Situation: The nurse is assigned as the circulating nurse in an operating room for a day of elective surgical cases. The second client, a 58-year-old woman, is to be placed in the lithotomy position after induction of general anesthesia. Which action by the nurse is correct?

In lithotomy, both legs are raised and lowered together and slowly to prevent hip strain and sudden blood pressure changes. Joints are kept near neutral without extreme flexion, and the lateral knee is padded away from the stirrup to protect the peroneal nerve.

Positioning a patient into lithotomy requires coordinated, controlled movement because the lower extremities are moved from a neutral supine alignment into a flexed, abducted, and externally rotated configuration while the patient is under general anesthesia and cannot provide protective muscle tone or sensory feedback. The correct action is to raise both legs together and slowly into the stirrups.

Simultaneous, slow elevation of both legs minimizes asymmetric strain on the lumbosacral spine, hip joints, and pelvic ligaments, and reduces abrupt venous pooling in the lower extremities. When both legs are lifted at the same time, the pelvis remains relatively stable and the lumbar lordosis changes gradually. If one leg is raised while the other remains flat, the pelvis rotates and the spine twists, which can strain the sacroiliac joint and lumbar facet joints. In an anesthetized patient, this strain is not perceived and can result in postoperative low back pain or ligamentous injury.

Slow movement is equally important for hemodynamic stability. General anesthesia causes vasodilation and blunts baroreceptor reflexes. Elevating both legs suddenly shifts blood from the lower extremities into the central circulation, transiently increasing venous return and cardiac preload. In a patient with reduced cardiac reserve or hypovolemia, this can precipitate arrhythmias or blood pressure instability. Gradual elevation allows the cardiovascular system to accommodate the volume shift. The same principle applies when lowering the legs at the end of the procedure: both legs are lowered together and slowly to avoid a sudden drop in venous return and subsequent hypotension.

The position of the legs within the stirrups is also critical. The hips should be flexed only to the degree necessary for surgical exposure, not maximally. Extreme hip flexion places tension on the femoral nerve as it passes beneath the inguinal ligament and can compress the femoral vessels, reducing lower extremity perfusion. Prolonged reduction in perfusion pressure is one of the mechanisms implicated in well-leg compartment syndrome, a rare but serious complication of lithotomy positioning ^[1]. Operating room nurses identify prevention of this condition as a key perioperative responsibility, including attention to leg positioning, padding, and duration of time in lithotomy .

The lateral aspect of the knee must not rest against the stirrup post. The common peroneal nerve wraps around the fibular head just below the lateral knee. Direct pressure from a hard stirrup post can compress this nerve, leading to foot drop and sensory loss over the dorsum of the foot and lateral lower leg. The stirrup should support the foot and calf, with the knee padded and positioned away from any rigid surface. Peripheral nerve injuries are among the position-related injuries systematically reviewed in surgical patients, and extrinsic factors such as direct pressure and improper positioning are modifiable risks .

Action	Correct practice	Rationale
Raising legs	Both legs together, slowly	Prevents pelvic rotation, lumbar strain, and abrupt hemodynamic shifts
Hip flexion	Moderate, only as needed for exposure	Extreme flexion risks femoral nerve and vessel compression, contributing to compartment syndrome risk [1]
Knee position	Padded, away from stirrup post	Prevents common peroneal nerve compression at the fibular head
Lowering legs	Both legs together, slowly	Avoids sudden venous pooling and hypotension

Additional perioperative considerations include minimizing the total time in lithotomy when feasible, as prolonged operative duration is associated with increased risk of lower extremity complications ^[1]. Intraoperative interventions such as neuromuscular electrical stimulation have been studied as adjuncts to standard thromboprophylaxis for reducing lower extremity deep vein thrombosis risk during lithotomy surgery, reflecting the broader circulatory concerns associated with this position . While the circulating nurse coordinates positioning, the entire operating team shares responsibility for verifying that the final position maintains neutral joint alignment and protects all pressure points.

Watch out! Raising one leg at a time creates asymmetric pelvic torque and can injure the lumbar spine or sacroiliac joint in an anesthetized patient. Key point! The peroneal nerve injury from stirrup pressure is preventable by ensuring the lateral knee never contacts the post; the support should be at the foot and calf with adequate padding.