Malawer Pelvic Resection Pelvic resection by malawer book reading

Pelvic resection by malawer book reading

1. Overview on : Pelvic Resection and Hemipelvectomy Stase Onkologi Feabruari – Maret 2024

2. The greatest problem involved in resection is the need for oncological radicalism on the one hand, while aiming to obtain a good functional outcome on the other

3. Firstly performed at 1891 -> Pati e t only survived for few hours P erioperative care has been a challenge for all health-care providers in- volved in this aggressive procedure Perioperative is challenging : Extensive tissue trauma related to the surgery The use of preoperative adjuvant chemotherapy and radiotherapy Significant blood and blood and fluid loss fl uid loss Bleeding disorders Large wound deffect Intense postoperative pain

4. BACKGROUND C ommon anatomic location for metastatic and primary musculoskeletal tumors Surgical resection is more challenging in the pelvis than in other location s because of the complex anatomy and the proximity to vital abdominal viscera and major blood vessels and nerves Therefore, preoperative evaluation and extensive imaging are critical Tumor surgery around the pelvis has the highest rate of complications , infections , wound dehiscence and mechanical failure of all anatomic sites. Early descriptions of the surgical technique of hemipelvectomy emphasized the importance of careful selection of patient s.

5. TERMINOLOGY The advent of limb-sparing pelvic resections has necessitated a distinction between internal and external hemipelvectomy , depending on whether preservation of the ipsilateral limb is performed Internal Hemipelvectomy External Hemipelvectomy Classic Hemipelvectomy Modified Hemipelvectomy Extended Hemipelvectomy Compound Hemipelvectomy Pelvic Resection Type I, II and III Hindquarter Amputation Posterior flap hemipelvetomy Preserves the hypogastric (internal iliac) vessels and the Inferior gluteal vessels Extending the margin for tumors that approach or involve the sacroiliac joint Resection of contiguous visceral structures such as bladder, rectum, prostate, or uterus

6. IMPORTANCE Patients Selection E arly diagnosis and follow-ups by imaging C hemotherapy and/or radiation regimes I mplants or bioengineering

7. ANATOMY Pelvic Nerves Sciatic Nerves Femoral Nerves Obturator Nerves Lumbar Plexus Sensory Nerves

8. ANATOMY (Pelvic Nerves) Sciatic Nerves The sciatic nerve arises from L4, L5, S1, S2, and S3 . It is essential to protect the sciatic nerve early in most procedures . The sciatic nerve is formed at the junction of the lumbar sacral plexus where these two trunks come together. N ot to injure the the accompanying inferior and superior gluteal nerves and arteries -> Gluteus maximus is essential for closure of most pelvic resections. Obturator Nerves posterior divisions of the ventral rami of L2 and L3 and passes inferolaterally between the psoas and iliacus muscles A lmost always preserved during pelvic resections Femoral Nerves formed from the anterior branches of L2, L3, and L4 , is the largest nerve formed from anterior divisions of the lumbar plexus. This nerve is routinely transected during pelvic resections (type 3) due to its intimate proximity to the tumor.

9. ANATOMY (Pelvic Nerves) Iumbar Pkxus Sensory Nerws The iliohypogastric (L1), ilioinguinal (L1), genitofemoral (L1, L2 ) and lateral femoral cutaneous nerves P ass underneath the lateral aspect of the inguinal ligament, and pass just distal and medial to the anterior superior iliac crest to innervate the anterolateral thigh This nerve is sacrificed during most pelvic surgical procedures Preserved Sacrified Sciatic Obturator Femoral Lumbar Plexus Sensory

10. ANATOMY Pelvic Vessel Aortic Bifuraction Common Iliac Artery External Iliac Artery Internal Iliac Artery Anterior Branches Posterior Branches Corona Mortis

