Long-lasting operations in the lithotomy position (Lloyd-Davies position) are acompanied by the risk of an acute compartment syndrome (ACS) of the lower extremities. In the gynecological literature, in contrast to other surgical fields, there are only isolated reports of this disastrous complication. Even though the occurrence of an acute ACS is overall rare, it must still be counted as one of the typical complications of surgery. For long-lasting operations a joint agreement must be reached between the surgeon and anesthetist on positional changes of the patient in order to avoid, for example, extreme joint flexion and low positioning of the legs. For possible operation times of more than 4 h, the patient should be preoperatively informed of the complication of ACS. As a consequence of experience of the risk of complications with ACS in combination with long-lasting gynecological operations in the lithotomy position, precautions should be taken to avoid extreme flexion of the groin and knee regions and likewise a head-down tilt <10°, independent of the operation method. Preventative measures will be presented as well as the spectrum of therapeutic interventions.