Prevention of compartment syndrome associated with the dorsal lithotomy position

There is a clear association between the dorsal lithotomy position and the development of a postoperative compartment syndrome. Compartment syndrome occurs when elevated pressure in an osteo-fascial compartment compromises local perfusion and often results in neurovascular damage and permanent disability. Surgeons must recognize this association and provide appropriate preventative measures, have a high index of suspicion in all patients, and be prepared to make an early diagnosis when it is encountered. We will report four cases we encountered, discuss the etiology, analyze the literature, and propose a modification on patient positioning that has minimized the incidence of compartment syndrome at our institution. A variety of intraoperative events, including hypotension, hypoxemia, leg elevation, hip and knee flexion, direct pressure, and compressive bandages may all contribute to compartmental ischemia. Ischemia is followed by reperfusion, capillary leakage from the ischemic tissue, and a further increase in tissue edema. Increased edema causes further embarrassment of perfusion and perpetuation of the cycle, ultimately resulting in neuromuscular compromise secondary to ischemia. To prevent this destructive cycle, emphasis must be placed on maintaining a high index of suspicion in all patients, minimizing leg elevation, and on the importance of early diagnosis and intervention.