The lithotomy position is freq uently used in urological surgery , when wide expos ure of the perineum is required. This position, above all if the patient is not positioned correctly or if the surgical operation las ts more than 5 hours, can have a series of complications such as dysfunction of the perineal nerve, femural neuropathy, compartmental syndrome 01′ the lower limbs. We report a case of compartmental syndrome after s urgery in the elaborated lithotomy position, which was treated conservatively.
Postoperative lower extremity compartment syndrome is a serious complication after prolonged surgery in the lithotomy position (1), and the pathogenesis and prevention of this condition have been described (2,3,4). The deep posteri or compartment of the calf is bound by the tibia, interosseous membrane, fibula and transverse crural septum, and contains the posterior tibial artery and vein, the peroneal artery and vein, and the posterior tibial nerve (3 ). A compartment syndrome is defined as a condition in which the circulation and function of tissues within a c10sed space are compromised by increased pressure within that space (1). The most likely cause of this condition related to the lithotomy position is prolonged externallimb compression caused by operating room stirrups (1). The pressure on the musc1e mass of the calf from the stirrups probably increases the pressure in the deep compartment (3). This would elevate the local venous press ure, thus lowering the blood flow in the capillaries and callsing neuromuscolar ischemia (3). Musc1e and nerve ischemia leads to edema, which further increases intracompartmental pressures and results in an escalating cycle of events (1). Permanent tissue damage and necrosis may occur if compartment syndrome is not promptly diagnosed and treated (1,2 ,3,4). In the management of compartment syndrome, the majority of allthors emphasize the need for early fasciotomy (1 ,2,3,4), but others have suggested the feasibility of a conservative approach (5,6). We report a case of a patient who underwent urological surgery in the lithotomy position, and developed a bilaterallower compartment syndrome, treated by conservative management, resulting in complete recovery.
A 29- year- old man underwent perineal elaborated urethroplas ty, in the lithotomy position, for recurrent stricture of the posterior urethra. The patient ‘s medicai history was remarkable for two previous urethroplasties and one lIrethrotomy withollt complications. Ali preoperative laboratory findings were norma!. Under generaI anesthesia, the patient was placed in the lithotomy position. The procedure was difficult owing to extensive scarring in the posterior urethra, and urethroplasty was carried out lIsing peri ne al and suprapllbic approaches. The patient was in the lithotomy position for 5 hours. In the postoperative peri od, the patient experienced pain in both lower extremities. Physical examination revealed bilateral swollen tense extremities, and the calves were tense , edematous and burning, and dorsiflexion was absent bilaterally. Laboratory data at this time showed serum CPK value of 74750, LDH 2225, AST 1631 , and ALT 391 , serum potassium 5.5 mEq/L and oliguria (40 mI/h). There was no evidence of Illyoglobinuria. Doppler exalllination of the lower extrelllities showecl a slowing down of tibial and popliteal venous flow of both legs ancl confirlllecl no steno s is of the arterial clistricts. COlllputed TOlllography (CT) scan of the legs showecl a wide hypoclense area of solea ancl lateral heacl of gas trocnelll i us m uscle of the two cal ves (Fig. 1). Bilateral compartment synclrome was the cliagnosis. Conservative management was used: lower legs positioned at heart level, analgesic anclmyorelaxant clrugs usecl to control pain ancl contracture of both calves, and aclmini stration of soclium bi carbonate ancl crystalloicls to prevent acute renal failure. On the seventeenth postoperative day, the patient was clischargecl without any neurologic sequelae, and ali laboratory fìnclings were normal.
The lithotomy position provides good exposure of the perineum ancllower abclomen, thus facilitating Illany urological surgical proceclures. Angenneier and Jorclan examinecl a seri es of 177 patients, p1acecl in the exaggerated lithotolllY position for urologic surgery, ancl cleterminecl that 15.8 per cent suffered neuropraxic complications (1). Compartmental syndrome is a condition in which the increasecl intracompartmental tissue pressure, re sulting in decreasecl bloocl flow and subsequent muscle and nerve ischemia and eclema, provide an uncontrolled cyc1e of events (1,3). Permanent tissue necrosis and renal failure may occur if this condition is not promptly diagnosed ancl treated (1 ,2,3,4).
Early fasciotomy is suggested as the only reliable methocl to terminate the ischemia-edema cycle (1 ,2,3,4). Decompression by fasciotomy shoulcl be done immediately after diagnosis is establishecl (2,3 ,4). Twelve hours appears to be a criticaI interval after which neuromuscolar clysfunction, post-ischemic contractures, necrosis ancl extensive skin sloughing, myoglobinuric renal failure ancl sepsis become common (3). Delayed decompression proclucecl a 54 per cent complication rate, with 20 per cent of patients requiring amputation (3).
Early fasciotomy was also suggestecl as elective therapy in patients affectecl by Crush Injury, following traumatic rabdomyolysis (7,8,9,10), ancl some authors suggest conservative management in Crush Injury , particularly if the injury is a closed one (5,11). The only inclication for early fasciotomy in Crush Injury is open Crush Injury (5) ancl the outcome for crush injurecllimbs not treated by fasciotomy is good (5).
Compartmental Synclrome ancl Crush Injury show different pathophysiology, but the injured anatomic area is the same ancl this similarity is important in establishing therapeutic management. We performecl conservative management in Compartmental Synclrome as suggested in Crush Injury. A conservative approach to compartment syndrome has been suggestecl (5 ,6). As a matter of fact, the use of intravenous hypertonic mannitol in dogs improves intracompartmental tamponacle in an animai moclel (12) . These clata suggested the feasibility of a conservative approach (5,6,12) to the management of compartmental synclrome in selected cases.