Keywords
compartment syndrome - lithotomy - leg loops - fasciotomy - intracompartmental pressure
Introduction
Compartment syndrome (CS) is a rare but severe complication resulting from a prolonged lithotomy position with leg loops. It affects 1 in every 3,500 patients operated on in this position.[1]
[2]
[3] In 1979, Leff and Shapiro[4] described the first case of CS associated with the lithotomy position.
Clinical Case
A 43-year-old male patient with Gilbert syndrome as the only relevant history underwent a Palminteri-like anterior bulbar urethroplasty in the usual lithotomy position for a 6-hour period. Two hours after the end of the surgery, the patient complained of intense pain and stiffening of the anterior and lateral compartments of both legs, in addition to intense pain on passive dorsiflexion of both ankles. He had no symptoms of peroneal nerve involvement or pain in other leg compartments.
Results
Intracompartmental pressure was determined due to suspicion of an anterolateral CS; the obtained value, of 40 mmHg, led to an urgent bilateral fasciotomy of both compartments, revealing a decrease in muscle perfusion and its improvement after fascial opening ([Figure 1]). The patient presented a progressive oincrease in the levels of serum creatine kinase (CK), from a baseline value of 109 U/L to 7,689 U/L 12 hours after the fasciotomy. Dressings were changed every 48 hours, and tissue viability was observed until the definitive closure at 4 days. At two weeks, the patient presented slight fatigue when walking with no assistance, and the lateral compartment of both legs was swollen. Ten months after surgery, the patient walked with no assistance or any neuromuscular deficit.
Fig. 1 Urgent bilateral fasciotomy of the anterolateral compartment of both legs. Fascial opening resulted in improved perfusion.
Discussion
This is a case of bilateral CS on healthy legs. Compartment syndrome often results from traumatic or vascular causes;[5] however, the scientific literature[2]
[3]
[4]
[6]
[7]
[8]
[9] reports some cases of CS associated with a prolonged lithotomy position. This complication arises from an increase in the intracompartmental pressure in the lower limbs produced by several factors: elevation of the lower limbs decreases the blood pressure (BP), which is already lower due to anesthetic agents; in addition, the use of leg loops increases the pressure in the supporting compartment, while hip and knee flexion decrease the venous return. All of these factors result in ischemia; once surgery is finished and the patient returns to a normal position, the rapid tissue reperfusion causes edema and increases the pressure, leading to CS.[2]
[5]
[6]
[8]
[9] As described by Matsen,[10] elevation of the leg alone causes a notable increase in intracompartmental pressure, of approximately 18 mmHg; as such, this position can be a very important factor in the development of this complication.
Delayed CS diagnosis causes irreversible muscle damage, resulting in limb dysfunction or amputation. Therefore, early diagnosis and surgical treatment are critical.[2]
[4]
[6]
[11]
[12] The diagnosis may be based on clinical history and physical examination alone. In case of doubts, however, the intracompartmental pressure can be measured to determine if it is higher than or within a 30 mmHg difference from the diastolic BP.[6]
Few cases of bilateral CS after prolonged lithotomy position have been described; in most reports,[8],[13] the surgical time ranged from 5 to 8 hours. Cases of CS have been described after surgeries lasting less than 2 hours; Stornelli et al.[11] reported a case after a surgery lasting only 90 minutes.
Regarding surgery duration and the lithotomy position, Yamamoto et al.[2] reported CS after a 16-hour procedure, with more intense symptoms and a greater increase in the levels of serum CK. A similar yet less florid case was described by García-Germán et al.[6] Oman et al.[14] presented a case of CS after a 6-hour gynecological surgery. As in our case, they performed a posterior compartment fasciotomy, but a revision surgery was required the next day to complete the fasciotomy of the three remaining compartments due persistence and worsening of the symptoms, with paresthesia on the left ankle and foot as a sequela. In these cases, which are similar to ours in terms of surgical time, the CS was more severe, perhaps due to the duration of the symptoms. Our patient has been hemodynamically stable, with no noticeable laboratorial or renal abnormalities; in addition, serum CK levels did not exceed 8,000 U/L, unlike the remaining cases,[2],[3],[7]
[8]
[9],[11] in which CK levels increased to 142,000 U/L. Similarly, during follow-up, our patient presented a rapidly-progressive improvement with no residual neurovascular deficits, as in the case presented by Stornelli et al.[11] This may be the result of early diagnosis and treatment, leading to a rapid limb recovery and prognostic improvement.
To date, only cases[15],[16] of chronic CS have been treated using minimally-invasive fasciotomy. Our report shows an alternative to the early treatment of acute CS.
Conclusion
Knowledge of the association between CS and prolonged laparoscopic surgery is essential for an early diagnosis and immediate surgical treatment to avoid serious sequelae. In our patient, the good outcomes resulted from quick action, since diagnosis is often delayed. Limiting the use of the lithotomy position to those surgical moments in which it is essential, and changing the position of the legs every 2 hours during prolonged procedures can reduce the occurrence and incidence of CS, preventing this complication. New leg boots have been introduced and they apparently reduce the incidence of CS. In these devices, the patient's legs rest on a surface covered by a soft material held by adjustable bands. In addition, they enable the change in the position of the lower limbs during surgery and also support of the soles, reducing the compression of the peroneal nerve and the development of SC.
