Lower limb compartment syndrome associated with the lithotomy position: concepts and perspectives for the urologist

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.

Bilateral Femoral Cannulation Is Associated With Reduced Severe Limb Ischemia-Related Complications Compared With Unilateral Femoral Cannulation in Adult Peripheral Venoarterial Extracorporeal Membrane Oxygenation: Results From the Extracorporeal Life Support Registry

OBJECTIVES

Peripheral venoarterial extracorporeal membrane oxygenation (ECMO) with femoral access is obtained through unilateral or bilateral groin cannulation. Whether one cannulation strategy is associated with a lower risk for limb ischemia remains unknown. We aim to assess if one strategy is preferable.

DESIGN

A retrospective cohort study based on the Extracorporeal Life Support Organization registry.

SETTING

ECMO centers worldwide included in the Extracorporeal Life Support Organization registry.

PATIENTS

All adult patients (≥ 18 yr) who received peripheral venoarterial ECMO with femoral access and were included from 2014 to 2020.

INTERVENTIONS

Unilateral or bilateral femoral cannulation.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the occurrence of limb ischemia defined as a composite endpoint including the need for a distal perfusion cannula (DPC) after 6 hours from implantation, compartment syndrome/fasciotomy, amputation, revascularization, and thrombectomy. Secondary endpoints included bleeding at the peripheral cannulation site, need for vessel repair, vessel repair after decannulation, and in-hospital death. Propensity score matching was performed to account for confounders. Overall, 19,093 patients underwent peripheral venoarterial ECMO through unilateral ( n = 11,965) or bilateral ( n = 7,128) femoral cannulation. Limb ischemia requiring any intervention was not different between both groups (bilateral vs unilateral: odds ratio [OR], 0.92; 95% CI, 0.82-1.02). However, there was a lower rate of compartment syndrome/fasciotomy in the bilateral group (bilateral vs unilateral: OR, 0.80; 95% CI, 0.66-0.97). Bilateral cannulation was also associated with lower odds of cannulation site bleeding (bilateral vs unilateral: OR, 0.87; 95% CI, 0.76-0.99), vessel repair (bilateral vs unilateral: OR, 0.55; 95% CI, 0.38-0.79), and in-hospital mortality (bilateral vs unilateral: OR, 0.85; 95% CI, 0.81-0.91) compared with unilateral cannulation. These findings were unchanged after propensity matching.

CONCLUSIONS

This study showed no risk reduction for overall limb ischemia-related events requiring DPC after 6 hours when comparing bilateral to unilateral femoral cannulation in peripheral venoarterial ECMO. However, bilateral cannulation was associated with a reduced risk for compartment syndrome/fasciotomy, lower rates of bleeding and vessel repair during ECMO, and lower in-hospital mortality.

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.

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.

'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.

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.

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.

Nontraumatic Compartment Syndrome in a Patient with Protein S Deficiency: A Case Report

CASE

Protein S deficiency, a hypercoagulable thrombophilia, often results in venous thromboembolism. Nontraumatic compartment syndrome in a patient with protein S deficiency has not been well publicized. Herein, we present a rare case of nontraumatic compartment syndrome of the hand and the thigh in a 48-year-old woman with a known history of protein S deficiency; emergency fasciotomies were needed.

CONCLUSION

Based on our patient and a review of the current literature, we advocate for a heightened awareness of compartment syndrome in patients with protein S deficiency.

Lower limb perfusion during robotic-assisted laparoscopic radical prostatectomy evaluated by near-infrared spectroscopy: an observational prospective study

Background

Decreased perfusion in the lower extremities is one of the several adverse effects of placing patients in a lithotomy or Trendelenburg position during surgery. This study aimed to evaluate the effects of patient positioning in lower limb perfusion patients undergoing robotic-assisted laparoscopic radical prostatectomy (RARP) using near-infrared spectroscopy (NIRS).

Methods

This observation study comprised 30 consenting males with American Society of Anaesthesiologists physical status classes I and II (age range, ≥20 to < 80 years). Regional saturation of oxygen measurements was obtained using an INVOS™ oximeter (Somanetics, Troy, MI, USA). A NIRS sensor was positioned on the surface of the skin at the mid-diaphyseal region of the calf muscles (the gastrocnemius and soleus), over the posterior compartment, in the right lower leg. Regional saturation of oxygen (rSO₂) was sampled during the following time points: before and 5 min after induction of anaesthesia (T0,T1); 5 min after establishment of pneumoperitoneum in a 0° lithotomy position (T2); 5 min after a 25° Trendelenburg position (T3); 30, 60, 90 and 120 min after pneumoperitoneum in a Trendelenburg position (T4, T5, T6 and T7, respectively); after desufflation in a supine position (T8); and after tracheal extubation (T9).

