'Well-leg' compartment syndrome associated with gynaecological surgery: a perioperative risk-reduction protocol and checklist

Complex hidradenitis suppurativa on a background of long-standing Crohn's disease requiring radical pelvic and perineal reconstruction: A case report

Key Clinical Message

A surgical MDT approach to high-complexity surgeries can allow maximal resection in order to achieve disease control and excellent functional outcomes, as demonstrated here for a case of hidradenitis suppurativa in a patient with Crohn's disease.

Abstract

Hidradenitis suppurativa is an autoimmune disease characterized by abscess and fistula formation with purulent discharge in intertriginous zones, and is associated with inflammatory bowel disease. We present the case of a patient with severe ongoing hidradenitis suppurativa causing osteomyelitis and affecting the perineum, on a background of Crohn's disease previously treated with panprotocolectomy and permanent ileostomy. The hidradenitis suppurativa was having a severe impact on the patient's quality of life, and she had failed to respond to conservative management. The patient opted for a radical two-step procedure: first her coccyx and sacrum were removed. The second step was a radical bilateral anterior vulvectomy and posterior vaginectomy, with preservation of the uterine body and cervix. An anterolateral thigh flap was used to reconstruct the perineum. This complex procedure required the expertise of multiple surgical specialties, including plastic, general, spinal, and gynecological oncology surgeons to achieve maximal disease resection, minimizing the risk of recurrence.

Efficacy of a portable interface pressure sensor for robotic surgery in preventing compartment syndrome

BACKGROUND/OBJECTIVE

This study determines whether the use of a portable interface pressure sensor (Palm Q) for robotic surgery could prevent compartment syndrome.

METHODS

In the present single center, non-trial observational study, patients diagnosed with gynecological diseases between April 2015 and August 2020 treated with laparoscopic or robotic surgery were enrolled. We assessed 256 cases involving surgery performed in the lithotomy position with an operative time >4 h. The Palm Q device was placed preoperatively on both sides of the patients' lower legs. The pressure was measured every 30 min preoperatively and intraoperatively and adjusted to ≤30 mmHg. If the pressure reached ≥30 mmHg, the operation was stopped, the patient was repositioned, the leg position was released, the pressure was reduced to ≤30 mmHg, and the procedure was resumed. We compared the maximum creatine kinase levels of the Palm Q and non-Palm Q groups. We also analyzed the correlation between the patients' symptoms postoperatively (shoulder and leg pain) and compartment syndrome.

RESULTS

Our data showed that immediate postoperative creatine kinase levels predict compartment syndrome. Propensity score matching of the 256 enrolled patients resulted in 92 cases (46 per group), balanced for age, body mass index, and lifestyle disease. Creatine kinase levels differed significantly between the Palm Q and non-Palm Q groups (p = 0.041). None of the patients in the Palm Q group experienced well-leg compartment syndrome complications.

CONCLUSION

Palm Q can potentially help to prevent perioperative compartment syndrome.

The role of multidisciplinary team and stepwise pelvic devascularization to minimize blood loss during total pelvic exenteration for patients refusing blood transfusion

Key Clinical Message

Radical gynecology oncology surgeries are feasible in patients refusing blood transfusion, when performed with careful preoperative (with hemoglobin optimization and patients' counseling), intraoperative (with hemostasis and stepwise devascularization, hemodilution, and autologous cell salvage) and postoperative (considering iron infusion or erythropoietin) planning with a multidisciplinary team involvement.

Abstract

We describe the case of a female Jehovah's Witness patient in her 60s undergoing pelvic exenteration, focusing on the preoperative, intraoperative, and postoperative measures that allowed an uncomplicated surgery without blood transfusion. Blood transfusions are common in the surgical management of gynecology oncology patients, up to 93% of patients undergoing pelvic exenteration may require blood products. However, increasingly more patients are cautious in receiving blood products, either for fear of potential risks or for religious believes. It is therefore vital to optimize the management of these patients in order to avoid blood transfusions. In this case, we summarize the management of a lady in her 60s who underwent laparotomy, pelvic exenteration, Bricker colicureterostomy, and end colostomy formation for recurrent endometrial carcinoma, despite previous total abdominal hysterectomy and bilateral salpingo-oophorectomy followed by brachytherapy, chemotherapy, and external beam radiotherapy for high-grade serous carcinoma. Preoperatively, an advance decision to refuse blood products was discussed to ascertain all the options that were suitable. As her preoperative hemoglobin was acceptable (127 g/L), no further intervention was required. Intraoperatively, blood loss was effectively minimized with meticulous hemostasis, stepwise pelvic devascularization, intraoperative hemodilution, and cell salvage. Despite these interventions, total blood loss was 1030 mL and postoperative hemoglobin was 113 g/L. Postoperative measures therefore included intravenous iron infusion, minimization of phlebotomy, and optimization of cardiopulmonary status. Erythropoietin was also considered, but was not necessary as patient responded to the previous measures well and was successfully discharged after an uncomplicated recovery. Only few cases of total pelvic exenteration have been described in the literature for Jehovah's Witness patients. However, our case shows that laparotomy and pelvic exenteration is feasible in patients refusing blood products, if performed under a multidisciplinary team and with careful preoperative, intraoperative, and postoperative planning, also in the setting of previous radical hysterectomy and co-adjuvant therapy.

