Compartment syndrome associated with lithotomy position and intermittent compression stockings

doi:10.1016/S0029-7844(00)01141-8

Obstetrics & Gynecology

Volume 97, Issue 5, Part 2, May 2001, Pages 832-833

https://doi.org/10.1016/S0029-7844(00)01141-8 Get rights and content

Abstract

Background: Compartment syndrome is a condition in which increased tissue pressure within a limited tissue space compromises the circulation and function of the contents of the space.

Case: A 43-year-old black woman, para 3, had repair of a recurrent vesicovaginal fistula. She was placed in a low lithotomy position with thigh length sequential compression sleeves. The procedure lasted more than 5 hours. On postoperative day 1, she complained of pain in her right leg and foot. Compartment syndrome was diagnosed and emergency fasciotomy was done.

Conclusion: Gynecologists should be aware of the possibility of compartment syndrome during prolonged procedures with patients in the lithotomy position. Concomitant intermittent compression sleeves might further increase the risk. Early diagnosis and treatment of compression syndrome are essential to minimize long-term neurovascular morbidity.

Section snippets

Case

A 43-year-old black gravida 3, para 3 who weighed 81 kg was scheduled for recurrent vesicovaginal fistula repair. The fistula developed after a radical abdominal hysterectomy with pelvic lymph node dissection for stage II-B cervical cancer 3 years before admission. She had two failed Latzko procedures and was scheduled for transabdominal transvesical repair of the fistula. Her hypertension was being treated with lisinopril, 20 mg daily; but her blood pressure (BP) at preoperative visit was

Comment

The muscles, vessels, and nerves of the extremities are confined in fascial spaces and potentially exposed to injury. Tight dressings, wraps, or localized external pressure can decrease compartment size. Edema or bleeding might increase compartment content. Either situation can cause acute compartment syndrome. When increased tissue pressure interferes with local blood flow and it is not adequate to meet metabolic tissue demands in the compartment, neuromuscular ischemia might occur. If that

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There are more references available in the full text version of this article.

Cited by (36)

