Lower Extremity Injury While Undergoing Urology Procedures in the Trendelenburg with Lithotomy Position: Three Case Reports

      Abstract

      Purpose

      To report and discuss the incidence of severe lower extremity injuries associated with robotic procedures in Trendelenburg with lithotomy position.

      Design and Methods

      A case study method was used to describe three cases of patients who underwent robotically assisted urological procedures in Trendelenburg with lithotomy position and developed serious lower extremities injuries resulting in fasciotomies. Furthermore, a literature review was conducted to evaluate risk factors and possible interventions for the prevention of similar injuries.

      Findings

      Case analysis revealed multifactorial causes, including patient comorbidities, long surgical procedures, and blood pressure decreases below the baseline for more than 30 minutes. The severity of lower extremity injury associated with lithotomy position may be underestimated. The etiology of peripheral nerve injury can be attributed to patient comorbidities, positioning, and surgical conditions. Injury prevention should include careful patient and procedural risk assessment, staff education, and communication strategies.

      Conclusions

      Extreme Trendelenburg with lithotomy position for longer periods can lead to serious lower extremities injuries. Preanesthetic screening and multidisciplinary team discussions for additional precautions for high-risk patients are crucial interventions to decrease incidence and severity of lower extremities injuries.

      Keywords

      Objectives–1. Describe the pathophysiology of lower extremity injuries associated with procedures in lithotomy with Trendelenburg position. 2. Discuss the risk factors for development of lower extremity injuries associated with procedures in lithotomy with Trendelenburg position. 3. Describe how to develop evidence-based strategies to reduce the risks of lower extremity injuries during surgical procedures.
      Patients who have surgical procedures while in Trendelenburg with lithotomy position may develop lower extremity nerve injuries (eg, peroneal nerve, saphenous nerve, lateral femoral cutaneous nerve, and sciatic nerve) that can result in temporary or permanent sensory or motor deficits. The American Society of Anesthesiologists Closed Claim Database stated that nerve injury accounted for 12% of malpractice claims between 1990 and 2013 for patients under general anesthesia.
      Practice Advisory for the Prevention of Perioperative Peripheral Neuropathies: A Report by the American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies.
      • Chui J.
      • Murkin J.
      • Posner K.
      • Domino K.
      Perioperative Peripheral Nerve Injury After General Anesthesia.
      • Welch M.
      • Brummett C.
      • Welch T.
      • et al.
      Perioperative Peripheral Nerve Injuries.
      However, the fact that the rate of these occurrences is relatively unchanged accentuates the need for a more comprehensive understanding of this persistent problem. The etiology of peripheral nerve injury can be attributed to a variety of factors arising from patient comorbidities, positioning, and surgical conditions.
      • Chui J.
      • Murkin J.
      • Posner K.
      • Domino K.
      Perioperative Peripheral Nerve Injury After General Anesthesia.
      • Welch M.
      • Brummett C.
      • Welch T.
      • et al.
      Perioperative Peripheral Nerve Injuries.
      • Clarke D.
      • Mullings S.
      • Franklin S.
      • Jones K.
      Well leg compartment syndrome.
      • Stornelli N.
      • Wydra F.
      • Mitchell J.
      • Stahel P.
      • Fabbri S.
      The dangers of lithotomy positioning in the operating room: case report of bilateral lower extremity compartment syndrome after a 90-minutes surgical procedure.
      • Warner M.
      • Warner D.
      • Harper C.
      • Schroeder D.
      • Maxson P.
      Lower Extremity Neuropathies Associated with Lithotomy Positions.
      • Sukhu T.
      • Krupski T.
      Patient Positioning and Prevention of Injuries in Patients Undergoing Laparoscopic and Robot-Assisted Urologic Procedures.
      Retrospective studies, case reports, and malpractice claims indicate that most common patient risk factors include male gender, age, body mass index (BMI), smoking, peripheral vascular disease (PVD), diabetes, and hypertension (HTN).
      • Chui J.
      • Murkin J.
      • Posner K.
      • Domino K.
      Perioperative Peripheral Nerve Injury After General Anesthesia.
      ,
      • Welch M.
      • Brummett C.
      • Welch T.
      • et al.
      Perioperative Peripheral Nerve Injuries.
      ,
      • Mizuno J.
      • Takahashi T.
      Male sex, height, weight, and body mass index can increase external pressure to calf region using knee-crutch-type leg holder system in lithotomy position.
      Iatrogenic risk factors include length of surgery, blood loss, and maintenance of mean arterial pressure (MAP) within 20% of patient's baseline.
      • Chui J.
      • Murkin J.
      • Posner K.
      • Domino K.
      Perioperative Peripheral Nerve Injury After General Anesthesia.
      ,
      • Warner M.
      • Warner D.
      • Harper C.
      • Schroeder D.
      • Maxson P.
      Lower Extremity Neuropathies Associated with Lithotomy Positions.
      Furthermore, evidence supports that for every hour a patient is in lithotomy position, the risk for developing a nerve injury increases by nearly 100-fold,
      • Chitlik A.
      Safe Positioning for Robotic-Assisted Laparoscopic Prostatectomy.
      while the pressure in the calf compartment increases at a rate of 1.1 mm Hg per hour.
      • Stornelli N.
      • Wydra F.
      • Mitchell J.
      • Stahel P.
      • Fabbri S.
      The dangers of lithotomy positioning in the operating room: case report of bilateral lower extremity compartment syndrome after a 90-minutes surgical procedure.
      For every centimeter that the limb is elevated above the level of the heart, the systolic blood pressure (BP) decreases 0.78 mm Hg.
      • Mizuno J.
      • Takahashi T.
      Male sex, height, weight, and body mass index can increase external pressure to calf region using knee-crutch-type leg holder system in lithotomy position.
      In this report, we describe three cases of patients sustaining serious lower extremity injuries while undergoing robotically assisted laparoscopic urology procedures in the Trendelenburg with lithotomy position in a large academic institution. All three patients required surgical interventions for their injuries. Chart reviews included analysis of the anesthesia preoperative documentation, intraoperative anesthesia records, surgical records, and postoperative multidisciplinary documentation regarding the associated injuries.
      This article adheres to the applicable Enhancing the QUAlity and Transparency Of health Research (EQUATOR) guideline. Written consents have been obtained from the three patients.

