Avoiding, diagnosing and treating well leg compartment syndrome after pelvic surgery

Well-leg compartment syndrome after laparoscopic low anterior resection in the lithotomy position: a case report and literature review

Well-leg compartment syndrome (WLCS) develops in healthy lower limbs because of surgical factors such as operative position, lower limb compression, and long operative time during abdominopelvic surgery. WLCS can lead to irreversible muscle and nerve damage if a prompt diagnosis and appropriate treatment are not provided. We report the case of a 57-year-old male who developed rectal cancer immediately after laparoscopic low anterior resection and was successfully treated with fasciotomy without sequelae. Patients who undergo surgery in the lithotomy position for a prolonged period are at risk of WLCS. Therefore, when determining the differential diagnosis of postoperative lower leg pain, it is necessary to consider WLCS because it is a complication caused by the intraoperative position.

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.

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.

The Extraperitoneal Approach to Left-Sided Colorectal Resections: A Human Cadaveric Study

INTRODUCTION

Technical challenges during laparoscopic and robotic anterior resection include identification of key retroperitoneal structures and obtaining clear views of the inferior mesenteric artery (IMA) pedicle and total mesorectal excision (TME) plane. Steep head-down position improves surgical exposure but is associated with cerebral oedema, high intrapulmonary pressures, and rare neurological complications. In this article we describe the key steps of an anterior resection performed via the extra-peritoneal (XP) space in the supine position.

METHODS

The technique of same-side lateral-to-medial XP dissection has been developed and refined in serial cadaveric workshops. A standard periumbilical port is inserted for initial laparoscopic exploration. Dissection is then performed in the left XP space via a 5 cm skin incision (later used as the extraction site) to allow for insertion of four (latterly three) working ports. The colon is mobilized along its lateral attachments, reflecting retroperitoneal structures down and away. The IMA pedicle is taken proximally, next to the duodenum. If required, TME dissection can be continued in the same plane. A short intraperitoneal phase is then required to complete the procedure.

RESULTS

Eight cadavers were studied (seven males; median 78 y). Four operations were performed laparoscopically and four robotically. Excellent views of the key retroperitoneal structures were achieved early in the procedure. Anatomical identification was performed sequentially for left-sided structures-psoas tendon, gonadal vessel, ureter, common iliac artery, IMA, and duodenum before ligation of the IMA pedicle. High ligation of IMA on the aorta and splenic flexure mobilization were performed in all eight procedures.

CONCLUSIONS

This novel study shows it is feasible to perform the key steps of an anterior resection using the XP space in the supine position. This will reduce the need for steep head-down positioning which may have meaningful clinical benefits. Prospective clinical studies are required to validate the technique within a patient population.

Synchronous robotic repair of anterior diaphragmatic (Morgagni) hernia & low anterior resection for rectal cancer

BACKGROUND

We present the case report of synchronous trans-fascial repair of a large congenital Morgagni hernia (MH) and low anterior resection using a fully robotic approach.

METHODS

A 61-year old female presented with fresh red blood in her stool. She had a previous history of abdominal hysterectomy and a performance status of 0. Imaging revealed a low rectal cancer and incidental large MH.

RESULTS

Using the Da Vinci X platform the procedure was successfully performed; total operating time of 450 min, <200 ml blood loss and 5 days hospital stay. Post-operative scan at 6 months, 1 and 2 years showed no evidence of hernia or cancer recurrence.

CONCLUSION

We have demonstrated that complex multi-visceral procedures can be safely performed on fully robotic platforms, even in previously disturbed surgical fields. The robotic approach may provide the opportunity for seamless multi-speciality operating simultaneously in multiple body cavities.

Analysis of external pressure on the left calf in the Lloyd-Davies position during colorectal surgery

PURPOSE

Well-leg compartment syndrome (WLCS) is a potentially life-threatening postoperative complication related to the Lloyd-Davies surgical position, which can place increased external pressure on the calf region. We conducted this study to analyze external pressure changes, by applying a leg holder system to the left calf region of patients placed in the Lloyd-Davies position during laparoscopic surgery.

