Surgical positioning and nerve injuries in gynaecology

It is 17:40 on the day-surgery ward. A 38-year-old has just had a robotic radical hysterectomy for early cervical cancer. The case was 4 hours, the Trendelenburg was steep, and you walked past the bed on the way to the next case. Six hours later the nurse calls: the patient's left arm is weak and she can't feel the back of her hand. Brachial plexus injury, the operating table's slow bill, and your documentation decides whether the claim is defensible or lost. This topic is the rehearsal — the position, the padding, the time, the note.^[1][3][4]

Overview and definition

Perioperative peripheral nerve injury (PPNI) is a deficit in motor or sensory function of a peripheral nerve first recognised after a surgical procedure, attributable to the procedure, the position, the anaesthetic, or a combination. Positioning injury is a subset — a nerve deficit caused by compression, stretch, or ischaemia from the surgical position itself. ^[1][2]

Three frameworks anchor the topic:

• By mechanism: compression (over a hard surface), stretch (joint hyperextension beyond the nerve's tensile reserve), ischaemia (compartment syndrome from prolonged hypoperfusion), direct trauma (cut, electrocautery, retractor).^[8][9]
• By lesion (Seddon, 1943): neurapraxia (temporary conduction block, intact axon — recovers in days to 6 weeks), axonotmesis (axon disrupted, sheath intact — recovers weeks to months at ~1 mm/day), neurotmesis (complete transection — does not recover without surgical repair).
• By timing: immediate (in PACU), early (24–48 h), delayed (within weeks — stretch injury evolving), chronic (persistent at 3 months — Wallerian degeneration established).

The numbers you quote at the station: PPNI after general anaesthesia affects under 1% in a general surgical population in large series, higher in cardiac, neurosurgery and some orthopaedic procedures; neuropathic symptoms are more common with focused prospective examination. In gynaecology lithotomy, the common peroneal nerve is the most commonly injured single nerve; in robotic surgery, brachial plexus injury is the leading cause of upper extremity deficit. ^[1][2][3]