Patients are placed in specific surgical positions for many reasons. Use of a specific surgical position gives the surgeon optimal, unobstructed access to the operative site. The needs for physiological stability, protection from injury, and access to the surgical site all affect positioning decisions. Each patient's unique considerations, such as age, joint mobility, and disease are important to consider when safely positioning patients. Because of the high risk of serious and permanent injury, the surgical team must be guided and directed in the positioning process. The anesthesia care provider, surgeon, and circulator draw this direction from their knowledge of the patient's status. The soup on position or dorsal recumbent position is used for procedures of the abdomen, thorax, and face, and an orthopedic and vascular surgery. The patient is positioned with the head and spine in alignment. When an armboard or toboggan is not used, the arm is placed in a natural position at the patient's side, and the draw sheet is tucked smoothly underneath. The patient's feet must not extend over the edge of the table, and the legs must not be crossed one over the other. The patient's weight is distributed over the occipital bone, back, sacrum, heels, and posterior legs. Patients with spinal or pelvic malformation or total joint prosthesis may require special padding to support irregular curvatures and prevent hyper extension. A foam or gel pad is used to support the head. The safety strap is placed midway between the knees and thighs. The Trendelenberg position is a variation of the soup on position in which the operating table is tilted head down. This position allows greater access to the lower abdominal cavity and pelvic structures by allowing gravity to retract organs such as the small intestine, proximal-loud bowel, and omentum toward the head. The position is commonly used during lower gastrointestinal surgery and pelvic surgery. Shoulder braces may be used to prevent the patient from sliding. Shoulder braces may be very dangerous, however, and may cause injury to the brachial plexus. If it is necessary to use them, they should be well padded and placed over the acromion process of the scapula rather than over the soft tissue overlying the brachial plexus. The reverse Trendelenberg position, also a modification of the soup on position or foot down is used when the surgeon requires unobstructed access to the upper paratoneal cavity and lower esophagus. When the operating table is tilted toward the patient's feet, gravity drops the viscera into the lower cavity, which allows a clear view of the diaphragm, cardiac sphincter, and esophagus. The lethautomy position is a variation of the soup on position. The patient's thighs are abducted and both the knees and hips are flexed. Special care must be taken to raise the patient's leg slowly and place them in the stirrups. Both legs should be raised slowly at the same time. The feet are suspended in the stirrups or the legs rest on low leg braces. Lethautomy position is commonly used for gynecological, obstetrical, and genito-urinary procedures. Respect the patient's dignity by placing a cover sheet over the perineum during positioning. When lowering the patient's legs from the stirrups to place them back on the OR table, the same technique must be used. The sitting or fouler position is used for facial, preneal, or reconstructed breast surgery. When this position is used, the general operating table is flexed to allow a fouler or semi-fouler position. The head may be secured by a craniotomy head rest or stabilized with a donut-shaped gel or foam pad. The lateral or sims position is used for procedures involving the renal system and for cardiothoracic surgery. When the lateral position is described, the side named is the side lying on the table. For example, in the left lateral position, the left side lies on the table. The opposite side is the operative side or upside. A number of different variations of the prone position are used to allow access to the spine, craniotomy, and perieno region. This position requires extreme caution. The pressure exerted on the abdomen restricts normal ventilation and the cervical spine may be forced into a position that would be intolerable to the patient if he or she were conscious. There is risk to nerves, eyes, genitalia, breasts, and spine. In the prone position, the patient's upper body rests on a raised padded frame or elongated pads placed on each side of the patient's thorax. Jackknife or craskey position is a modification of prone position. The lower table break is flexed downward to achieve a simultaneous head down and foot down posture. This position may be used for anorectal surgery. The lower legs are elevated and rest on pads to distribute the weight.