Well-Leg Compartment Syndrome After Percutaneous Nephrolithotomy in the Galdakao-Modified Supine Valdivia Position

Abstract

Purpose

The objective is to present a case of well-leg compartment syndrome in the Galdakao-modified supine Valdivia position.

Results

The case of a 32-year-old male, obese (105 Kg) and a former smoker is presented. The patient was positioned in the Galdakao-modified supine Valdivia position, with lower limbs bandaged, to perform a right percutaneous nephrolithotomy. In the immediate postoperative period, significant pain was reported in the left lower limb. The limb appeared oedematous and cyanotic, although pedis pulses were preserved. Doppler ultrasound ruled out venous thrombosis. Suspecting compartment syndrome, the patient underwent a complete decompression fasciotomy of the four left leg compartments. After the surgery, values of creatine phosphokinase reached 80.000 UI/L and serum creatinine levels were 1.53 mg/dL. The patient was taken to the intensive care unit. Six months after the episode, the patient still needs rehabilitation care. The compartment syndrome is a rare complication in lithotomy position, but never described in the Galdakao-modified supine Valdivia position before, with the lower limbs in moderate flexion, and with the ipsilateral lower limb in a slightly inferior position with respect to the other. It may lead to skin necrosis, permanent neuromuscular dysfunction, myoglobinuric renal failure, amputation and even death. Therefore, this complication must be suspected and early decompression of the compartment must be performed. Risk factors include obesity, peripheral vascular disease (advanced age, hypertension, hyperlipidemia and diabetes mellitus), height, hypothermia, acidemia, BMI, male sex, combined general-spinal anesthesia, prolonged surgery time, systemic hypotension, ASA (American Society of Anesthesiologists) class, lack of operative experience, vasoconstricting drugs, important bleeding during the surgery and increased muscle bulk.

Conclusion

Compartment syndrome is a potentially life-threatening complication that may occur in the Galdakao-modified supine Valdivia position. It should be suspected in cases with risk factors and compatible clinical symptoms and signs, and treated rapidly to avoid further complications.

Keywords:

• well-leg compartment syndrome
• percutaneous nephrolithotomy
• Galdakao-modified supine Valdivia position

Acknowledgments

We would like to thank Mr Graham McKee, who greatly assisted the study.

Abbreviations

SD, standard deviation; PCNL, percutaneous nephrolithotomy.

Ethics Approval and Informed Consent

The study was carried out in accordance with the Declaration of Helsinki. Written informed consent has been provided by the patient to have the case details and any accompanying images published. It was approved by Ramón y Cajal University Hospital Ethics Committee.

Author Contributions

Drs Laso-García and Arias-Fúnez contributed to the study conception and design. Material preparation and data collection were performed by Drs Díaz-Pérez and Lorca-Álvaro. The first draft of the manuscript was written by Drs Burgos-Revilla, Duque Ruiz and Laso-García. Drs Arias-Fúnez, Díaz-Pérez and Lorca-Álvaro critically reviewed the article. All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors report no conflicts of interest in this work.