pressure
Sitting upright in a chair	Full trunk weight directly on the perineal wound	Contraindicated on the second postoperative day
High Fowler's with knees flexed	Weight shifted toward sacrum and buttocks; tension across perineal closure	Increases pressure and wound tension