Postoperative compartment syndrome and the lithotomy position: a report of three cases and analysis of potential risk factors

There exists a definite association between the placement of patients in the modified lithotomy position and the development of postoperative compartment syndrome. It must be appreciated that this syndrome is potentially life-threatening and frequently results in long-term sequelae. We report three cases which illustrate the problem and analyze the multifactorial etiology of this condition and propose a strategy for its prophylaxis. The combination of direct pressure on the posterior compartment of the calf, elevation of the legs above heart level, a number of intraoperative variables, the preexistence of any lower limb arterial insufficiency, and in some cases, the use of intraoperative compression boots, may lead to a state of hypoperfusion in the anterior and posterior compartment musculature. Upon completion of the operation, removal from the lithotomy position, and correction of the etiological factors, a reperfusion occurs with the development of a capillary leak with subsequent tissue edema causing an increase in compartmental pressure which may result in neurovascular compromise. This is the compartment syndrome. Emphasis must be placed on the identification of high-risk patients, the prevention or rapid correction of any etiological factors, the early diagnosis of the problem, and an aggressive approach to its treatment.