We present a 71-year-old man who developed left calf pain after an elective laparoscopic assisted anterior resection. A clinical picture with a raised creatine kinase and negative Doppler ultrasound was suggestive of compartment syndrome. Successful surgical management was performed with two incisional fasciotomies to release all four compartments of the left leg. The patient recovered well postoperatively. The lateral incision was closed primarily while the medial incision required vacuum-assisted closure dressings and healed by secondary intention. Neither wound required skin grafts. The patient recovered well but had an extended hospital stay due to extensive physiotherapy requirements and mild foot drop. This report is intended as a guide for clinicians when considering differentials in calf pain following surgery and to keep in mind the small risk of developing compartment syndrome after pelvic surgery.
- gastrointestinal surgery
- vascular surgery
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Compartment syndrome is a rare but serious condition whereby increased intracompartmental pressure develops inside a muscle leading to decreased tissue perfusion and ischaemia.1 It is most commonly associated with lower limb trauma but can also develop after prolonged surgery, particularly operations performed in the Lloyd-Davies position.2
Signs and symptoms include paraesthesia, pain out of proportion to signs, pain on passive stretch, tight calf and in more advanced stages absent peripheral pulses.3 Raised serum creatine kinase (CK) is associated with the diagnosis of acute compartment syndrome,3 though the diagnosis remains an urgent clinical diagnosis. The treatment is prompt diagnosis and immediate all four-compartment fasciotomy. Delay can pathologically lead to tissue necrosis and myoglobin release.4 Clinically, this can cause muscle and nerve damage, kidney damage and contractures, and potentially lead to organ failure, limb amputations and death.4
We report a case of a patient who developed compartment syndrome postoperatively after a laparoscopic-assisted low anterior resection. This case identifies important considerations and differentials when patients present with calf pain postoperatively.
A 71-year-old man presented with rectal cancer for an elective laparoscopic-assisted anterior resection, total mesocolic excision and stapled anastomosis with formation of a loop ileostomy. The procedure was performed in the Lloyd-Davies position with intraoperative Thrombo-embolus deterrent stockings (TEDS) in situ, lasting 6 hours, with approximately 300 mL of blood loss. The patient was intermittently tilted head-down for the pelvic dissection and head-up for splenic flexure mobilisation.
The patient was hypovolvaemic immediately postoperatively and postoperative analgesia included an epidural and patient-controlled anaesthesia (PCA). He had prophylactic low-molecular-weight heparin and antiembolism stockings. Day 2 postoperatively, he developed acute left calf pain. On examination, he had left foot swelling and tenderness in the posterior compartment with absent foot pulses. CK was raised and he was diagnosed clinically with compartment syndrome. After urgent involvement of the on-call vascular surgeon, four-compartment fasciotomy was performed.
The patient’s history includes intermittent claudication, hypertension, chronic obstructive pulmonary disease and benign prostatic hyperplasia. Although preoperatively he described symptoms of intermittent claudication, he was not on any antiplatelet therapy, able to walk for 30 min without stopping and able to climb a flight of stairs. His body mass index was 28 kg/m2 and American Society of Anaesthesiologists (ASA) grade 3.
His preoperative staging CT scan noted aortoiliac occlusion.
Laboratory blood tests reported a white cell count of 10.8×109/L, C reactive protein 106 mg/dL, haemoglobin 120 g/L, platelet count 152×109/L, CK 3780 U/L, with a normal liver and kidney function.
A Doppler ultrasound reported no Deep Vein Thrombosis (DVT). Ankle-Brachial Pressure Index (ABPI) was not measured.
The patient underwent emergency left calf fasciotomies with two incisions to release all four compartments in the leg. Operative findings showed healthy muscles and no oedema in the anterior and lateral compartments, with significant oedema but mostly healthy muscle in the superficial and deep posterior compartments. The long saphenous vein and saphenous nerve were identified and preserved.
Postfasciotomy, he had ongoing swelling at the medial site and a vacuum-assisted closure (VAC) dressing was applied. Wounds were reviewed 48 hours postfasciotomy and primary closure was performed for the lateral side as the tissue was healthy with easily approximated wound edges. The medial side was not amenable to primary closure and had ongoing VAC dressings.
On day 8 postfasciotomy, wound review noted the lateral side closed with staples was clean and dry and the medial was healthy and healing well with delayed primary closure and no need for a skin graft. A mild left foot drop was noted with weak dorsiflexion.
