Two fasciotomies performed for well-leg compartment syndrome after robot-assisted surgery: A case report

Compartment syndrome due to prolonged lithotomy position and low head position is a known perioperative complication following robot-assisted pelvic surgery. We report a case of bilateral lower leg compartment syndrome (CS) after robot-assisted modified radical hysterectomy (RAMRH) for uterine cancer (UC) in a 55-year-old woman, which required two fasciotomies. She had gravidity and parity of two and was obese with a body mass index of 39.3. She underwent RAMRH with bilateral salpingo-oophorectomy for UC. She was in lithotomy position and 25 degrees head-down for ４ h and 45 min during the operation. Postoperatively, pain and swelling in the right lower leg (RLL) and creatine kinase (CK) elevation (4,419 IU/l) were observed; therefore, CS was suspected. However, since the symptoms had temporarily improved, cooling and lower extremity elevation were performed conservatively. Thereafter, increased pain and pressure in the muscle compartment of RLL and further CK elevation (55,736 IU/l) were noted. Therefore, she was diagnosed with lower limb CS and emergency fasciotomy was performed. Additionally, 25 h after the surgery, pain and increased pressure in the muscle compartment of the left lower leg (LLL) were observed; thus, an emergency fasciotomy of LLL was performed. Postoperatively, no complications such as wound infection or necrosis were observed; hence the wound was closed with skin grafting on postoperative day 16. In this case, the patient was at risk for multiple CSs, due to prolonged surgery, lithotomy position, low head position, and high obesity. Preoperative risk assessment and appropriate intraoperative management are important to prevent CS.