We report a rare case of acute compartment syndrome of both lower extremities in a 41-year-old healthy woman who developed bilateral lower extremity ACS and rhabdomyolysis after a conventional laparoscopic myomectomy in the lithotomy and head-down positions for only 118 min.

Existing studies have fully demonstrated that lithotomy position is a risk factor for ACS, especially when the operation time exceeds 2–4 h [3,4,5,6,7,8,9]. When patients undergo prolonged abdominal and pelvic surgery in the head-down tilted Lloyd-Davies/lithotomy position, the position of the lower limbs above the heart can lead to decreased perfusion pressure.The onset of compartment syndrome is precisely the initiating factor of lower limb perfusion disorder.This initiates a chain reaction that includes fluid leakage due to muscle necrosis and the breakdown of capillary wall integrity, leading to significant edema within the compartment. As the edema worsens, the pressure inside the compartment rises, further compromising vascular supply, perpetuating a vicious cycle [2, 10]. Once initiated, this cycle can escalate quickly, and if not recognized and treated in time, it can result in permanent damage to the muscles, nerves, and surrounding tissues within the compartment. The only effective treatment is surgical fasciotomy [11]. Delayed fasciotomy is the most important factor leading to poor prognosis, which may lead to limb necrosis, amputation and rhabdomyolysis, which may result in acute renal failure and pose a life-threatening risk. If ACS is not diagnosed and treated promptly with an urgent fasciotomy, it can advance to severe complications, including limb amputation and rhabdomyolysis [12], which may result in acute renal failure and pose a life-threatening risk. Therefore, leg pain after surgery is a serious symptom that requires immediate evaluation. Other related symptoms include paresthesia, loss of sensation, intact pulses, and tightness and swelling in the affected area [13].

In this case study, elastic compression stockings were used to prevent DVT in patients after surgery. It is unclear whether the use of elastic compression stockings to prevent DVT will induce ACS [14], but the constant pressure exerted by elastic compression stockings on the calf can reduce local blood flow [15, 16]. Literature has noted that ill-fitting ES can be a contributing factor to ACS [17]. Although the intermittent pneumatic compression device for the calf was not used in this case, it is also commonly used to prevent DVT after surgery. According to literature reports [8, 18, 19], the use of intermittent pneumatic compression is associated with the occurrence of ACS.

The most direct way to diagnose ACS is to measure the pressure in the fascial compartment (more invasive), which may not be familiar to non-orthopedic doctors [20, 21]. In this case, ACS was suspected due to calf pain and the exclusion of DVT. By conducting less invasive blood tests to monitor dynamic changes in CK and CK-MB levels [22], and correlating these findings with clinical symptoms, ACS was diagnosed early. This timely diagnosis allowed for prompt intervention, preventing more severe complications. Physicians should remain vigilant for the potential development of ACS in patients undergoing surgery in the lithotomy position. To reduce ACS risk, it is beneficial to limit the duration that patients’ legs remain elevated and to periodically adjust the operating table position [23]. The use of sequential compression devices and anti-thromboembolic stockings warrants caution to prevent excessive external compression, which could exacerbate compartment pressure. Eliminating the pressure on the calf caused by the lithotomy position and reducing the pressure on the calf contact area during surgery are effective prevention strategies [24].