Compartment syndrome after gynecologic operations: evidence from case reports and reviews

Evaluation of the Postoperative Risk of Deep Tissue Injury to the Lower Extremities Following Surgery in the Lithotomy Position

Background The aim of this study was to determine the incidence of deep tissue injury (DTI) and potential risk factors after surgery in the lithotomy position. Methods All patients who underwent surgery in the lithotomy position under general anesthesia at a single center between January 2017 and December 2021 were retrospectively evaluated. The medical records of these patients were reviewed, and patient demographic and clinical characteristics, surgical data, and occurrence of DTI were recorded. Results During the study period, 5146 patients, 2055 (39.9%) males and 3091 (60.1%) females, with a mean age of 57.3 ± 17.4 years, underwent surgery in the lithotomy position. Seven (0.14%) patients developed DTI on their calf following surgery. All presented with severe pain and swelling, requiring prolonged hospital stay. Multivariate analysis showed that male sex (odds ratio (OR): 11.43; 95% confidence interval (CI): 1.15-113.34, p = 0.037), higher BMI (OR: 1.32; 95% CI: 1.17-1.50, p = 0.0001), and longer operation time (OR: 1.01; 95% CI: 1.004-1.014, p = 0.0002) were independent risk factors for postoperative DTI. Optimal cut-off values for BMI and operation time were 23.5 kg/m2 (sensitivity = 100%; specificity = 64%) and 285 minutes (sensitivity = 100%; specificity = 90%), respectively. Conclusion Factors significantly associated with DTI include male sex, higher BMI, and prolonged operation time.

Preventing well leg compartment syndrome among patients in the lithotomy position-Operating room nurses' perspectives: A qualitative study

AIM

To describe operating room nurses' experiences of well leg compartment syndrome and how they work perioperative to prevent it during the lithotomy position.

DESIGN

The study had a qualitative design.

METHODS

Focus group interviews were performed with 10 operating room (OR) nurses. The interviews were semi-structured and analysed by qualitative content analysis. The study complied with the Consolidated Criteria for Reporting Qualitative Research (COREQ).

RESULTS

The main theme showed that the OR nurses shoulder duty and responsibility, independently and in the team, but they need more structural support and knowledge. The themes showed that they follow routines whenever possible and take responsibility for positioning; however, they have to balance between flexibility and strict routines. Although they also develop and participate in teamwork, they still need further knowledge.

CONCLUSION

The severe complication of well leg compartment syndrome (WLCS) can occur when the patient is in the lithotomy position. Maintaining the same routines and paying attention to the WHO's surgical safety checklist were described as actions that could prevent well leg compartment syndrome.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution. We have interviewed nurses but without financial support since the study was performed and supervised within a master programme.

Well-leg compartment syndrome after robot assisted laparoscopic surgery for rectal cancer: A case report

INTRODUCTION

Lower limb compartment syndrome caused by improper positioning during surgery is called well-leg compartment syndrome. Although well-leg compartment syndrome has been reported in urological and gynecological patients, there have been no reports of well-leg compartment syndrome in patients who have undergone robot-assisted surgery for rectal cancer.

PRESENTATION OF CASE

A 51-year-old man was diagnosed with lower limb compartment syndrome by an orthopedic surgeon due to pain in both of his lower legs immediately following robot-assisted surgery for rectal cancer. Due to this, we started placing the patient in the supine position during these surgeries, and repositioned the patient to the lithotomy position following intestinal tract cleansing after rectal movement in the latter half of the surgery. This avoided the long-term effects of being in the lithotomy position. We compared the operation time and complications before and after the above measures were changed, in 40 cases of robot-assisted anterior rectal resection for rectal cancer performed at our hospital from 2019 to 2022. We found no extension of operation time and no occurrence of lower limb compartment syndrome.

DISCUSSION

There have been several reports describing the risk reduction of WLCS using intraoperative postural changes. An intraoperative postural change from a natural supine position without pressure which we reported is considered to be a simple preventive method for WLCS.

CONCLUSION

Changing the patient from the supine position to the lithotomy position during surgery may be a clinically acceptable countermeasure to prevent lower limb compartment syndrome.

Well leg compartment syndrome due to the lithotomy position in orthopedic surgery: a report of two cases and a review of the literature

The well leg compartment syndrome (WLCS) is a complication that can occur because of the lithotomy surgical position. Although it is a very rare entity, it can lead to a permanent disability if not properly treated. Very few cases have been described in the literature as a result of orthopedic surgery. We present two cases of WLCS that developed because of the lithotomy position. The first case concerns a patient who sustained a left floating knee and developed a compartment syndrome of the right uninjured calf during surgery. A good outcome has been achieved after early fasciotomies. The second case is about a patient who developed a compartment syndrome of the right buttock after a left unicompartmental knee replacement. This patient was treated conservatively because of delayed diagnosis. A brief literature review regarding the WLCS in orthopedic surgery is also conducted.

