This case involves a male patient who underwent a number of surgical procedures after being diagnosed with bilateral urethral strictures. The patient was placed in the lithotomy position. All of the procedures were performed at once and took a total of 10 hours. Upon awakening, it was noted that the patient had developed acute posterior lower extremity compartment syndrome. The patient was taken for emergent fasciotomy but suffered permanent injury to his left tibial nerve.
Question(s) For Expert Witness
- 1. How often do you perform urethroplasty, cystoscopy, and adult circumcision procedures?
- 2. Is compartment syndrome a known risk factor of these procedures?
- 3. What steps can be taken to reduce the risk of compartment syndrome in the lithotomy position?
Expert Witness Response E-014220
This is a case of a prolonged, likely complex, urologic surgery performed in lithotomy position that led to lower extremity compartment syndrome. This was likely due to prolonged pressure and compression of lower extremity below the knee which resulted in increase swelling and intracompartmental pressure leading to compromise blood flow and required emergency surgery (fasciotomy). Any prolonged lithotomy procedure is at risk for this event because the lower extremities are placed in stirrups. The lower leg, typically the calf, is lying on the firm portion of the stirrup; and if lying on this surface for extended period of time (>6 hrs) there is the risk for compression and compromise to blood flow which would ultimately lead to compartment syndrome. This complication can be prevented by ensuring patients are properly positioned and the extremities are protected from pressure and stress. This involves ensuring the foot is comfortably resting on the base of the stirrup, all surfaces are well padded and joints/muscles are not resting on hard/firm surface.