11. ANATOMY (Pelvic Vessel) Aortic Bifurcation Aorta bifurcates at the level of L4 into common iliac vessels at the level of L4 – L5 . I nternal and external iliacus vessels at the level of S1. Preoperative evaluation with angiography is required for evaluation and preoperative to avert such an occurrence Common Iliac Artery M ust be identified early to correctly identify the aorta as well as the the internal iliac (hypogastric) artery No arterial branches arise from the artery The bifurcation of the common iliac artery into the external and internal iliac arteries is at the exact level at which the ureter crosses on the adjacent peritoneal surface

12. ANATOMY (Pelvic Vessel) External Iliae Artery The external iliac artery contributes to the inferior epigastric artery and extends distally, as the superficial femoral artery Internal Iliac Artery Anterior Branches The internal iliac (hypogastric) artery descend from the lumbosacral articulation -> greater sciatic notch -> several arteries. The hypogastric vessels are routinely ligated in performing modified hemipelvectomies as well as many pelvic resections Corona Mortis A n anastomosis of the external iliac, inferior epigastric, and obturator vessels located in the retropubic region approximately 3 em from the symphysis pubis Can Lead to Extensive Bleeding Posterior Branches

13. ANATOMY (Pelvic Vessel) Internal Iliac Artery

14. ANATOMY (Pelvic Viscera) Pelvic Viscera The bladder and urethra, and the prostate in male patients, arc loated above and under the pubic symphysis. Venous surrounding the prostate can be a significant source of bleeding that can be diffi c ult to conttol even with good visualization of the organ. Ovaries, fallopian tubesm uterus, cervix and vagina is identified and protected . Most of the gasttointestinal tract is protected by the peritoneum and is gently retracted out of the operative field

15. BOUNDARIES Sciatic Notch Osseus Boundaries Posterior Margin Should be identified early both internally and externally I lium and the rim of the great sciatic notch Piriformis muscle and Sciatc Nerve Superior gluteal vessels and nerve Inferior Margin The sacrospinous and sactrotuberous ligaments are released during type 1 and 2 pelvic resections.

16. INDICATIONS Unresponsive Sarcomas Involving Multiple Compartments F ails to respond to neoadjuvant demotherapy or radiation. Extremely large sarcomas involving multiple compartments Anatomic location of the tumor and the expected defect to be created by the resection Chondrosarcoma, Ewing sarcoma, plasmocytoma and osteosarcoma

17. INDICATIONS Contamination of Surrounding Structures pathologic fractures of the proximal femur often contaminate unexpectedly large volumes of tissue Nonviable Extremity Precluding Limb Salvage Peripheral vascular disease and patients with fungating, infected sarcomas Very young and skeletally immature children with primary sarcomas

18. INDICATIONS Failure of Previous Resection local recurrence in the thigh or buttock after aggressive surgical and medical treatment Control Infection Palliative uncontrollable pain from tumor involvement of the lumbosacral plexus, sciatic, and femoral nerves Non controllable local disease from metastatic carcinoma who have failed to respond to all conventional treatments

19. INDICATIONS Metastatic Adenocarcinoma Breast, Prostate, Renal, Lung, Colon Acetabular destruction with an impending pathological fracture that requires surgical reconstruction. Soft Tissue Sarcomas E valuated for gastrointestinal, genitouretal , vascular or peripheral nerve involvement.

20. IMAGING AND OTHER STAGING STUDIES Plain Radiography Limited value in the assessment of pelvic girdle lesions. Should be a low tlu:eshold for performing further imaging, especially for initial screening and the postoperative evaluation of reconstructions.