      Case Presentations

      Case 1

      A 59-year-old male presented for elective robotically assisted laparoscopic radical cystectomy and prostatectomy. Medical history was significant for bladder cancer, obesity (BMI, 27.8), and former smoker of 15 pack-years. Preoperative physical examination and laboratory values were unremarkable. The patient was not taking any prescribed medications at home. Preoperative BP was 124/86, MAP was 98, heart rate (HR) was 65 beats/min, and electrocardiogram showed normal sinus rhythm.
      General anesthesia was induced uneventfully, and tracheal intubation was performed. An arterial line was placed, and anesthesia was maintained with oxygen (50%) and sevoflurane. The patient's legs were placed in Allen stirrups, and the patient was positioned in lithotomy with steep Trendelenburg (32°). Continuous compression devices on both lower legs were used for venous thrombosis prophylaxis throughout the procedure.
      BP lower than 20% from baseline (lowest reading 90/48 mm Hg; MAP, 62) during the case was noted, including three periods of approximately 30 minutes each with lowest MAPs (66 to 70). Fluid management included administration of 3,500 mL crystalloids, 400 mL urine output, and 700 mL blood loss. The total anesthesia time was 553 minutes, and total time in lithotomy position was approximately 240 minutes.
      The patient was transferred to the postanesthesia care unit (PACU) at approximately 16:30 with an MAP of 101. The patient was later transferred to the surgical floor by 19:15, and during that time, the patient complained of severe pain in his right calf and numbness in right lower leg. Initial evaluation revealed right lower extremity foot drop, swelling, and tightness of the anterolateral aspects. The patient was treated symptomatically with intravenous analgesic boluses. The patient's pain discomfort continued to escalate. An urgent right lower extremity Doppler ultrasound was obtained, which was positive for nonobstructive deep venous thrombosis of the peroneal vein. He was found to have a right common peroneal nerve injury and compartment syndrome. Heparin infusion was started intravenously in addition to the routine dose of subcutaneous heparin for deep venous thrombosis prophylaxis. The patient underwent a right lower leg fasciotomy on the next day, and the diagnosis of compartment syndrome was confirmed intraoperatively.

