Compartment syndrome following surgery in the lithotomy position

We report a case of severe bilateral calf compartment syndrome following anaesthesia in the lithotomy position. A patient with urothelial carcinoma of the bladder and the upper urinary tract underwent anaesthesia for a radical cystectomy and bilateral nephro-uretherectomy. Besides obesity (BMI 29) she had no other medical conditions of note. The patient was positioned in the Lloyd-Davies lithotomy position throughout the whole procedure. During the 6-h intra-operative course, complicated by significant blood loss, she received 2 l of crystalloid, 3.5 l of colloid solution, 12 units of red cell concentrate and 11 units of fresh frozen plasma. The lowest mean arterial blood pressure was 60 mmHg, the lowest body temperature 35.4 °C. Postoperatively, the patient was transferred to ICU. Her trachea was extubated 5 h after the end of surgery. The immediate postoperative course was uneventful with a stable cardiovascular state and satisfactory analgesia. Thirteen hours postoperatively, the patient complained of bilateral painful lower legs, paraesthesia and painful dorsiflexion of her feet. Her serum creatinine phosphokinase was 50 000 IU.l−1. She was transferred to theatre where a bilateral extensive fasciotomy was performed to decompress all three calf compartments in each leg. In the next few days the patient developed sepsis, required continuous renal replacement therapy and subsequently underwent six operations for wound debridement and plastic surgery. She was discharged from ICU after 29 days. Despite early diagnosis and intensive therapy, she remained unable to walk due to persistent neurovascular damage. In compartment syndrome the perfusion pressure falls below the tissue pressure in a closed anatomical space, with subsequent compromise of circulation and function of the tissues. External restriction of the compartment can be due to casts, military antishock trousers, malfunctioning sequential compression devices and the lithotomy position [1, 2]. Compartment syndrome following urological surgery in the lithotomy position is a rare complication [3]. The impaired limb perfusion is due to elevation above the heart and or external pressure from equipment or personnel. Aggravating intra-operative factors include hypovolaemia, hypotension and hypothermia with vasoconstriction. After the insult, the ischaemia-induced capillary leak leads to oedema formation during reperfusion. The classical clinical findings are pain worsened by dorsiflexion of the foot, paraesthesia, paresis, intact pulses and pink skin. Because the syndrome is a reperfusion injury these signs and symptoms may not be immediately apparent. If diagnosed late, it may cause rhabdomyolysis, irreversible nerve deficits, loss of limb, renal failure, sepsis and death [4]. A recent postal survey among UK urologists found an estimated incidence at around 1 in 500 cystectomies [5]. The length of time spent in the lithotomy position and the degree of elevation are the most important factors in its development [5]. This report emphasises the clinical significance of a bilateral calf compartment syndrome following prolonged surgery in the lithotomy position. All staff involved should be aware of this serious complication. For procedures where elevation is prolonged the legs should be lowered every 2 h to avoid the development of this devastating complication [5]. The time in this position should be kept at a minimum.