21. IMAGING AND OTHER STAGING STUDIES CT and MRI CT with intravenous contrast and three-dimensional reconstruction is the optimal technique for assessing the extent of bone involvement and destruction, the osseous anatomy, and the relation between the tumor and the major blood vessels of the pelvis. MRI with constrast is critical for imaging soft tissue ( ie , vcssels , nerve, muscle) and osseous involvement

22. IMAGING AND OTHER STAGING STUDIES Additional Examination Bone Scan : rule out systemic metastasis and to assess the focal osseous involvement and tumor vas cularity in the initial fiow phase. Angiography : Angiography is mandatory for determining the vascular anatomy that often is distorted by large pelvic tumors FDG – PET : May be useful in assessing the “Grade” of malignancy , evaluating response from neoadjuvant chemotherapy, local recurrence. Biopsy : to Evaluate a valid tumor diagnosis (benign vs malignant), tumor grade (high vs low) and tumor subtype. (Should avoid gluteal and groin area)

23. CONSIDERATION Evaluation of the full anatomic extent of a pelvic tumor cannot be based on a single imaging modality. The authors review the structures from the back ( midsacral region) and follow the pelvic girdle to the front (symphysis pubis), as described in the following paragraphs. A. Sacrum, Sacral Alae and Sacroiliac joint : Most Hemipelvectomy which Tumor resection that through the ipsilateral neural foramina, regain function of gastrointestinal and genitourinary tracts Adding contralateral compromise of sacral roots will create dysfunction Tumor that penetrate the sacrum and cross the midline are considered unresectable because involvement of bilateral roots

24. CONSIDERATION A. Sacrum, Sacral Alae and Sacroiliac joint : Common iliac artery pass anterior to Sacral Ala . So any cortical breakthrough by a tumor may extend to the blood vessels. SI Joint as a Landmark -> Major vessels and nerves are medial to it. B. Major Pelvic Blood Vessels and Structures : The common iliac artery bifurcates along the sacral ala, and the ureter crosses the bifurcation on each side. Tumor near sacral ala or SI Joint have a risk of major bleeding, carefully en block escision .

25. CONSIDERATION C. Sciatic Notch and Nerve : Site of pelvic osteotomy in iliac / periacetabular region. Piriformis as a key structure for sciatic and superior gluteus nerve. Adequate supply of gluteal region is mandatory for flap design D. Ilium : Iliacus can act as anatomic barrier for tumor and can be used as a safe oncologic margin resection. In contrast, metastatic carcinoma usually affecting adjacent muscle

26. CONSIDERATION E. Extension to pelvic Viscera : Left Sided tumors are more likely to involve a component of GI tract because its close proximity to pelvic gridle D. Acetabulum and Hip Joint : Iwide resection in periacetabular region would leave a major impairment on the function of hip joint. F. Pubis : - Tumor extend or arising from pubic ramus are in close proximity to femoral artery, vein and nerve, urethra.

27. SURGICAL MANAGEMENT Preoperative Planning : Complete imaging and laboratory studies, also team from gynecologyst , digestive, vascular, urology surgeries Consider possible prophylactic urethral stents if there is urethral obstruction A risk of major blood loss is estimated equal to one total body transfusion (>7% body weight in Kg) Bowel preparation ICU Reservation

28. SURGICAL MANAGEMENT B. Position : All patients should have a DC and rectal tube placed, for minimizing caontamitaion and also as a landmark. C. Pelvic Resection : Type 1 resection (Iliac) -> Lateral decubitus with anterior tilt Type 2 resection (Periacetabular) -> LLD Type 3 resection (Pelvic floor) -> Supine, with LE flexed and abducted Type I Resection Type II Resection Type III Resection

29. Pelvic Resection (Internal Hemipelvectomy)

30. SURGICAL MANAGEMENT Approach : Utilitarian pelvic incision -> Expose entire retrogluteal , sciatic notch and nerve, abductor muscle and hip joint , retroperitoneal,retrogluteal area, ilium. Begin at posterior inferior iliac spine and extend along iliac crest to anterior inferior iliac spine. It creates 2 arms, 1 in upper from siymphisis pubic and inguinal ligament , others distally over anterior femur to greater trochanter and follow inserion of gluteus maximus muscle . If biopsy is indicated, the suitable technique and suitable approach must be chosen and along with utilitarian incision line, remote from major neurovascular bundle and abductors.