      Case 2

      A 55-year-old male presented for elective robotically assisted laparoscopic radical prostatectomy. Medical history was significant for prostate cancer, HTN, obesity (BMI, 29.4), hyperlipidemia, PVD, alcohol abuse, and current daily smoker of 35 pack-years. Surgical history was significant for left common iliac and femoral artery aneurysm repair. Preoperative computerized tomography scan showed remaining extensive atherosclerotic calcification as well as left common iliac and femoral artery aneurysms. Current medications included sertraline, pantoprazole, aspirin, cilostazol, clopidogrel, gabapentin, Januvia, glyburide, metformin, pravastatin, verapamil, and lisinopril. Preoperative physical examination and laboratory values were unremarkable with preoperative BP 130/84 mm Hg, MAP 99, HR 68 beats/min, and normal sinus rhythm on the electrocardiogram.
      General anesthesia was induced uneventfully, and tracheal intubation was performed. An arterial line was placed, and anesthesia was maintained with oxygen (40%) and sevoflurane. The patient's legs were placed in Allen stirrups, and the patient positioned in lithotomy with steep Trendelenburg (32°). Continuous compression devices on both lower legs were used for venous thrombosis prophylaxis throughout the procedure.
      BP drop of more than 20% (lowest BP, 94/62) from baseline was noted with MAP 48—60 mm Hg for a duration of 15 minutes on three occasions. Overall, MAP was maintained above 80 mm Hg (which was the lower limit of the baseline MAP) for most cases. On emergence from anesthesia, the BP was 148/96 mm Hg and MAP was 113. Fluid management included administration of 1,500 mL crystalloids, urine output not documented, and 150 mL blood loss. The total anesthesia time was 250 minutes, and the total time in lithotomy position was 170 minutes.
      The patient was transferred to PACU by 16:00 with an MAP of 102, with complaints of pain in left lower extremity on emergence from anesthesia. Vascular surgery consult was ordered, and an urgent left lower extremity Doppler ultrasound was obtained at the bedside. The patient was found to have a large left femoral aneurysm with compartment syndrome and cold foot. The same day, the patient underwent percutaneous endovascular revascularization of the iliac artery with stent placement and angioplasty. The vascular surgeon noted that the patient had severe atherosclerotic disease in the iliac artery and thrombosed his femoral artery aneurysm. Five days later, the patient underwent closure of the left lower extremity fasciotomy incisions with a skin graft.

      Case 3

      A 62-year-old male presented for elective robotically assisted laparoscopic radical cystectomy with ileal conduit. His medical history was significant for HTN, hyperlipidemia, diabetes mellitus type 2, obesity (BMI, 29.5), chronic obstructive pulmonary disease, bladder cancer, and currently smoking. Surgical history included vascular repair of gunshot wound to the left leg 19 years ago. Current medications included lisinopril, atorvastatin, tamsulosin, and aspirin. A recent physician's office visit note revealed that the patient complained of left lower leg pain, which began after his first round of chemotherapy, and at the time, it was attributed to his history of gunshot wound. Preoperative physical examination and laboratory values were unremarkable with preoperative BP 142/87 mm Hg, MAP 105, HR 64 beats/min, and normal sinus rhythm on the electrocardiogram.
      General anesthesia was induced uneventfully, and tracheal intubation was performed. An arterial line was placed, and anesthesia was maintained with oxygen (40%) and sevoflurane. The patient's legs were placed in Allen stirrups, and the patient positioned in lithotomy with steep Trendelenburg (32°). Continuous compression devices on both lower legs were used for venous thrombosis prophylaxis throughout the procedure.
      BP drop of more than 20% from baseline (lowest recorded BP 92/41 and MAP 64 to 67) was noted in the first 30 minutes and remained below 20% from baseline for most of the case duration. In addition, the pulse pressure variations (PPVs) were in the range of 16% to 20% for nearly 2 hours (Figure 1). Fluid management included administration of 4,100 mL crystalloids, urine output 200 mL, and 500 mL blood loss. The total anesthesia time was 526 minutes, and the total time in lithotomy position was 240 minutes.
      Figure thumbnail gr1
      Figure 1Changes in blood pressure and systolic pressure variations, case 3. NIBP, noninvasive blood pressure; ART, arterial; SpO2, peripheral capillary oxygen saturation; SPV, systolic pressure variation. This figure is available in color online at www.jopan.org.
      The patient was transferred to PACU by 11:00 with an MAP of 117. The patient was transferred to the surgical floor, and about 5 hours postoperatively, the patient complained of severe pain to the left lower extremity. On physical examination, pedal pulses were not palpable, and the leg was pale and cold to touch, with concerns for acute critical limb ischemia. Serial examinations with creatinine phosphokinase levels showed unrelenting symptoms despite what was deemed adequate pain control. Concerns for vascular compromise were raised, for which the patient underwent emergent left lower extremity angiogram with revascularization and fasciotomies the same day, approximately 9 hours postoperatively.