Results

Lower limb perfusion evaluated by NIRS was increased after induction of anaesthesia and maintained during steep Trendelenburg positions in RARP patients with no risk for lower limb compartment syndrome (LLCS) (T0:65 ± 7.2%, T1:69 ± 6.1%, T2:70±:6.1%, T3:68 ± 6.7%, T4:66 ± 7.5%, T5:67 ± 6.9%, T6:68 ± 7.2%, T8:73 ± 7.2%, T9:71 ± 7.9%, respectively).

Conclusions

Lower limb perfusion evaluated by NIRS was maintained during the RARP procedure. Correct patient positioning and careful assessment of risk factors such as vascular morbidity could be important for the prevention of LLCS during RARP.

Anaesthetic issues in robotic-assisted minimally invasive surgery

Over the past decade there has been an exponential increase in the number of robotic-assisted surgical procedures performed in Australia and internationally. Despite this growth, there are no level I or II studies examining the anaesthetic implications of these procedures. Available observational studies provide insight into the significant challenges for the anaesthetist. Most anaesthetic considerations overlap with those of non-robotic surgery. However, issues with limited patient access and extremes of positioning resulting in physiological disturbances and risk of injury are consistently demonstrated concerns specific to robotic-assisted procedures.

Well Leg Compartment Syndrome After Abdominal Surgery

BACKGROUND

Well leg compartment syndrome (WLCS) is a complication to abdominal surgery. We aimed to identify risk factors for and outcome of WLCS in Denmark and literature.

METHODS

Prospectively collected claims to the Danish Patient Compensation Association (DPCA) concerning WLCS after abdominal operations 1996-2013 and cases in literature 1970-2013 were evaluated. Cases of fasciotomy within 2 weeks after abdominal surgery 1999-2008 were extracted from the Danish National Patient Register (DNPR).

RESULTS

There were 40 cases in DPCA and 124 in literature. In 68 % legs were supported under the knees during surgery. Symptoms of WLCS presented within 2 h after surgery in 56 % and in only 3 cases after 24 h. Obesity was not confirmed as risk factor for WLCS. The mean diagnostic delay was 10 h. One-third of fasciotomies were insufficient. The diagnostic delay increased with duration of the abdominal surgery (p = 0.04). Duration of the abdominal surgery was 4 times as important as the diagnostic delay for severity of the final outcome. DNPR recorded 4 new cases/year, and half were reported to DPCA.

CONCLUSION

The first 24 h following abdominal surgery of >4 h' duration with elevated legs observation for WLCS should be standard. Pain in the calf is indicative of WLCS, and elevated serum CK can support the diagnosis. Mannitol infusion and acute four-compartment fasciotomy of the lower leg is the treatment. The risk of severe outcome of WLCS increases with duration of the primary operation. A broad support and change of legs' position during surgery are suggested preventative initiatives.

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.

Male sex, height, weight, and body mass index can increase external pressure to calf region using knee-crutch-type leg holder system in lithotomy position

Background

Well-leg compartment syndrome (WLCS) is one of the catastrophic complications related to prolonged surgical procedures performed in the lithotomy position, using a knee-crutch-type leg holder (KCLH) system, to support the popliteal fossae and calf regions. Obesity has been implicated as a risk factor in the lithotomy position-related WLCS during surgery. In the present study, we investigated the relationship between the external pressure (EP) applied to the calf region using a KCLH system in the lithotomy position and selected physical characteristics.

Methods

Twenty-one young, healthy volunteers (21.4±0.5 years of age, eleven males and ten females) participated in this study. The KCLH system used was Knee Crutch^®. We assessed four types of EPs applied to the calf region: box pressure, peak box pressure, contact pressure, and peak contact pressure, using pressure-distribution measurement system (BIG-MAT^®). Relationships between these four EPs to the calf regions of both lower legs and a series of physical characteristics (sex, height, weight, and body mass index [BMI]) were analyzed.