Perioperative considerations for cancer patients with obesity: A narrative review

Cancer in patients with obesity has become increasingly common throughout much of the world. Based on our experiences in a specialized cancer center, we have developed a set of standards and expectations that should streamline the surgical journey for this patient population. These recommendations should inform the perioperative management of oncology patients with obesity and help raise awareness of this critical and under-discussed topic.

Acute limb ischemia following perineal reconstruction in lithotomy position: take-home message for plastic surgeons

Despite the extensive use of lithotomy position in several plastic surgery procedures, most reports regarding the related incidence of complications are presented in the urologic, gynecologic, and anesthesiologic fields. We present the case of a 54-year-old male patient. polytrauma patient who underwent internal iliac artery embolization leading to extensive gluteal necrosis requiring: debridement, abdominoperineal resection and composite anterolateral thigh flap reconstruction with prolonged lithotomy position. The patient presented lower limb ischemia briefly after surgical theater. A computed tomography scan revealed the obstruction of the left superficial femoral artery requiring emergency revascularization. Arterial thrombosis is a potentially devastating complication and plastic surgeons should be aware of the possible dangers when performing surgeries in prolonged lithotomy position. Preoperative detection of patients at high risks for developing complications should be performed in order to implement preventive measures and avoid potentially life-threatening sequelae.

The Safe Practice of Female Genital Plastic Surgery

The purpose of this article is to guide surgeons in the safe practice of female genital plastic surgery when the number of such cases is steadily increasing. A careful review of salient things to look for in the patient's motivation, medical history, and physical examination can help the surgeon wisely choose best candidates. The anatomy is described, with particular attention given to the variations not generally described in textbooks or articles. Descriptions are included for labiaplasty, including clitoral hood reduction, majoraplasty, monsplasty, and perineoplasty with vaginoplasty. Reduction of anesthetic risks, deep venous thromboses, and pulmonary emboli are discussed, with special consideration for avoidance of nerve injury and compartment syndrome. Postoperative care of a variety of vulvovaginal procedures is discussed. Videos showing anatomic variations and surgical techniques of common female genital procedures with recommendations to reduce the complication rate are included in the article.

The Prevention of Positioning Injuries During Gynecologic Surgery. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry Number 015/077, October 2020)

Purpose Positioning injuries are relatively common, forensically highly relevant complications of gynecologic surgery. The aim of this official AWMF S2k-guideline is to provide statements and recommendations on how to prevent positioning injuries using the currently available literature. The literature was evaluated by an interdisciplinary group of experts from professional medical societies. The consensus on recommendations and statements was achieved in a structured consensus process. Method The current guideline is based on the expired S1-guideline, which was updated by a systematic search of the literature and a review of relevant publications issued between February 2014 and March 2019. Statements were compiled and voted on by a panel of experts. Recommendations The guideline provides general and specific recommendations on the prevention, diagnosis and treatment of positioning injuries.

Prevention of well-leg compartment syndrome following lengthy medical operations in the lithotomy position

Purpose

Compartment syndrome that occurs after lengthy surgery in the lithotomy position is known as well-leg compartment syndrome. It has serious consequences for patients, including amyotrophic renal failure, limb loss, and sometimes even death. This study aimed to identify effective preventive measures against well-leg compartment syndrome using a retrospective cohort study of 1,951 patients (985 and 966 in the prevention and control groups, respectively).

Material and methods

The following preventive interventions were analyzed: (1) changing from the lithotomy position to the open-leg position, (2) removing lower leg pressure caused by the lithotomy position, (3) limiting leg elevation based on the height of the right atrium, (4) horizontally repositioning the operating table every 3 hours, and (5) decompressing the contact area of the lower leg in the lithotomy position during operation.

Results

Eight cases of well-leg compartment syndrome occurred in the control group, whereas no well-leg compartment syndrome occurred in the prevention group.

Conclusion

These findings suggest that the five interventions assessed can prevent the development of well-leg compartment syndrome.