      Discussion

      Peripheral nerve injury can result in temporary or permanent sensory and motor deficits and represent a notable source of anesthetic complications. Lower extremity injuries after urologic procedures in lithotomy position may be more common than currently recognized by the health care community, and may have been underreported in the past years. Lower extremity compartment syndrome is a pathologic condition in which an increase in tissue pressure within a closed space compromises blood circulation, leading to tissue necrosis and edema because of ischemia.
      • Stornelli N.
      • Wydra F.
      • Mitchell J.
      • Stahel P.
      • Fabbri S.
      The dangers of lithotomy positioning in the operating room: case report of bilateral lower extremity compartment syndrome after a 90-minutes surgical procedure.
      The pressure within the compartment continues to increase, further compromising the blood supply and leading to more hypoxia, resulting in a vicious cycle.
      • Stornelli N.
      • Wydra F.
      • Mitchell J.
      • Stahel P.
      • Fabbri S.
      The dangers of lithotomy positioning in the operating room: case report of bilateral lower extremity compartment syndrome after a 90-minutes surgical procedure.
      Clinical diagnosis of compartment syndrome includes signs and symptoms of paresthesias, tightness, pain, pulselessness, and pallor.
      • Stornelli N.
      • Wydra F.
      • Mitchell J.
      • Stahel P.
      • Fabbri S.
      The dangers of lithotomy positioning in the operating room: case report of bilateral lower extremity compartment syndrome after a 90-minutes surgical procedure.
      • Craig A.
      Entrapment Neuropathies of the Lower Extremity.
      Chui et al
      • Chui J.
      • Murkin J.
      • Posner K.
      • Domino K.
      Perioperative Peripheral Nerve Injury After General Anesthesia.
      described peripheral nerve injuries as multifactorial and resulting from a combination of local (eg, stretching, compression, ischemia, and transection) and systemic (eg, systemic hypotension and inflammation) insults. The manifestation of patient symptoms depends on the severity and duration of the nerve insult and the underlying neuronal reserves, which are impaired with pre-existing peripheral neuropathy.
      • Chui J.
      • Murkin J.
      • Posner K.
      • Domino K.
      Perioperative Peripheral Nerve Injury After General Anesthesia.
      During Trendelenburg in lithotomy position, nerve compression and interruption of perfusion seem to play the highest role based on our analysis of the three cases, in addition to specific patient-related factors.
      • Sukhu T.
      • Krupski T.
      Patient Positioning and Prevention of Injuries in Patients Undergoing Laparoscopic and Robot-Assisted Urologic Procedures.
      ,
      • Craig A.
      Entrapment Neuropathies of the Lower Extremity.