Results

All four EPs applied to the bilateral calf regions were higher in males than in females. For all subjects, significant positive correlations were observed between all four EPs and height, weight, and BMI.

Conclusion

EP applied to the calf region is higher in males than in females when the subject is supported by a KCLH system in the lithotomy position. In addition, EP increases with the increase in height, weight, and BMI. Therefore, male sex, height, weight, and BMI may contribute to the risk of inducing WLCS.

Compartment syndrome after total knee arthroplasty: regarding a clinical case

Although compartment syndrome is a rare complication of total knee arthroplasty, it is one of the most devastating complications. It is defined as a situation of increased pressure within a closed osteofascial space that impairs the circulation and the functioning of the tissues inside this space, thereby leading to ischemia and tissue dysfunction. Here, a clinical case of a patient who was followed up in orthopedic outpatient consultations due to right gonarthrosis is presented. The patient had a history of arthroscopic meniscectomy and presented knee flexion of 10° before the operation, which consisted of total arthroplasty of the right knee. The operation seemed to be free from intercurrences, but the patient evolved with compartment syndrome of the ipsilateral leg after the operation. Since compartment syndrome is a true surgical emergency, early recognition and treatment of this condition through fasciotomy is crucial in order to avoid amputation, limb dysfunction, kidney failure and death. However, it may be difficult to make the diagnosis and cases may not be recognized if the cause of compartment syndrome is unusual or if the patient is under epidural analgesia and/or peripheral nerve block, which thus camouflages the main warning sign, i.e. disproportional pain. In addition, edema of the limb that underwent the intervention is common after total knee arthroplasty operations. This study presents a review of the literature and signals that the possible rarity of cases is probably due to failure to recognize this condition in a timely manner and to placing these patients in other diagnostic groups that are less likely, such as neuropraxia caused by using a tourniquet or peripheral nerve injury.

Compartment syndrome following lower limb arthroplasty: a review

Compartment syndrome is an urgent clinical entity characterised by an increase in the interstitial pressure within a closed osseofascial compartment. Although well recognised as a potential complication after orthopaedic trauma, it is very rarely presented after elective orthopaedic surgery and especially joint arthroplasty. In these rare cases a number of variables are associated with it (positioning, coagulopathy, extensive soft tissue dissection, previous scarring, and epidural analgesia). In this study we present the current evidence with regard to incidence and causation of compartment syndrome after lower limb joint arthroplasty and make recommendations on how to avoid the development of this devastating complication.

Upper transverse scrotal approach for muscle- and nerve-sparing urethral stricture repair

OBJECTIVE

Open surgery on bulbar urethral strictures has become a widespread procedure. While there is inconsistency which procedure to perform at the bulbar region, there is consistency of the used incisional approach despite of several potential disadvantages. Therefore, to bypass disadvantages, we performed an upper transverse scrotal approach for stricture repair in the pendulous urethra and the distal bulbar urethra as previously reported for the placement of an artificial urinary sphincter.

METHODS

Thirteen patients (n = 13) with bulbar urethral stricture were operated by upper transverse scrotal incision approach. On five patients a free foreskin graft in dorsal onlay technique was performed. Eight patients obtained an end-to-end-anastomosis procedure. Pre- and postoperative uroflowmetry as well as retrograde urethrocystography were done. Pre- and postoperative residual postvoid urine were estimated by transabdominal ultrasound. The patients were followed-up for up to 12 months.

RESULTS

After stricture repair, Qmax improved from mean 9.0 mL/s (SD +/- 3.2) preoperatively to mean 20.3 mL/s (SD +/- 3.1), postoperatively. Postvoid residual urine decreased from mean 90.0 mL (SD +/- 68.7) to mean 41.5 mL (SD +/- 16.1). All retrograde urethrocystographies showed regular reconstructed urethral conditions.

CONCLUSION

The upper transverse scrotal incision may combine the advantages of a less traumatical approach with the excellent results of perineal approach.

Compartment syndrome with thrombosis of common iliac artery after gynecologic surgery

BACKGROUND

Compartment syndrome is a potentially devastating complication with possible permanent neuromuscular and kidney damage.

CASE

A woman who had undergone radical hysterectomy with pelvic and paraaortic lymphadenectomy was diagnosed with compartment syndrome of the lower left limb. Thrombosis of the left common iliac artery was also found after emergency fasciotomy.

