Question 12

A 53 yo was placed in stirrups and underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy and lymph node dissection for endometrial cancer. A wound protector/retractor was used to provide exposure. She has a BMI of 62, diabetes and hypertension. On post-op day 2, she has difficulty walking. Her foot is limp and she cannot dorsiflex. She has no other symptoms. The measure that could have prevented this injury is:

Answer Choices:

Improved diabetes control

Omission of lymph node dissection

Delayed postoperative ambulation

Appropriate positioning of legs in stirrups

Correct Answer:

Appropriate positioning of legs in stirrups

Explanation:

  • Nerve injuries happen in about 2% of pelvic surgeries

  • Transection injuries occur at the time of incision (higher with transverse incisions), higher risk of incision extends lateral to the rectus muscle (ilioinguinal and iliohypogastric nerves). These typically present as paresthesia

  • Transection of the obturator nerve has been reported during LN dissection, but this injuries are rare

  • Entrapment nerve injuries can happen during skin closure

  • Compression or stretch injuries are usually due to patient positioning or retractor blade placement. Compression of the nerve can affect the nerve’s vascular supply and lead to ischemic injury and lead to sensory or motor defects

  • Compression of the peroneal nerve can lead to foot drop (inability to dorsiflex) and paresthesia of the shin and dorsum of the foot