Safety in Female Genital Plastic Surgery

LEARNING OBJECTIVES

After studying this article, participants should be able to: (1) Identify the most appropriate type of anesthesia for the female genital plastic surgical patient and minimize risks of nerve injury and thromboembolic event through proper preoperative evaluation and knowledge of positioning. (2) Define the vulvovaginal anatomy, including common variants, and assess vulvovaginal tissues after childbirth and menopause. (3) Apply surgical techniques to minimize complications in female genital plastic surgery. (4) Classify the types of female genital mutilation/cutting and design methods of reconstruction after female genital mutilation/cutting.

SUMMARY

Female genital plastic surgery is growing in popularity and in numbers performed. This CME article covers several aspects of safety in the performance of these procedures. In choosing the best candidates, the impact of patient motivation, body mass index, parity, menopause and estrogen therapy is discussed. Under anesthesia, consideration for the risks associated with the dorsal lithotomy position and avoidance of compartment syndrome, nerve injury, deep venous thromboses, and pulmonary embolus are covered. Anatomical variations are discussed, as is the impact of childbirth on tissues and muscles. Surgical safety, avoidance of complications, and postoperative care of a variety of vulvovaginal procedures are discussed. Videos showing anatomical variations and surgical techniques of the most common female genital procedures with recommendations to reduce the complication rate are included in the article. Finally, female genital mutilation/cutting is defined, and treatment, avoidance of complications, and postoperative care are discussed.

Postoperative non-traumatic compartment syndrome (PNCS) in gynecologic surgery

PURPOSE

The postoperative non-traumatic compartment syndrome (PNCS) is a rare, but serious postoperative complication. Etiology, risk factors and clinical manifestation of PNCS are not well characterized since data in gynecologic and obstetric patients are limited.

METHODS

We performed a retrospective monocentric study of patients who underwent surgery for gynecologic or obstetrics conditions and identified five cases of PNCS, which were analyzed and compared to a control cohort in regard of incidence, clinical presentation, risk factors and clinical outcome.

RESULTS

Five cases of PNCS were identified among 19.432 patients treated between 2008 and 2019 with an incidence rate of 0.026%. The clinical examination was shown to be unreliable, lacking sensitivity in most clinical signs. Young age, obesity and long operation time were risk factors for the development of a PNCS. Fasciotomy for the treatment of a PNCS should not be delayed, since permanent function loss may occur early.

CONCLUSION

A low threshold of clinical suspicion might be prudent to identify PNCS following gynecologic surgery. In the presence of the described risk factors, any suspicion of a PNCS should be evaluated further and if necessary treated with fasciotomy urgently.

Well leg compartment syndrome in trauma surgery - femoral shaft fracture treated by femoral intramedullary nailing in the hemilithotomy position: case series and review of the literature

Well leg compartment syndrome (WLCS) is a rare complication which can occur following urological, gynecological, general surgical or orthopedic surgeries carried out with the lower limb in the hemilithotomy position. WLCS is associated with significant morbidity and mortality because delay in diagnosis and treatment can lead to loss of function and even life-threatening complications. During orthopedic surgeries on a traction table, such as femoral nailing, the contralateral “well leg” is often placed in the hemilithotomy position, thus facilitating the use of fluoroscopy. This position (also named the Lloyd-Davis position) consists of hip flexion, abduction, external rotation and knee flexion. We present the cases of two teenaged patients who underwent femoral nailing on an extension table of a femoral fracture and developed WLCS. We also present a review of the literature and a discussion of the pathophysiology, risk factors and treatment of this condition. Clinicians need to be aware of the risk factors for WLCS and have high index of suspicion. Further studies looking at the risks, benefits and feasibility of ways to reduce this risk are required.

A systematic review of mechanical thromboprophylaxis in the lithotomy position

BACKGROUND

Venous thrombosis and compartment syndrome are potentially serious complications of prolonged, lithotomy position surgery. It is unclear whether mechanical thromboprophylaxis in this group of patients modifies the risk of compartment syndrome. This qualitative systematic review examines the evidence base to guide clinical practice.

METHOD

A systematic review was performed guided by Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) criteria, to identify studies reporting relationships between lithotomy position, compartment syndrome and mechanical thromboprophylaxis. The aim was to determine if mechanical thromboprophylaxis influenced compartment syndrome risk in the lithotomy position.

RESULTS

Sixteen studies were identified: eight case reports or case series (12 patients), two completed audit cycles (approximately 2000 patients), four reviews and two volunteer case control studies (33 subjects). There were no randomised studies. Nine studies associated mechanical thromboprophylaxis with compartment syndrome risk but in each case a causative relationship was speculative. In contrast, five papers, including an experimental, cohort study and two observational, population studies recommended intermittent pneumatic compression as prevention against compartment syndrome in lithotomy position. One review and one case report were unable to make a recommendation.

