Complications related to the surgical wound and patient positioning

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Boris Gershman, Matthew K. Tollefson, Stephen A. Boorjian and Bradley C. Leibovich
Complications of Urologic Surgery, 9, 99-111.e5

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Abstract

Complications related to the surgical wound and patient positioning represent important sources of potential morbidity. Wound complications include seroma, hematoma, surgical site infection, and wound dehiscence. Their incidence may be reduced by appropriate antimicrobial prophylaxis and meticulous surgical technique. The most common positioning-related injuries are neuromuscular injuries to the upper and lower extremities, including injuries to the brachial plexus and femoral nerve. Less common positioning-related injuries include rhabdomyolysis, compartment syndrome, and vision loss. Robotic-assisted surgery, with the use of high degrees of Trendelenburg, may be associated with increased risk of positioning injuries. Several additional risk factors have been identified for positioning injuries, including prolonged operative time, use of lithotomy position, and obesity. Prevention of positioning injuries requires coordination with the entire surgical team with careful attention to positioning of the upper and lower extremities and avoidance of predisposing factors such as prolonged operating time, particularly when using extreme surgical positions.

Keywords
Complications, Patient positioning, Robotic surgery, Surgical site infection, Wound dehiscence, Seroma, Hematoma, Nerve injury, Rhabdomyolysis, Compartment syndrome


Chapter Outline
Seroma
Pathogenesis and Clinical Features
Prevention and Management
Hematomoa
Pathogenesis and Clinical Features
Prevention and Management
Surgical Site Infection
Definition
Risk Stratification
Microbiology
Prevention
Preoperative and Intraoperative Techniques
Antimicrobial Prophylaxis
Diagnosis and Management
Wound Dehiscence
Pathogenesis and Clinical Features
Suture Selection and Technique
Layered Versus Mass Closure
Nerve/Plexus Injuries
Upper Extremity Nerve Injuries
Lower Extremity Nerve Injuries
Injuries to the Femoral Nerve
Injuries Resulting From Lithotomy Position
Injuries Related to Positioning for Robotic Surgery
[CR]
Key Points
1. Large hematomas that collect in the retroperitoneum or rectus sheath may cause paralytic ileus, anemia, and ongoing bleeding resulting from the consumption of coagulation factors.
2. Wounds that involve large skin flaps or those with large potential spaces in which blood could collect should be drained with a closed-suction surgical drain until the output of these drains decreases.
3. Intraoperative strategies to prevent wound infection include aseptic technique to reduce the microbial inoculum as well as good surgical practice to minimize dead space and devitalized tissue.
4. Antibiotic prophylaxis is recommended for all class II (clean-contaminated) wounds and for class I D (clean) wounds in which prosthetic material or a vascular graft is implanted because the consequences of infection are serious in these instances.
5. Severe infections, such as necrotizing fasciitis, represent surgical emergencies, and patients should be taken immediately back to the operating room for wide debridement.
6. The use of vacuum-assisted closure should be limited when wounds are near conduits, anastomoses, and neobladders because this technique may be associated with an increased rate of cutaneous fistula formation.
7. If clinical suspicion of dehiscence remains despite equivocal physical examination findings, imaging studies such as ultrasound or computed tomography can be used.
8. Investigators have demonstrated that wounds that have been closed with a suture length that is twice as long as the wound have a higher rate of wound dehiscence than do wounds closed with suture that is four times the length of the wound.
9. Although brachial plexus injuries have been reported to result from excessive extension and external rotation during surgical procedures in the supine position, including radical prostatectomy, most brachial plexus injuries occur during procedures in the flank position, which is commonly used for procedures involving the kidney and retroperitoneum.
10. Retractor injuries to the femoral nerve occur when the blades of the retractor are placed directly on the psoas muscle, where they may compress the nerve directly or indirectly by trapping the nerve against the lateral pelvic wall.
11. Robotic-assisted surgery may be associated with increased risk of positioning injuries, including both traditional neuromuscular injuries to the upper and lower extremities as well as less common injuries such as vision loss, rhabdomyolysis, and compartment syndrome.
Successful surgical therapy depends on proper healing of the surgical wound. Problems with wound healing can lead to seromas, hematomas, surgical site infections (SSIs), dehiscence, and incisional hernias. In addition, nerve injuries related to patient positioning or retractor placement may affect postoperative mobility. All these complications increase morbidity and can contribute to mortality in surgical patients.

Complications related to the incision and patient positioning are important for all surgeons to be aware of because they are among the most common complications following operative procedures. Often, these complications are relatively minor and may resolve with conservative management (e.g., simple wound seromas or hematomas). However, at times their resolution may be expensive and time-consuming (e.g., complicated wound infection), may require additional surgical procedures (e.g., incisional hernia), or may cause permanent disability (e.g., postoperative neurapraxia). Therefore management of these complications is focused on prevention, as well as prompt recognition and appropriate treatment. The objective of this chapter is to review common complications of the incision and patient positioning with respect to their pathogenesis, clinical features, prevention, and management.

Seroma
Pathogenesis and Clinical Features
One of the most common and likely underreported complications following operative procedures is the development of a wound seroma ( Fig. 9.1A ). Although typically a benign finding, when not treated, seromas may lead to more serious wound infections, wound breakdown, or potentially skin necrosis. A seroma is a collection of sterile, clear, ultrafiltrated serum, lymphatic fluid, or liquified fat.  1  The fluid is usually clear, amber, and slightly viscous. Seromas are located under the incision, above the fascial layer, and directly beneath the dermis of the skin. They are more likely to occur when large tissue flaps are mobilized or when extensive lymphadenectomy is performed, such as during axillary  2  or inguinal lymph node dissection.  3  Thus, efforts to limit the extent of dissection where feasible without compromising cancer control such as sentinel lymph node procedures  4  or preservation of the saphenous vein during inguinal lymphadenectomy  5 6  may reduce the risk of seroma formation.

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Figure 9.1
Selected wound complications. A, Seroma (arrow) as seen on postoperative cross-sectional imaging. (Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.) B, Superficial surgical site infection (SSI) healing by secondary intention. (Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.) C, Superficial SSI managed with vacuum-assisted closure with surrounding cellulitis. (Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.) D, Fascial wound dehiscence.
(Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.)
Prevention and Management
Most postoperative seromas are discovered incidentally and require no active intervention. However, when large or symptomatic, seromas can be evacuated by opening the overlying skin edges, packing the wound with sterile saline-soaked gauze, and allowing the wound to heal by secondary intention. Seromas that develop under flaps (i.e., after inguinal lymph node dissection), however, may be more difficult to manage because these have the potential to damage the delicate vascular supply to the flap. Therefore, in incisions that involve extensive skin flaps, placement of closed-suction drains is typically performed and recommended. These drains are left in place until their output decreases to a minimal amount (typically <30 24-hour="" a="" allow="" and="" aspiration="" be="" concern.="" develop="" drain="" drains="" dressings="" formation="" in="" is="" may="" ml="" occasionally="" of="" or="" p="" percutaneous="" period="" placement="" postoperatively="" premature="" pressure="" removal="" required.="" seroma="" the="" to="" useful="" when="">
Hematomoa
Pathogenesis and Clinical Features
A hematoma is a collection of blood in or near a recent surgical incision. Hematomas typically occur in the subcutaneous space, but they may also occur deeper in the incision, such as in the rectus sheath. Wound hematomas are most often caused by inadequate hemostasis after the skin has been closed. Many factors contribute to the formation of hematomas. First, hemostasis at the time of wound closure may be inadequate. Extra care should be taken in patients who are hypotensive or in shock at the time of wound closure. Additionally, the use of epinephrine may mask small bleeding vessels during closure. Postoperatively, anticoagulants such as aspirin, nonsteroidal antiinflammatory drugs, heparin, and warfarin also increase the likelihood of postoperative bleeding and therefore should be used with care in the perioperative period. Finally, a host of disease processes may be present that may predispose patients to the development of hematomas, including myeloproliferative disorders, renal or hepatic insufficiency, deficiency of clotting factors, and platelet dysfunction.

