Left Lateral Position Research Articles

True Knot of the Umbilical Cord and its Implications in the Fetal Well-Being

The true knot of the umbilical cord is a pathology with a relatively low incidence. However, it is associated with the risk of loss of fetal well-being and in severe cases with perinatal death. There are both maternal and fetal risk factors, with different associated perinatal outcomes. Prenatal diagnosis is a challenge for the attending physician and almost all cases are findings at birth once the cord has been observed. However, over time, ultrasound methods have been developed to search for it in cases where suspicion is high. and most cases are findings at birth, however, today ultrasound methods are available for their intentional search, mainly in patients with unidentified risk factors. Similarly, it should be suspected in the presence of an altered cardiotocographic record or one that shows a non-reassuring pattern, especially when there is no response to established intrauterine resuscitation maneuvers, such as left lateral decubitus position, supplemental oxygen and maternal hydration.

Diaphragmatic endometriosis: robotic approaches and techniques

To present different approaches used in the surgical management of diaphragmatic endometriosis using the Davinci Robotic system. A video article presenting patient positioning, port placement, and surgical techniques used in robotic excision of diaphragmatic endometriosis with concomitant pelvic disease. Endometriosis center. Patients undergoing excision of diaphragmatic endometriosis. Systematic robotic approach to excise diaphragmatic lesions depending on the depth of invasion. The advantages and disadvantages of the lithotomy and the lateral decubitus approach were reviewed. Ports placements are illustrated according to the chosen approach. Diaphragmatic peritoneal stripping, diaphragmatic shaving, and diaphragmatic excision are different techniques used according to the depth of invasion. N/A. The choice of approach between the lithotomy position and the left lateral decubitus position depend on the extent of the diaphragmatic disease and the presence of concomitant pelvic lesions. Despite the lack of high-quality evidence, the advantages of the robotic system may improve the outcomes in such difficult cases in comparison with conventional laparoscopy.

Regional ventilation in spontaneously breathing COVID-19 patients during postural maneuvers assessed by electrical impedance tomography.

Gravity-dependent positioning therapy is an established concept in the treatment of severe acute respiratory distress syndrome and improves oxygenation in spontaneously breathing patients with hypoxemic acute respiratory failure. In patients with coronavirus disease 2019, this therapy seems to be less effective. Electrical impedance tomography as a point-of-care functional imaging modality for visualizing regional ventilation can possibly help identify patients who might benefit from positioning therapy and guide those maneuvers in real-time. Therefore, in this prospective observational study, we aimed to discover typical patterns in response to positioning maneuvers. Distribution of ventilation in 10 healthy volunteers and in 12 patients with hypoxemic respiratory failure due to coronavirus disease 2019 was measured in supine, left, and right lateral positions using electrical impedance tomography. In this study, patients with coronavirus disease 2019 showed a variety of ventilation patterns, which were not predictable, whereas all but one healthy volunteer showed a typical and expected gravity-dependent distribution of ventilation with the body positions. Distribution of ventilation and response to lateral positioning is variable and thus unpredictable in spontaneously breathing patients with coronavirus disease 2019. Electrical impedance tomography might add useful information on the immediate reaction to postural maneuvers and should be elucidated further in clinical studies. Therefore, we suggest a customized individualized positioning therapy guided by electrical impedance tomography.

Left Lateral Positioning during Caesarean Section - Myth or Truth?

AbstractPositioning the pregnant patient in her third trimester in a 15° left lateral tilt position with the rationale to reduce inferior vena cava (IVC) compression is a longstanding practice of both obstetric and anesthesia care. Recent data from MRI imaging studies have challenged this traditional dogma, since the IVC was found to remain compressed at a 15° angle, with a tilt of at least 30° necessary to provide a certain relief of the vessel. However, even the 15° tilt is regularly underestimated by visual judgement and improperly executed, but comes with several disadvantages without adding any benefit on fetal outcome. Current evidence supports all efforts to cease the dogma of a 15° left lateral position for its lack of effectiveness and instead put emphasis on proven measures, such as volume coloading and the timely administration of vasopressors.

