Patients undergoing prolonged pelvic surgery may develop compartment syndrome in one or both lower limbs in the absence of trauma or pre-existing vascular disease known as Well-Leg Compartment Syndrome (WLCS). Although uncommon with incidence of 0.03% it has devastating consequences for postoperative recovery including loss of life, limb or disability. Our primary aim was to create a novel scoring system for WLCS preoperative risk assessment and run a timer based repositioning protocol for patients undergoing prolonged pelvic surgery. Secondary aim was to asses feasibility and surgeon satisfaction of these measures in the operating room.

We recruited Colorectal, Urology and Plastics Surgery patients undergoing surgery in lithotomy or Trendelenburg position at Sengkang General Hospital (SKH) from July to December 2024. Preoperative novel WLCS score was calculated based on 3 parameters: Body mass Index (BMI) ≥ 25, Age < 35 and Preexisting Peripheral Vascular Disease or Chronic Venous Insufficiency which each category scoring 1 point. Highest WLCS score was 3 and lowest 0. Intraoperatively, timer based repositioning was performed once operative time reached 4 hours for 15 minutes. Repositioning was defined as levelling the patient and lowering the calves to level of heart or lower. Postoperatively patients who were repositioned were assessed till post operative day 3 for signs of WLCS. Feasibility and satisfaction was measured with pre and post study surveys.

A total of 484 patients were recruited. There were 0 WLCS cases during our study. Preoperative WLCS score was 0 in 246 (50%), 1 in 219 (45%), 2 in 19 (4%), 3 in 0 (0%) patients. 56 (12%) of patients were repositioned, of whom 98% were repositioned once. Preoperative WLCS scoring did not correlate with number of repositioning. Surveys revealed the 95% of surgeons, anesthetists and nurses to be very satisfied with the protocol and willing to continue with timer based repositioning beyond the end of the project.

WLCS score and timer-based repositioning are both measures which should be performed for all patients undergoing prolonged pelvic surgery to keep risks of WLCS low. These measures have minimal disruption to the nursing and surgical processes and are well-received by all staff with high levels of satisfaction