31. SURGICAL MANAGEMENT Type I Resection : Ilioinguinal resection following Symphisis pubis -> iliac crest -> Sacroiliac joint Combined with a lateral incision to expose outer portion of the ilium, sciatic notch and retrogluteal space. All muscle attachment to iliac crest are resected en bloc with tumor, except iliacus and gluteus medius . Anterior (retroperitoneal) Continue interplane of psoas and iliac muscle. (Danger : Femoral Nerve) Not require ligation of large blood vessel

32. SURGICAL MANAGEMENT A : This approach provides good exposure of retroperitoneal space as posterior retrogluteal area. C : Abdominal wall transected from iliac crest. Sartorius and TFL and Iliotibial band is transected . Rectus femoris let intact. D : Retroperitoneal exposure. The plane is between iliacus and psoas developed with caution. Psoas muscle and femoral nerve reflected medially.

33. SURGICAL MANAGEMENT E : Exposed of retrogluteal area. Gluteus maximus is released. Sciatic nerve is preserved. It is important to preserve as much muscle as possible. F : Supa-Acetabular osteotomy and sacroiliac disarticulation. Protect the viscera using malleable retractor. Care is taken not to enter the hip joint. The pelvis is opened within pelvis. The iliac vessel must be immobilized and retracted before attempting to open SI joint.

34. SURGICAL MANAGEMENT G : Soft Tissue Reconstruction. Gluteus medius is sutured to abdominal wall with ipsilateral femur in Abduction. The suture line is reinforced by oversewing the TFL and sartorius muscle Closure of the muscle layer must be meticulous, because poor healing and wound dehiscence will expose the abdominal and pelvic contents and will be difficult to manage.

35. SURGICAL MANAGEMENT The patient is in the lateral decubitus position with posterior tilt to maximize anterior dissection. The Utilitarian incision is used to expose inra and extrapelvic , inguinal incision is used the retroperitoneal plane, posterior gluteus maximas -> Fasciocutaneous flap. The iliac vessels are mobilized first , following by hypogastric artery. Sciatic and femoral nerves identified and protected. Osteotomy through ilium within pel vis as aret the superior pubic rami -> need mobilization of external iliac and femoral vessels as they cross the ramus. Posterior myocutaneous flap use gluteus maximus and retracted posteriorly -> expose retrogluteal space (Ilium, sciatic notch, sciatic nerve and hip joint. Ischium identified through posterior incision above biceps femoris insertion Complete removal of acetabulum with release of sacrospinous ligament and pelvic floor muscle. Type of resection : 1) Supra-Acetabular, 2) Superior pubic ramus, 3) ischial

36. SURGICAL MANAGEMENT without interruption of the pelvic ring, no bony reconstruction is essential Floating Hip -> Reconstruction after type 2 resection : Composite allograft Saddle reconstruction Partial pelvic prosthesis Icshiofemoral arthrodesis

37. SURGICAL MANAGEMENT Using Utilitarian pelvic incision with ipsilateral hip slightly elevated This incision allows exposure and mobilization of the femoral vessels and nerve through a distal-based anterior flap. Perineal incision to expose ischium when a large pubic lesion resected Inguinal ligament is transected from its pubic insertion and reflected laterally Neurovascular bundle retracted laterally -> expose adduct or magnus and pectineus . Origin of harmstring , adductor and gracilis is transected from ilium . Osteotomy through symphysis pubis and pubic rami is performed Usually need continuous suction for post operative wound closure