Evaluation of diurnal and postural intracranial pressure employing telemetric monitoring in idiopathic intracranial hypertension

ObjectivesIntracranial pressure (ICP) has been thought to vary diurnally. This study evaluates diurnal ICP measurements and quantifies changes in ICP occurring with changes in body posture in active idiopathic intracranial hypertension (IIH).MethodsThis prospective observational study utilized telemetric ICP monitoring in people with active IIH. Participants had the Raumedic p-Tel ICP intraparenchymal device (Raumedic, Hembrechts, Germany) surgically inserted. Changes in ICP in the supine position were evaluated. Then, the ICP was measured in the standing, sitting, supine, left lateral decubitus positions and with coughing and bending. Ultimately, changes in ICP over the course of 24 h were recorded. ISRCTN registration number 12678718.Results15 women were included, mean (standard deviation) age 29.5 (9.5) years, body mass index 38.1 (6.2) kg/m2, and baseline mean ICP of 21.2 (4.8) mmHg (equivalent to 28.8 (6.5) cmCSF). Mean ICP rose with the duration in the supine position 1.2 (3.3) mmHg over 5-minutes (p = 0.175), 3.5 (2.8) mmHg over 30-minutes (p = 0.0002) and by a further 2.1 (2.2) mmHg over 3 h (p = 0.042). Mean ICP decreased by 51% when moving from the supine position to standing (21.2 (4.8) mmHg to 10.3 (3.7) mmHg respectively, p = 0.0001). Mean ICP increased by 13% moving from supine to the left lateral decubitus position (21.2 (4.8) mmHg to 24.0 (3.8) mmHg, p = 0.028). There was no significant difference in ICP measurements at any point during the daytime, or between 5-minute standing or supine recordings and prolonged ambulatory daytime and end of night supine recordings respectively. ICP, following an initial drop, increased progressively in conjunction with lying supine position from 23:00 h to 07:00 h by 34% (5.2 (1.9) mmHg, p = 0.026).ConclusionThis analysis demonstrated that ICP does not appear to have a diurnal variation in IIH, but varies by position and duration in the supine position. ICP rose at night whilst the patient was continuously supine. Furthermore, brief standing and supine ICP measures in the day predicted daytime prolonged ambulatory measures and end of night peak ICP respectively. This knowledge gives reassurance that ICP can be accurately measured and compared at any time of day in an ambulant IIH patient. These are useful findings to inform clinical measurements and in the interpretation of ICP analyses in IIH.Trial registrationISTCRN (12678718).

Real Time Ultrasound-Guided Thoracic Epidural Catheterization with Patients in the Lateral Decubitus Position without Flexion of Knees and Neck: A Preliminary Investigation.

Objectives: For some patients, such as pregnant women, it can be difficult to maintain the ideal "forehead to knees" position for several minutes for epidural catheter placement. We conducted this study to investigate the feasibility of real-time ultrasound-guided (US) epidural catheterization under a comfortable lateral position without flexion of knees and neck. Materials and Methods: 60 patients aged 18-80 years with a body mass index of 18-30 kg/m2 after general surgery were included. In a comfortable left lateral position, thoracic epidural catheterization was performed under real-time US for postoperative analgesia. The visibility of the neuraxial structures, procedural time from needle insertion to loss of resistance in the epidural space, the number of needle redirections, success rate of epidural catheter placement and postoperative analgesic effect were recorded. Results: In the paramedian oblique sagittal view, the well visible of vertebral lamina, intervertebral space and posterior complex under ultrasound were as high as 93.33%, 81.67% and 70.00%, respectively. The success rate of thoracic epidural catheterization was as high as 91.67%, and the satisfactory postoperative analgesic effect was 98.2% for patients without nausea, pruritus and other discomfort. Discussion: Thoracic epidural catheterization with patients in the lateral position without flexion of knees and neck under real time ultrasound guidance has a high success rate and strong feasibility. This visual manipulation makes epidural catheterization not only "easier" to perform, but also reduces the requirements of the procedure.

Time to Resuscitate Cardiopulmonary Resuscitation: The 3R/CPR Refill-Recoil-Rebound

Introduction: Sudden cardiac arrest (SCA) remains a major healthcare issue worldwide with gloomy outcomes due to poor perfusion of cardiopulmonary resuscitation (CPR), deemed unsuitable for hemostatic conditions, cardiotorsal anatomy, electrophysiology, and thoracic biomechanics. Alternatively, we propose a new management, implementing rational exploitation of the stagnant blood masses: manually with a novel technique of cardiac massage and mechanically with a circulatory flow restoration (CFR) device.
 Methods: Simulated chest compressions were performed through the 5th intercostal space in professional Lifeguards volunteers, placed in the left lateral decubitus position with raised legs and abdominal compression.
 Results: Bypassing the sternal barrier, refilling the heart, and then compressing the chest with a recoil-rebound maneuver (3R / CPR) can significantly promote return of spontaneous circulation (ROSC). The effectiveness of the CFR device versus CPR has previously been demonstrated in the literature.
 Conclusion: Unlike current CPR, the 3R/CPR adapts human morphology and provides adequate myocardial perfusion promoting ROSC safely, under all circumstances. Preclinical computational models can confirm the effectiveness of the technique.