METHODS

The study participants were 50 patients who underwent laparoscopic surgery for colorectal cancer in the Lloyd-Davies position. We assessed the maximum external pressure (MEP) on the left calf region using a pressure-distribution measurement system. Intraoperative measurements were taken continuously, and the MEP was evaluated with the patient horizontal and every 30 min during surgery in the head and right-down tilt position.

RESULTS

The intraoperative MEP increased gradually when the patient was in the head and right-down tilt position and decreased when the patient was returned to the horizontal position. The MEP was higher in patients aged < 60 years, those who were obese, and those with a thick calf circumference. Both body mass index (BMI) and the maximum left calf circumference (MLCC) were found to correlate with the MEP.

CONCLUSIONS

In addition to a high BMI, which is a well-known risk factor for WLCS, a high MLCC should be considered another risk factor, especially for patients under 60 years.

Thenar Compartment Syndrome Related to Tightened Radial Arterial Line During Robotic Laparoscopic Surgery: A Case Report

We present a 54-year-old man who developed an unexpected thenar space compartment syndrome after robotic laparoscopic surgery, which was caused when the radial arterial pressure tubing was pulled too tightly around the base of the thumb while changing the surgical position. A conventional method of securing the tubing by looping it around the thumb appeared to be the primary cause. This complication went unnoticed during the surgery because the arm was tucked out of sight; there were no remarkable findings on monitoring. This case highlights the risks of looping tubing around the thumb, especially if continual inspection is not possible.

Effect of intraoperative operating table rotation on lower limb perfusion index in patients in the lithotomy position

We focused on "returning to the horizontal position," one of the measures for preventing well leg compartment syndrome implemented at our hospital, and aimed to clarify the effect of intraoperative positional changes by operating table rotation on blood perfusion in the lower extremities during lithotomy in patients under general anesthesia. This prospective observational study examined 64 patients scheduled to undergo general anesthesia in the lithotomy position from March 2021 to May 2022. The primary endpoint was the perfusion index (PI) of the lower limb before and after operating table rotation. The baseline lower limb PI before the operating table rotation was 2.376 (1.591), and the lower limb PI after the change from Trendelenburg to the horizontal position was as follows: immediately after, 2.123 (1.405); 5 minutes, 1.894 (1.138); 10 minutes, 1.915 (1.167); and 15 minutes, 1.993 (1.218). Compared with the baseline, no significant difference was noted in the change in the lower limb PI due to the Trendelenburg to horizontal positional change. The baseline lower leg pressure before the operating table rotation was 51.4 (13.4) mm Hg, and the lower leg pressure after the change from the Trendelenburg to the horizontal position was as follows: immediately after, 36.6 (10.3) mm Hg; 5 minutes, 36.5 (10.2) mm Hg; 10 minutes, 36.4 (10.0) mm Hg; and 15 minutes, 36.5 (10.2) mm Hg. Compared with the baseline, the change in lower leg pressure due to the Trendelenburg to horizontal positional change showed a significant decrease immediately afterward (P < .001). After operating table rotation from the Trendelenburg to the horizontal position, the lower limb PI did not change significantly after 15 min. However, lower leg pressure showed a significant decrease immediately after returning to the horizontal position. This result provides evidence for operating table rotation as a preventive measure for well leg compartment syndrome.

