Multiple Postoperative Neuropathies After Open Total Hysterectomy #pencis #researchawards

Introduction

Morbid obesity significantly increases the risk of perioperative neuropathies due to a combination of mechanical compression, altered tissue perfusion, and metabolic vulnerability. The presented case of a 49-year-old woman undergoing open total hysterectomy highlights the rare but clinically important occurrence of multiple nerve injuries arising simultaneously after surgery. Despite careful preoperative positioning, the patient developed progressive neuropathic symptoms involving both the upper and lower limbs, illustrating the complexity of managing obese patients in surgical settings. Persistent iliopsoas weakness, long-term sensory deficits, and delayed diabetes mellitus diagnosis underline the multifactorial nature of nerve injury in obese individuals. This case emphasizes the need for meticulous intraoperative monitoring, optimal positioning, and early multidisciplinary intervention to improve outcomes.

Pathophysiology of Multiple Perioperative Neuropathies in Morbid Obesity

The coexistence of multiple neuropathies following surgery in morbidly obese patients suggests an interplay between mechanical compression, impaired microcirculation, and metabolic derangements. Excess adipose tissue increases susceptibility to traction injuries and prolonged pressure on peripheral nerves, especially during Trendelenburg positioning. Additionally, subclinical metabolic disorders—later revealed as diabetes in this case—may silently exacerbate nerve vulnerability. Understanding these mechanisms is essential to improving surgical planning and reducing postoperative nerve complications.

Intraoperative Positioning Challenges and Risk Mitigation Strategies

The case illustrates how positioning devices, pillow height, arm abduction angles, and retractor placement can collectively contribute to neuropathy when not continuously reassessed. Morbidly obese patients require individualized positioning protocols with regular intraoperative checks due to shifting soft tissue and prolonged operative times. Research into advanced pressure-mapping systems, optimized surgical tables, and automated alerts may improve the prevention of nerve injuries during gynecological and abdominal surgeries.

Diagnostic Evaluation of Postoperative Neuropathy

Timely diagnosis is crucial for differentiating between reversible mechanical nerve injury and serious complications such as epidural hematoma. In this patient, postoperative imaging excluded hematoma, helping clinicians focus on neuropathic etiologies. Future research should explore early biomarkers, high-resolution nerve imaging, and electrophysiological monitoring to accelerate diagnosis, reduce uncertainty, and guide appropriate interventions in high-risk obese populations.

Rehabilitation Approaches and Long-Term Functional Outcomes

Persistent iliopsoas weakness and gait disturbance required prolonged rehabilitation supported by neuropathic pain management using pregabalin. Despite partial improvement, long-term deficits remained, reflecting the severe functional impact of multi-nerve injuries. Studies are needed to evaluate tailored rehabilitation programs, neuromodulation techniques, and metabolic optimization to improve recovery trajectories in obese patients experiencing perioperative neuropathy.

The Role of Metabolic Disorders, Including Undiagnosed Diabetes, in Nerve Injury

The later diagnosis of diabetes mellitus highlights the importance of metabolic screening before major surgery, particularly in morbidly obese individuals. Unrecognized hyperglycemia and microvascular dysfunction may prime nerves for injury even before surgical stress occurs. Future research should investigate the role of preoperative metabolic optimization, glycemic thresholds, and nerve-protective therapies to minimize complications in high-risk surgical patients.

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