Does Spinal Anesthesia Affect Huff Cough Strength in Parturient Under Elective Cesarean Section?

Background: Spinal anesthesia in parturients that undergo cesarean section is a method of choice, but some patients complain about shortness of breath after surgery. This might be due to spinal block may have effect on huff cough strength resulting in the difficulty to expel the mucus from the lungs. The Mini-Wright Peak Flow Meter, the surrogate device of huff cough strength, is a bedside equipment used to assess exhalation force by its peak expiratory flow rate (PEFR). As a result, the investigators would like to know if the spinal block affected the parturient huff cough strength. Objective: To evaluate the spinal anesthesia during cesarean section effect on the parturient huff cough strength and to find the factors that influence the difference of PEFR beside the spinal block. Materials and Methods: The PEFR was recorded three times in 161 healthy term pregnant women at 38 to 42 weeks of gestational age that were scheduled for elective cesarean section, at preoperative, immediate after spinal block, and before discharge from the recovery room. The measurement was performed in all parturients with 15 degree left lateral tilt position and the highest PEFR achieved in three successive attempts. The spinal anesthesia with 10.75 to 11 mg of 0.5% hyperbaric bupivacaine and 0.15 to 0.2 mg morphine was performed under the standard anesthetic care. Results: One hundred sixty-one patients successfully completed the present study. The PEFR appeared to decrease significantly after spinal block from 285.53±55.21 L/minute to 238.70±49.69 L/minute (p<0.001) and seemed to sustain till the time of discharge from the recovery room at 235.40±47.29 L/minute (p=0.493). These implied that though the patients fulfilled the discharge from recovery criteria, the level of sensory blockade was not yet improved. Interestingly, these values were comparable and showed no correlation with age, BMI, and solid sensory blockade. Conclusion: Spinal anesthesia might affect huff cough strength in parturients that underwent elective cesarean section as evidenced by the decrease of PEFR even at the time of discharge from the recovery room. Keywords: Bupivacaine; Cesarean section; Huff cough strength; Parturient; Peak expiratory flow rate; Spinal anesthesia

V-021 REPORT OF AN ACQUIRED INTERCOSTAL HERNIA REPAIR USING A BILAYER MESH

Abstract Aim A 53-year-old male underwent a T10/11 discectomy with partial removal of the right T9 rib. 10 years later, he developed an acquired painful intercostal hernia, worsened by leaning against the defect. CT imaging demonstrated an 8cm hernial defect containing the posterior lobe (segment VII) of the liver with a loss of integrity of the diaphragm. Methods Open surgical repair though the original incision was undertaken, with the patient in the left lateral position. The hernia was entirely reducible in this position. Results The liver was replaced into the peritoneal cavity, the hernial sac and the weakness at the postero-lateral edge of the diaphragm were then identified. The edges of the hernial sac were dissected off the ribs. An intraperitoneal mesh (SymbotexTM; Medtronic, Lyon) was cut to size, placed, and fixed to the undersurface of the ribs, with a 5cm overlap obtained medially and laterally. Care was taken to avoid damaging the neurovascular bundle and breach of the pleural cavity was not observed. A bridging mesh was then used to reinforce the repair (VersatexTM; Medtronic, Lyon) with fixation to the ribs using ethibond sutures and cyanoacrylate glue (Glubran®; Viareggio). The repair was checked by Valsalva manoeuver prior to wound closure. Post operative pain control was achieved using intercostal nerve block and patient-controlled analgesia. A post-operative chest x-ray did not demonstrate a pneumothorax. The patient was discharged on postoperative day 2. Discussion The patient experienced no serious postoperative sequelae and was pain free with no hernia at 30 days post-surgery.