A Case of Well Leg Compartment Syndrome After Robot-assisted Laparoscopic Prostatectomy:With Review

Robot-assisted laparoscopic prostatectomy (RALP) for prostate cancer was introduced in 2000 and rapidly gained popularity. The Da Vinci Surgical System? can ensure improved local control of cancer and fewer perioperative complications. However, RALP is performed in the steep-Trendelenburg position (a combination of lithotomy and head-down tilt position/Lloyd-Davies position) to obtain a good surgical view, and as a result, well leg compartment syndrome (WLCS) can become a serious complication of RALP. Here, we report a case of WLCS after RALP. A 75-year-old man underwent surgery for prostate cancer and immediately complained of pain and numbness after surgery. The pressure of the four leg compartments increased. Ultimately, we diagnosed the patient with WLCS in his right leg, and an emergency fasciotomy was performed. He completely recovered with no permanent disability and was discharged one month after rehabilitation. Although WLCS after RALP is a rare and severe complication, the patient recovered completely with early diagnosis and intervention. Measuring the compartment pressure is useful when the patient is drowsy immediately after recovery from anesthesia. Preventing WLCS requires identifying this condition as a potential complication of RALP and all urologic surgeries performed in the lithotomy position. J. Med. Invest. 69 : 145-147, February, 2022.

Intraoperative pressure monitoring of the lower leg for preventing compression-related complications associated with the lithotomy position

BACKGROUND

Several serious complications are associated with the lithotomy position, including well-leg compartment syndrome and peroneal nerve paralysis. The aims of this study were to identify risk factors for the intraoperative elevation of lower leg pressure and to evaluate the effectiveness of monitoring external pressure during surgery for preventing these complications.

METHODS

The study included 106 patients with a diagnosis of sigmoid colon or rectal cancer who underwent elective laparoscopic surgery between June 2019 and December 2020. We divided the posterior side of the lower leg into four parts (upper outside, upper inside, lower outside, lower inside) and recorded the peak pressure applied to each area at hourly intervals during surgery (called "regular points") and when the operating position was changed (e.g., by head-tilt or leg elevation; called "points after change in position"). When the pressure was observed to be higher than 50 mmHg, we adjusted the position of the leg and re-recorded the data. Data on postoperative leg-associated complications were also collected.

RESULTS

The pressure was measured at a total of 1125 points (regular, n = 620; after change of position, n = 505). The external pressure on the upper outer side of the right leg (median, 36 mmHg) was higher than that on any other area of the lower leg. The pressure increase to more than 50 mmHg was observed not only during the change of position (27.5%) but also during regular points (22.4%). Bodyweight, strong leg elevation, and low head position were identified as factors associated with increased external pressure. There have been no compression-related complications in 534 cases at our institution since the introduction of intraoperative pressure monitoring.

CONCLUSIONS

Several risk factors associated with increased external pressure on the lower leg were identified. Intraoperative pressure monitoring might help reduction of pressure-related complications, needing further and larger prospective data collections.

Bilateral Well Leg Compartment Syndrome as a Complication of Prolonged Lithotomy Position in Abdominoperineal Resection Surgery

Patients undergoing prolonged surgery in a lithotomy position may develop acute lower limb compartment syndrome in the absence of trauma or pre-existing vascular disease, otherwise known as well-leg compartment syndrome (WLCS). Early recognition and management would prevent the potential, lethal complications associated with this condition. We present a case of a 55-year-old gentleman who developed bilateral WLCS after prolonged abdominoperineal resection of his pelvic liposarcoma.

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.

•

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

•

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

•

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

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

'Well-leg' compartment syndrome (WLCS) is an uncommon, but potentially devastating, complication associated with prolonged patient positioning for abdomino-pelvic surgery. Gynaecologists, anaesthetists and the wider theatre team share a responsibility to minimise the risk of this highly morbid, and even fatal, postoperative complication. This article provides an overview of WLCS related to gynaecological surgery - raising awareness amongst gynaecologists and highlighting the time-critical nature of diagnosis and management. Given the potential litiginous nature of this complication, we also present a perioperative checklist and risk-reduction protocol to suggest a standardised approach to prevention and relevant documentation. TWEETABLE ABSTRACT: Gynaecologists share a responsibility to minimise the risk of postoperative 'well-leg' compartment syndrome.

