Lloyd-Davies position with Trendelenburg - A disaster waiting to happen?

PURPOSE: Lower limb compartment syndrome has been reported to occur after c olorectal, urological, and gynecological procedures during which the patien t's lower limbs are elevated for prolonged periods of time. METHOD: We inve stigated lower limb perfusion in a group of patients undergoing prolonged p elvic surgery both during and immediately after surgery, using intraarteria l blood pressure monitoring, laser doppler flowmetry, and pulse oximetry. R ESULTS: Use of the modified lithotomy position was not associated with any demonstrable decrease in lower limb perfusion. The addition of 15 degrees h ead-down tilt, however, during pelvic dissection, led to an immediate and s ignificant drop in lower limb perfusion (P < 0.05; Mann-Whitney U test). Th e subgroup of patients analyzed postoperatively showed a ten-fold increase (P < 0.01) in perfusion that was confined to the muscle compartment with no demonstrable increase in skin perfusion or intra-arterial pedal blood pres sure. CONCLUSION: The use of the modified lithotomy position during pelvic surgery is not associated with lower limb ischemia. Addition of Trendelenbu rg position, however, causes profound ischemia of the lower limbs, and this is followed during the recovery period by hyperperfusion that is confined to the muscle compartments, which may put patients at risk of developing lo wer limb compartment syndrome.