V-014 OPEN REPAIR OF PRIMARY LUMBAR HERNIA WITH PREPERITONEAL MESH

Abstract This video presents an open repair of a primary lumbar hernia with preperitoneal mesh performed at a high-volume hernia center. The patient was a 71-year-old female referred due to chronic pain from a primary hernia of the right superior lumbar triangle. The patient was positioned in the left lateral decubitus position with the bed slightly flexed. A skin incision was created sharply, and electrocautery used to dissect subcutaneous tissue and superficial fascia, revealing the hernia contents. Circumferential lysis of adhesions was performed with blunt and cautery dissection to release the hernia contents from the abdominal wall. Once the hernia contents were mobilized, they were then carefully reduced through the fascial defect. The hernia defect measured approximately 3.5×3.5 cm. Next, the preperitoneal space was circumferentially developed. This was done primarily with blunt finger dissection, using a rolling motion to direct pressure towards the abdominal wall and sweep the peritoneum and other attachments down. Larger attachments are gently retracted and divided with electrocautery. The preperitoneal space was measured at 20×19 cm and the mesh trimmed to those dimensions. The mesh was carefully laid flat in the preperitoneal space. No mesh fixation was required. Fascial edges were dissected free for 1–2cm surrounding the defect. Two running 1–0 PDS sutures were used to close the hernia defect. A closed-suction drain was placed superficial to the fascia to minimize seroma formation. The superficial fascia and dermis were closed in layers. The patient had a routine hospital course and was discharged on post-operative day 3.

THERAPEUTIC MANUAL ASPIRATION OF LARGE VENOUS AIR EMBOLISM IN A PATIENT WITH SHOCK

THERAPEUTIC MANUAL ASPIRATION OF LARGE VENOUS AIR EMBOLISM IN A PATIENT WITH SHOCK

SOPHISTICATED AIR HEAD: A UNIQUE PRESENTATION OF IATROGENIC AIR EMBOLISM IN SOFT TISSUE OF THE NECK AND CHEEK

SOPHISTICATED AIR HEAD: A UNIQUE PRESENTATION OF IATROGENIC AIR EMBOLISM IN SOFT TISSUE OF THE NECK AND CHEEK

Right Kidney Position for Laparoscopic Liver Resection of Tumors Located in the Posterosuperior Region

Laparoscopic liver resection (LLR) for tumors located in posterosuperior (PS) region of the liver (segment 7 or 8) is extremely challenging. Several techniques have been proposed; however, no standard procedure has yet been established. The aim of this study was to present and discuss the usefulness of the right kidney position as a unique idea of surgical position in LLR for tumors located in the PS region. For the right kidney position, the patient lay on the operating table in the left lateral decubitus position with the body bent so that the kidney rest (approximately the level of the twelfth rib) was elevated to extend the surgical area. The surgeon was positioned on the right or left side of the patient according to the situation during operation. An intercostal port was not used in any of the cases. The operating table was liberally rotated as per the surgeon's preference. The liver was mobilized by dividing the right triangular and coronary ligaments. Full mobilization of the right liver was not routinely performed. Liver transection was performed under intermittent inflow occlusion in all cases. Thirteen patients with tumors located in the PS region underwent LLR in the right kidney position at Shinshu University Hospital between June 2019 and May 2021. Of the 13 patients, 11 patients underwent limited liver resection and two underwent anatomic liver resection of segment 8. The right kidney position enables the surgeon to secure a wider surgical field under the dome and prevent the camera and forceps from hitting the ilium and interfering with the operation, and the surgical device can easily reach the lesion under the dome because of the migration to the caudal side of the liver. No patients required blood transfusion or conversion to open liver resection. The median surgical margin was 6 mm (range 0 to 9 mm). The right kidney position is useful, especially for the resection of tumors located in the PS region of the liver.

Dystocia and its management in a captured wild Monkey

A stray wild female monkey, aged 5-6 years were presented to the Referral Veterinary Polyclinics, ICAR- Indian Veterinary Research Institute, with a history of straining and discharge from the vulva since morning. A close physical examination of the external genitalia of the monkey revealed it as prominent, red and swollen implying pregnancy. The vulva was open due to the internal pressure revealing foetal part visible with reduced fetal fluid. Per-vaginal examination revealed a foetal head in the birth canal, but absence of foetal responses. Per vaginal examination revealed foetal presentation to be anterior longitudinal, dorso-sacral position, but it was difficult to palpate postural condition. To relieve the condition female monkey was positioned in a left lateral recumbent position followed by ample lubrication of the birth canal with CMC (Carboxymethyl cellulose) gel using an intrauterine catheter and syringe. The traction approach was used to extract the dead foetus. Following successful delivery bleeding was prevented by administering ethamsylate injections at a dose rate of 15 mg/Kg (1 ml), and other supportive medications were administered. The macaque monkeys can postpone labour making it difficult for an observer to determine the indicators of dystocia until the condition has worsened. This makes dystocia in nonhuman primates a grave condition requiring prompt medical attention.