Compartment syndrome: a rare complication following laparoscopic colorectal surgery

We present a 71-year-old man who developed left calf pain after an elective laparoscopic assisted anterior resection. A clinical picture with a raised creatine kinase and negative Doppler ultrasound was suggestive of compartment syndrome. Successful surgical management was performed with two incisional fasciotomies to release all four compartments of the left leg. The patient recovered well postoperatively. The lateral incision was closed primarily while the medial incision required vacuum-assisted closure dressings and healed by secondary intention. Neither wound required skin grafts. The patient recovered well but had an extended hospital stay due to extensive physiotherapy requirements and mild foot drop. This report is intended as a guide for clinicians when considering differentials in calf pain following surgery and to keep in mind the small risk of developing compartment syndrome after pelvic surgery.

Perioperative management and anaesthetic considerations in pelvic exenterations using Delphi methodology: results from the PelvEx Collaborative

Background

The multidisciplinary perioperative and anaesthetic management of patients undergoing pelvic exenteration is essential for good surgical outcomes. No clear guidelines have been established, and there is wide variation in clinical practice internationally. This consensus statement consolidates clinical experience and best practice collectively, and systematically addresses key domains in the perioperative and anaesthetic management.

Methods

The modified Delphi methodology was used to achieve consensus from the PelvEx Collaborative. The process included one round of online questionnaire involving controlled feedback and structured participant response, two rounds of editing, and one round of web-based voting. It was held from December 2019 to February 2020. Consensus was defined as more than 80 per cent agreement, whereas less than 80 per cent agreement indicated low consensus.

Results

The final consensus document contained 47 voted statements, across six key domains of perioperative and anaesthetic management in pelvic exenteration, comprising preoperative assessment and preparation, anaesthetic considerations, perioperative management, anticipating possible massive haemorrhage, stress response and postoperative critical care, and pain management. Consensus recommendations were developed, based on consensus agreement achieved on 34 statements.

Conclusion

The perioperative and anaesthetic management of patients undergoing pelvic exenteration is best accomplished by a dedicated multidisciplinary team with relevant domain expertise in the setting of a specialized tertiary unit. This consensus statement has addressed key domains within the framework of current perioperative and anaesthetic management among patients undergoing pelvic exenteration, with an international perspective, to guide clinical practice, and has outlined areas for future clinical research.

Well leg compartment syndrome following robot-assisted radical cystectomy in the lithotomy position: a case report

Background

The indications for robot-assisted urologic surgeries have expanded due to their low invasiveness. However, complicated surgical procedures lead to prolonged surgical duration, requiring patients to remain in the lithotomy position for an extended time. Well leg compartment syndrome (WLCS) is a known severe postoperative complication related to the lithotomy position.

Case presentation

We report a case of WLCS after robot-assisted radical cystectomy (RARC), in which the patient recovered without neurological sequelae. A 55-year-old, obese male who underwent RARC complained of right leg pain and paresthesia 3 h after the surgery that lasted for 481 min. Emergency evaluation revealed unilateral WLCS in the anterior and lateral compartments. Urgent fasciotomy was performed 4 h after symptom onset. He thereafter recovered completely and was discharged without any neuromuscular dysfunction.

Conclusions

Early detection of WLCS, surgical treatment, and additional measures are crucial to prevent its life-threatening and/or disabling outcomes.

[CLINICAL OUTCOMES OF GENDER AFFIRMING SURGERY FOR GENDER DYSPHORIA/INCONGRUENCE: A SINGLE-INSTITUTE EXPERIENCE]