CONCLUSIONS

The level of evidence addressing the interaction between the lithotomy position, compartment syndrome and mechanical thromboprophylaxis is weak. There is no conclusive evidence that mechanical thromboprophylaxis causes compartment syndrome in the lithotomy position. There is limited evidence to suggest intermittent pneumatic compression may be a safe method of mechanical thromboprophylaxis if accompanied by strict adherence to other measures to reduce the chance of compartment syndrome. However further studies are required.

Robot-assisted gynaecological cancer surgery-complications and prevention

Ever since the US Food and Drug Administration approval of the use of da Vinci surgical systems (Intuitive Surgical Inc., Sunnyvale, California) in gynaecology in 2005, robot-assisted surgery has been widely adopted in different countries. Some of the applications in benign and oncological gynaecology include myomectomy, sacrocolpopexy, tubal anastomosis, simple hysterectomy, radical hysterectomy, radical trachelectomy, pelvic and/or para-aortic lymphadenectomy and even debulking surgery for ovarian cancer and pelvic exenteration for recurrent cervical and vaginal cancer. Although there is robust evidence on the safety and treatment outcomes in robot-assisted surgery, complications still rarely occur. Team approach is particularly important in robotic surgery and thorough communication between the bedside assistant and the console surgeon cannot be stressed any more. Thus, complications can be due to miscommunication between the console surgeon and bedside assistant, positioning of the patients, the length of the operations, the malfunction of the instrument and the risks specific to the types of anaesthesia and surgery per se, leading to thromboembolism, haemorrhage, organ damage, and so on. The most important strategies that can prevent complications are to have thorough preoperative assessment of the patients' fitness, good communication between surgical team members, caution regarding the positioning, a good knowledge of the pelvic and abdominal anatomy, careful and meticulous manipulation of the instrument and early recognition of the complications. In this article, different types of complications and the preventive measures are described.

Lower limb compartment syndrome by reperfusion injury after treatment of arterial thrombosis post-laparoscopic radical hysterectomy and pelvic lymph node dissection for cervical cancer

Compartment syndrome is a clinical condition associated with decreased blood circulation that can lead to swelling of tissue in limited space. Several factors including lithotomy position, prolonged surgery, intermittent pneumatic compressor, and reperfusion after treatment of arterial thrombosis may contribute to compartment syndrome. However, compartment syndrome rarely occurs after gynecologic surgery. In this case, the patient was diagnosed as compartment syndrome due to reperfusion injury after treatment of arterial thrombosis, which occurred after laparoscopic radical hysterectomy and pelvic lymph node dissection for cervical cancer. Despite its rarity, prevention and identifying the risk factors of complication should be performed perioperatively; furthermore, gynecologist should be aware of the possibility of complications.

Delayed diagnosis of single compartment muscle contusion after radical hysterectomy in the lithotomy position: A case report

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In lithotomy position, surgeries performed can result in muscle contusion.

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MRI can help to detect light muscle contusion.

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Routine physical examination may be needed for identification of muscle contusions.

Introduction

Muscle contusions usually occur as a result of blunt trauma, which damages the muscle fibers and connective tissue without breaking the skin. Rapid bleeding can cause an increase in pressure that requires surgical intervention, commonly referred to as compartment syndrome. Here, we report a case with delayed diagnosis of single compartment muscle contusion in which compartment syndrome did not develop.

Presentation of case

A 50-year-old woman underwent radical hysterectomy. She complained of edema and tenderness in the lower left leg on postoperative day 6. The serum creatine phosphokinase level was slightly elevated at 177 IU/L (normal range: 6–142 IU/L). T2-weighted magnetic resonance imaging revealed swelling of the muscle in the deep posterior compartment of the lower left leg, edematous fascia, and subcutaneous adipose tissue. She recovered naturally without other complications.

Discussion

In the lithotomy position during surgery, muscle contusion might occur, without general symptoms.

Conclusion

Magnetic resonance imaging is useful for diagnosis. For patients who complain of edema and tenderness in the lower leg after surgery in the lithotomy position, muscle contusions should be considered.