Laterally extended endopelvic resection as part of the surgical management of disseminated retroperitoneal leiomyomatosis mimicking low-grade sarcoma in a patient with a solitary kidney

Leiomyomas are common benign uterine smooth muscle tumours. Rarer subsets may demonstrate aggressive extrauterine growth which mimic metastatic disease. We discuss the case of a female patient in her 40s, with a long-standing atrophic right kidney, presenting with a 17 cm uterine mass demonstrating bilateral para-aortic and pelvic sidewall spread. Although biopsies favoured the diagnosis of a benign tumour, a leiomyosarcoma could not be excluded. The surgical complexity of the case was compounded by a tumour residing close to the only functioning kidney and engulfment of the inferior mesenteric artery. The surgical procedures indicated were a radical hysterectomy, the laterally extended endopelvic resection procedure to achieve clear margins in the pelvic sidewall and a left hemicolectomy. In the absence of formal guidelines, we present this challenging case to provide clarity into the histological assessment and surgical management of rare leiomyomas, as well as an overview of the current literature.

Radical abdomino-pelvic surgery in the management of uterine carcinosarcoma with concomitant para-aortic lymphadenopathy metastasising from anal carcinoma

Uterine carcinosarcomas are aggressive gynaecological cancers comprising less than 5% of uterine malignancies. We present the case of a woman in her 70s with a complicated history of advanced anal carcinoma treated with pelvic radiotherapy and multiple laparotomies, who was referred to gynae-oncology following MRI surveillance imaging showing evidence of endometrial carcinoma and para-aortic lymphadenopathy. Successful surgical excision required multidisciplinary teamwork between gynae-oncology, colorectal and urology surgeons. The patient underwent midline laparotomy, with adhesiolysis, ileum resection and side to side anastomosis, posterior exenteration, left kidney mobilisation and suspension, para-aortic lymph node debulking and left ureteric stent insertion. Significant challenge was posed by the extensive adhesions from previous laparotomies and the debulking of the para-aortic lymph nodes around the renal vessels. This case demonstrates the importance of a multidisciplinary approach in complex pelvic surgery and the vitality of good communication between colleagues in achieving effective patient care.

Well Leg Compartment Syndrome: Pathophysiology, Prevention, and Treatment

The development of compartment syndrome involving the lower limb is a potentially devastating complication of prolonged surgery in patients held in the lithotomy position. Well leg compartment syndrome (WLCS) was recognized in 1953. The incidence of this condition has been reported to range from 0.20% to 0.03%. The mechanism of WLCS development in the absence of trauma appears to be related to prolonged hypoperfusion of the limb, pressure on the muscle compartments, and in some cases, reperfusion of the ischemic limb. This grave complication develops either during or immediately after prolonged surgery in which the patient was held in the Lloyd-Davies lithotomy or hemi-lithotomy position. Surgeons must be aware of the potential for WLCS development during prolonged surgery. Signs of developing WLCS include swelling, increased firmness of the muscle compartments, discoloration, and cooling of the limb. Preventive measures can be taken without contaminating the surgical field by returning the limb to the right atrium level. Once the diagnosis has been made, failure to prevent the development of WLCS requires extensile fasciotomy of each leg compartment to restore perfusion and relieve elevated intra-compartment pressures. This article reviews the pathophysiology, prevention, and treatment of WLCS.

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

Introduction and importance

Well-leg compartment syndrome (WLCS) develops from abnormal positioning of the limb during surgery. There have been few reports of WLCS in rectal cancer patients, although the lithotomy position, which is widely applied for rectal surgery, is a risk factor for WLCS.

Case presentation

A 56-year-old man with rectal cancer underwent laparoscopic low anterior resection of the rectum, left lateral lymph node dissection and diverting ileostomy. The operation time was 393 min. The patient was in the head-down tilt lithotomy position and rotated to the right side. Postoperatively, he complained of left lower leg pain and swelling and difficulty moving his legs. The compartment pressure of his right and left lower legs was 80 mmHg and 120 mmHg, respectively. A diagnosis of bilateral WLCS was made, and fasciotomy of both lower legs was performed 2 h after surgery. Although he was able to live his daily life, mild numbness remained in his toes one year after surgery.

Clinical discussion

In addition to risk factors previously reported for WLCS, our review shows that the male sex and left side are associated with a greater risk of WLCS, especially in rectal surgery. Additionally, our review reveals that the type of rectal surgery leading to WLCS is almost always laparoscopic surgery.

Conclusion

Surgeons should be especially vigilant for WLCS when they encounter patients, especially males, who complain of left lower leg pain after laparoscopic rectal surgery.

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Male sex, left leg, and laparoscopic are key factors for WLCS in rectal cancer.

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Leveling the patient every 3 h is important for prevention of WLCS.

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Surgeon's vigilance is vital for early diagnosis and resolution without sequela.