Hematomas usually manifest by ecchymosis of the overlying skin, localized wound swelling, pain or pressure, and drainage of blood from the surgical site. The diagnosis can be confirmed by inspection, palpation, and gentle probing of the wound. If these measures prove insufficient, ultrasound evaluation can be useful to delineate the hematoma.  7  In addition, large rectus sheath hematomas may manifest with signs of significant hemorrhage, including hemodynamic shock. Often these hematomas result in large ecchymoses that track subcutaneously a long distance from the patient's surgical site. Large hematomas that collect in the retroperitoneum or rectus sheath may cause paralytic ileus, anemia, and ongoing bleeding resulting from the consumption of coagulation factors. One of the most common problems associated with the development of a surgical hematoma is the risk of secondary infection. Blood is a good medium for growth of bacteria that may infiltrate the hematoma and result in a substantial surgical site infection (SSI).

Prevention and Management
The most important factor in the prevention of wound hematoma is meticulous hemostasis at the time of closure of the subcutaneous tissue. Prevention is also facilitated by correction of all clotting abnormalities preoperatively and by discontinuing all medications that can prolong the bleeding time. In addition, wounds that involve large skin flaps or those with large potential spaces in which blood could collect should be drained with a closed-suction surgical drain until the output of these drains decreases. Management of wound hematomas is similar to management of wound seromas, discussed earlier.

Surgical Site Infection
Since the development of modern surgical technique and the innovations of Joseph Lister, surgeons have battled microbial infection. However, despite advances in antimicrobial therapy, aseptic technique, and perioperative patient management, SSIs continue to be the most common infectious complications suffered by surgical patients. Monitoring for these complications is even more complex because shorter hospital stays, outpatient surgery, and the mobility of patients who often see several physicians during the recovery period may affect the rates of complication reporting.  8  In healthy, nonobese patients, the overall SSI rate is estimated at 2.5% of all open surgical procedures, whereas this rate can be many-fold higher in patients with additional risk factors.

The impact of these infections is not insignificant. From an economic standpoint, patients with SSI often require extended hospital stays, additional nursing care, wound supplies, and possibly additional surgical procedures.  9 The estimated cost of this additional care can exceed $30,000 in patients with complicated infections.  10 Moreover, SSIs have significant quality of life implications for patients who may require weeks to months of additional treatment following a surgical procedure. Finally, some series have linked SSIs to an overall increase in postoperative mortality.  11 12

Definition
The term surgical site infection distinguishes a postoperative infection from a traumatic wound infection. The Centers for Disease Control and Prevention (CDC) developed a universal nomenclature for SSIs that involves categorization according to the depth of infection ( Fig. 9.2 ).  13  Infections that are confined to the skin and subcutaneous tissue (above the fascia) are considered superficial incisional SSIs . These infections account for the majority of all SSIs. Infections that involve the deep soft tissue (below the fascia) are termed deep incisional SSIs . Deep incisional SSIs include postoperative necrotizing fasciitis and osteomyelitis. Finally, an infection that involves an organ space that was manipulated during a procedure is termed an organ space SSI . Organ space SSIs may include peritonitis or other infections that involve the cavitary space entered during the procedure. Usually these infections are diagnosed within 30 days of the procedure. An exception to this rule is the case of implanted material, when SSIs are recorded up to 1 year from the surgical procedure and appear to be related to the operation.  13

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Figure 9.2
Centers for Disease Control and Prevention classification of surgical site infection (SSI). Superficial incisional SSIs are limited to skin and subcutaneous tissues and deep incisional SSIs involve muscle and fascia, whereas organ space SSIs include infections within the cavitary space of the procedure.
(Copyright © 2007, Mayo.)
Risk Stratification
The development of an SSI depends on complex interactions between the pathogenic organism and the host's local and systemic defense mechanisms. Factors influencing the pathogenic organism include the virulence of the contaminating organism itself and the number of organisms inoculated into the wound. In 1964, the National Research Council (NRC) of the National Academy of Sciences reported on a study designed to evaluate the effect of ultraviolet irradiation on postoperative infections.  14  Although this study did not reach its desired end point, it was the first effort to categorize incisions based on the estimated degree of bacterial contamination. The four categories of incision described by the NRC ( Table 9.1 ) remain the most widely accepted classification of surgical wounds to date, and the system remains useful to estimate the risk of SSI, predict pathogens, and determine the need for antimicrobial prophylaxis. This effort represented the first connection between the contaminating flora at various surgical sites and the subsequent infecting pathogens:

Class I, or clean, wounds: Those wounds in which only skin flora are likely to contaminate the operative field because no hollow viscus has been entered. The risk of infection in these cases is low (0.5–2%). A subset of class I wounds, class I D , consists of wounds in which prosthetic material is implanted. These wounds are classified differently because, although the incidence of infection is also low, the consequences of the infection can be dire and may obviate the entire purpose of the procedure.
Class II, or clean-contaminated, wounds: Those wounds in which a hollow viscus likely to harbor bacteria is entered under controlled circumstances. In these cases, both skin flora and microbes within the viscus may contribute to the SSI and thus the incidence of infection is higher (2–5%).
Class III, or contaminated, wounds: Those wounds in which substantial microbial contamination exists and the risk of infection is even greater (5–15%), particularly if the skin is closed.
Class IV, or dirty-infected, wounds: Those wounds in which the wound is infected preoperatively and the organisms causing the postoperative infection are presumed to be present before the surgical procedure.
Table 9.1
Surgical Wound Classification
Classification Wound Description Example Definition
Class I Clean Varicocele ligation; herniorrhaphy An uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, or uninfected genitourinary tract is not entered; in addition, clean wounds are primarily closed and, if necessary, drained with closed drainage
Class I D Clean; prosthetic material implanted Penile prosthesis implantation Same as class I (clean), with the exception of placement of prosthetic material
Class II Clean-contaminated Radical prostatectomy Operative wounds in which the respiratory, alimentary, or genitourinary tract is entered under controlled circumstances and with minimal contamination
Class III Contaminated Radical cystectomy with stool spillage Open, fresh, accidental wounds; in addition, wounds with a major break in sterile technique or gross spillage from the gastrointestinal tract and incisions in which acute nonpurulent inflammation is encountered
Class IV Dirty-infected Perineal debridement for Fournier's gangrene Old, traumatic wounds with devitalized tissue and those in which purulent infection is encountered  View full size
In an effort to improve this risk stratification for SSIs the CDC introduced the National Nosocomial Infection Surveillance (NNIS) risk index.  15  The NNIS risk index incorporates additional patient- and procedure-related factors into the previously described wound classification. It is operation specific and assigns points based on patient-related risk factors (as defined by the American Society of Anesthesiologists preoperative assessment score), the duration of the operation, and the degree of microbial contamination of the incision. The duration of the operation is important because lengthy procedures may result in increased exposure to microbial contamination as well as compromised local defenses resulting from desiccation, hypothermia, and lower concentrations of prophylactic antibiotics.

