Nerve Injury (1)
A 45 yr old lady undergoes TAH. Surgery was performed while patient is supine, using a pfannenstiel incision and a self-retaining retractor, and lasted 120 minutes. On post op day 1, the patient falls while attempting to mobilize out of bed.
- Weak right knee extension and sensory loss over the anterio-medial aspect of the right thigh. Right patellar reflex is absent.
- Left lower limb is normal
- Low transverse abdominal incision
- Self-retaining Retractor
Fall on first attempt to mobilize
- Common peroneal
Neurological injuries following pelvic surgery are rare complications, often managed conservatively, or with minimal intervention. Occasionally, however, the sequelae of such an injury may be grave, with long term disability or permanent loss of function.
Gynecologic surgery is the most common cause of iatrogenic femoral neuropathy, with abdominal hysterectomy being the leading culprit.
This patient appears to suffer from a post-operative femoral nerve injury. The classical description of this injury is a patient falling from their bed or chair on their first attempt to ambulate following the operation.
Clinical assessment commonly reveals motor limitation with reduced ability to extend the knee joint and thus difficulty getting up from a seated position and walking up stairs. Sensory involvement may also be evident along the distributions of the lateral cutaneous femoral and saphenous branches.
- Incision location and extension
- Surgical dissection
- Retractor placement
- Patient positioning
The major mechanism of femoral nerve injury lies within nerve compression. A pfnannestiel incision, or any
transverse incision at that, amplifies the probability of this occurring by allowing for a more lateral placement of the retractor blades, pressing the nerve against the unforgiving pelvic side wall.
Risk factors for a femoral nerve injury include a transverse abdominal incision, inappropriate use of self-retaining retractor, improper patient positioning, or a maintained lithotomy position for longer than 4 hours in prolonged operations.
- Proper placement of surgical retractors
- Periodic assessment of retractor placement throughout operation
- Use of the shortest blades allowed for, within technical feasibility
- Consider relieving pressure during long operations
- W I, W A, P T, L R. Minimizing the risk of neurologic injury in gynecologic surgery. Obstet Gynecol, 2004 https://pubmed.ncbi.nlm.nih.gov/14754710/
- Moore AE, Stringer MD. Iatrogenic femoral nerve injury: a systematic review. Surg Radiol Anat 2011 https://link.springer.com/article/10.1007/s00276-011-0791-0
- OS A, MA B, T F. Nerve Injuries in Gynecologic Laparoscopy. J Minim Invasive Gynecol [Internet]. 2017 https://pubmed.ncbi.nlm.nih.gov/27639546/
- Bohrer JC, Walters MD, Park A, Polston D, Barber MD. Pelvic nerve injury following gynecologic surgery: a prospective cohort study. 2009 www.AJOG.org
- AD B, AP A. Postoperative neuropathy in gynecologic surgery. Obstet Gynecol Clin North Am . Available from: https://pubmed.ncbi.nlm.nih.gov/20674786/