Complications from Vaginal Surgery Case File

Complications from Vaginal Surgery Case File

Eugene C. Toy, MD, Konrad P. Harms, MD, Keith O. Reeves, MD, Cristo Papasakelariou, MD, FACOG

Case 29

A 45-year-old Caucasian G4 P4004 woman with uterovaginal prolapse is scheduled for a planned procedure of vaginal hysterectomy, anterior and posterior colporrhaphy, and sacrospinous ligament fixation. Except for her uterovaginal prolapse, the patient is in good health and has no chronic diseases. On the day of surgery, the patient is positioned in “candy cane” hanging stirrups, and the initial parts of the operation are accomplished without any noticeable complication. A Capio device (Boston Scientific, Boston, MA) is employed to place the permanent suture used for securing the vaginal apex to the right sacrospinous ligament. Following the patient’s recovery from general anesthesia, she complains of difficulty walking and getting her right foot to function normally.

➤ What is the most likely diagnosis?

➤ What is your next step?

ANSWERS TO CASE 29:

Complications from Vaginal Surgery

Summary: A 45-year-old woman has a vaginal hysterectomy, anterior and posterior colporrhaphy, and right sacrospinous ligament fixation. She awakens with difficulty walking and altered ability to make her right foot function normally.

➤ Most likely diagnosis: Right foot drop from compression of the common perineal nerve by pressure on the nerve by the stirrup at the site of the lateral epicondyle.

➤ Next step: Reassure the patient that this is likely a transient problem. Consult physical therapy for assistance in rehabilitation to restore normal foot function.

ANALYSIS

Objectives

1. Recognize the types of neuropathy related to vaginal surgery.
2. Describe the various mechanisms and preventative strategies of nerve injury associated with vaginal surgery: positioning of the patient, intraoperative injury, and nerve entrapment/injury.
3. Describe the classic presentations of nerve injury and the therapy for these conditions.

Considerations

This patient’s immediate postoperative complaint of right foot drop is a known complication of vaginal surgery, especially if the patient was positioned in hanging stirrups which did not have adequate lateral padding to prevent compression of the common peroneal nerve at the lateral epicondyle. This is but one of the types of neuropathy that may occur in association with vaginal surgery. Knowing how to avoid these types of neurologic injury and how to recognize and treat them promptly when they occur is an essential tool for the accomplished vaginal surgeon.

APPROACH TO

Neurologic Injury in Vaginal Surgery

DEFINITIONS

FOOT DROP:Weakness of the ability to dorsiflex the foot, usually due to peroneal nerve or sciatic nerve injury.

SCIATICA: Pain originating from the buttocks and radiating down the posterior aspect of the leg, usually due to irritation of the sciatic nerve.

CLINICAL APPROACH

Neurologic injury in vaginal surgery may arise from two distinct causes— injury due to incorrect preoperative positioning of the patient resulting in nerve stretching, and direct injury to nerve tissue during the actual surgical procedure. Prevention must therefore be twofold; the patient must be correctly positioned prior to the onset of the surgical procedure, and nothing should be done during the surgical procedure itself that will result in stretching or compression or vascular compromise of nerve tissue. Knowledge of the nerve supply to the pelvis is critical to avoid neurologic injury, especially in some of the vaginal operative procedures for reestablishing apical vaginal support where nerve tissue is intimately close to structures utilized for achieving restored vaginal vault integrity (Table 29–1).

How Nerve Injuries Occur in Vaginal Surgery

Most vaginal surgical procedures are accomplished with the patient in the dorso-lithotomy position. It has been demonstrated that vaginal retractors do not have the capability to compress the femoral nerve during vaginal surgery, but that injury to the femoral nerve may result from incorrect patient positioning. If the patient’s hips are in excessive rotation, excessively flexed, and abducted, then the femoral nerve is placed at an 80- to 90-degree angle as it comes under the inguinal ligament, which is relatively nonpliable and fixed. This results in pressure, which may progress to ischemia to the femoral nerve, and neuropathy distal to the site of compression. The preferred lithotomy position for the patient having vaginal surgery is to have the thighs flexed and abducted, the knees should be flexed, and there should be minimal external rotation of the hips.1,2

Sciatic or peroneal nerve injury is relatively rare, occurring only 0.2% to 0.3% of the time. Sciatic nerve injury likewise is a positioning problem, resulting in excessive stretching of nerve tissue. This occurs if there is excessive hip flexion, excessive extension of the knees, or extreme external hip

rotation.3 The sciatic nerve is also vulnerable to injury if a surgical assistant leans on the inner thigh during the operation and places excessive tension on the nerve, stretching it during the operative procedure.2 The common peroneal nerve is subject to compression injury most likely due to compression at its most vulnerable location, that being at the lateral fibular head, where it is most superficial. Injury to the peroneal nerve can be successfully avoided with adequate cushioning on the lateral aspect of the calf during vaginal surgery.

Many of the classic papers describing neurologic injury resulting from vaginal surgery were written when “candy cane” stirrups were in common use. Supporting the patient’s legs with fully cushioned, multiadjustable (Allen) stirrups will eliminate many, if not most, of the cases of neurologic injury which result from improper positioning.

