Emergency hemipelvectomy

Emergency

Hemipelvectomy

OTHO C. HUDSON, M.D., Diplomate, M.D.,

American Board of Orthopedic Surgery, AND DONALD E. JANELLI, Diplomate, American Board of Surgery, Mineola, New York

HE

first interinnomino-abdominal ampuwas done in r8gr by BiIlroth for sarcoma of the peIvis and had a rapidIy fata termination.’ In succeeding years, through repeated sporadic tria1, the procedure became regarded as so formidabIe, disabIing and mutiIating that it a11but feI1 into compIete discard. Many’considered it to be a form of exhibitionism in which no respectabIe surgeon wouId participate. As Iate as 1933, Gordon-TayIor stated that “interinnomino-abdominaI amputation is fortunateIy an infrequent operation of surgery and must remain for a11 time one of the most coIIosa1 mutilations practiced on the human frame.” He predicted that the operation wouId be used Iess and less in the future.6 At the present time approximatel, LOOcases of hindquarter amputation have been reported in the worId Iiterature. It is interesting to note that by rgfo Gordon-TayIor reported in a persona1 communication to Saint that he had now performed forty-two hindquarter amputations.” The foIIow-up in this series has been exceptionaIIy good and Iong-term survivaIs up to seventeen years are reported.496 The Iongterm surviva1 rate is Iow because the procedure is deIayed unti1 a11 measures short of radica1 surgery have been utiIized. Consequently the amputation has generaIIy been used as a paIliative procedure in cases presenting massive tumors which often have aIready metastasized. As the current concepts of radical extirpation for maIignant disease have become estabIished, hindquarter amputation has been used with increasing frequency and has recentIy been favorabIy compared with hip disarticuIation by Ravitch.‘O The operative mortaIity rate of 55 to 70 per cent+ which existed prior to 1935 was reduced to 14 per cent in the next decade’ and in more recent years a few small series have been reported without a fataIity.2J The indications for interinnomino-abdomina1 amputation are primary maIignant tumors of the upper femur, hip joint and peIvis, or the surrounding soft tissue structures and meta-

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340

static tumors to the peIvis.7g It is beIieved by CoIey and Gordon-Taylor that the best resuIts may be anticipated in the cases of chondroma and chondrosarcoma.374 There is genera1 agreement that the procedure is important in paIIiation.3JJ Patients with massive disabIing tumors have been reIieved of pain and have become ambuIatory with crutches or specia1 prostheses.13 The purpose of this paper is to report a case of hindquarter amputation done as an emergency life-saving procedure. Use of this amputation under emergency conditions has not to our knowIedge been previousIy described. CASE

REPORT

R. T., a fifty-three year old white woman, was admitted to Nassau HospitaI on ApriI 29, 1953, with a massive tumor of the Ieft thigh of five months’ duration. LocaI excision of a part of the tumor had been done three months previousIy at another hospita1 with a pathoIogic diagnosis of sarcoma. At the time of the present admission, the patient compIained of massive, painfu1, tender enIargement of the Ieft Ieg. There was a recent weight loss of unspecified amount. PhysicaI examination was not remarkabIe except for the Ieft leg which showed enIargement of the thigh to two to three times norma size, edema of the entire extremity and prominent superficia1 veins. (Fig, I.) X-ray of the chest taken on the day folIowing admission reveaIed multipIe metastatic Iesions in both lung fields. X-ray examination of the Ieft hip area showed evidence of soft tissue tumor in the upper IateraI thigh with early invasion of the femur. UrinaIysis showed a few epitheIia1 and white bIood ceIIs and a faint trace of aIbumin. The hemoglobin was 7.4 gm. per cent and the red ceII count was 2.5 milIion. The white blood count was 17.0 thousand with ninety-three poIymorphonucIear ceIIs. During the first three hospita1 days the

Emergency

Hemipelvectomy

FIG. I. Preoperative appearance of the involved Ieg. Note the scar of previous surgery and the hemorrhagic, dark area in the upper part of this scar. It was at this point that the wound disrupted and from which hemorrhage occurred.

