(138) Evidence-based Strategies for Preventing Lower-limb Complications Secondary to Prolonged Use of the Dorsal Lithotomy Position
Authors: Sandhu S , Mallavarapu S , Smith S , Garcia M 
Published: February 2024

Abstract

Introduction
Patient positioning at the time of surgery plays a critical role in determining patient outcomes. Specific to patients undergoing genital gender-affirming surgery (gGAS), these patients are required to be placed in the lithotomy position to access the pelvis and perineum for their procedures. Lower-extremity injury due to prolonged surgical time in the lithotomy position can have significant post-operative morbidity affecting patient outcomes. This risk is increased in patients undergoing gGAS procedures due to high surgical complexity and especially long operative times as compared to other surgical procedures. Careful attention must be directed to the patient’s specific position intraoperatively due to significant risk of potential injury with prolonged surgeries. Prolonged stasis can cause injuries ranging from mild soft-tissue injuries which rapidly resolve, such as mild pressure injuries to bony prominences, to severe injuries including pressure ulcers, nerve injuries, rhabdomyolysis, and compartment syndrome. These complications can have lasting impact on the patient, with associated morbidity and mortality risk, and can also impact healthcare systems through additional dollars spent caring for patients who suffer these complications and their associated rehabilitation, and legal recourse on behalf of the patient who suffered these severe complications.

Objective
Our study aimed to describe our technique for preventing lower extremity injuries in the dorsal lithotomy position, and to evaluate our positioning-related post-operative complications and rates.

Methods
We describe our technique for lower-limb positioning in the dorsal lithotomy position, with an emphasis on injury prevention for patients undergoing gGAS. We assessed positioning-related outcomes and complications among patients undergoing gGAS for prolonged periods (&gt;300 minutes) in the lithotomy position between January 2017 to March 2023.

Results
A total of 227 patients underwent 310 gGAS procedures were included in our study (156 masculinizing:154 feminizing gGAS procedures). Mean operative time was 495.5 minutes +/- 156.5 minutes (SD) (Range 300–1095 minutes) (Table 1a). A total of 6/227 (2.6%) patients (2 masculinizing and 4 feminizing surgical patients) had transient, self-limited LE pain post-operatively. No (0%) patients had major or chronic complications including chronic nerve injury, pressure ulcers, rhabdomyolysis or compartment syndrome (Table 1b). Our patient positioning employs the use of ½ inch foam placed to surround the lower extremity, ensuring that all at-risk areas of compression are adequately protected when placing the patient’s leg in the Allen stirrups whilst in the lithotomy position (Figure 1). In addition, a perioperative list is also utilized with regular leg checks every 2 hours with nursing documentation and also, ensuring patients are able to move their lower extremities without any pain post-operatively (Figure 2).

Conclusions
Our study is the first to describe and illustrate specific techniques, and outline strategies, for protecting the lower extremities to prevent injuries in patients undergoing prolonged surgical procedures in the lithotomy position. The low complication rates associated with our technique warrants attention to further refine this technique, and, to integrate these strategies into operating-room programs across diverse specialties.

Disclosure
No.