Complications of Hysteroscopic and Uterine Resectoscopic Surgery

Adverse events associated with hysteroscopic procedures are generally rare, but, with increasing operative complexity, it is now apparent that they are experienced more often. There exists a spectrum of complications that relate to generic components of procedures, such as patient positioning, anesthesia, and analgesia, to a number that are specific to intraluminal endoscopic surgery that largely comprise perforation and injuries to surrounding structures and blood vessels. Whereas a number of endoscopic procedures require the use of distending media, the response of premenopausal women to excessive absorption of nonionic fluids used for hysteroscopy is somewhat unique, and deserves special attention on the part the surgeon. There is also an increasing awareness of uncommon but problematic sequelae related to the use of monopolar radiofrequency uterine resectoscopes that involve thermal injury to the vulva and vagina. Furthermore, the uterus that has previously undergone hysteroscopic surgery may behave in unusual ways, at least in premenopausal women who experience menstruation or who become pregnant. Fortunately, better understanding of the mechanisms involved in these adverse events, as well as the use or development of a number of innovative devices, have collectively provided the opportunity to perform hysteroscopic and resectoscopic surgery in a manner that minimizes risk to the patient.

The dangers of lithotomy positioning in the operating room: case report of bilateral lower extremity compartment syndrome after a 90-minutes surgical procedure

BACKGROUND

Lower extremity acute compartment syndrome after gynecologic surgery in the lithotomy position is a rare, yet potentially devastating complication. A high level of suspicion is paramount for early recognition and mitigation of acute compartment syndrome originating from prolonged surgery in lithotomy position.

CASE PRESENTATION

A 23-year-old female, gravida 1, para 0, underwent a laparoscopic salpingectomy for a ruptured ectopic pregnancy. Surgical time was 90 min. Postoperatively, the patient developed acute compartment syndrome of both legs necessitating emergent bilateral four-compartment fasciotomies, with repeated returns to the operating room for 2nd look procedures and delayed wound closures. The patient regained full function within 3 months and returned to an unrestricted baseline activity level.

CONCLUSION

Technical diligence in applying a lithotomy position is paramount for preventing postoperative lower extremity compartment syndrome. A high level of suspicion for this severe complication in conjunction with early recognition and immediate surgical management can mitigate long-term adverse sequelae and improve postoperative outcomes.

Well leg compartment syndrome after surgery for ulcerative colitis in the lithotomy position: A case report

INTRODUCTION

Well leg compartment syndrome (WLCS) is an uncommon and severe complication that occurs after colorectal surgery in the lithotomy position.

PRESENTATION OF CASE

The current patient was a 28-year-old male suffering from ulcerative colitis. He was underwent elective proctectomy, including ileal J pouch formation and anal anastomosis with temporary loop ileostomy. The ileoanal pouch procedure was quite difficult, and during this procedure, the high lithotomy and head down tilt positions were continued for 255min. After the operation, the patient complained of severe cramping pain, swelling and serious tenderness on palpation in both legs. On the first postoperative day, the patient's complaints gradually worsened. The intra-compartmental pressure was measured, and WLCS was diagnosed. Emergency bilateral fasciotomy was performed. Initially, the patient had a sensory deficit and analgesia, however, his sensory disturbance and pain had almost recovered two months after fasciotomy by rehabilitation.

DISCUSSION

In the current case, the important factors associated with the development of WLCS are thought to be a prolonged operative time in which the patient is placed in the high lithotomy position during ileoanal pouch procedure.

CONCLUSION

We would thus like to emphasize that operations for the ileoanal pouch procedure to treat ulcerative colitis have a high potential for inducing WLCS, because it usually requires a prolonged operative time in which the patient remains in the high lithotomy position.

The Prevention of Positioning Injuries during Gynecologic Operations. Guideline of DGGG (S1-Level, AWMF Registry No. 015/077, February 2015)

Purpose: Official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). Positioning injuries after lengthy gynecological procedures are rare, but the associated complications can be potentially serious for patients. Moreover, such injuries often lead to claims of malpractice and negligence requiring detailed medical investigation. To date, there are no binding evidence-based recommendations for the prevention of such injuries. Methods: This S1-guideline is the work of an interdisciplinary group of experts from a range of different professions who were commissioned by DGGG to carry out a systematic literature search of positioning injuries. Members of the participating scientific societies develop a consensus in an informal procedure. Afterwards the directorate of the scientific society approves the consensus. The recommendations cover.

Lower Leg Compartment Syndrome after Appendicectomy

A 10-year-old boy presented with severe left lower leg pain, uncontrolled with increasing analgesia after appendicectomy. A diagnosis of acute compartment syndrome was made after a delayed referral to the orthopaedic service. The patient subsequently underwent an emergency fasciotomy and made a good functional recovery. To the best of our knowledge this is the first reported case of paediatric lower leg compartment syndrome after appendicectomy in the literature. The case report serves to highlight the importance of maintaining a high index of suspicion for compartment syndrome.