patient had a febrile course with temperature elevation to 103%. and required repeated doses of opiates for pain. It was noted that the left thigh showed increase in size and several elevated hemorrhagic areas appeared on the anterior aspect of the thigh. On the fourth day, the wound of previous surgery spontaneously disrupted and hemorrhaged. Pressure dressings did not control the bleeding and the patient deteriorated very rapidly with onset of shock and mental confusion. It was elected to do an emergency amputation as an immediate Iife-saving procedure. With the patient in supine position under cycIopropane anesthesia an incision was made parallel to the inguinaI ligament and was carried a1ong the anterior part of the iIiac crest. The muscIes of the anterior abdominal wall were detached from the peIvis and the retroperitonea1 space entered. Because of massive tumor infiItration in this area it was necessary to Iigate the common iliac artery and vein. The ureter, bladder, rectum and peritoneum were retracted medially and the patient rotated to the right side. The incision was carried downward and posteriorIy across the buttocks and then carried anteriody to join the medial end of the inguinal incision. Skin ffaps were e1evated and the pubic symphysis divided with bone forceps. The psoas and pyriformis muscIes were divided and the muscles of the posterior abdomina1 wall were detached from the iliac crest. The sacra1 pIexus was divided near the

FIG. 2. One month postoperatively, secondary surgical dbbridement.

just

prior

to

rectum. The sacroiliac joint was divided with a chise1 and bone forceps and the specimen removed. During the operation which lasted one hour and forty minutes, the patient received 1,000 cc. of b1ood. FolIowing surgery the patient made good recovery except for wound infection necessitating surgica1 ditbridement one month Iater. (Fig. 2.) She was greatIy reIieved of pain, requiring only smaI1 doses of codeine, and from the sixth postoperative day on, was out of bed every day. She expired on June 29, 1953, sixty-six days after hemipeIvectomy, of puImonary metastases as we11as paIpabIe abdomina1 metastases. Autopsy consent was not obtained. The patho-

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Emergency

Hemipehectomy

FIG. 3. The gross specimen wideIy opened. Note the areas of hemorrhage which necessitated emergency amputation.

logic report Fig. 3.1

was

sarcoma

of

tumors of the peIvic parietes and upper thigh. Surg., Gynec., CT.+ Obst., 81: 36, 1945. 2. SORONDO,J. P. and FERRE, R. L. InteriIioabdominaI amputation. Am. &Cop. Traumat., I: 143,

the subcuti;.

COMMENT

1948.

The use of hindquarter amputation has slowIy evolved from a position of disrepute to one of acceptance as a paIIiative procedure.12 Its utiIization as an early radica1 surgica1 attack has not yet been accorded adequate trial. The mutiIation consequent to this amputation appears to be the chief deterrent to its more widespread use. However, the degree of difference in this respect between hemipelvectomy and hip disarticuIation is surprisingly IittIe; and when the two procedures are compared in terms of cancer eradication, the difference is negIigibIe.

3. COLEY, B. L., HIGINBOTHAM,N. L. and ROMIEN, C. HemipeIvectomy for tumors of bone. Report of 14 cases. Am. J. Surg., 82: 27, 1951. 4. GORDON-TAYLOR, G. and PATEY, D. H. A further review of the interinnomino-abdomina1 operation, based on 21 personal cases. Brit. J. Surg., 34: 61, 1946-1947. 5. GORDON-TAYLOR, G. A further review of the interinnomino-abdomina1 operation: eIeven personal cases. Brit. J. Surg., 27: 643, 19391940. 6. GORDON-TAYLOR. G. and WILES. P. Interinnominoabdominal (hind-quarter) amputation. Brit. J. Surg., 22: 671, 1934-1935. 7. JAMES, A. G. and FURSTE, W. Radical surgery for cancer of the extremities. Am. J. Surg., 85: 503, ‘953. 8. LEE, C. M., JR. and ALT, L. P. HemipeIvectomy and hip disarticulation for malignant tumors of the peIvis and Iower extremity. Ann. Surg.,

SUMMARY I. The deveIopment and present day status of hindquarter amputation is briefly presented. 2. A case of hindquarter amputation done as an emergency procedure is reported. 3. It is predicted that use of this operation has not yet undergone its full evoIution and that it wilI be used earlier and with greater frequency in the future, in dealing with malignant tumors of the femur, hip joint and peIvis.

‘37: 704~ 1953. 9. LEIGHTON, W. E. InterpeIviabdominaI amputation. Report of three cases. Arch. Surg., 45: 913, 1942. 10. RAVITCH, M. M. HemipeIvectomy. Surgery, 26: rgg, 1949. I I. SAINT, J. H. The hindquarter (interinnominoabdominal) amputation. Am. J. Surg., 80: 142, 1950. 12. PACK, G. T., EHRLICH, H. E. and GENTIL, F. RadicaI amputations of the extremities in the treatment of cancer. Surg., Gynec. & Obst., 84: 1105. 1947. 13. COOPER, J. F. and TAYLOR, G. W. Prosthesis foIlowing hemiplevectomy. New England J. Med., 241: 1047. 1949.

REFERENCES I. SUGARBAKER, E. and ACKERMAN, L. V. Disarticu-

Iation

of the innominate

bone

for malignant

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