A systematic review of mechanical thromboprophylaxis in the lithotomy position
2018, Surgeon
Citation Excerpt :
Only two, experimental, volunteer, studies provided Level II evidence11,16; the remaining publications were Level III standard or less. Nine studies reported a link between IPC and compartment syndrome.8,10,14,16–19,22,24 In contrast, five publications recommended IPC as a preventative measure against compartment syndrome in the lithotomy position.11,12,20,21,23
Venous thrombosis and compartment syndrome are potentially serious complications of prolonged, lithotomy position surgery. It is unclear whether mechanical thromboprophylaxis in this group of patients modifies the risk of compartment syndrome. This qualitative systematic review examines the evidence base to guide clinical practice.
A systematic review was performed guided by Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) criteria, to identify studies reporting relationships between lithotomy position, compartment syndrome and mechanical thromboprophylaxis. The aim was to determine if mechanical thromboprophylaxis influenced compartment syndrome risk in the lithotomy position.
Sixteen studies were identified: eight case reports or case series (12 patients), two completed audit cycles (approximately 2000 patients), four reviews and two volunteer case control studies (33 subjects). There were no randomised studies. Nine studies associated mechanical thromboprophylaxis with compartment syndrome risk but in each case a causative relationship was speculative. In contrast, five papers, including an experimental, cohort study and two observational, population studies recommended intermittent pneumatic compression as prevention against compartment syndrome in lithotomy position. One review and one case report were unable to make a recommendation.
The level of evidence addressing the interaction between the lithotomy position, compartment syndrome and mechanical thromboprophylaxis is weak. There is no conclusive evidence that mechanical thromboprophylaxis causes compartment syndrome in the lithotomy position. There is limited evidence to suggest intermittent pneumatic compression may be a safe method of mechanical thromboprophylaxis if accompanied by strict adherence to other measures to reduce the chance of compartment syndrome. However further studies are required.
Delayed diagnosis of single compartment muscle contusion after radical hysterectomy in the lithotomy position: A case report
2016, International Journal of Surgery Case Reports
Citation Excerpt :
This case suggests that surgeries performed in the lithotomy position can result in a single-compartment muscle contusion without compartment syndrome, that occurs almost a week after surgery. Further, blood loss and anti-DVT devices [4–8] likely contributed to the muscle contusion, with similar underlying mechanisms as those of compartment syndrome. Compartment syndrome occurs when the circulation and function of tissues within a closed space are compromised by increased pressure [9].
Muscle contusions usually occur as a result of blunt trauma, which damages the muscle fibers and connective tissue without breaking the skin. Rapid bleeding can cause an increase in pressure that requires surgical intervention, commonly referred to as compartment syndrome. Here, we report a case with delayed diagnosis of single compartment muscle contusion in which compartment syndrome did not develop.
A 50-year-old woman underwent radical hysterectomy. She complained of edema and tenderness in the lower left leg on postoperative day 6. The serum creatine phosphokinase level was slightly elevated at 177 IU/L (normal range: 6–142 IU/L). T2-weighted magnetic resonance imaging revealed swelling of the muscle in the deep posterior compartment of the lower left leg, edematous fascia, and subcutaneous adipose tissue. She recovered naturally without other complications.
In the lithotomy position during surgery, muscle contusion might occur, without general symptoms.
Magnetic resonance imaging is useful for diagnosis. For patients who complain of edema and tenderness in the lower leg after surgery in the lithotomy position, muscle contusions should be considered.
Compartment syndrome after gynecologic operations: Evidence from case reports and reviews
2014, European Journal of Obstetrics and Gynecology and Reproductive Biology
Compartment syndrome (CS) of the lower leg is a rare but severe complication of operations in the lithotomy (LT) position after urologic, gynecologic and general surgery. A delay in diagnosis and treatment can lead to loss of function and even life-threatening complications. The pathophysiology is still not fully understood but it is believed that ischemia as a result of increased compartment pressure and decreased perfusion pressure may lead to CS. The type of leg support and the intraoperative hypotension have been discussed as risk factors but evidence is mainly based on case reports and expert opinion. Studies suggest that time spent in the LT position and the addition of head-down tilt are associated with CS. As these positions are routinely applied during various gynecologic procedures, forensically CS has to be considered as a specific complication of gynecologic surgery in the LT position. Despite the low incidence there is a need for prospective studies and guidelines for its prevention.
Sixteen case reports describing 19 cases of CS following gynecologic surgery in lithotomy position were found during a literature search. This review is based on 14 of these case reports (17 cases), which describe a postoperative compartment syndrome in a previously healthy leg. We summarize the reported cases and literature on CS after gynecologic procedures in order to increase awareness among medical staff and to give careful recommendations regarding perioperative management based on available information.
Complications of hysteroscopic and uterine resectoscopic surgery
2010, Obstetrics and Gynecology Clinics of North America
Assessing changes in flow velocimetry and clinical outcome following use of an external aortic compression device in women with postpartum hemorrhage
2010, International Journal of Gynecology and Obstetrics
Citation Excerpt :
This may be because we excluded patients with a history of neurologic disorders. Investigators have attributed ischemic changes in the lower limbs of women treated on gynecologic tables (used in the previous study) to the compression of the legs produced by the stirrups [16–18]. We used regular hospital beds in this study to avoid this factor, and the absence of serious ischemic complications even in our first study supports their assumption.
To monitor femoral artery blood flow by Doppler velocimetry in women treated for postpartum hemorrhage (PPH) with and without the adjunction of the External Aortic Compression Device (EACD), and to assess the possible adverse effects of the device.
Blood flow velocity in the femoral artery, as well as skin color and sensory or motor changes in the lower limbs, were assessed in 120 women with primary PHH of any cause, quasi randomized to either treatment group. Pulse rate, oxygen saturation, respiratory rate, urinary output, and gastrointestinal symptoms were checked in the study group.
While blood flow velocity was significantly less in the study group than control group (P < 0.001), the lowest flow volume velocity of 310.40 mL/sec exceeded the acceptable minimum after device application. The intensity of abdominal discomfort correlated with body mass index. No device complications were observed.
The EACD contributed safely and effectively to the treatment of 60 women with PPH of different causes.
Lower limb compartment syndrome as a complication of laparoscopic laser surgery for severe endometriosis
2009, Fertility and Sterility
Citation Excerpt :
About 100 years later, LLCS, as a result of a long duration lithotomy position, was first reported by Leff and Shapiro (6). Over the last 30 years, several reports on LLCS have been published in the field of urology (4, 7), gastroenterologic surgery (8–11), and gynecologic surgery (12, 13). General etiologic factors for LLCS include increased compartmental content, decreased compartmental volume, and external pressure.
To report a case of lower limb compartment syndrome (LLCS) during long duration laparoscopic interventions for resection of extensive endometriosis, and evaluate the efficiency of a novel patient positioning method to reduce its prevalence.
Case report and observational study.
University Hospitals, Belgium.
Thirty-year-old woman undergoing a long duration laparoscopic intervention for resection of stage IV pelvic endometriosis.
Laparoscopic intervention for resection of stage IV pelvic endometriosis.
The occurrence of LLCS after laparoscopic surgery for extensive endometriosis, in this case, and the prevention of subsequent LLCS after the application of a novel patient positioning method including the following steps: maximal avoidance of the lithotomy position, patient positioning in a modified supine position, mobilization of the legs of the patient in between different surgical phases, and application of intermittent compression stockings.
The prevalence of lower limb compartment syndrome has been reduced to 0 since the application of the new patient positioning method.
Lower limb compartment syndrome can be prevented in patients undergoing long duration multidisciplinary laparoscopic resection of extensive endometriosis by a novel sequential positioning method of patients before and during surgery.

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Compartment syndrome associated with lithotomy position and intermittent compression stockings

Abstract

Section snippets

Case

Comment

Am J Obstet Gynecol

Compartmental syndromeA unified concept

Clin Orthop Rel Research

Diagnosis and management of compartmental syndromes

J Bone Joint Surg