Since the NNIS risk index was produced, additional risk factors for SSIs have been identified. For example, hypothermia has been identified as an independent risk factor for infection, and therefore maintenance of normothermia is an important aspect of intraoperative and postoperative care.  16  Strict glucose control has been independently associated with decreased wound infection rates as well as with decreased mortality in an intensive care setting.  17  Serum albumin level has long been identified as an important risk factor because it reflects a wide range of comorbid conditions that contribute to wound healing.  18  Other important risk factors are age, vascular insufficiency, diabetes, radiation, preoperative smoking, and obesity.

Microbiology
Endogenous pathogenic organisms implicated in SSI most commonly come from the patient's skin, alimentary tract, or genitourinary tract. The patient's microflora may be altered by preoperative admission to the hospital. In fact, a demonstrable shift in the microbial environment toward more resistant bacterial species occurs within 48 to 72 hours of hospital admission.  9 19  Exogenous contamination can be minimized by strictly following aseptic technique and maintaining a sterile operating room environment.

The most common organisms isolated from surgical sites remain gram-positive cocci, specifically Staphylococcus aureus ( Table 9.2 ). However, gram-negative infections are common in class II wounds. It is important to recognize the type of infection associated with various operative sites to select appropriate antimicrobial prophylaxis.

Table 9.2
Prevalence of Organisms Isolated From Surgical Sites
Organism Percentage (%)
Staphylococcus aureus 26.9
Escherichia coli 18.8
Streptococcus epidermidis 10.1
Pseudomonas aeruginosa 9.6
Enterococcus faecalis 3.8
Enterococcus faecium 3.8
Proteus mirabilis 3.4
Candida albicans 3.0
Klebsiella pneumoniae 1.5  View full size
Prevention
Preoperative and Intraoperative Techniques
Prevention of infection in the surgical wound begins by reducing the potential number of microbial contaminants that have access to the wound. Therefore whenever possible, one should identify and treat all infections before surgical intervention. As discussed earlier, lengthy preoperative hospitalizations can increase bacterial antimicrobial resistance and can make any future SSIs more difficult to manage.  19  Patients should be encouraged to stop use of tobacco products for ≥30 days before the operation.  20

The value of preoperative bowel preparation for reducing SSIs has been debated because several randomized trials  21 22 23 24  and meta-analyses  25  demonstrated an increased rate of anastomotic leakage and wound complications when mechanical bowel preparations were used. Indeed, evidence indicates that preoperative bowel preparation is associated with increased stool spillage intraoperatively.  26  Therefore we no longer routinely utilize mechanical bowel preparation for patients undergoing procedures involving bowel interposition.

When the patient reaches the operating room, surgical preparation should consist of an appropriate antiseptic agent for skin preparation. Removal of hair at the surgical site can create nicks and cuts in the skin that may become colonized and increase postoperative infection rates.  27  The CDC recommends that hair not be removed unless excess hair at the operative site would interfere with the operation.  13  When necessary, hair removal should be performed with clippers, rather than razors, because razors are associated with more frequent epithelial damage. Some evidence indicates that the hair should be removed as close to the surgical time as possible.

Intraoperative strategies to prevent wound infection include aseptic technique to reduce the microbial inoculum as well as good surgical practice to minimize dead space and devitalized tissue. An adequate preoperative surgical scrub of at least 2 to 5 minutes should be performed for surgical procedures. Instruments should be adequately sterilized, and efforts should be made to avoid breaks in aseptic technique. During the procedure, gentle handling of the tissue minimizes desiccation and necrosis that may serve as a nidus of infection. Electrocautery was thought to increase the incidence of wound complications because of devitalized tissue. However, more recent studies  28 29  did not show a relationship, and electrocautery may be used according to the surgeon's preference. Foreign bodies such as staples and sutures may provide a nidus of infection, and their use must be weighed against the risks of poor hemostasis and hematoma formation.

Antimicrobial Prophylaxis
The purpose of antimicrobial prophylaxis is to reduce microbial contamination of the incision and to decrease the incidence of SSI. Surgeons have recognized the importance of antimicrobial prophylaxis in the prevention of SSI for many years.  30 31 32  For optimal prophylaxis, an antibiotic with a targeted spectrum should be administered at sufficiently high concentrations in serum, tissue, and the surgical wound during the entire time that the incision is open and at risk for bacterial contamination.  33

To optimize the effectiveness of antibiotic prophylaxis, the antibiotic should be given approximately 60 minutes before surgical incision and dosed according to body mass. In lengthy cases, the antibiotic will need to be readministered approximately every two half-lives of the drug, at which point only 25% of the drug remains in active circulation. In cases with excessive blood loss, an additional dose should be given for every 4 U of estimated blood loss.

Antibiotics, when given in a prophylactic setting, should be discontinued within 24 hours of the procedure.  34 Antibiotics given too late (<30 35="" afterward="" and="" antibiotics="" are="" before="" concentrations="" do="" effective="" given="" in="" incision="" less="" long="" minutes="" nbsp="" not="" of="" prevention="" reach="" ssi="" surgical="" the="" tissue="" too="" whereas="">24 hours after the procedure) increase the incidence of bacterial resistance  36  and raise the economic cost of therapy  37  without decreasing the rate of SSI.

Prophylaxis is recommended for all class II (clean contaminated) wounds and for class I D (clean) wounds in which prosthetic material or a vascular graft is implanted because the consequences of infection are serious in these instances. The routine use of prophylactic antibiotics is less clear in elective class I cases with no prosthetic material. In addition, patients with class III or IV wounds are considered to have an infected wound, and most of these patients are treated with antibiotics empirically.

Diagnosis and Management
Most SSIs manifest within 4 to 8 days of the surgical procedure. However, they may manifest within 30 days of the operation or up to 1 year in cases with implanted prosthetic material. This finding implies that, in the current medical environment of outpatient surgery or early discharge, most of these infections occur in the outpatient setting.  8  This implication emphasizes the importance of patient education in the postoperative period. Patients should be aware of the signs and symptoms of SSI and should know when to seek additional care.

The diagnosis of SSI is clinical and has been described for as long as surgical procedures have been performed. Classically, the most common symptoms have been described (in Latin) as rubor (“erythema”), dolor (“pain”), tumor (“induration”), and calor (“warmth”). Some patients may also note drainage from the wound or separation of the skin closure. If the SSI is not treated, systemic symptoms may develop, including fever (38–39°C), fatigue, leukocytosis, and increased heart rate.

