Compartment syndrome following pelvic surgery in the lithotomy position
Ann R Coll Surg Engl 2002; 84: 170-171
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Response to: Compartment syndrome following pelvic surgery in the lithotomy position D O'Leary 19 Aug 04 |
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The authors of this article draw attention to the risk of lower limb compartment syndrome associated with prolonged pelvic operations in the lithotomy position with Trendelenberg tilt. They emphasise the importance of flattening the operating table intervals to prevent this complication. May I suggest a variation of this strategy: 1) Lloyd-Davies leg supports should be abandoned in favour of modern supports which may be easily adjusted through the drapes to alter the position of the legs during different phases of an operation. 2) The patient's legs should be in the lithotomy position only for perineal procedures or for perineal phases of pelvic operations. Anterior resection requires access to the anus for staplers or for sigmoidoscopy. This may be achieved with legs supported in abduction but without elevating the heels to the lithotomy position. 3) Trendelenberg tilt should be used only for those phases of a pelvic operation that require it. Otherwise the operating table should be horizontal. This approach should reduce the risk of compartment syndrome by making the 'default' position for the patient's legs the safe position. |
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Response to: Compartment syndrome following pelvic surgery in the lithotomy position N Orpen 19 Aug 04 |
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I read with interest this article and note good explanations to the pathogenesis of this unusual but well described condition. The literature relating to vascular complications following patient positioning during surgery is vast and although our concerns are usually relating to the risk and prevention of deep venous thrombosis, these cases illustrate how other potential vascular complications exist and should not be forgotten. Alternative hypotheses for the development of this condition however may also be explored. During the course of the operative procedure in the prone position, enough pressure is placed on the arteries to limit their supply of blood in the lower limb so as to cause muscle ischaemia.1,4 Due to the compartmental nature of the bone unit, intraosseous hypertension due to venous congestion has been proposed as a mechanism for damage to the hip joint2,3 during surgery. Vossler et al describe altered blood flow through the femoral arteries during spinal surgery in the prone position resulting in limb ischemia,4 while Ziser et al describe raised creatinine kinase and myoglobinuria due to muscle damage.5 Akagi et al suggest that prolonged direct pressure on the inguinal area, as is potentially produced during prone positioning, can result in arterial thrombosis. This area is potentially at greater risk with the obese patient, long operating times and thrombotic disorders.1 It would seem reasonable to suppose a similar compromise in the arterial supply by the high pressure over the inguinal ligament with the lithotomy position thus altering the blood supply to the legs. The bone unit is similar in many ways to the muscle compartment in that there is little forgiveness for sudden rises in intra-compartmental pressure and so it seems reasonable to assume a similar method of action may result in muscle ischaemia and damage. Regardless of the pathogenesis, the cases described by the authors remind us of how patient positioning is so important as part of the total intra-operative management of the patient and how unusual post-operative changes should be viewed with suspicion. References
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