431. THORACOSCOPIC ESOPHAGEAL CANCER SURGERY IN THE LEFT LATERAL POSITION WITH EMPHASIS ON SAFETY AND RADICAL CURE

Abstract Compared with thoracoscopic esophagectomy in the prone position (PP), the conventional thoracoscopic esophagectomy in the left lateral position (LL) with artificial pneumothorax is slightly more difficult for dissection of the middle and lower mediastinum, but is superior to PP because the operation can be performed with good visual field in the upper mediastinum. The purpose of this study was to clarify the safety and curative potential of this technique. We retrospectively reviewed 246 cases of thoracic esophageal cancer surgery from April 2012 to December 2018. Thoracoscopic surgery (group V) was performed in 154 patients and open right thoracotomy (group O) in 92 patients. When this procedure was judged to be feasible, it was started thoracoscopically, and when it was judged to be unfeasible, a small thoracotomy of about 10–15 cm was added to allow one hand to enter. Thoracoscopy not only reduces the invasiveness of the procedure, but also allows us to share the anatomy, and improves the maneuverability of esophageal transfer and ensures safety in emergency situations. Postoperative complications with Clavien-Dindo classification II or higher were 40% in group O and 51% in group V. In group V, anastomotic leak was 15 (9.7%), vocal cord paralysis 34 (22%), pneumonia 17 (11%), SSI 16 (10%). The mean postoperative hospital stay was 20 days. 8 (8.7%) patients in the O group had anastomotic leak, 10 (11%) had vocal cord paralysis, 8 (8.7%) had pneumonia, 12 (7.8%) had SSI. The mean postoperative hospital stay was 28 days. Of 27 salvage procedures, 14 (52%) were performed thoracoscopically. Thoracoscopic surgery was completed in 10 cases and combined thoracotomy in 4 cases. Short-term outcomes of thoracoscopic surgery show an increase in vocal cord paralysis compared to open surgery. The procedure does not improve infectious complications. This technique has the advantage of easy conversion to open thoracotomy, including in emergency situations, and is more advantageous in advanced cancer, and can be a curative and safe treatment for highly advanced cancer.

650. ROBOTIC ESOPHAGEAL LEIOMYOMA ENUCLEATION

Abstract Leiomyomas are rare benign esophageal neoplasms. Surgery is indicated in symptomatic patients or if malignancy is suspected. A 20-year-old female presented with dysphagia to solids. Contrast enhanced computed tomography showed a 33-mm by 30-mm by 51 mm well circumscribed lobulated mass arising from the right anterolateral wall of the upper thoracic esophagus, causing luminal narrowing and abutting the azygos vein. An esophageal ultrasound performed for confirmation showed the lesion arising from the muscularis propria. Patient was scheduled for a robotic leiomyoma excision. Patient was placed in left lateral position, lung isolation was obtained with a double lumen tube. Four standard ports were placed in the sixth intercostal space. Robotic instruments used were the monopolar scissors, Maryland bipolar forceps, fenestrated bipolar forceps for dissection and needle holder for suturing. The leiomyoma was identified, mediastinal pleura and muscle layer were incised longitudinally. The leiomyoma was dissected all around in the submuscular plane taking care not to injure the underlying mucosa. However, while delivering the deep lobulated portion, there was an inadvertent injury to the mucosa. The mucosal tear was repaired with interrupted sutures utilising 4-0 Polydiaxanone sutures and the muscle layer was closed with V-Lock sutures. A check endoscopy was performed on table along with air insufflation with saline in the pleural cavity to check for an air leak. A nasogastric tube was placed, specimen was retrieved in a bag through the assistant port. Surgery was completed in 155 minutes with 50 ml blood loss. Post-operative course was uneventful, and the patient was discharged on full diet on the fourth post-operative day. Histopathology showed a SMA and desmin-positive spindle cell neoplasm without conspicuous mitotic activity. Precise dissection in a confined space is possible due to wrist-like movements, three-dimensional view and magnification offered by the robot. Repair of the injured mucosa and myotomy closure to prevent future diverticulum formation is easily accomplished with robotic suturing. Intraoperative endoscopy is useful in evaluating the integrity of the mucosa and muscle repair. Hence a robotic approach may be superior to a thoracoscopic/open leiomyoma enucleation and can be utilised even in moderate size masses.

A Young Man With Epigastric Abdominal Pain

A Young Man With Epigastric Abdominal Pain

Safety and Efficacy of the Supine Position with the Right Shoulder Raised versus the Left Lateral Position in Peroral Endoscopic Myotomy for Achalasia: A Large-Sample Retrospective Study.