The management of SSI depends on the extent and type of infection. Drainage and debridement have been and remain the cornerstones of management. Superficial SSIs are treated by opening the incision to provide adequate drainage. A small piece of saline-soaked gauze may be placed in the wound to serve as a wick and to prevent closure of the skin while allowing deeper aspects of the wound to heal by secondary intention. Wet-to-dry dressing changes have been a staple of wound care after SSI, although it may take several weeks to months for the wound to heal by secondary intention (see Fig. 9.1B ). A culture and Gram stain may identify the offending organism, although these methods are not always necessary. In the setting of superficial SSI, antibiotics need be given only when patients are at risk for systemic dissemination of the infection. Severe infections, such as necrotizing fasciitis, represent surgical emergencies, and patients should be taken immediately back to the operating room for wide debridement. The identification of only “dishwater” pus, subcutaneous crepitus, or sepsis should alert the clinician to the possibility of necrotizing fasciitis. These infections progress rapidly and are caused by either Clostridium perfringens or group A β-hemolytic streptococci.

The development of vacuum-assisted closure has eased the process of multiple daily dressing changes (see Fig. 9.1C ). Vacuum-assisted closure was designed to promote healing of large wounds by constant or oscillating application of negative pressure. This negative pressure promises to increase local blood flow, control exudates, and reduce edema of the surrounding tissue.  38 39 40  In our experience, these negative pressure techniques have proved useful in treating large, chronic wounds. However, their use should be limited when wounds are near conduits, anastomoses, and neobladders because in our experience, they may be associated with an increased rate of cutaneous fistula formation.

Wound Dehiscence
Pathogenesis and Clinical Features
Surgical wound dehiscence (see Fig. 9.1D ) is one of the most alarming complications faced by abdominal surgeons. Put simply, a dehiscence represents the mechanical failure of wound healing and is defined as a separation of the facial layers early in the postoperative period. Evisceration, in turn, is a related term referring to the extrusion of peritoneal contents through the dehisced wound. Dehiscence is of great concern because it may rapidly lead to evisceration. Abdominal dehiscence with evisceration has been associated with a mortality rate nearing 50%.  41  When diagnosed early in the postoperative period, complete wound dehiscence almost always requires a return to the operating room for fascial closure or repair. However, small partial wound dehiscences that are diagnosed >2 weeks postoperatively may often be watched with delayed repair of the resultant incisional hernia, because the risk of evisceration is very low in such patients.

Unfortunately, wound dehiscence frequently occurs without warning. Up to 80% of the time, it manifests as sudden, dramatic drainage of a large volume of clear, serous fluid from the incision. Patients may also note a pulling or ripping sensation. This often occurs when the patient is standing or changing positions, because the pressure on the incision is greatest at these times. The diagnosis is then confirmed by gently probing the incision with a sterile, cotton-tipped applicator to determine the integrity of the fascia. If clinical suspicion remains despite equivocal physical examination findings, imaging studies such as ultrasound or computed tomography can be used. When a large segment of the incision is open, immediate plans for closure in the operating room should be made. In the event of evisceration, the eviscerated intraperitoneal contents should be covered with a sterile saline moistened towel until an emergency operation can be performed.

Numerous factors can contribute to wound dehiscence ( Table 9.3 ). However, despite advances in suture material and perioperative care, the incidence of abdominal fascial dehiscence has remained steady at nearly 1% of abdominal wounds.  42 43  Other factors that contribute to wound dehiscence remain. Obesity, for example, is associated with increased difficulty in identifying the fascia and in closing the incision. Corticosteroids, over long periods, can decrease the tensile strength of healing wounds.  44  Patients with cancer are more likely to have problems with wound healing, because these patients are more likely to have a contaminated wound and have undergone previous irradiation or chemotherapy.  45  Radiation causes obliterative sclerosing endarteritis that can decrease the microvascular arterial supply to the wound.  46  Malnourished patients nearly uniformly have decreased protein synthesis and turnover, which lead to poorer fascial integrity. Finally, diabetic patients encounter more healing problems than do patients without diabetes and have a greater risk of wound dehiscence. 41  The likely reason is that diabetic patients have less collagen synthesis and deposition, decreased wound breaking strength, and impaired leukocyte function.

Table 9.3
Risk Factors Associated With Wound Dehiscence
Preoperative Risk Factors Intraoperative and Postoperative Risk Factors
Malnutrition Technical error with fascial closure
Anemia Emergency procedures
Hypoproteinemia Wound complications (infection, seroma, hematoma)
Obesity
Comorbid disease (e.g., diabetes, renal failure, chemotherapy, irradiation)
Increased intraabdominal pressure (e.g., coughing, straining, ascites)
Advanced age
Long-term corticosteroid use View full size
Suture Selection and Technique
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Numerous suture materials are available for wound closure. These sutures can be classified as natural or synthetic as well as rapidly absorbable, slowly absorbable, and nonabsorbable. Synthetic material has the advantages of being more uniform, inducing less tissue reaction, having greater tensile strength for a given diameter, and eliminating the risk of disease transmission. In 2001 the United Kingdom eliminated the use of catgut suture because of the risk of transmission of bovine spongiform encephalopathy (BSE, or mad cow disease).

Nonabsorbable sutures have been widely used to close abdominal incisions for many years. However, stainless steel wire and braided silk, once commonplace, have been replaced by more modern suture materials. Nonabsorbable monofilament sutures are associated with less tissue reaction  50  and more resistance to infection 51  than are absorbable sutures. However, they are associated with a higher incidence of sinus formation and long-term wound pain.  52 53 54 55  The primary benefit of nonabsorbable sutures is that they maintain tensile strength throughout the process of wound healing.

Absorbable sutures are designed to reapproximate the fascia through the initial phases of wound healing until the fascia itself has regained enough tensile strength. Rapidly absorbable sutures are not recommended for closure of abdominal incisions because this suture type has been demonstrated to have a higher incidence of wound dehiscence  56  and postoperative hernia formation  55 57  when compared with nonabsorbable sutures. However, slowly absorbable sutures, such as polydioxanone (PDS) and polyglyconate (Maxon), have been shown to cause less incisional pain and suture sinuses, with no effect on the long-term hernia rate. Additionally, these newer-generation monofilament sutures are more resistant to infection than are multifilament sutures.  58 59  They are degraded by hydrolysis and are not as subject to enhanced absorption resulting from bacterial enzymatic activity. 60

When a suture is placed through the fascia in the operating room, wound dehiscence has three potential causes:

1. The suture may break
2. The knot may slip
3. The suture may cut through the tissue.
Several studies have demonstrated that suture breakage and knot failure are rarely the source of wound dehiscences, and in the majority of wounds that have dehisced, the suture and knots are intact but the suture has torn through the fascia.  49 61  This finding brings to light the importance of suture diameter because smaller-diameter sutures are associated with a greater likelihood of tearing through tissue.  43 62 63  Therefore most sutures used for abdominal wound closure are number 0 or larger. Additionally, the use of continuous running looped sutures has gained popularity as a method to increase the speed and tensile strength of wound closure. A double-looped closure has been demonstrated to be the strongest method of wound closure, but it has been associated with increased pulmonary complications, potentially because of decreased abdominal compliance.  43

Surgical dictum states that sutures should be placed ≥1 cm from the fascial edge while advancing ≤1 cm with each throw. This recommendation results from concern for thermal injury related to the use of electrocautery on the fascial edge. Jenkins  64  demonstrated that the length of a midline laparotomy can increase up to 30% in the postoperative period as a result of elasticity and increased intra-abdominal pressure. Therefore it is important when closing using a running suture that the suture is of adequate length. Investigators have demonstrated that wounds that have been closed with a suture length that is twice as long as the wound have a higher rate of wound dehiscence  64  than do wounds closed with suture that is four times the length of the wound. This concept is referred to as the suture-to-wound length ratio, and a ratio of at least 4 : 1 provides good wound security.  65 66 67 68  Theoretically, this approach affords adequate approximation of the fascial tissues while minimizing the ischemic effects of increased tension along the suture line.

