Compartment syndrome after prolonged surgery with leg supports

Compartment syndrome of the non-injured limb

Compartment syndrome is a common limb-threatening entity in trauma. However, the occurrence of the same in the non-injured limb is rare. It seems to be multifactorial in origin, with abnormal positioning being the most common cause. We present such a case of well-leg compartment syndrome which was treated by an urgent fasciotomy. We emphasise on the fact that the diagnosis of compartment syndrome is clinical and the management remains the same irrespective of whether the limb has sustained an injury or not.

Lower limb compartment syndrome following laparoscopic colorectal surgery: a review

AIM

  In spite of recent advances in technology and technique, laparoscopic colorectal surgery is associated with increased operating times when compared with open surgery. This increases the risk of acute lower limb compartment syndrome. The aim of this review was to gain a better understanding of postoperative lower limb compartment syndrome following laparoscopic colorectal surgery and to suggest strategies to avoid its occurrence.

METHOD

A MEDLINE search was performed using the keywords 'compartment syndrome', 'laparoscopic surgery' and 'Lloyd-Davies position' between 1970 and 2008. All relevant articles were retrieved and reviewed.

RESULTS

A total of 54 articles were retrieved. Of the 30 articles in English, five were reviews, six were original articles and 19 were case reports, of which only one was following laparoscopic colorectal surgery. The remaining 24 were non-English articles. Of these, two were reviews and 22 were case reports, of which only one was following laparoscopic colorectal surgery. The incidence of acute compartment syndrome following laparoscopic colorectal surgery is unknown. The following are believed to be risk factors for acute lower limb compartment syndrome: the Lloyd-Davies operating position with exaggerated Trendelenburg tilt, prolonged operative times and improper patient positioning. Simple strategies are suggested to reduce its occurrence.

CONCLUSION

Simple preventative measures have been identified which may help to reduce the incidence of acute lower limb compartment syndrome. However, if suspected, timely surgical intervention with four-compartment fasciotomy remains the standard of care.

A Pitfall of Protracted Surgery in the Lithotomy Position: Lower Extremity Compartment Syndrome

Although the lithotomy position is frequently used in urologic, gynecologic, and colorectal surgery, the potentially devastating complication of lower extremity compartment syndrome is not widely recognized. The authors report a 50-year-old woman who underwent 8 hours of colorectal surgery in the lithotomy position. After surgery she complained of bilateral calf pain and was noted to have episodes of ventricular tachycardia. After emergency dialysis for hyperkalemia, she required bilateral four-compartment calf fasciotomy. Prevention of compartment syndrome and its sequelae, when using the lithotomy position, requires minimizing the duration of time in lithotomy. If protracted surgery in lithotomy is necessary, the patient should be carefully monitored for compartment syndrome postoperatively. Urgent four-compartment fasciotomy is the treatment of choice if a compartment syndrome is clinically suspected.

Compartment syndrome of the lower leg after surgery in the modified lithotomy position: report of seven cases

PURPOSE

Acute compartment syndrome is known to develop after trauma or after postischemic revascularization. It also can occur when a patient has been lying in the lithotomy position during prolonged surgery. Methods were searched for the prevention of this iatrogenic complication after a series of seven patients who developed compartment syndrome after surgery at our hospital.

METHODS

A series of seven consecutive patients who developed compartment syndrome of the lower leg(s) after abdominoperineal surgical procedures from 1997 to 2002 is presented and so are the lessons learned to prevent this problem.

RESULTS

When comparing our experiences with data from literature, the seven patients had the usual risk factors for development of a compartment syndrome: lengthy procedure (>5 hours); decreased perfusion of the lower leg because of Trendelenburg positioning combined with the lithotomy position; and external compression of the lower legs (because of positioning, stirrups, or antiembolism stockings). Measures have been taken to prevent compartment syndrome from developing after prolonged surgery in the lithotomy position. This complication has not occurred again after the introduction of these measures two years ago.

CONCLUSIONS

Acute compartment syndrome can be prevented if adequate measures are taken, but after lengthy surgery, maximum alertness for emerging acute compartment syndrome remains indicated. Early diagnosis and treatment by four-compartment fasciotomy is still the only way to prevent irreversible damage.

Acute compartment syndrome of the legs after colorectal surgery

This review considers the causes, diagnosis and management of compartment syndrome affecting the legs after colorectal surgery.

Lower Limb (Well Leg) Compartment Syndrome After Urological Pelvic Surgery

PURPOSE

Well leg compartment syndrome (WLCS) is being seen more frequently as the complexity and duration of pelvic urological surgery increases, ie reconstruction/radical cancer surgery. The etiology of WLCS is multifactorial and prevention should form the mainstay of treatment. With significant morbidity and mortality, in particular lower limb morbidity secondary to fasciotomy wounds and long-term neurological sequelae, all urologists should be aware of this iatrogenic complication and how to prevent or treat it when it occurs.

MATERIALS AND METHODS

A retrospective review of the world literature using MEDLINE was performed from 1966 to 2002, searching for lower limb compartment syndrome (well leg compartment syndrome), and its association with the lithotomy position and pelvic surgery.