He was eventually discharged 37 days postabdominal operation to a rehabilitation facility for further physiotherapy due to ongoing weak dorsiflexion. His extended inpatient stay was due to a combination of a high output stoma, extensive physiotherapy requirements and the COVID-19 crisis.
Outcome and follow-up
This man underwent a telephone clinic follow-up 4 months postdischarge. He had some ongoing pain in his left leg that is being managed by the vascular team. He is titrating his medication according to stoma output. He is otherwise well and discharged from the rehabilitation facility.
The incidence of the condition varies from as high as one in 500 patients undergoing cystectomy,2 to 1 in 3500 (0⋅03%) or 6 of 52 319 (0⋅01%) undergoing abdominopelvic surgery in the lithotomy or Lloyd-Davies position.5 6 When a patient is in the lithotomy position, the lower leg compartment systolic pressure falls and if this pressure falls below the perfusion pressure then tissue ischaemia occurs.7 When circulation returns to normal postoperatively, reperfusion injury occurs, leading to capillary leakage and tissue oedema, which can lead to the development of compartment syndrome.7
Our patient had multiple risk factors for developing compartment syndrome, including extensive procedure duration (>4 hours), lithotomy positioning (Lloyd-Davies), antiembolism stockings, postoperative hypovolaemia, epidural anaesthesia and peripheral vascular disease.1
The cardinal features of acute compartment syndrome include paraesthesia, pain out of proportion to clinical signs, pain on passive stretch, tight calf and in more advanced stages, absent peripheral pulses.3 The epidural analgesia and PCA may have reduced the symptoms of compartment syndrome in our case.2
A high index of clinical suspicion is key in managing compartment syndrome; recognising perioperative risk factors (such as ABPI and preoperative CT scan results), intraoperatively maintain perfusion blood pressure and optimising patient position. Measurements of CK levels in patients complaining of new calf pain may also aid diagnosis as demonstrated in our patient,3 though this is a clinical diagnosis and investigations should not delay treatment.
The treatment of compartment syndrome as highlighted by the Assocation of Coloproctology of Great Britain and Ireland guidelines recommends immediate surgical decompression of the compartments.8 Fasciotomy is performed to release the pressure of all four compartments (anterior, lateral, superficial posterior and deep posterior) in the leg. It is important to recognise and treat compartment syndrome early because delayed treatment in patients is associated with increased morbidity and mortality.9 The common options for the closure of fasciotomy wounds include direct closure or split-thickness skin grafts.9
In summary, if a patient presents with new calf pain and swelling in the postoperative period following surgery then the possibility of acute compartment syndrome needs to be considered with prompt intervention to prevent acute complications such as muscle necrosis and organ failure.
Prior to the operation I felt I was clear on the different risks of the procedure and I just wanted the cancer gone. However the extended admission was a shock. I was admitted for a lot longer and when I got the leg pain it was unbearable, nothing seemed to reduce the pain especially on walking. The consultants explained why I might have got the compartment syndrome well and apologised for what happened. I then had an extended stay due to the COVID-19 situation and because it took me a long time to regain my strength. I was discharged to a rehabilitation facility and though I am now home I still find that my left leg doesn’t lift properly.
If a patient develops calf tenderness in the postoperative period following surgery, the possibility of compartment syndrome must be kept in mind and prompt clinical diagnosis, investigation and treatment of compartment syndrome is essential due to its high morbidity and mortality.9
Surgery itself presents multiple risk factors for acute compartment syndrome including procedure duration (>4 hours), lithotomy positioning (Lloyd-Davies), antiembolism stockings, postoperative hypovolaemia, epidural anaesthesia, peripheral vascular disease and surgical retraction of major vessels intraoperatively.1
Where elevation of the legs is required to facilitate surgery, the maximum unbroken period of elevation should not exceed 4 hours. The patient’s legs should be kept at a lower level than the heart for a minimum of 15 min after each 4-hour interval. The duration of elevation and the time allowed for recovery should be monitored and documented in the patient’s operation note/anaesthetic chart.8
This case report highlights the importance of a holistic approach to patient care. In particular, the staging CT scan showed aortailiac occlusion and this highlights the importance being aware of all findings in the scan, both specialty-specific and incidental, and for this awareness to be maintained throughout the patient journey by all members of the team involved in the patient’s care and highlights the need for vigilance in managing patients undergoing complex major surgery with comorbidities.
Where peripheral arterial disease is suspected, an Ankle-Brachial Pressure Index is recommended preoperatively to determine further management.
Contributors JC: drafted article, underwent literature review. KS: revising article critically for important intellectual content. DM and AP: further revising of article; final approval of the version to be published.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
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