Head-down tilt lithotomy position and well-leg compartment syndrome: An international survey of current practice

Abstract

Aim: Well-leg compartment syndrome (WLCS) is a serious complication of prolonged surgery in the head-down tilt lithotomy (HDTL) position associated with increased postoperative morbidity and mortality. However, there is a lack of awareness and clinical guidance regarding prevention of WLCS. The aim of this study was to assess current HDTL-related practices and occurrence of WLCS among a global cohort of clinicians.

Method: An international online survey of clinicians was conducted between July and December 2023. Data analysis involved descriptive statistics, machine learning techniques and qualitative content analysis.

Results: A total of 595 clinicians from 71 countries and 14 specialities participated. Most (98%) reported routine use of HDTL, 27% of whom did not implement any preventive strategies. 'Leg rest' was the most reported preventive measure (41%), commonly initiated after 2 or 3 h of HDTL (79%), for 10-15 min (56%). Overall, 170 cases of WLCS were reported by 21% of respondents. The majority reported unilateral WLCS (81%) following a laparoscopic procedure (63%) performed in HDTL (64%). Only 28% of respondents discussed WLCS during consent for operations in HDTL. Machine learning identified 'duration of uninterrupted HDTL' as a positive predictor of the occurrence of WLCS (p < 0.001). Content analysis demonstrated that clinician perspectives and practices regarding WLCS are significantly influenced by personal experience, mostly due to a poor evidence base and lack of standardized institutional policies.

Conclusion: Perioperative practices during procedures in HDTL vary substantially, and are primarily informed by clinician experience and preferences. There is a need for evidence-based consensus on best practices to enhance safety during procedures in HDTL.

Keywords: Lloyd‐Davies; compartment syndrome; global survey; perioperative practices; prevention and management; robotic surgery.

FIGURE 1

Current clinical practices and perceived risk factors for well‐leg compartment syndrome (WLCS). Data are presented as a proportion of the total number of responses for each question. HDTL, head‐down tilt lithotomy; IPCD, intermittent pneumatic compression device; TED, thromboembolic deterrent; VTE, venous thromboembolism. *Multi‐answer question—respondents had the option of more than answer.

FIGURE 2

Characteristics of the reported cases of well‐leg compartment syndrome (WLCS). CP, compartment pressure; HDTL, head‐down tilt lithotomy. *Multi‐answer question—respondents had the option of more than answer.

FIGURE 3

Predictive variables for the occurrence of well‐leg compartment syndrome (WLCS). (A) Ordinary least squares (OLS) [49] regression performs backward elimination by iteratively fitting OLS models and excluding the variable with the highest p‐value > 0.05 until all remaining variables have p‐values < 0.05. (B) Recursive feature elimination (RFE) [50] employs a linear regression model to select relevant variables, ranking them according to importance. Variables assigned a rank of 1 are considered the most important, with p‐values indicating their statistical significance. (C) Least absolute shrinkage and selection operator with cross‐validation (LassoCV) [51] identifies important variables via regularization and selection of the best parameter through cross‐validation. Some coefficients are set to zero, with nonzero coefficients corresponding to the important variables. HDTL, head‐down tilt lithotomy; MIS, minimally invasive surgery.