{"id":57,"date":"2025-05-21T08:53:08","date_gmt":"2025-05-20T22:53:08","guid":{"rendered":"https:\/\/escope.ages.com.au\/volume-01-2025\/?p=57"},"modified":"2025-07-11T09:20:22","modified_gmt":"2025-07-10T23:20:22","slug":"surgical-mm-case-this-is-a-true-story-it-happened-to-a-friend-of-a-friend-of-mine","status":"publish","type":"post","link":"https:\/\/escope.ages.com.au\/july-2025\/surgical-mm-case-this-is-a-true-story-it-happened-to-a-friend-of-a-friend-of-mine\/","title":{"rendered":"Surgical M&M Case – This is a true story. It happened to a friend of a friend of mine"},"content":{"rendered":"\n

\n\t\t\tSurgical M&M Case – This is a true story. It happened to a friend of a friend of mine \t<\/h1>\n\t

A 28-year-old nulliparous patient, non-smoker with BMI of 42 kg\/m2, presented with rectal and vaginal bleeding. Pelvic MRI showed deep infiltrating endometriosis at the anterior rectal wall and rectosigmoid junction. A large endometriotic deposit measuring 37x19x16mm was located 48 mm cranial to the anal verge, approximately 21 mm clear of the anorectal junction (Figure 1). A second nodule was seen at the rectosigmoid junction measuring 22 mm in size, 13 cm above the anal verge.<\/p>\n

\"FigureFigure 1<\/p>\n

Initial medical management with Zoladex provided partial symptom relief, but the patient experienced breakthrough vaginal bleeding and persistent abdominal pain. She subsequently elected to proceed with definitive surgical treatment.<\/p>\n

The primary colorectal procedure included a laparoscopic ultra-low anterior resection with loop ileostomy, following preoperative ureteric catheter insertion. Gynaecological involvement consisted of laparoscopic excision of nodular endometriosis from the left ovarian fossa, superficial deposits from the right ovarian fossa, and a full-thickness nodule from the posterior upper third of the vaginal wall. A Mirena intrauterine device was inserted. The gynaecological portion lasted two hours, with a total operative time of 10 hours in the lithotomy position.<\/p>\n

Postoperatively, the patient reported right lower leg pain and paraesthesia. Examination revealed a tense, erythematous right calf with pain on passive ankle dorsiflexion. Ultrasound excluded deep vein thrombosis or collection. She was reviewed by the surgical team at 1-hour post-op, with orthopaedic assessments at 2, 4, and 8 hours. Pedal pulses were faint but present. Compartment syndrome was considered, but observation continued until biochemistry revealed a creatine kinase level of 6402 U\/L.<\/p>\n

Emergency fasciotomy performed 9 hours after symptom onset revealed necrosis in all four compartments. Debridement was undertaken, and a vacuum-assisted dressing applied. The patient was admitted to ICU and underwent four further theatre returns for re-look and additional debridement, with final closure achieved primary closures and one skin graft.<\/p>\n

After six weeks of rehabilitation, she regained independent mobility and had full recovery of leg function at six months. Her stoma was reversed at five months.<\/p>\n\t

Compartment syndrome results from elevated pressure within a closed osseo-fascial space, leading to compromised vascular perfusion, tissue ischemia, and potentially irreversible neurovascular damage or death. While often linked to trauma, such as fractures or soft tissue injuries, it can also occur without underlying vascular disease-this is known as well-leg compartment syndrome (WLCS).1,2<\/sup> WLCS has an incidence of approximately 1 in 3,500 patients in the lithotomy position, increasing to 1 in 260 with operative time greater than 180minutes.1,4<\/sup> Contributing factors include limb elevation above the heart, reduced perfusion during hypotensive anaesthesia, and reperfusion injury upon repositioning.3<\/sup> To minimize risk, the lithotomy position should be limited to procedures requiring perineal access; most gynaecological laparoscopic surgeries can be performed in a modified supine position (Figure 2).4<\/sup> Resting the legs, by positioning them below the level of the heart, every 2-4 hours for a duration of 10-15minutes has been suggested as a preventative strategy.4,5<\/sup> Symptoms include severe post operative limb pain, pain when the affected compartment is stretched, numbness or tingling, skin pallor, weakness, and a lack of pulse in the lower limb. Probability of compartment syndrome is 93% if three or more symptoms are present.4,6<\/sup> Awareness, preventative strategies, and early recognition are essential to avoid the serious complications of WLCS.<\/p>\n

\"Figure<\/p>\n

Figure 2: low lithotomy with a thigh-trunk angle of 170\u00b0 and with the knees above the abdominal plane4<\/sup><\/p>\n\t

Questions:<\/p>\n

    \n
  1. What are the risk factors in this case for positioning injuries\/compartment syndrome?<\/strong>\u00a0<\/strong><\/li>\n<\/ol>\n

    A: Increased BMI; Prolonged operative time; Lithotomy positioning<\/p>\n

      \n
    1. Describe the mechanisms of injury which contribute to compartment syndrome.<\/strong>\u00a0<\/strong><\/li>\n<\/ol>\n

      A: Compartment pressure > arterial perfusion pressure \u2192 ischemia \u2192 tissue necrosis. Elevation of legs above right atrium decreases perfusion. Intraoperative hypotension may contribute. Dorsiflexion of the ankle increases compartment pressure; plantar flexion is protective. (Figure 3)<\/p>\n

      \"Figure<\/p>\n

      Figure 3<\/p>\n

        \n
      1. What measures can be taken perioperatively to decrease the risk of positioning injuries\/compartment syndrome?<\/strong>\u00a0<\/strong><\/li>\n<\/ol>\n

        A: Identification of patient & procedure risk factors, minimize use of high\/standard lithotomy and use low lithotomy where appropriate, maintain ankle in neutral\/plantar flexion, rest the legs by leveling table from Trendelenburg and lowering legs to level of the right atrium every 2-4 hours for 10-15mins, avoid intraoperative hypotension and vasoconstriction<\/p>\n

          \n
        1. Post operatively, what are the clinical signs and symptoms to be aware of to diagnose compartment syndrome?<\/strong>\u00a0<\/strong><\/li>\n<\/ol>\n