Layered Versus Mass Closure
Layered closure of the abdominal wound involves separate closure of each of the distinct fascial layers with or without closure of the peritoneum. Mass closure, or Smead-Jones closure, is the closure of all layers of the abdominal wall, except the skin, as a single structure. Classically, this approach involved interrupted sutures. However, no benefit has been demonstrated over a continuous suture technique. Layered closure was believed to decrease intraperitoneal adhesions, increase wound strength, and promote hemostasis. These effects were especially noted with paramedian incisions,  69 70 71  which currently are used less frequently than are muscle-splitting midline incisions. However, several prospective, randomized studies  54 72  and large meta-analyses  57 73 74  demonstrated that layered closure is associated with higher rates of dehiscence and prolonged operative times as compared with mass closure. Separate peritoneal closure, in particular, has been associated with more intraperitoneal adhesions, increased operative times, and obscured fascial closure.  75 76 77  Furthermore, evidence indicates that the peritoneum re-epithelializes within 48 to 72 hours without closure,  78  and separate closure of this layer is unnecessary.

Retention sutures are sutures that are placed through all layers of the abdomen, including skin. They are often secured around a piece of rubber tubing and tied down ( Fig. 9.3 ). Although historically they were used to decrease the incidence of abdominal dehiscence in patients at high risk, more recent studies did not demonstrate a beneficial effect on the rate of dehiscence. These sutures have also been associated with increased pain and inconvenience.  79

Open full size image
Figure 9.3
Retention sutures are placed through all layers of the abdominal wall and are secured around rubber tubing.
(Copyright © 2007, Mayo.)
Nerve/Plexus Injuries
Nerve injury during urologic surgery may be caused by direct surgical trauma (i.e., nerve transection) or by stretch and compression of nerves from improper patient positioning or retractor placement. With regard to injuries caused by surgical trauma, all surgical incisions risk division of cutaneous sensory nerves and thereby may result in abdominal wall neuralgias or sensory deficits.  80  These complications are likely underreported by physicians, and therefore the incidence of such events is difficult to quantitate. The following discussion is a review of nerve injuries resulting from stretch and compression.

Improper patient positioning or retractor placement may cause stretch and compression of nerves that manifest as a deficit in postoperative neurologic function. In addition, ischemic injury compromising the blood supply of a nerve (i.e., ischemia of the intraneural vasa nervorum) may result in nerve injury as well.  81  Anesthetized patients have reduced muscle tone and are unable to report the discomfort of improper positioning, factors that place these patients at particular risk of injury. Although such nerve injuries are usually temporary, they significantly affect patients' quality of life and may result in permanently debilitating complications. For example, nerve injuries may limit postoperative ambulation and thereby increase the risk for thromboembolic events. Therefore a thorough understanding of the risk factors, presentation, and management of nerve injuries associated with common urologic procedures is essential for the urologic surgeon.

Although nerve injuries may occur during any of a variety of urologic procedures, the most common circumstances in which we have encountered these events involve brachial plexus injuries after surgery in the flank position, femoral nerve injuries from radical pelvic surgery, and lower extremity nerve injury from procedures in the lithotomy position. Therefore, these injuries are the focus of this section.

Upper Extremity Nerve Injuries
Upper extremity nerve injuries during urologic surgery most often are the result of injuries to the brachial plexus, which contains the C5–T1 nerve roots and runs between the prevertebral fascia and the axillary fascia of the arm. This plexus supplies multiple nerve branches including the musculocutaneous, axillary, radial, median, and ulnar nerves. The brachial plexus is particularly vulnerable to injury because of its lack of mobility, being fixed to the vertebrae, prevertebral fascia, and axillary fascia, as well as its proximity to bony structures, including the first rib, clavicle, coracoid process, and the head of the humerus.  82  Injuries to the brachial plexus may be the result of direct trauma, excessive stretching, external pressure, or a combination of these factors. In our experience, although brachial plexus injuries have been reported to result from excessive extension and external rotation during surgical procedures in the supine position ( Fig. 9.4 ), including radical prostatectomy,  83  most brachial plexus injuries occur during procedures in the flank position, which is commonly used for procedures involving the kidney and retroperitoneum.

Open full size image
Figure 9.4
Supine position for midline approach. A, Anterior view. The arms are tucked at the sides and supported by toboggans.
(Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.) B, Lateral view. The arms are tucked at the sides and supported by toboggans. (Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.)
Given that the flank position is one of the most common positions for urologic surgery, we describe here our technique of flank positioning, which aims to achieve optimum operative exposure while avoiding neurologic injury ( Fig. 9.5 ). After general anesthesia is established, patients should be placed in the lateral decubitus position with the nonoperative side against the operating table. The lower leg is then flexed at the knee and hip, the upper leg is kept straight, and pillows are placed between the knees to prevent contact of potential pressure points. Heels and knees are padded, and the patient is secured to the operating table using either cloth tape or Velcro straps. The head is padded as well to prevent angulation of the neck. Indeed, excessive dorsal extension or lateral flexion of the neck risks stretching of the brachial plexus to the opposite side of the patient between the fixed points at the transverse processes of the cervical vertebrae and the axillary fascia of the upper arm.  81

Open full size image
Figure 9.5
Flank position.
A, Posterior view of flank position. The patient is placed in the lateral decubitus position with the head padded to prevent excessive neck flexion or extension. The lower leg is flexed at the knee and hip, with the heel and knee padded for protection. The upper leg is straight, and a pillow is placed between the upper and lower legs at the knees. (Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.) B, The lower arm is supported on a gel-padded armboard at an approximately 90-degree angle and secured. The upper arm is supported in a padded armrest. The torso is positioned so that the upper arm rests in a neutral position. An axillary roll is placed underneath the chest just below the axilla, and the table is flexed and the kidney rest raised to expand the flank.
(Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.)
The downside arm is then placed at an approximately 90-degree angle to the table and is secured to the armboard. Suspension of the upside arm (i.e., from an anesthesia screen, from a bar anchored to the operating table, or on blankets placed over the downside arm) must be done with care because excessive tension or abduction may stretch the brachial plexus around the clavicle and compress the nerves against the tendon of the pectoralis minor muscle.  81  A somewhat misnamed “axillary roll,” which should more correctly be considered a chest roll, is then placed just beneath the true axilla. In fact, placement of this roll (we use a blanket) within the true axilla may result in compressive injury to the brachial plexus or vascular obstruction of the upper extremity.

After securing the patient to the bed, we then flex the operating table and raise the kidney rest, which should lie just above the iliac crest, until the muscles of the flank become tight.  81  This maneuver maximizes separation of the costal margin and iliac crest for surgery while minimizing the risk of vena caval compression.