Injury to the pudendal nerve is not uncommon in association with sacrospinous ligament fixation. The pudendal nerve exits from the pelvis through the greater sciatic foramen, and then it lies directly behind the sacrospinous ligament along the lateral one-third of the ligament that attaches to the ischial spine. Nerve fibers are entrapped when the surgeon places the suture securing the vaginal cuff to the sacrospinous ligament too near to its origin at the ischial spine. Most experts describe the optimal suture placement as being 1.5 to 2 finger breaths medial to the ischial spine to avoid nerve entrapment.4 Anatomic studies have indicated that suture placement should be through the medial one-third of the ligament to completely avoid the pudendal nerve complex.5 Injury can occur with any of the devices used to place a suture through the sacrospinous ligament, including the Deschamps ligature carrier (Surgipro, Shawnee, KS), the Miya hook, Carrier device (Thomas Medical, Indianapolis, IN), or the Capio device. None seems uniquely designed to allow the surgeon to avoid the possibility of nerve entrapment, though the likelihood of pudendal nerve injury is reduced to the extent that the suture can be placed through the front of the ligament, and avoid going around or toward the posterior aspect of the ligament where the nerve courses. Injury to the pudendal nerve will result in the patient having persistent pain long after normal postoperative pain has resolved. Patients complain of perineal pain, pain in the buttocks on the affected side, and of being unable to sit comfortably. Patients need to be taken back to the OR as soon as this diagnosis is made, and the problematic suture needs to be removed. If this is recognized in the immediate postoperative period, then the suture may be placed more medially, or if the procedure has been done as a unilateral procedure, then the fixation may be done to the contralateral ligament. It is important to keep this particular neuropathy in mind, because this complication can occur even in the experience of the best of gynecologic surgeons, possibly because there is a demonstrable anatomic variability in the path of pudendal nerve fibers along the course of the sacrospinous ligament. This complication has been reported as being amenable to surgical correction by reexploration and removal of the offending suture up to 2 years following the initial surgical procedure. In that instance, pain relief was described as being “immediate.” This nerve injury has also been reported following uterosacral ligament suspension of the vagina, occurring seven times in 182 procedures.6

Treatment Considerations

Fortunately, the incidence of neuropathy from vaginal surgery is relatively low, and recovery is generally complete in most instances, though this may take months rather than weeks if the problem is due to a stretch injury. Neurologic consultation and rehabilitation consisting of physiotherapy, a foot drop brace if indicated, and electrical stimulation of the involved musculature is frequently required. Physical therapy will be necessary if motor deficits are identified, as this will prevent atrophy and wasting of involved muscle groups innervated by the involved nerve. Some authors have also used medical therapy in the form of gabapentin as an adjunct to rehabilitation procedures.

Comprehension Questions

29.1 A 33-year-old woman underwent a vaginal hysterectomy due to dysfunctional uterine bleeding unresponsive to medical therapy. On postoperative day 1, the patient was noted to have difficulty walking. On examination, she has difficulty lifting her right leg off the bed. Her right patellar reflex is absent. Which of the following is the most likely mechanism for the nerve injury?

A. Intraoperative injury with suture

B. Intraoperative pressure with retractor

C. Hyperflexion of the hip

D. Lack of padding to the lateral leg

29.2 Which nerve is most subject to injury as a result of a sacrospinous ligament fixation procedure?

A. Femoral

B. Common peroneal

C. Pudendal

D. Sciatic

29.3 A 55-year-old woman is noted to have foot drop following a vaginal surgery. Which of the following findings would more likely indicate a sciatic nerve problem rather than peroneal nerve issue?

A. Lack of ankle reflex

B. Posterior leg pain

C. Lack of padding to the lateral fibular area

D. Sacrospinous ligament fixation as part of the procedure

ANSWERS

29.1 C. This patient likely has a right femoral nerve injury. The femoral nerve innervates the quadriceps muscles leading to difficulty walking and a diminished or absent patella reflex. The most common mechanism of femoral nerve palsy in vaginal surgeries involves hyperflexion of the hips leading to pressure and ischemia of the femoral nerve under the inguinal ligament.

29.2 C. The course of the pudendal nerve just behind the lateral aspect of the sacrospinous ligament, near the ischial spine, makes it vulnerable to injury while performing SSLF.

29.3 B. Injury to either the sciatic nerve and peroneal nerve will result in foot drop and diminished ankle reflex. Lack of padding to the fibular head leads to common peroneal nerve palsy. Buttocks or posterior leg pain is consistent with sciatic nerve damage.

Clinical Pearls

See Table 1-2 for definition of level of evidence and strength of recommendation

➤ When tying the sutures affixing the vaginal apex to the sacrospinous ligament, leave the cut ends of the suture long enough so that they can be readily identified to facilitate removal of the suture if pudendal nerve entrapment is diagnosed (Level C).

➤ Caution your surgical assistants not to put any pressure on the medial aspect of the patient’s thigh while she is in lithotomy position (Level C).

➤ Make sure the patient is correctly positioned in the stirrups before the operation starts. Nerve injury prevention is much simpler, easier, and cheaper than treatment for postoperative neuropathy (Level B).

REFERENCES

1. Irvin W, Andersen W, Taylor P, Rice L. Minimizing the risk of neurologic injury in gynecologic surgery. Obstet Gynecol. 2004;103:374-382. 

2. Burkhart FL, Daly JW. Sciatic and peroneal nerve injury: a complication of vaginal operations. Obstet Gynecol. 1966;28:99-102. 

3. Alevizon SJ, Finan MA. Sacrospinous colpopexy: management of postoperative pudendal nerve entrapment. Obstet Gynecol. 1996;88:713-715. 

4. Verdeja AM, Elkins TE, Odol A, Gasser R, Lamoutte E. Transvaginal sacrospinous colpopexy: anatomic landmarks to be aware of to minimize complications. Am J Obstet Gynecol. 1995;173:1468-1469. 

5. Batres F, Barclay DL. Sciatic nerve injury during gynecologic procedures using the lithotomy position. Obstet Gynecol. 1983;62(suppl):92S-94S. 

6. Flynn MK, Weidner AC, Amundsen CL. Sensory nerve injury after uterosacral ligament suspension. Am J Obstet Gynecol. 2006;195:1869-1872.

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