Unilateral compartment syndrome of the lower limbs after robotic radical cystectomy and ileal conduit

Sir,

Robotic radical cystectomy (RRC) is found to be a feasible way for treatment of bladder cancer. It is associated with advantages like reduced blood loss, lesser fluid replacement, less rates of blood transfusion and reduced morbidity.[1,2] A robotic approach is safe and can facilitate surgery in the most challenging patients including morbidly obese patients avoiding laparotomy-associated morbidity and mortality.[3]

We present here a rare case of compartment syndrome of unilateral lower limb following robotic radical cystectomy and ileal conduit (RRC IC) surgery which is a long duration surgery. The patient was a known case of hypertension, diabetes and obesity which are risk factors for developing peripheral vascular disease. The patient's vitals were normal and all routine investigations were within normal limits.

In the operating room, routine monitors were attached and arterial and central lines were secured. Balanced general anaesthesia was administered. Steep head-down tilt with modified lithotomy position was given. Pneumatic device was attached. Intraoperative blood sugar measured by glucometer remained normal throughout the procedure and patient remained haemodynamically stable. After completion of surgery, the patient was extubated and shifted to high dependency room. After 4 hours of shifting, he complained of burning pain in the right lower limb. He was monitored and immediately blood samples were sent for creatine phosphokinase-myocardial band (CPK-MB) and serum creatinine.

The patient was again taken into the operation theatre where an emergency right lower limb fasciotomy was done under general anaesthesia. On the second day, CPK-MB was about 14000 IU/L, urine myoglobin was absent. Initially, patient's renal functions were altered but afterwards they came to normal limits. Regular dressing, antibiotics and physiotherapy were given. The patient had a good recovery; nevertheless the management of this morbidly obese patient in the modified lithotomy with steep head-down position for long duration of surgery was a challenge to the anaesthesiologist.

The sequelae of compartment syndrome (CS) left untreated was first described by Volkmann in 1881. The prevailing theory at the time was that tight bandages caused the ischaemic insult. Waters and Beall defined the compartment syndrome in a case series of British World War II victims in 1941. Labelled initially as crush injury with impairment of renal function, the authors described a swollen limb developing into shock, diminished pulse in the injured extremity, impending limb gangrene, progressive renal failure, and ultimately death. This was further elucidated and better characterised by Cone as muscle trauma leading to increased pressure within a muscular compartment that impairs blood supply, leading to necrosis.[4] The incidence of leg CS following major pelvic surgery done in lithotomy position is 1:3,500.[5] Recent literature shows that the estimated incidence after cystectomy is one in 500.[6] Possible causes of development of CS are hypoperfusion of the arteries as the leg is above the level of the heart, compression of veins in the groin resulting in venous obstruction by the stirrups or intermittent compression cuffs and limb weight in the stirrups or passive plantar flexion causing an increase in compartment pressure. The main risk factors for development of CS include the type of leg holder (ankle blood pressures were low and equivalent in lithotomy with heel and calf support), duration of surgery >4 h, pre-existing peripheral vascular disease, body mass index >25 kg/m², intraoperative hypotension and/or use of vasoconstrictors.[7]

The diagnosis of CS depends on high clinical suspicion. Technical difficulty in performing RRC IC leads to increased duration of surgery. Early recognition and immediate intervention are important measures to avoid irreversible damage and complications arising from compartment syndrome like paralysis, sensory deficits, need for limb amputation and multiple organ insufficiency.

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Conflicts of interest

There are no conflicts of interest.