Wednesday, March 3, 2010

Well Leg Compartment Syndrome:Deadly but avoidable entity every Urologist should know

We had a patient around 50 years for trans-pubic urethroplasty which went on for 6 hours duration.The surgery went on smooth.But in the evening the duty doctor informed us saying the left leg of the patient was swollen and painful.The patient was in agony.As a routine;compression ultrasound was performed to rule out venous thrombosis.The calf was swollen,tender and turgid.Immediately fasciotomy was done to relieve the leg of compartment syndrome having in mind very high suspicion of leg compartment syndrome.The patient immediately got relief from pain and the wound was allowed to heal gradually with secondary intention.

Lower limb compartment syndrome is a rare but potentially devastating complication .The overall incidence of compartment syndrome after major pelvic surgery in the lithotomy position has been estimated at 1 in 3500.It is s being seen more frequently as the complexity and duration of pelvic urological surgery increases, i.e. reconstruction/radical cancer surgery.
With significant morbidity and mortality, in particular lower limb morbidity, all urologists should be aware of this iatrogenic complication and how to prevent or treat it when it occurs.Especially even for routine prostatectomies most patients are old with metabolic syndrome so likelihood of having peripheral vascular disease;any prolongation without adequate padding of calves may causecompartment syndrome.

Causes for lower limb compartment syndrome:
• Prolonged operation time,
• Elevation of the lower limbs, ankle dorsiflexion,
• Pelvic surgery
• Trendelenburg position,
• Perioperative hypotension
• peripheral vascular disease,
• and obesity

Pathophysiology: Compartment syndrome is attributable to prolonged impairment of lower limb perfusion secondary to a rise in compartment pressure.
A reduction in perfusion pressure causes tissue ischaemia. Ischaemia may be followed by reperfusion with subsequent capillary leakage and tissue oedema.
A vicious circle of tissue oedema and further impairment of perfusion then occurs.Once compartment pressure rises above 50 mm Hg for more than four hours irreversible neuromuscular damage will occur. Although damage is reversible up to two to three hours Well Leg Comaprtment Syndrome(WLCS) typically presents postoperatively with leg pain out of proportion to the clinical findings.The classic findings of calf swelling, paraesthesia, weakness of toe flexion, and pain during passive toe extension.
This is mainly clinical based.
The normal range of compartment pressure during an operation is between 0 mm Hg and 10 mm Hg. The definitive diagnosis of a compartment syndrome is made by a direct measurement of intracompartmental pressure.This can be done by using either a transducer tipped catheter or by a conventional fluid filled system. The most common clinical misdiagnosis is with deep venous thrombosis (DVT). However DVT will have normal peripheral pulsations and there will be presence of limb edema, both of which will be absent in WLCS. Innovative techniques like surface electromyography and myotonometry parameters are indicative of intramuscular pressure, but neither of these methods can be used alone to diagnose non-invasively chronic compartment syndrome with acceptable accuracy.
There is no universal agreement on the precise intracompartmental pressure at which you should consider intervention.
• The decision to operate should be made in conjunction with clinical findings although a value of >30 mm Hg usually shows that surgical decompression is needed .
• Early fasciotomies of all three compartments of the involved leg leads to complete functional recovery of the limb and can avoid the serious complications like muscle ischemia,

Because the lithotomy position is one of the most common positions used in urology, it is mandatory for urologists to be familiar with the complications associated with it limb loss rhabdomyolysis, renal failure and even death.
These precautions can be taken by the urologists:
• Avoid high/exaggerated lithotomy
• Hydraulic stirrups, Allen stirrups with ankle support

• Lower legs every 2 hours(The break can be used as coffee break for the urologist so that he also can relax and resume the surgery with vengence)

• Avoid dorsiflexion at ankle

• Avoid head down position
• Adeqate padding
• High index of suspicion post-op(Many cases are missed as leg is the last thing to be noticed by urologist.Even if patient complains of pain it is passed off as some muscle sprain because of stirrups.)
The incidence of WLCS is probably under reported due to failed diagnosis or misdiagnosis.Clinical diagnosis and prompt institution of treatment in the form of fasciotomy holds the key of successful managent in functional recovery and avoiding disastrous complications


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