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

Colorectal Dis. 2025 Jun;27(6):e70134. doi: 10.1111/codi.70134.

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.

MeSH terms

  • Adult
  • Compartment Syndromes* / epidemiology
  • Compartment Syndromes* / etiology
  • Compartment Syndromes* / prevention & control
  • Female
  • Head-Down Tilt* / adverse effects
  • Humans
  • Leg
  • Male
  • Patient Positioning* / adverse effects
  • Patient Positioning* / methods
  • Postoperative Complications* / epidemiology
  • Postoperative Complications* / etiology
  • Postoperative Complications* / prevention & control
  • Practice Patterns, Physicians'* / statistics & numerical data
  • Surveys and Questionnaires

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