A Case of Well Leg Compartment Syndrome Following Laparoscopic Myomectomy

Well leg compartment syndrome (WLCS) is a rare but potentially devastating complication that is seen after gynecological, urological, and colorectal operations. We report a case of a 31-year-old woman presenting with right lower limb WLCS after laparoscopic myomectomy. The operation was performed in the lithotomy position combined with the Levitator and Trendelenburg positions and the duration of the procedure was approximately 6 hours. Both legs were attached with elastic stockings and intermittent pneumatic compression applied for prevention of deep vein thrombosis. Hemodynamic parameters of the patient were stable during the procedure. The Trendelenburg position was suspended, with the aim of preventing WLCS, for 5 minutes and 50 minutes at about 3 hours and 4 hours, respectively, from the beginning of the operation. Immediately after the operation, the patient complained of right crural pain, yet serum creatine phosphokinase (CPK) was detected to be within the normal range (100 IU/L). The following morning, on examination, we observed foot drop, paresthesia, swelling of the right calf, and an increased CPK (5316 IU/L). Three-dimensional computed tomography (3D CT) revealed the right lower limb muscle to be swollen and edematous in the posterior compartment. Acute arterial occlusion or deep vein thrombosis was not found. Fortunately, the patient did not need to undergo fasciotomy as the foot drop recovered after 3 months. WLCS is believed to be a life-threatening iatrogenic complication following surgery in the lithotomy position. As a result of this clinical experience, we have decided not to use elastic stockings, to mobilize the legs every 2 hours, and to take the supine position without Trendelenburg for 10 minutes at 3.5 hours from the beginning of the operation in this position. Moreover, to prevent irreversible damage, 3D CT angiography should not be delayed if WLCS is clinically suspected even in cases in which CPK is within the normal range.