Despite vigilant attention to patient positioning, injuries to the brachial plexus may occur during procedures in the flank position. Injuries to the brachial plexus of the downside arm during flank positioning, for example, are most often compressive, although stretch injuries may occur if the dependent arm shifts position during the surgical procedure.  81  Brachial plexus injuries of the upside arm in the flank position, meanwhile, are most often the result of abduction, extension, and external rotation of the humerus that stretch the plexus around the clavicle, the tendon of the pectoralis minor, and the head of the humerus.  84

The presentation of brachial plexus injuries varies somewhat with the level of injury but most often involves some degree of weakness of the affected upper extremity, including the deltoid, supraspinatus, biceps, brachioradialis, and triceps muscles, as well as the wrist and finger flexors and extensors.  82  Patients may also report decreased pinprick sensation along a dermatomal (i.e., C7–T1) distribution. Deep tendon reflexes of the biceps and brachioradialis muscles are characteristically absent on physical examination. Peripheral branches of the brachial plexus may be injured after their exit from the axilla, and these injuries may manifest as isolated nerve deficits; for example, the median and ulnar nerves can be damaged if the arm is allowed to hang unsupported over the edge of the operating table, whereas the radial nerve of the downside arm may be injured if the arm is pushed cephalad against the vertical bar of the anesthesia screen, thus compressing the nerve between the humerus and the bar.  81  The role of electromyography in the evaluation of patients with a suspected nerve injury is discussed further later in the section on femoral nerve injuries.

Management of a suspected brachial plexus injury includes careful neurologic examination, protection of potentially hypesthetic skin from injury, and physical therapy consultation to prevent muscle wasting.  82  Other treatments including intermittent galvanic stimulation to the affected muscle and surgical repair have been described.  82 85  We have seen considerable variability in the course of recovery of function after brachial plexus injury, from hours to months. Nevertheless, we, as others,  82 86  have noted that sensation consistently returns before motor function, and that the lower nerve roots recover function before the upper nerve roots.

Lower Extremity Nerve Injuries
Various injuries to the nerves that innervate the lower extremities have been described during urologic procedures. These injuries include direct trauma to the nerves, such as intraoperative transection, injuries that relate to patient positioning, and injuries that result from retractor compression. Here, we separate the discussion into injuries of the femoral nerve, which may occur by any of these mechanisms but are most commonly the result of compression from retractor placement, and nerve injuries related to the lithotomy position that may involve the femoral nerve but often affect other nerves of the lower extremity.

Injuries to the Femoral Nerve
The femoral nerve, which arises from the second through the fourth lumbar nerve roots, represents the largest branch of the lumbar nerve plexus. The femoral nerve is formed within the body of the psoas major muscle and then passes inferolaterally within the psoas before emerging just superior to the inguinal ligament, in a groove between the psoas and iliacus muscles.  87  The blood supply to the extrapelvic portion of the femoral nerve is the lateral femoral circumflex artery, whereas the intrapelvic component of the femoral nerve is supplied by the iliolumbar and deep circumflex iliac arteries.  88  A more extensive collateral blood supply to the right femoral nerve has been demonstrated,  89  a finding suggesting that the left femoral nerve may be more susceptible to ischemic injury than is the right.  88

The femoral nerve contains both sensory and motor components, including the sensory branches of the anterior and medial femoral cutaneous nerve, as well as the long saphenous nerve. Motor innervation from the femoral nerve is provided to the psoas, iliacus, quadriceps femoris, pectineus, and sartorius muscles. Therefore injury to the femoral nerve may result in weakness of hip flexion, knee extension, adduction, and external rotation.  88 90 91  Clinically, femoral nerve injuries usually manifest as difficulty with ambulation in the early postoperative period. Patients whose injuries are not recognized before discharge commonly report difficulty in climbing stairs at home.  91  In addition, patients may report numbness and paresthesias of the anteromedial thigh.  92  On physical examination, weakness of the quadriceps muscles and diminished or absent deep tendon reflexes at the knee (patellar reflex) are consistent findings.

Femoral nerve injuries may result from patient positioning, retractor-related compression, or direct operative trauma. Direct injury is usually suspected intraoperatively, and careful inspection along the course of the nerve is recommended in such cases. Positioning-related femoral nerve injuries in urology have most consistently been reported from procedures in the lithotomy position,  93 94  and they are discussed in the next section.

The most common mechanism for femoral nerve injury during urologic procedures, however, is compression of the nerve by self-retaining retractors. This situation typically occurs during prolonged abdominal cases such as radical cystectomy, although injuries have been reported after radical prostatectomy and even perineal prostatectomy.  95  Retractor injuries occur when the blades of the retractor are placed directly on the psoas muscle, where they may compress the nerve directly or indirectly by trapping the nerve against the lateral pelvic wall ( Fig. 9.6 ).  88  In addition, retractor blades may compromise the blood supply to the femoral nerve by compressing the iliolumbar artery.  92  Thin patients, in whom the retractor blades are more likely to compress the psoas muscle, are at particular risk for femoral nerve injury from retractor compression.  96  Moreover, the length of time of retraction has been correlated with the severity of nerve injury.  97  Therefore care should be taken to ensure that retractor blades retract only the rectus muscle and do not sit directly on the psoas muscle. Periodic inspection of retractor placement during the surgical procedure by placing the surgeon's fingers beneath the blades to ensure clearance off the psoas muscle is mandatory to avoid inadvertent compression injury.

Open full size image
Figure 9.6
Common mechanism of femoral nerve injury by retractor placement. A and B, Compression of the femoral nerve by placement of the retractor along the iliopsoas muscle. C, Correct position of the retractor to retract the rectus muscle only.
(Copyright © 2007, Mayo.)
The initial evaluation of a suspected femoral nerve injury includes careful documentation of the neurologic findings, along with physical therapy consultation. Immediate physical therapy helps to prevent muscle atrophy and may decrease the risk of thromboembolic complications associated with prolonged bed rest.  96  Ambulation may be facilitated in the case of femoral nerve injury by locking the ipsilateral knee to compensate for the associated thigh muscle weakness.  88  Although most femoral nerve injuries in our experience are caused by retractor-related compression, nerve compression from pelvic or retroperitoneal hematomas has been described. 88 98  Therefore, if one clinically suspects bleeding, three-dimensional imaging should be obtained as well.

In the setting of a persistent postoperative nerve deficit clinically consistent with a femoral nerve injury, neurologic consultation and an electromyogram to evaluate for anatomic denervation are warranted. Electromyography should be performed ≥3 weeks from the time of injury to maximize its prognostic value.  99 Although the recovery process may be prolonged, compression-related nerve injuries usually resolve over time, and patients regain nerve function. Early return of function has been thought to correlate with full recovery,  91 and sensory lesions are more frequently transient than are motor lesions.

Prevention of femoral nerve injury is paramount because the consequences may significantly affect patients' quality of life. Vigilant attention to patient positioning, limiting surgical time, and periodically inspecting retractor placement are key to avoiding these injuries.

