Compartment Syndrome Incidence and Prevention in Surgical Positioning

Acute compartment syndrome in the limbs is a serious but rare complication of surgical positioning that arises when elevated pressure within a closed muscle compartment compromises tissue perfusion. The incidence in patients placed in lithotomy or Trendelenburg positions is estimated at 1 in 3 500 operations, although the true rate may be higher due to under-recognition. Pathophysiology includes direct external compression of muscle compartments, impaired venous return, and ischaemia–reperfusion injury on repositioning. Risk factors encompass prolonged duration, extreme limb flexion, high body-mass index and underlying vascular comorbidity. Prevention strategies focus on meticulous positioning with pressure-dispersing supports, regular intraoperative repositioning, real-time perfusion monitoring using near-infrared spectroscopy or perfusion indices, and early clinical vigilance. Recent advances underline the importance of ergonomically designed leg supports and protocols for scheduled table repositioning to reduce intramuscular pressures without compromising surgical access. Given the growth of minimally invasive and robotic techniques that often entail extended head-down tilt and limb elevation, a concerted global effort to standardise preventive measures and integrate technological monitoring is essential to mitigate the risk of compartment syndrome and its debilitating sequelae.

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Compartment Syndrome Incidence and Prevention in Surgical Positioning publication trend

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Technical terms

Compartment syndrome: A condition of raised pressure within a closed muscle compartment leading to ischaemia and potential tissue necrosis.

Well-leg compartment syndrome (WLCS): Acute compartment syndrome affecting the non-operative leg, often due to prolonged lithotomy positioning.

Lithotomy position: Surgical posture with hips and knees flexed and legs elevated, commonly used in gynaecological, urological and colorectal procedures.

Trendelenburg position: Patient inclined head-down with feet elevated to improve pelvic access but liable to impair venous return from the lower limbs.

Fasciotomy: Surgical incision of the fascia to relieve compartment pressure and restore tissue perfusion.

Creatine kinase (CK): An enzyme released by damaged muscle; elevated serum levels indicate muscle injury or stress.

Near-infrared spectroscopy (NIRS): A non-invasive technique for monitoring tissue oxygenation and perfusion in real time.

References

1. Preliminary comparative study of lower extremity pressure measurements under the conditions using former models and new lithotomy stirrups in rectal cancer surgery. World Journal of Surgical Oncology (2024).
2. Assessing risk factors for elevated creatine kinase levels as an indicator of compartment syndrome following laparoscopic or robot-assisted colorectal cancer surgery in the lithotomy-trendelenburg position. Surgical Endoscopy (2024).
3. Effect of intraoperative operating table rotation on lower limb perfusion index in patients in the lithotomy position. Medicine (2022).