A Rare Case of Lower Limb Gangrene Following Anterior Exenteration in a Previously Irradiated Pelvis

Purpose

Limb-threatening ischemia following arterial thrombosis in a patient with no known history of arterial disease or vascular injury following surgery is difficult to explain. This case report illustrates a rare complication of arterial thrombosis leading to limb gangrene in a patient with recurrent carcinoma cervix who underwent anterior exenteration.

Case Report

A 43-year-old woman irradiated 10 years back for FIGO stage IIA carcinoma cervix presented with recurrence. Since the workup revealed localized disease, surgery was planned. Under general anesthesia with an epidural catheter in situ, patient was placed in lithotomy position and abdomen opened through a lower vertical midline incision. As the lesion was adherent to urinary bladder, a decision was made to do anterior exenteration with uretero-colostomy. The surgery lasted for 7 h, and patient was placed in head-low position for more than 3 h to assist small-bowel packing. Postoperatively, patient developed ischemia of right lower leg with documented thrombosis of right common femoral artery. As the arterial embolectomy failed and gangrene had set in, the limb was amputated on the fourth postoperative day.

Results

At the time of this write up, the patient has completed 5 years of disease-free status. She is rehabilitated with the below-knee prosthesis and is mobile.

Conclusion

Prolonged lithotomy positioning in the presence of a prior history of radiation may be associated with arterial thrombosis which can threaten limb perfusion, which if not diagnosed and treated early can result in limb gangrene.