38. HEMIPELVECTOMY (POSTERIOR FLAP)

39. SURGICAL MANAGEMENT HEMIPELVECTOMY (POSTERIOR FLAP) Positioning : Ilionguinal retroperitoneal in Semisupine position, Perineal in hip abd + flexed, posterior in semilateral . Semisupine position, Incission of abdominal wall and retroperitoneal dissection of the iliac vessels are performed first with common iliac, external iliac or internal iliac (hypogastric) vessels are selectively ligated . Approach : Expose pubis, bladder neck, urethra, symphysis pubis Iliac wing, sacroiliac joint and sacrum -> divided to domplete amputation. Division of lumbosacral plexus at the level of the sacrum / pelvis is divided at the same time . A Fasciocutaneous or a mytocutaneous flap ( Posterior : Gluteus maximus, Anterior : anterior thigh ) is completed F lexion and adduction + Abduction of the hip allow the surgeon to divide the muscle and ligament of pelvic floor and complete amputation

40. SURGICAL MANAGEMENT HEMIPELVECTOMY (POSTERIOR FLAP) It is important to identify all vascular structure initially to prevent any mistake in ligation. Retroperitoneal space is easily entered by detaching abdominal wall musculature from above ilioinguinal ligament and off iliac crest A modified hemipelvectomy is an amputation preserving major pedicle to gluteus maximus pedicle flap. Perineal Incision From symphysis pubis to ischium along the inferior pubic ramus. Ischiorectal space is exposed along inferior pubic ramus to symphysis pubis. Symphisis pubis is disarticultated . Protect urethra and bladder by malleable retractor

41. SURGICAL MANAGEMENT HEMIPELVECTOMY (POSTERIOR FLAP) Posterior Flap Retrogluteal Area Exploration Immobilized along the iliotibial band and GT toward SI joint A Classic hemipelvectomy is resected all of gluteal structures and only left subcutaneous flap remains A classic hemipelvectomy -> need release of abdominal muscle to paraspinal muscle with iliolumbar as landmark. Abdominal wall mucle is relesead from crest of ilium with 1-2 cm cuff remain along the ilium. The psoas muscle is oversewn due to high risk of bleeding.

42. SURGICAL MANAGEMENT HEMIPELVECTOMY (POSTERIOR FLAP) Detachment of Pelvic Floor Musculature Hip abducted and flexed, surgeon stand between extremities The muscle is stretched and ligatetd through Kelly C lamps bent at pubic ramus and end at SI joint This complete the amputation (release of SI joint and remaining pelvic muscle attached of ilium and pelvic floord If a left sided hemipelvectomy is performed, great care must taken to immobilizie the rectum to avoid injury Anterior capsule of SI joint and sacrolumbar trunks ar e only remaining structure that must be opened and released.

43. SURGICAL MANAGEMENT HEMIPELVECTOMY (POSTERIOR FLAP) Cont .. SI joint disarticulation Anterior SI joint is identified and vessel are mobilized of SI joint for preparation of SI joint disarticulation final step Closure of the wound with tubes drainage

44. HEMIPELVECTOMY (ANTERIOR FLAP)

45. SURGICAL MANAGEMENT HEMIPELVECTOMY (ANTERIOR FLAP) Anterior flap hemipelvectomy is a modified version of the classic posterior flap hemipelvectomy . This modification has permitted the treatment of difficult buttock and pelvic tumors where the posterior flap was involved or contaminated by tumor The major advantage of anterior flap hemipelvectomy is the creation of a large vascularized myocutaneous flap that is ideal for closure of signillcant posterior defects

46. SURGICAL MANAGEMENT HEMIPELVECTOMY (ANTERIOR FLAP) Positioning : After being placed supine on the operating table, the patient is rolled into the lateral position , with the iliac crest at the flexion point of the table. The operating room table is flexed to open the angle between the crest of the ilium and the lumbar vertebrae. Anus is sutured.

47. SURGICAL MANAGEMENT HEMIPELVECTOMY (ANTERIOR FLAP) Anterior and posterior skin incision : Drawn from medial to the tumor at or near the midlune posterior above anus. Superior and laterally should parallel to wing of ilium to SIAS. Continue distally to lateral aspect of thigh to lower middle third of thigh. Medial incision from 2-3 cm lateral to anes to junction of the thigh.

