Case report: morbid obesity and lithotomy positioning: a high-risk triad with GCS leading to severe rhabdomyolysis with impending acute compartment syndrome following ovarian cancer cytoreduction.

BACKGROUND

Venous thromboembolism (VTE) prophylaxis with graduated compression stockings (GCS) is a standard of care in gynecologic oncology surgery; however, the mechanical risks in specific patient populations require critical attention. CASE PRESENTATION: A 24-year-old morbidly obese patient (BMI 41.7 kg/m²) with ovarian carcinoma developed severe rhabdomyolysis and impending acute compartment syndrome (ACS) after a 7.5-hour fertility-preserving cytoreduction performed in the Trendelenburg position with lithotomy, during which routine GCS were applied. Postoperative symptoms included severe bilateral leg pain, swelling, and myoglobinuria. Laboratory studies revealed extreme elevations in creatine kinase (peak CK 22,476 U/L), myoglobin (3,852 ng/mL), and lactate dehydrogenase, alongside hyperkalemia and hypocalcemia. A delayed initial CK reading due to hemolysis postponed targeted therapy. Aggressive conservative management, focusing on hydration and urine alkalinization, successfully resolved the rhabdomyolysis without the need for fasciotomy.

CONCLUSIONS

While mechanical prophylaxis is vital, the convergence of morbid obesity, prolonged lithotomy positioning, and GCS application creates a high-risk triad that can precipitate severe rhabdomyolysis with impending ACS. Distinguishing severe rhabdomyolysis from established ACS is critical for guiding medical versus surgical management. Clinicians should maintain a low threshold for measuring intracompartmental pressures in symptomatic patients to prevent permanent neuromuscular damage or unnecessary surgical interventions.