Operative Factors

Operative Time

Operative time is also a risk factor for rhabdomyolysis and peripheral nerve injury, making it a greater concern in laparoscopy, which can subject the patient to prolonged periods on the operating table. Rhabdomyolysis has been reported in as little as 4.5 hours in the full flank position (5), and similar times are reported for the lithotomy position.

In peripheral neuropathies caused by nerve compression or stretching, risk of nerve injury increases as operative time increases. Prolonged positioning in the lithotomy position is known to increase risk of lower extremity neuropathy (6).

Operative Position

The risk of peripheral nerve injury and rhabdomyolysis also depends on operative position. The occurrence of rhabdomyolysis during extreme lithotomy positioning is well documented. Wolf et al. found that all patients in their survey who developed clinical rhabdomyolysis were placed in the flank position. Although this condition was more common in patients in full flank position (67% of patients with rhabdomyolysis) versus modified flank (37%), table flexion did not appear to make a difference (3).

Operative positioning plays a major role in development of postoperative peripheral neuropathy. The flank position places upper extremity nerves at risk. The downside brachial plexus is at risk for compression injury in this position. The lithotomy position is associated with a host of lower extremity neuropathies, including femoral, peroneal, and sciatic neuropathies.

The flank and modified flank positions can be associated with postoperative pain in the upside shoulder secondary to stretch injury to the suprascapular nerve during circumduction or because of joint contusion (3). Wolf et al. found that patients who are thin and young with relatively free range of motion of the shoulder joint were at risk for this type of complication (3).

Upper Abdominal vs. Lower Abdominal Procedures

In their analysis of neuromuscular complications in urologic laparoscopy, Wolf et al. drew a distinction between upper retroperitoneal and lower retroperitoneal procedures (3). They found that upper retroperitoneal procedures were more than twice as likely (3.1% vs. 1.5%) to result in neuromuscular complication than lower retroperitoneal procedures. While the authors did not speculate as to the reason for this difference, it is likely that use of the flank position in upper retroperitoneal procedures may be a contributing factor.

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