      Patients' Risk Factors

      In these case reports, commonalities included that all three patients were males, aged 55 to 62, with lower extremity injuries after undergoing robotically assisted laparoscopic urology procedures in the Trendelenburg with lithotomy position. The three patients had extensive histories of smoking and were overweight (BMI greater than 25). Two patients had a preoperative diagnosis of PVD and HTN, and the third patient was at risk for hypercoagulable state because of cancer and chemotherapy treatment. Their history was consistent with the findings in the literature about risk factors for peripheral nerve injuries.
      • Sukhu T.
      • Krupski T.
      Patient Positioning and Prevention of Injuries in Patients Undergoing Laparoscopic and Robot-Assisted Urologic Procedures.
      These patients suffered serious lower extremities injuries (neuropraxia and compartment syndrome) necessitating surgical intervention.

      Procedural Risk Factors

      Common provider-mediated attributes included procedure length of more than 4 hours, positioning, and MAP less than 20% of baseline.
      • Chui J.
      • Murkin J.
      • Posner K.
      • Domino K.
      Perioperative Peripheral Nerve Injury After General Anesthesia.
      • Welch M.
      • Brummett C.
      • Welch T.
      • et al.
      Perioperative Peripheral Nerve Injuries.
      • Clarke D.
      • Mullings S.
      • Franklin S.
      • Jones K.
      Well leg compartment syndrome.
      • Stornelli N.
      • Wydra F.
      • Mitchell J.
      • Stahel P.
      • Fabbri S.
      The dangers of lithotomy positioning in the operating room: case report of bilateral lower extremity compartment syndrome after a 90-minutes surgical procedure.
      • Warner M.
      • Warner D.
      • Harper C.
      • Schroeder D.
      • Maxson P.
      Lower Extremity Neuropathies Associated with Lithotomy Positions.
      Evidence suggests that for every hour a patient is in lithotomy position, the risk for developing a nerve injury increases by nearly 100-fold.
      • Chitlik A.
      Safe Positioning for Robotic-Assisted Laparoscopic Prostatectomy.
      Furthermore, the pressure in the calf compartment increases at a rate of 1.1 mm Hg/h.
      • Stornelli N.
      • Wydra F.
      • Mitchell J.
      • Stahel P.
      • Fabbri S.
      The dangers of lithotomy positioning in the operating room: case report of bilateral lower extremity compartment syndrome after a 90-minutes surgical procedure.
      A systematic review by Chui et al
      • Chui J.
      • Murkin J.
      • Posner K.
      • Domino K.
      Perioperative Peripheral Nerve Injury After General Anesthesia.
      found that the peripheral nerves are very sensitive to ischemic insult, and an intraoperative hypotension with MAP less than 55 mm Hg for 5 minutes or longer was associated with development of abnormal somatosensory potentials. The authors suggest that the MAP needs to be maintained at more than 80 mm Hg intraoperatively to be protective against peripheral nerve injuries.
      • Chui J.
      • Murkin J.
      • Posner K.
      • Domino K.
      Perioperative Peripheral Nerve Injury After General Anesthesia.
      Our case analysis revealed that the patients were in lithotomy for nearly 4 hours and had episodes of hypotension.

      Strategies to Mitigate Risks and Injury Prevention

      Early Identification of Patients At Risk

      The authors suggest careful evaluation of the comorbidities of patients scheduled for procedures in the Trendelenburg with lithotomy positions, as this position may increase risks for lower extremities injuries. Further investigation should be conducted in patients with a history of leg pains, PVD, smoking, or other conditions placing them at risk for hypercoagulable states and hypoperfusion of their extremities.