48. SURGICAL MANAGEMENT HEMIPELVECTOMY (ANTERIOR FLAP) P osterior skin incision : Medial margin is closest to line excision. Initial in cision is superficial sacrum in midline through fascia of midsacral spines. 2-3 cm skin is preserved around anus. Gluteus maximus, erector spinae divided from the origins. Lateral skin incision : Abdominal and back muscles that arise on the sacrum and the iliac crest are incised in the plane of attachment Muscles to be cut include the external oblique, erector spinae, latissimus dorsi, and quadratus lumborum

49. SURGICAL MANAGEMENT HEMIPELVECTOMY (ANTERIOR FLAP) Transection of superficial femoral : The extremity is flexed at the hip to place the tissues in the area of the gluteal crease under tension. The deep dissection is continued lateral to the rectum into the ischiorectal fossa. The remaining origins of the gluteus maximus muscle are now severed from the coccyx and sacrotuberous ligament. Release of vastus lateralis : Transecting the entire quadriceps muscle. Laterally, this incision is continued superiorly toward the greater trochanter to the anterior superior iliac spine.

50. SURGICAL MANAGEMENT HEMIPELVECTOMY (ANTERIOR FLAP) Transection of superficial femoral artery : Vastus lateralis is severed from the femur using electrocautery. Care must be taken not to separate muscle bundles of the myocutaneous flap from the overlying skin and subcutneous tissue. Release of Quadricep muscle from femur : The medial skin incision is from the area of Hunter’s canal to the pubic tubercle The superficial femoral vessels are ligated. Multiple small branches from the superficial femoral vessels to the abductor muscles must be clamped, divided, and ligated

51. SURGICAL MANAGEMENT HEMIPELVECTOMY (ANTERIOR FLAP) Release of myocutaneous flap from the femur : Upward traction on myocutaneous flap -> origin of vastus intermedius and vastus medialis is severed from femur . Profunda femuris is ligated. Myocutaneous flap is released from pelvic attac hment. Sartotius and rectus femoris is transected from its origin . Tracttion the flap medially and allow access vessel and nerve to be transected.

52. SURGICAL MANAGEMENT HEMIPELVECTOMY (ANTERIOR FLAP) Division of symphisi pubis Transection of iliac vessel : The internal iliac artery and vein divided from common iliac.

53. SURGICAL MANAGEMENT HEMIPELVECTOMY (ANTERIOR FLAP) Division of psoas muscle and nerve roots : Psoas muscle is divided with iliacus muscle . Obturator nerve is divided. Preserve femoral nerve for myocutaneous flap. Lumbosacral and sacral nerve are ligated close to sacral foramina. Division of sacral foramina and sacrum : The leg is elevated. Protect urethra, bladder and rectum. Urogenital diaphragm, levator and piriformis muscle are divide from attachment. Sacral osteotome should parallel to midsacral spines.

54. SURGICAL MANAGEMENT HEMIPELVECTOMY (ANTERIOR FLAP) Wound Closure : The operative site and myocutaneous flap are copiously irrigated and bleeding points are secured . The myocutaneous flap is folded posteriorl y into the operative defect over two sets of suction drains. The fascia of the quadriceps femoris is sutured to the musculature of the anterior abdominal wall, to the back muscle, to the sacrum , and to the muscles of the pelvic diaphragm. The skin is closed with interrupted sutures

55. POST OPERATIVE CARE P hantom limb sensations are to be expted and that they can be treated with analgesics. The discomfort will lessen over time. A positive attitude toward functional recovery augmented by early postoperative ambulation may move the patient rapidly to his or her goals. OUTCOMES : Patients who are free of disease use a prosthesis regularly. Patients walk with the prosthesis without the use of crutches or a cane. Because of the vascular nature of this flap, the surgical wound heals rapidly in the vast majority of patients. T he 10% to 30% risk of ischemic necrosis associated with posterior flap hemipelvectomy is not seen with an anterior flap procedure.

56. HEMIPELVECTOMY (POST OPERATIVE CARE )