Bilateral Lower Extremity Compartment Syndromes following Prolonged Surgery in the Low Lithotomy Position with Serial Compression Stockings

A POTENTLALLY devastating complication of prolonged surgery in the lithotomy position is lower extremity compartment syndrome.',' Compartment syndrome arises from impaired perfusion that causes tissue ischemia, edema, and increased fascial compartment pressures.Presentation may be delayed up to 24 h or longer postoperatively."*Contributing factors include vascular insufficiency, intraoperative hypotension, and surgical positioning.The lithotomy position decreases perfusion to the legs even in persons without vascular d i ~e a s e .~. ~ Use of compression stockings for deep venous thrombosis prophylaxis may further decrease blood flow to the We report a case of a man who underwent a lengthy urologic procedure while in the low lithotomy position and who developed bilateral lower extremity compartment syndromes necessitating emergent fasciotomies. Case ReportA 34-yr-old man (90 kg, physical status I) underwent a cystoscopy, urethrectomy, and urethroplasty while in the low lithotomy position for hypospadias repair.Preoperative blood pressure was 130/72 mmHg.A subarachnoid block was performed using bupivacaine and preservative-free morphine sulfate to augment a general anesthetic.Induction and intubation were performed using sodium pentothal and rocuronium.The patient was placed in the low lithotomy position, with his calves raised approximately 25 cm above his heart.Sequential compression stockings set to intermittently compress to 40 mmHg were used along with antithromboembolism hose, and egg crating and gel padding were placed beneath his calves.The patient remained in this position for 10 h 10 min.Systolic blood pressure remained above -