      Perioperative Management

      Prompt anesthetic management of hypotension and maintaining MAP at or above 20% from baseline is prudent as the lower extremities' perfusion is quickly compromised in lithotomy position. Goal-directed fluid therapy and monitoring of PPV in anesthetized intubated patients can be used to optimize fluid balance and correct hemodynamic instability. Meta-analysis shows that the PPV threshold predicting fluid responsiveness to fluid bolus is 10.5% with range of 8% to 15%
      • Messina A.
      • Pelaia C.
      • Bruni A.
      • et al.
      Fluid Challenge During Anesthesia: A Systematic Review and Meta-analysis.
      ; therefore, the goal should be to maintain PPV less than 15% while assuring the patients are adequately hydrated and normotensive. Careful positioning, padding, and documenting length of time in lithotomy serve as a reminder when nearing the 4-hour mark. Finally, allowing the patient to remain supine until absolutely necessary to position into lithotomy, or evaluating the possibility of changing the position during the procedure can decrease the risk of lower extremity injuries. In this particular institution, after these incidents, interdisciplinary meetings with the operating room management, nurses, urology, and the anesthesia departments were held to evaluate the root cause and discuss the aforementioned strategies for injury prevention. Moving forward, all robotic laparoscopic urology procedures (prostatectomies and cystectomies) are performed in supine Trendelenburg position, and no further lower extremities injuries have been reported so far.

      Staff Education and Communication Strategies

      The operating room nurses, technologists, surgeons, and anesthesia professionals need to take a team approach to proper patient positioning and injury prevention. The operating room nurses are in a unique position to serve as safeguards to patients during the perioperative period. In addition to completing a multitude of safety checklists, they are also required to maintain a current level of knowledge and understanding of a myriad of surgical techniques and technologies. The operating room nurse needs to have an appreciation of the risk for patient injuries related to incorrect Trendelenburg with lithotomy positioning, as it can lead to nerve damage, pressure ulcers, and other complications as mentioned by Chitlik.
      • Chitlik A.
      Safe Positioning for Robotic-Assisted Laparoscopic Prostatectomy.
      The surgical team needs to have understanding of the pathophysiology and mechanism of injuries as well as evaluation of risk factors. The anesthesia professionals need to be vigilant and maintain the patient's MAP within 20% of their baseline and avoid periods of prolonged hypotension. Additional safeguards that have proven helpful in other instances are incorporation of procedure-specific checklists to address risk factors, expected length of procedure, and positioning; utilization of electronic health record reminders for change in position at the nearing of the fourth hour; minimize the time in steep Trendelenburg position as much as possible, and level off the bed as soon as the procedure allows. In addition, as part of patient care handoff to PACU nurses, patient's position during the surgical procedure should be discussed to alert them to monitor for specific lower leg nerve injuries such as pain, swelling, sensory, or motor deficits. Early identification of postoperative peripheral nerve injuries could lead to an earlier diagnosis and treatment.

      Limitations

      The aforementioned cases were performed in an academic teaching institution where these types of procedures generally have longer surgical time and the patients have multiple coexisting conditions placing them at higher risk for complications.

      Conclusion

      In light of the presented case studies and supported by the current literature, patients scheduled for procedures in the Trendelenburg with lithotomy positions require careful preanesthetic evaluation and screening to stratify risks for lower extremities injuries. The multifactorial pathogenesis of lower extremity injury requires a multidisciplinary team approach. Surgical team discussions for additional precautions for high-risk patients with regard to surgical positioning and anesthetic management are crucial interventions to decrease incidence and severity of the injuries.

      Test ID W012221 – Expiration Date January 31, 2023

      Lower Extremity Injury While Undergoing Urology Procedures in the Trendelenburg with Lithotomy Position: Three Case Reports
      1.25 Contact Hours
      Purpose of the Journal of PeriAnesthesia Nursing: To facilitate communication about and deliver education specific to the body of knowledge unique to the practice of perianesthesia nursing.
      Outcome of this CNE Activity: To enable the nurse to increase knowledge on lower extremity injuries associated with robotic procedures in the Trendelenburg with lithotomy position
      Target Audience: All perianesthesia nurses
      Article Objectives
      • 1.
        Describe the pathophysiology of lower extremity injuries associated with procedures in lithotomy with Trendelenburg position
      • 2.
        Discuss the risk factors for development of lower extremity injuries associated with procedures in lithotomy with Trendelenburg position
      • 3.
        Describe how to develop evidence-based strategies to reduce the risks of lower extremity injuries during surgical procedures
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      American Society of Perianesthesia Nurses is accredited with distinction as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation.
      Provider approved by the California Board of Registered Nursing, Provider Number CEP5197, for 1.25 contact hours.
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