RESULTS

Although WLCS is not commonly reported in the urological literature, it has significant morbidity and mortality. The incidence of WLCS is probably under reported due to failed diagnosis or misdiagnosis. With increased awareness the incidence of this iatrogenic complication may be minimized or avoided altogether.

CONCLUSIONS

Because the lithotomy position is one of the most common positions used in urology, it is mandatory for urologists to be familiar with the complications associated with it. If this complication is recognized early, prompt treatment decreases morbidity and mortality. Minimizing the risk of WLCS will leave urologists less open to litigation, which may follow this significant iatrogenic complication.

Well-leg compartment pressures during hemilithotomy position for fracture fixation

OBJECTIVE

To evaluate the relationship between the well-leg compartment pressures and time during hemilithotomy position for fracture fixation.

DESIGN

Prospective.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Ten patients who underwent intramedullary nailing of a fractured femur in the hemilithotomy position (with a well-leg holder).

INTERVENTION

Continuous pressure monitoring was achieved with in-dwelling slit catheters inserted into the calf compartments of the well leg. Baseline measurements were obtained in the supine position. After the leg was placed in the hemilithotomy position, compartment pressures were monitored throughout surgery.

MAIN OUTCOME MEASUREMENTS

Calf compartment pressures at baseline, during hemilithotomy position, and post-hemilithotomy were compared. The association between body mass index and compartment pressure was analyzed.

RESULTS

A consistent pattern was observed between compartment pressures and time. The curve was that of a step function in which the pressure increased as soon as the leg was placed in the well-leg holder and remained elevated until the leg was taken down. The pressure jumped from a baseline of 9.2 to 27.3 millimeters of mercury (mm Hg) (p<0.0001). While in the hemilithotomy position, the leg pressure trended slightly upward. Once the leg was taken down, the pressure immediately returned to a near-baseline level of 8.1 mm Hg (p<0.0001). A significant correlation was also found between the body mass index and leg pressure (R2 = 0.713; F = 0.002).

CONCLUSIONS

The use of the well-leg holder to maintain hemilithotomy position increases the calf compartment pressures dramatically and significantly. Therefore, we recommend avoiding this position for fracture fixation in at-risk patients.

Lloyd-Davies position with Trendelenburg--a disaster waiting to happen?

PURPOSE

Lower limb compartment syndrome has been reported to occur after colorectal, urological, and gynecological procedures during which the patient's lower limbs are elevated for prolonged periods of time.

METHOD

We investigated lower limb perfusion in a group of patients undergoing prolonged pelvic surgery both during and immediately after surgery, using intra-arterial blood pressure monitoring, laser doppler flowmetry, and pulse oximetry.

RESULTS

Use of the modified lithotomy position was not associated with any demonstrable decrease in lower limb perfusion. The addition of 15 degrees head-down tilt, however, during pelvic dissection, led to an immediate and significant drop in lower limb perfusion (P < 0.05; Mann-Whitney U test). The subgroup of patients analyzed postoperatively showed a ten-fold increase (P < 0.01) in perfusion that was confined to the muscle compartment with no demonstrable increase in skin perfusion or intra-arterial pedal blood pressure.

CONCLUSION

The use of the modified lithotomy position during pelvic surgery is not associated with lower limb ischemia. Addition of Trendelenburg position, however, causes profound ischemia of the lower limbs, and this is followed during the recovery period by hyperperfusion that is confined to the muscle compartments, which may put patients at risk of developing lower limb compartment syndrome.

Neurovascular morbidity from the lithotomy position

The lithotomy position is used in pediatric surgery when it is necessary to have simultaneous access to the abdomen and perineum. At the authors' institution, after a prolonged period in the lithotomy position, significant lower limb complications developed in four patients. Two patients with Hirschsprung's disease underwent a redo Duhamel procedure, one had an anorectal leiomyoma excised, and one had an ileoanal anastomosis for ulcerative colitis. Sciatic nerve injury developed in two patients and deep venous thrombosis and bilateral compartment syndrome resulting in myonecrosis developed in one each. There is an association between operations that require prolonged lithotomy position and the development of postoperative neurovascular complications. By placing the child in the lithotomy position only when access to the perineum is required, these significant injuries may be avoided.

Effects of limb elevation on abnormally increased intramuscular pressure, blood perfusion pressure, and foot sensation: an experimental study in humans

OBJECTIVES

To study the effects of limb elevation on abnormally increased intramuscular pressure (IMP) and blood perfusion pressure in the anterior compartment of the leg.

DESIGN

An experimental cross-over design. The test leg was elevated and the control leg was kept at heart level.

PARTICIPANTS

Eight healthy subjects with a mean age of twenty-nine years.

INTERVENTION

IMP was measured in the anterior compartment of the leg, and blood pressures were taken in the left arm and both legs. Four variables were recorded (with or without venous stasis, with or without plaster cast). All measurements were made simultaneously in both legs.

