Background and aims Lower extremity compartment syndrome (CS) is a complication related to prolonged laparoscopic pelvic surgery, especially in the Lithotomy-Trendelenburg position (LTT) with the use of leg cuffs. We present two cases of CS who needed urgent fasciotomy after an 8 hour surgery, the first patient after a radical prostatectomy and the second after a radical cystectomy.

Methods CS occurs when perfusion to an extremity is inadequate because of either decreased arterial flow or venous outflow from LTT and pneumoperitoneum. Once reversed, results in tissue edema. We report two patients of middle age diagnosed with CS. The first patient had a history of obesity and SAOHS; the second one, chronic venous insufficiency. Both cases were treated by urgent surgical decompression under spinal anesthesia. The first one, after 48 hours, multiple surgical procedures were necessary for function recovery at one year. The second patient underwent surgery during the first 6 hours. After 5 months he walked without help.

Results We report two cases of CS in the postoperative period, focusing on the importance of an immediate surgical treatment. So far no evidence-based recommendation for prevention exists. The knowledge of this syndrome associated with prolonged LTT is essential to suspect it, contributing individual risk factors. Differential diagnosis should be made with deep venous thrombosis; intra-compartmental pressure measurement should never delay surgery with clinical suspicion.

Conclusions Lower extremity CS is a rare but devastating complication. A delay in diagnosis and treatment can be life-threatening. All medical personal involved should be aware after a long-lasting operation in the LTT position.