Injuries Resulting From Lithotomy Position
Standard lithotomy position requires the patients' legs to be separated from the midline into 30 to 45 degrees of abduction, with the hips flexed until the thighs are angled between 80 and 100 degrees. The patient's legs are placed into stirrups, with the knees bent such that the lower legs are parallel to the plane of the torso.  100  An understanding of potential postoperative complications related to this position is essential to the care of urologic patients. In addition to neurologic complications, which are discussed here, other complications that have been reported after procedures in the lithotomy position include lower extremity compartment syndrome, venous thrombosis, and rhabdomyolysis.  101 102  The frequency of perioperative complications may increase with an exaggerated or “high” lithotomy position because the angle of the hips and lower extremities in this position is even more pronounced.  103

Neurologic injuries related to the lithotomy position may affect the femoral, sciatic, and common peroneal nerves. One series found that the most common lower extremity neuropathies associated with procedures in the lithotomy position were common peroneal (81%), sciatic (15%), and femoral (4%).  104  Other, less commonly injured nerves include the obturator and femoral cutaneous nerves. A study of 1170 patients operated on in the lithotomy position found postoperative neurapraxic complications in 1% of patients.  103  Age >70 years, operative time >180 minutes, and improper positioning were cited as risk factors for neurologic injury.  103 These findings were supported by a separate investigation, which noted lower extremity neuropathies in 1.5% of 991 patients undergoing procedures in the lithotomy position and found that prolonged (>2 hours) positioning in the lithotomy position was a risk factor for injury.  105  A previous study reported postoperative neurapraxia in 21% of patients undergoing perineal prostatectomy using the exaggerated lithotomy position.  106

Positioning-related nerve injuries in the lithotomy position have been attributed to overflexion of the hips and knees, which causes stretching and compression of the nerves. For example, hyperabduction of the thighs with external rotation of the hips may lead to injury of the femoral nerve secondary to ischemia from compression of the nerve beneath the inguinal ligament.

The sciatic nerve, meanwhile, is the largest nerve in the body. It arises from the fourth lumbar through the third sacral nerve roots of the lumbosacral plexus and exits the pelvis through the sciatic foramen, traveling through the thigh before dividing in the popliteal fossa into the common peroneal and tibial nerves. The sciatic nerve functions to provide cutaneous innervation to the foot and leg, as well as motor innervation of the biceps femoris (hamstring muscle), leg, and foot.  107

Excessive stretching of the sciatic nerve by overflexion of the hip and extension of the knee during establishment of the lithotomy position or by shifting of the patient during the procedure may result in injury. In particular, investigators have suggested that excessive hip flexion in the lithotomy position may compress the nerve as it passes through the sciatic notch, thus potentially resulting in ischemic neuropathy.  108 109  The potential sequelae of sciatic injury depend on the location of the insult along the course of the nerve. Injury to the thigh portion of the sciatic nerve, for example, results in difficulties with flexion of the leg, whereas disruption of the tibial nerve abolishes the ankle jerk reflex.

The common peroneal nerve arises from the sciatic nerve behind the knee and then wraps around the head of the fibula before separating into the superficial peroneal, which provides sensory innervation to the lateral leg, and the deep peroneal, which provides motor innervation to the tibialis anterior that allows dorsiflexion of the foot. Because this nerve is very superficial when it crosses the head of the fibula, it may easily be compressed and injured at this point (i.e., by direct contact of the leg against an immobile, hard support). Therefore padding the lateral leg supports during positioning for lithotomy procedures is recommended. Injury to the peroneal nerve most commonly manifests as foot drop, resulting from an inability to dorsiflex the foot. In addition, patients may experience numbness of the lateral aspect of the lower leg and dorsum of the foot.  109

Overall, nerve injuries during procedures in the lithotomy position may be minimized by careful attention to proper patient positioning, including padding of exposed peripheral nerves, avoiding unnecessary tension on the hips and knees by checking to see that the muscles of the lower extremity are not taut after the lithotomy position is established, and minimizing operative times. Modifications in stirrup design have also been proposed to help minimize the complications of lithotomy positioning.  110

Injuries Related to Positioning for Robotic Surgery
Robotic-assisted surgery has undergone rapid dissemination in the last decade and is now the most frequently employed surgical approach for radical prostatectomy,  111  with increasing utilization for renal and bladder surgery as well. While robotic renal surgery may be performed in a modified flank position, robotic-assisted pelvic surgery poses unique considerations for patient positioning ( Fig. 9.7 ) and presents new risks for positioning injuries.  112 113  Notably, the incidence of positioning injuries associated with robotic surgery may be greater than that in conventional laparoscopic or open surgery. For instance, a recent single-institutional study reported a 6.6% incidence of upper or lower extremity injury with robotic urologic surgery,  114  compared with 2.7% for conventional laparoscopic urologic surgery,  80  and 0.3% in open radical prostatectomy.  115 Interestingly, the rate of positioning injury may be greater with upper abdominal or retroperitoneal procedures. 80 114

Open full size image
Figure 9.7
Modified lithotomy position for robotic-assisted radical prostatectomy. A, Overview of modified lithotomy position used for robotic-assisted radical prostatectomy. The patient is placed on a nonskid gel pad to prevent cephalad migration during Trendelenburg position and secured using a padded chest strap and stirrups. (Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.) B, The arms are positioned on padded armboards with minimal abduction, with Gelfoam used to protect the wrists.
(Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.)
Robotic-assisted pelvic surgery is most frequently performed in a modified lithotomy position in conjunction with steep Trendelenberg.  112 113  The arms may be either tucked or abducted on armboards. Accordingly, robotic pelvic surgery carries risks of upper extremity nerve injuries analogous to those discussed above for the supine position, which include injuries to the brachial plexus, as well as median, ulnar, and radial nerves.  116 Careful attention must be paid to arm positioning, as one study noted that 84% of upper extremity injuries were associated with an extremity that was tucked or at the patient's side.  114  Lower extremity nerve injuries may occur from the lithotomy position as discussed above and may include injuries to the common peroneal, sciatic, and femoral nerves.  112 117  Increased operative time has been associated with an increased risk of such injuries. 80 104 118

The use of steep Trendelenburg presents special considerations to attempts to prevent positioning injuries. For instance, the risk of cephalad patient movement requires careful attention to patient fixation on the operating table. The use of shoulder braces has been discouraged as they may increase the risk of brachial plexus injuries when used improperly.  112 117 119  Alternatively, some surgeons utilize a bean bag  114  or anti-skid material  119 to prevent cephalad migration. Our practice has been to use a gel pad, which when placed directly underneath the patient's back, provides resistance to cephalad migration on the operating table. In addition, the patient is secured using a padded chest strap and further stabilized by the feet anchored in stirrups ( Fig. 9.7A ).

Robotic surgery in the steep Trendelenburg position also poses unique considerations for the anesthesia team, including increased difficulty with respiratory gas exchange and ventilation, cardiopulmonary changes related to pneumoperitoneum, and restricted access to the patient.  120 121 122  Communication between the surgeon and anesthesiologist is essential to ensure patient safety. Robotic surgery in the steep Trendelenburg position has been associated with vision loss from ischemic optic neuropathy.  117 123 124  The mechanism is hypothesized to be related to increased intraocular pressure (IOP) stemming from increased intracranial pressure and disturbed cerebrovascular and ophthalmic circulatory autoregulation.  120 125 126  Duration of surgery in steep Trendelenburg has been identified as a risk factor for increased IOP.