CONCLUSION

Arterial thrombosis is less common than deep vein thrombosis during gynecologic operations, but the lithotomy position may cause insufficient arterial circulation in both the pelvis and legs.

Percutaneous Nephrolithotripsy With the Patient in a Modified Supine Position

PURPOSE

The supine position has potential advantages over the prone position for percutaneous nephrolithotripsy but it is neglected by most urologists. We analyzed the efficacy and safety of percutaneous nephrolithotripsy with the patient in a modified supine position.

MATERIALS AND METHODS

In a prospective study 88 consecutive patients underwent percutaneous nephrolithotripsy in a modified supine position. Mean+/-SD stone size was 3.6+/-1.9 cm and 26 patients (29.5%) had complete staghorn stones. Ten patients (11.4%) also had ureteral stones and underwent concomitant ureteroscopy. Complications and success rates were analyzed.

RESULTS

The lower, middle and upper calix was the only access in 42 (47.7%), 10 (11.4%) and 5 patients (5.7%), respectively. Four patients (4.5%) had supracostal access. A single percutaneous nephrolithotripsy session was needed in 78 patients (88.6%), while 10 (11.4%) required 2 sessions. A total of 62 patients (70.5%) were stone-free. Five patients (5.7%) required blood transfusion. Postoperative complications included ureteral obstruction due to migration of stones in 3 cases (3.4%), serious bleeding requiring arterial embolization in 2 (2.3%) and prolonged fever in 4 (4.5%). The need for direct access to the upper pole and the need for concomitant ureteroscopy did not affect the success and complication rates of percutaneous nephrolithotripsy. The colon was never damaged and we had no cases of hydrothorax, kidney loss or sepsis.

CONCLUSIONS

Percutaneous nephrolithotripsy with the patient in a modified supine position is effective and safe. It may be considered for most patients requiring percutaneous nephrolithotripsy, especially if concomitant ureteroscopy is planned.

Compartment Syndrome of Bilateral Lower Extremities Following Laparoscopic Surgery of Rectal Cancer in Lithotomy Position: Report of a Case

A 67-year-old man underwent laparoscopic surgery for rectal cancer in the lithotomy position. After surgery he complained of bilateral lower limb pain, swollen legs, and sensory disturbance. The serum creatine kinase value was 46 662 U/l. Venography demonstrated compression from outside without any obstruction. The T2 image of magnetic resonance imaging (MRI) showed a massive swollen muscle and a partial high-intensity area in the bilateral lower limbs. The posterior compartment pressures of lower legs were high (gastrocnemius muscle: 30 mmHg [right] and 44 mmHg [left]). Compartment syndrome (superficial posterior compartment) was thus diagnosed. He underwent a fasciotomy using the single dorsal approach and the administration of a large amount of fluid. He recovered well without any motor or sensory deficits. Compartment syndrome is rare, occurring only once in every 3500 cases, but it is a severe complication of surgery in the lithotomy position. Several risk factors have been pointed out: including prolonged operation, hardness of the operating table, obesity, dehydration, and hypothermia. To prevent compartment syndrome, appropriate positioning during surgery is therefore essential. To make a timely diagnosis and identify the precise location of muscle edema, the T2 image of MRI is useful.

Well leg compartment syndrome after pelvic and perineal surgery in the lithotomy position

OBJECTIVE

Lower limb compartment syndrome after prolonged surgical procedures performed in the lithotomy position is a rare but potentially devastating complication. It is recognised after urological, colorectal, and gynaecological procedures. Sixteen cases of compartment syndrome after urological surgery have been reported. The objective of this study was to estimate the incidence of this complication in urological practice and identify risk factors for its development.

DESIGN

A postal survey of UK consultant urologists was conducted.

RESULTS

Replies were received from 261 consultants. In total there were 65 cases of compartment syndrome. Compartment syndrome occurred after radical cystectomy and urinary diversion in 51 cases and was rare in procedures lasting less than four hours. The incidence of compartment syndrome after cystectomy was estimated at around 1 in 500 cases. Risk factors for its development included perioperative blood loss, peripheral vascular disease, and obesity.

CONCLUSIONS

Compartment syndrome after use of the lithotomy position may be more common than is generally appreciated and has been underreported in the past. All staff should be aware of this serious complication and adopt strategies for its avoidance.