Background The correct surgical position is very important in the treatment of peroral endoscopic myotomy (POEM) for achalasia, which can make the procedure safer and more efficient. Currently, there are two commonly used positions: the supine position with the right shoulder raised and the left lateral position. This study aims to evaluate the differences in the safety and efficacy of these two positions. Methods We conducted a retrospective study of 702 patients with achalasia undergoing POEM from December 2010 to December 2020. These patients were divided into the supine position with the right shoulder raised group (n = 579) and the left lateral position group (n = 123). The efficacy of POEM and adverse events were analyzed. Results The clinical characteristics were similar in both groups, and there were no significant differences between the two groups in the Eckardt score change, lower esophageal sphincter (LES) basal pressure or residual pressure after POEM (all p > 0.05). The mean operative time in the supine position with the right shoulder raised group was significantly shorter than that in the left lateral position group (43.5 min vs. 54.6 min, respectively, p < 0.001). In addition, the differences between the two groups in terms of gas-related complications, such as pneumoperitoneum, pneumomediastinum, and subcutaneous emphysema were statistically significant (all p < 0.05). Conclusions The efficacy of POEM was comparable between the two groups. However, the supine position with the right shoulder raised significantly reduced the operative time and the rate of procedure-related adverse events, especially gas-related complications.

Influence of patient position in thoracoscopic esophagectomy on postoperative pneumonia: a comparative analysis from the National Clinical Database in Japan.

Two prominent patient positions during thoracoscopic esophagectomy are the left lateral decubitus position (LP) and the prone position (PP). However, whether the patient position during thoracoscopic esophagectomy influences short-term outcomes, especially postoperative pneumonia, remains unclear. We aimed to elucidate the impact of patient position on the occurrence of postoperative pneumonia. We analyzed 9850 patients who underwent oncologic thoracoscopic esophagectomies between 2016 and 2019 from the National Clinical Database. We compared the short-term outcomes between the LP and PP groups, and the primary outcome measure was the incidence of postoperative pneumonia. This study included 2637 (26.8%) and 7213 (73.2%) patients in the LP and the PP groups, respectively. The baseline characteristics of the two groups were well-balanced. Compared with the LP group, the PP group had a longer operative time and less blood loss. There were no significant differences in the incidences of postoperative pneumonia, recurrent laryngeal nerve palsy, anastomotic leakage, severe complications, and reoperation between the groups. Meanwhile, prolonged ventilation and surgery-related mortality occurred more frequently in the LP than in the PP group (P < 0.001 and 0.046, respectively). After multivariable adjustment, the patient position did not significantly influence the incidence of postoperative pneumonia (odds ratio 0.91, 95% confidence interval 0.80-1.04). Although prolonged ventilation and surgery-related mortality occurred more frequently in the LP group than in the PP group, the patient position did not significantly influence the occurrence of postoperative pneumonia.

Effect of Lateral Positioning on Oxygen Levels in an Obese, Critically Hypoxic COVID-19 Patient

COVID-19 is an infectious disease caused by SARS-CoV-2 virus. COVID-19 patients can develop a severe disease that can lead to hypoxic respiratory failure and acute respiratory distress syndrome (ARDS), which requires mechanical ventilation, prone ventilation, and salvage therapy like extracorporeal membrane oxygenation. The COVID lung is a hypoxic lung with myriad of reasons of hypoxia including poor ventilation perfusion mismatch and atelectasis. We present a case report of a morbidly obese individual managed with lateral positioning as a salvage for deteriorating PaO2/FiO2 ratio. We also demonstrated that the improvement of oxygenation was due to the recruitment of previously nonventilated lung areas as demonstrated by electrical impedance tomography (EIT). Our patient was morbidly obese and there was a dearth of man power to perform the prone position on this patient. Moreover, the sheer weight of this patient prevented us from trying the prone position. Hence, this patient was placed in a cycle of left lateral, right lateral, and supine position for 120 minutes each for the subsequent 24 hours. Significant improvement in oxygenation and ventilation was noticed in the EIT and SpO2 measurements. The EIT reading indicated ventilation redistribution to previously collapsed areas of the lung and this change persisted even when the patient was turned supine due the application of positive end expiratory pressure (PEEP) to maintain positive expiratory transpulmonary pressure. These results provide evidence of effectiveness of a lateral positioning in the improvement of oxygenation in COVID-19 ARDS.