RESULTS

When the leg was obstructed by venous stasis and elevated to between thirty-three and thirty-five centimeters, IMP decreased from 16.5 to 9.8 millimeters of mercury. When venous stasis was simulated in a level casted leg, the IMP was thirty-eight (SD = 6.4) millimeters of mercury but showed only a slight decline to thirty-five (SD = 7.8) millimeters of mercury after the leg was elevated. Blood perfusion pressure fell significantly once the leg was elevated, decreasing 53 percent from forty-seven (SD = 7.8) to twenty-five (SD = 8.0) millimeters of mercury (p < 0.001). All subjects experienced loss of foot sensation in the elevated limb.

CONCLUSION

In those cases in which venous stasis increased IMP levels in the anterior compartment of the leg, elevating the limb produced a 40 percent reduction in IMP. However, limb elevation did not significantly reduce increased IMP levels when the venous stasis occurred in a casted leg. Therefore, we believe casted legs in which abnormally increased IMP is attributable to venous stasis should not be elevated above heart level because elevation induces low perfusion pressure and sensory dysfunction.

Compartment syndrome as a complication of the prolonged use of the Lloyd-Davies position

Compartment syndrome in the legs is a rare complication of the prolonged use of the lithotomy position. We report two cases of compartment syndrome developing as a complication of the prolonged use of the Lloyd-Davies position. Both patients received combined general and epidural anaesthesia and postoperative epidural analgesia. The diagnosis was delayed in the first case, resulting in the avoidable complications of renal failure and permanent neuromuscular dysfunction.

Surgical cure for early rectal carcinomas (T1). Transanal endoscopic microsurgery vs. anterior resection

PURPOSE

This study was undertaken for the comparison of local resection for early rectal carcinomas using transanal endoscopic microsurgery or anterior resection.

METHODS

Data from 50 of 52 patients with proven adenocarcinoma (GI/II) and intraluminal ultrasound with Stage uT1 N negative (uTNM) were evaluated in a prospective randomized study with two therapeutic arms: transanal endoscopic microsurgery (TEM; n = 24) or anterior resection (AR; n = 26), performed under general anesthesia.

RESULTS

Patients' ages and rectal tumor locations showed insignificant differences of distribution in comparison of TEM with AR (Welsh's alternate t-test; t-test). Local recurrence (4.2 percent) and five-year survival rates (96 percent) differed insignificantly (log-rank test). Early postoperative mortality was zero. Significant differences were found comparing time of hospitalization, loss of blood, operation time, and opiate analgesia (Welsh's alternate t-test; Wilcoxon's test; each P < 0.05). Early and late morbidity differed considerably.

CONCLUSIONS

Lower morbidity, similar local recurrence, and survival rates favor the TEM technique. Comparable results in survival rate to the gold standard (AR) are objective arguments for choosing the adequate surgical procedure. For early rectal cancer, the minimum invasive TEM technique should be preferred because of superior overview during operation with safer suturing after meticulous full wall thickness excision.

Compartment syndrome following prolonged pelvic surgery

Compartment syndrome is a rare but serious complication of prolonged pelvic surgery. Prompted by two recent cases the authors studied the effect of limb angulation and elevation on Doppler ankle artery pressure and compartment pressure in ten normal subjects. Mean ankle pressure when supine was 130.5 (95 per cent confidence interval (c.i.) 124.5-136.5) mmHg and fell to 77.2 (95 per cent c.i. 64.6-89.8) mmHg in the Lloyd-Davies position with 10 degrees of head-down tilt. Reversing table tilt to bring the ankle elevation to 0 degrees in Lloyd-Davies supports restored mean ankle pressure to 114.3 (95 per cent c.i. 105.5-122.9) mmHg (P < 0.001). Placing the lower limb in calf supports was found to increase the mean intracompartmental pressure from 3.0 (95 per cent c.i. 1.2-4.8) mmHg to 11.6 (95 per cent c.i. 9.1-14.1) mmHg. Reversing table tilt significantly restores limb perfusion in patients undergoing prolonged pelvic surgery with the legs elevated and may protect against subsequent compartment syndrome.

Neurovascular lower extremity complications of the lithotomy position

The lithotomy position is commonly used during the performance of a variety of abdominal and pelvic operations. Previous publications reporting complications with these operations have been largely anecdotal. We report our experience with eight patients over the past four years who have suffered serious lower extremity complications following operations in which the lithotomy position was used. The average time in the lithotomy position for our patients was 7.4 hours (range: 3.7-12 hours). The mean interval between the original operation and the secondary operation to treat the lower extremity complication was 18.9 hours (range: 2-51 hours). The average hospital length of stay for these patients, 38.4 days (range: 11-119 days), was often prolonged as a direct result of their limb complication. Serious lower extremity complications may result from operations in which the lithotomy position is used. To prevent such complications, strict attention should be paid to the positioning of the limbs in the operating room and the time in the lithotomy position should be minimized. Perioperative monitoring of the lower extremity circulation and compartment pressures are essential in these patients since early detection and treatment of these complications is the only way to prevent permanent limb injury.