Compartment Syndrome of Bilateral Lower Extremities Following Laparoscopic Surgery of Rectal Cancer in Lithotomy Position: Report of a Case

Abstract

A 67-year-old man underwent laparoscopic surgery for rectal cancer in the lithotomy position. After surgery he complained of bilateral lower limb pain, swollen legs, and sensory disturbance. The serum creatine kinase value was 46 662 U/l. Venography demonstrated compression from outside without any obstruction. The T2 image of magnetic resonance imaging (MRI) showed a massive swollen muscle and a partial high-intensity area in the bilateral lower limbs. The posterior compartment pressures of lower legs were high (gastrocnemius muscle: 30 mmHg [right] and 44 mmHg [left]). Compartment syndrome (superficial posterior compartment) was thus diagnosed. He underwent a fasciotomy using the single dorsal approach and the administration of a large amount of fluid. He recovered well without any motor or sensory deficits. Compartment syndrome is rare, occurring only once in every 3500 cases, but it is a severe complication of surgery in the lithotomy position. Several risk factors have been pointed out: including prolonged operation, hardness of the operating table, obesity, dehydration, and hypothermia. To prevent compartment syndrome, appropriate positioning during surgery is therefore essential. To make a timely diagnosis and identify the precise location of muscle edema, the T2 image of MRI is useful.

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“…T2‐weighted MRI has been suggested to be useful in demonstrating and localizing muscle oedema. However, the findings are not specific and a scan should not be allowed to delay treatment.…”

Open Abdominoperineal Resection

“…Hyperfl exion of the hip joints should be avoided to avoid excessive traction impinging on the sciatic nerve. Appropriate fi tting of the leg in the stirrup is particularly important in obese patients, because excessive compression can lead to compartment syndrome [ 23 ]. When positioning is completed, the surgeon should reconfi rm tumor location by digital exam and/or endoscopy.…”