(Purpose) To investigate clinical outcomes of gender affirming surgery performed for gender dysphoria/incongruence. (Material and methods) This retrospective observational study included 59 transgender persons (41 transgender men and 18 transgender women) who received gender affirming surgery at Sapporo Medical University Hospital from June 2006 through December 2018. Their medical charts were reviewed and peri- and postoperative complications within one year after surgery were checked and graded according to the Clavien-Dindo classification. In addition, the voiding condition in transgender men, and the length of the constructed vagina in transgender women were investigated over time as functional outcomes. (Results) The median age at surgery was 32 years and the median duration of gender affirming hormone treatment was 40 months. In transgender men, the median operation time and blood loss were 393 minutes and 970 ml, respectively. Two subjects needed red blood cell transfusion. For transgender women, the operation time was 347 minutes, and the blood loss was 590 ml, and none needed transfusion. Some postoperative complications were observed in the 18 transgender men, and 6 patients required surgical repair associated with the neo-urethra. Among the transgender women, 17 had postoperative complications but none of them was classified as grade 3 or more. Gait disorder occurred in 7, and remained in three even in the final observational period. This event occurred more often in those with a body mass index of 25 kg/m² or more, higher values of postoperative serum creatine kinase, and was more likely to occur with the use of a boot-type leg holder. As functional outcomes, urinary retention was observed in one transgender man after the cystostomy was removed, and temporary re-catheterization was needed. Others had no complaint about their urination. In the transgender women, the constructed vaginal length after skin inversion was gradually shortened (from 10 to 8 cm) for three months after surgery. (Conclusion) Gender affirming surgery was performed safely in our institution. It is necessary to investigate the long-term functional outcomes and/or the changes in quality of life between the pre- and postoperative periods in the future.

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.

Well-Leg Compartment Syndrome After Percutaneous Nephrolithotomy in the Galdakao-Modified Supine Valdivia Position

Purpose

The objective is to present a case of well-leg compartment syndrome in the Galdakao-modified supine Valdivia position.

Results

The case of a 32-year-old male, obese (105 Kg) and a former smoker is presented. The patient was positioned in the Galdakao-modified supine Valdivia position, with lower limbs bandaged, to perform a right percutaneous nephrolithotomy. In the immediate postoperative period, significant pain was reported in the left lower limb. The limb appeared oedematous and cyanotic, although pedis pulses were preserved. Doppler ultrasound ruled out venous thrombosis. Suspecting compartment syndrome, the patient underwent a complete decompression fasciotomy of the four left leg compartments. After the surgery, values of creatine phosphokinase reached 80.000 UI/L and serum creatinine levels were 1.53 mg/dL. The patient was taken to the intensive care unit. Six months after the episode, the patient still needs rehabilitation care. The compartment syndrome is a rare complication in lithotomy position, but never described in the Galdakao-modified supine Valdivia position before, with the lower limbs in moderate flexion, and with the ipsilateral lower limb in a slightly inferior position with respect to the other. It may lead to skin necrosis, permanent neuromuscular dysfunction, myoglobinuric renal failure, amputation and even death. Therefore, this complication must be suspected and early decompression of the compartment must be performed. Risk factors include obesity, peripheral vascular disease (advanced age, hypertension, hyperlipidemia and diabetes mellitus), height, hypothermia, acidemia, BMI, male sex, combined general-spinal anesthesia, prolonged surgery time, systemic hypotension, ASA (American Society of Anesthesiologists) class, lack of operative experience, vasoconstricting drugs, important bleeding during the surgery and increased muscle bulk.

Conclusion

Compartment syndrome is a potentially life-threatening complication that may occur in the Galdakao-modified supine Valdivia position. It should be suspected in cases with risk factors and compatible clinical symptoms and signs, and treated rapidly to avoid further complications.

Well Leg Compartment Syndrome after Contralateral Femoral Neck ORIF

The authors present a case of WLCS after femoral neck fracture fixation. While this is a rare complication, a high index of suspicion should exist. Surgeons should use well leg holders with caution and limit utilization time. Alternative methods of positioning to allow for fluoroscopic imaging exist. WLCS remains a clinical diagnosis; intracompartmental measurements can be used but should be cautiously interpreted. When the diagnosis of WLCS is made, emergent fasciotomies of the affected compartments should be performed. Surgeons should be aware of this complication when using a well leg holder and the potential catastrophic consequences if left ignored.