Compartment syndrome and rhabdomyolysis have also been reported related to positioning for robotic surgery. 113 125 127 128 129 130  The use of lithotomy position combined with steep Trendelenburg increases risk for both injuries due to direct pressure on muscles in conjunction with reduced perfusion from elevation of lower extremities above the level of the heart. Prolonged hypoxia from compartment syndrome may lead to rhabdomyolysis. Gluteal compartment syndrome has been reported from direct muscle pressure.  128  A recent population-based study of renal surgery reported an increased incidence of rhabdomyolysis with the robotic compared to laparoscopic approach.  131  Several studies have identified obesity and prolonged operative time as risk factors for compartment syndrome and rhabdomyolysis in robotic surgery.  127 130 131 132

Prevention of robotic positioning injuries begins with careful attention to positioning of upper and lower extremities as discussed above and coordination with the entire operating room team.  133  Interestingly, a volume–outcome relationship has been described for positioning injuries, including positioning for robotic surgery,  80 118 134  highlighting that experience is an essential component to preventing such injuries. It is also important to recognize that some risk factors for positioning injuries, such as obesity, are not modifiable, whereas others, such as operative time and degree of Trendelenburg, may be modifiable. Specific suggestions for prevention of perioperative peripheral neuropathies have been outlined by the American Society of Anesthesiology.  135  In addition, side docking of the robot has recently been described as a novel approach to reduce risk of positioning injuries associated with either lithotomy position or steep Trendelenberg.  136

Chapter 9 Questions
1. When closing fascial wounds using a running suture, the suture length should be at least ____ times the length of the wound:
a. 1.5
b. 2
c. 3
d. 4
e. 6
2. Which of the following is not an important factor in reducing the incidence of surgical site infections (SSIs) after radical cystectomy?
a. Antimicrobial prophylaxis given 60 minutes before incision
b. Adequate mechanical bowel preparation
c. Maintenance of normothermia during and after the procedure
d. Length of preoperative hospitalization
e. Redosing of the antimicrobial prophylaxis every two half-lives
3. What is the most common nerve injured by self-retaining retractors during open urologic procedures in the supine position?
a. Common peroneal nerve
b. Iliolumbar nerve
c. Obturator nerve
d. Sciatic nerve
e. Femoral nerve
4. What is the most likely clinical manifestation of injury to the common peroneal nerve?
a. Foot drop
b. Weakness of flexion of the leg
c. Weakness of hip extension
d. Numbness of the posterior lower leg and ankle
e. Weakness of hip adduction
5. Which of the following has been reported as a risk factor for positioning injuries related to robotic surgery?
a. Steep Trendelenburg position
b. Increased operative time
c. Obesity
d. Abduction of the arms
e. All of the above
6. A 55-year-old obese male is planned to undergo robotic-assisted laparoscopic prostatectomy. He has a history of previous colon resection with postoperative bowel leak and abscess drainage, and thus prolonged lysis of adhesions is anticipated. The best technique to reduce the likelihood of calf compartment syndrome is:
a. To carry out staged lysis of adhesions, with return to OR for prostatectomy
b. To perform procedure in flat supine position, without Trendeleburg
c. To use compression stockings
d. To use side docking of the robot
e. To administer subcutaneous heparin
7. In preventing dehiscence of fascial closure, which of the following techniques should be avoided:
a. Mass closure
b. Retention sutures
c. Peritoneal closure
d. Use of nonabsorbable suture
e. Passage of suture 5 mm from cut fascial edge
8. The most common organism found in wound infection cultures is:
a. Escherichia coli
b. Candida albicans
c. Staphylococcus aureus
d. Streptococcus epidermidis
e. Klebsiella pneumoniae
9. The procedure presenting the greatest risk for wound infection is:
a. Radical prostatectomy
b. Hydrocelectomy
c. Penile prosthesis
d. Cystectomy/ileal conduit
e. Inguinal lymph node dissection
10. Potential consequences of steep Trendelenburg position utilized for robotic-assisted radical prostatectomy include all of the following except:
a. Increased intraocular pressure
b. Increased peak airway pressure
c. Brachial plexus injury
d. Hearing loss
e. Vision loss
Answers
1. d. Fascial sutures should be placed at least 1 cm from the fascial edge while advancing no more than 1 cm with each throw. The length of a midline laparotomy may increase up to 30% in the postoperative period due to elasticity of the fascia and increased intraabdominal pressure. Several studies have demonstrated a higher rate of dehiscence and hernia formation when the length of suture used to close the wound is less than four times the length of the wound itself.
2. b. Several randomized trials have failed to demonstrate an improved rate of SSI with the use of mechanical bowel preparation. Instead, it may be associated with a higher rate of stool spillage during the procedure. All of the other factors listed have been associated with decreased rates of SSIs.
3. e. The femoral nerve arises from the second through fourth lumbar nerve roots. It is then formed within the psoas major muscle and emerges superior to the inguinal ligament. It is most commonly injured by retractors during prolonged abdominal cases when the nerve is compressed against the lateral pelvic wall. The common peroneal nerve is located in the lower extremity. The sciatic nerve arises from the fourth lumbar to third sacral nerve roots and exits the pelvis through the sciatic foramen. It may be injured during the dorsolithotomy position. The obturator nerve is not commonly injured because of retractor positioning.
4. a. The common peroneal nerve is the most common nerve injured in the lithotomy position. It provides motor innervation to the tibialis anterior, which allows dorsiflexion of the foot, and sensory innervation to the lateral leg. Injury to the sciatic nerve results in difficulties with flexion of the leg, whereas weakness of hip extension may be caused by injury to the femoral nerve.
5. e. Robotic-assisted surgery has been associated with increased risk of positioning injuries. The use of steep Trendelenburg position may result in patient movement on the operating table, increased pressure on nerves and muscles, and elevated intraocular pressure. Prolonged operative time, obesity, and abduction of the arms have also been associated with increased risk of positioning injuries.
6. d. By side docking the robot, the legs can be placed supine rather than in stirrups, thus reducing the risk of calf compartment syndrome due to compression. While avoidance of Trendelenburg position would reduce the risk of positioning injury to the upper extremities, the procedure would not be feasible. Compression stockings and subcutaneous heparin reduce the risk of venous thromboembolic complications, but not compartment syndrome.
7. e. Of the listed factors, peritoneal closure and retention suture utilization have been theorized to reduce fascial dehiscence though the benefit of peritoneal closure is unclear. Mass closure has been demonstrated in multiple studies to have lower dehiscence rates than does layered closure. Use of nonabsorbable suture has not been associated with fascial dehiscence and is thought to be preferable to the use of rapidly absorbing sutures. Placement of sutures too close to the fascial edge risks tearing of the fascia, either upon tying the stitch or upon strain in the postoperative setting. This is the most common cause of dehiscence.
8. c. The organism most commonly found in wound infections is Staphylococcus aureus . Gram-negative organisms are less commonly found, but are frequently encountered in bowel and bladder surgery.
9. d. Hydrocelectomy, penile prosthesis, and inguinal lymph node dissection would all be considered “clean” procedures with low risk of infection upon proper observance of aseptic techniques. Both prostatectomy and cystectomy are considered “clean-contaminated” since a hollow viscus potentially harboring bacteria is opened during the case. Cystectomy with ileal conduit diversion carries the highest risk of infection given the exposure of the field to both urinary tract and bowel contents. Infectious risk would be greatest in the setting of excessive or gross fecal spillage.
10. d. Steep Trendelenburg position, commonly utilized in pelvic robotic-assisted laparoscopic procedures, is associated with increased peak airway pressure due to elevation of the diaphragm, increased intraocular pressure, and brachial plexus injury if shoulders and upper extremities are not supported. Vision loss has been reported as a result of ischemic optic neuropathy as a result of increased intraocular pressure, but hearing loss has not been directly linked.
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