Trendelenburg-Related Brachial Plexus Injuries in Gynecologic Surgery
Nigel Pereira, MD, Loretta Hallock, DO, Colleen Yen, BS, Irene Grias, DO, Minda A. Green, MD
Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, PA, USA (Dr. Pereira). Department of Surgery, Danbury Hospital, Danbury, CT, USA (Dr. Hallock). Drexel University College of Medicine, Philadelphia, PA, USA (Dr. Yen). Division of Minimally Invasive Surgery, Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, PA, USA (Drs. Grias, Green).
Introduction: Brachial plexus injuries are infrequent but preventable complications of laparoscopic and robot-assisted gynecologic surgery.
Case Description: A 32-year-old woman with a history of uterine leiomyomata, menorrhagia, and chronic pelvic pain underwent a robot-assisted laparoscopic myomectomy. Preoperative radiologic imaging showed an enlarged uterus with a large, 8.6 7.2 9.2–cm, intramural left uterine body leiomyoma. Bleeding and difficulty visualizing the surgical dissection planes complicated intraoperative enucleation of the leiomyoma. This resulted in a total surgical time of 400 minutes, during which the patient spent approximately 320 minutes in the steep Trendelenburg position. On postoperative day 1, the patient reported weakness and tingling in her left arm and fingers and was found to have an acute left brachial plexus injury. After a course of oral corticosteroids and outpatient physical therapy, the patient reported no residual neurologic deficits during her subsequent postoperative visits.
Discussion: As gynecologists cope with the learning curve associated with laparoscopic and robot-assisted laparoscopic surgery, longer operating times will be encountered, with patients spending a significant amount of intraoperative time in the Trendelenburg position. The resulting risks of intraoperative nerve injuries, particularly brachial plexus injuries, may therefore be higher than expected. Because these injuries can cause significant postoperative morbidity, and sometimes even have medicolegal implications, every effort should be made to prevent them. To achieve this, we emphasize the combined efforts of the nursing, surgical, and anesthesia teams to ensure proper patient positioning in the operating room.
Key Words: Brachial plexus injury, Laparoscopy, Robotics, Patient positioning, Trendelenburg.