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Variants of hemipelvectomy and their complications
Variants of Hemipelvectomy Their Complications Constantine P. Karakousis,
MD, PhD,
Lawrence J. Emrich,
In the period from 1976 through 1986,62 procedures were performed. Of these, 42 were posterior flap hemipelvectomies, 5 anterior flap hemipelvectom&s, and 15 internal hemipelvectomies. The median duration of these procedures was 6.5 hours, and the median blood loss was 2,541 ml. Postoperatively, there were no wound problems in 38 procedures (61 percent). The overall rate of flap necrosis was 15 percent, and the overall rate of wound infection, 17 percent. The viability of the posterior flap was not dependent on the level of division of the iliac vessels. By leaving the gluteus maximus muscle attached to the posterior flap, the rate of flap necrosis, initially 55 percent, was eliminated completely in the last 38 patients. Including 11 recently performed procedures, the operative mortality rate was 1 percent (1 of 73 procedures). For patients operated on with curative intent, the estimated 5-year survival rate was 43 percent.
he term or hindquarter amputation, denotes the removal of the entire lower extremiT ty and the ipsilateral hemipelvis [1,2]. The procedure is hemipelvectomy,
qualified as radical when the bone is divided proximally through the sacroiliac joint or sacral ala, or conservative when a portion of the iliac bone is preserved [3,4]. For most of the tumors located in the iliac fossa or groin, a posterior flap is constructed to cover the defect, whereas for tumors extensively involving the buttock, an anterior flap is advisable [&a. The term internal hemipelvectomy signifies the removal of the entire hemipelvis or a portion of it, with preservation of the lower extremity [7-101. These procedures are performed for malignant tumors when more conservative operations are not applicable. Usually, they are performed with curative intent, although occasionally palliative considerations may invoke their use. From the Departments of Surgical Oncology and Biomathematics, Roswell Park Memorial Institute, Buffalo, New York. Requests for reprints should be addressed to Constantine P. Karakousis, MD, Surgical Oncology Department, Roswell Park Memorial Institute, 666 Elm Street, Buffalo, New York 14263.
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PhD,
and
Deborah L. Driscoll,
BA, Buffalo, NW York
In the following study, the recent experience in our institution is presented, with special emphasis on surgical technique and postoperative complications. MATERIAL
AND METHODS
In the period from 1976 through 1986, 59 patients underwent 62 procedures. Three patients with internal hemipelvectomy were later treated with standard hemipelvectomy due to local recurrence. Thirty-three involved the right side (53 percent) and 29, the left side (47 percent). There were 21 female and 38 male patients. The mean age was 47 and the median age, 48 years (range 13 to 86 years). The histologic diagnosis was soft tissue sarcoma in 32, chondrosarcoma in 7, osteogenic sarcoma in 4, Ewing’s sarcoma in 1, squamous cell carcinoma in 8, and malignant melanoma in 7. Thirty-six patients were operated on with curative intent, whereas 23 patients were operated on for palliation. The latter group included 11 patients with massive, painful involvement of the groin by metastatic disease in the nodes or ulcerated tumors postirradiation with exposed vessels and 12 patients with a small amount of distant metastatic disease in whom hemipelvectomy was performed for control of pain or tumor ulceration. Of the procedures, 42 were posterior flap hemipelvectomies, 5 were anterior flap hemipelvectomies, and 15 were internal hemipelvectomies. Of the last group, complete resection of the entire hemipelvis was performed in seven instances, resection of the iliac bone in three, and resection of the pubic bone in five, with preservation of the acetabulum. Among the 42 posterior flap hemipelvectomies, the common iliac vessels were divided in 25 patients and the external iliac vessels in 17 patients. Early in the series, the gluteus maximus muscle was removed with the specimen (9 patients), whereas later it was left attached to the posterior flap (33 patients). In two patients, due to extensive resection of the lower abdominal muscles, Marlex@ mesh was used to repair the defect. In one patient each, the hemipelvectomy was combined with pelvic exenteration, resection of the sigmoid, and resection of the cecum. In nine patients, a lower midline abdominal incision was used in continuity with the oblique suprainguinal portion of the incision for posterior flap hemipelvectomy, a maneuver permitting proximal exposure and resection of pelvic sarcomas extending to the vicinity of the fourth and fifth lumbar vertebrae. Technical considerations: Posterior flap hemipelvectomy. This procedure has been extensively described [Z-4]. In many patients, it can be performed in the supine
position with folded sheets or other support under the upper half of the ipsilateral buttock. If it is anticipated that the bone has to be divided proximally through the
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sacroiliac joint or through the sacral ala, a lateral or semilateral position may be preferable as it provides more accurate orientation for the division of the joint through the exposure of both its anterior and posterior aspects [I]. In many patients, this is an extraperitoneal operation. A transperitoneal approach is necessary when the ipsilateral lower quadrant of the abdomen has been radiated, in which case the peritoneum is adherent and cannot be displaced superiorly; when en-bloc resection of adjacent pelvic organs is anticipated; and when the tumor extends high, close to the lower lumbar spine, in which case the often employed anteriorly, suprainguinal oblique incision is inadequate for providing proximal exposure. In this case, the combination of a low midline transperitoneal incision and the usual, low oblique incision permits the necessary exposure. This incision heals well without any complications (Figure 1). A transperitoneal approach is also advisable when, on the basis of a computed axial tomography scan, the anterior tumor surface is adjacent to the posterior parietal peritoneum, in which case the latter structure is best left attached to the tumor in order to secure a better margin. When the peritoneum has been resected, loops of small bowel are in direct contact with the deep surface of the posterior flap postoperatively; however, this did not cause any problem. In many descriptions of construction of the posterior flap, the flap consists of skin and subcutaneous fat, the dissection being carried immediately next, either superficial or deep, to the fascia lata covering the gluteus maximus muscle, the latter being removed with the specimen. Aware of the high frequency of posterior flap necrosis previously reported by our institution [I I] and the distinct possibility that this was due to the policy of removing the gluteus maximus muscle with the specimen, the policy was changed about 10 years ago to leaving this muscle attached to the posterior flap whenever the location of the tumor permitted this, which is a situation pertaining to the majority of patients suitable for this operation. The preservation of the gluteus maximus muscle has completely eliminated posterior flap necrosis and has made possible the construction of long, viable posterior flaps reaching up or above the level of the umbilicus THE AMERICAN
when the lower abdominal wall needs to be sacrificed due to tumor involvement (Figure 2). Anterior jlap hemipelvectomy. This operation involves the construction of an anterior flap for tumors involving the upper portion of the buttock. It is possible to construct a long anterior flap consisting of skin, subcutaneous fat, fascia lata, and a portion of sartorius muscle, with the superficial femoral vessels attached to it and providing its blood supply. The flap is centered over the course of the superficial femoral vessels, which are divided just above the point they traverse the adductor hiatus. This flap will cover the resulting defect and it can reach posteriorly the level of the skin corresponding to the posterior superior iliac spine [A. If one needs a very wide flap, the dissection may be carried out deep to the surface of rectus femoris muscle or the vastus intermedius, thereby preserving branches of the proximal portion of the profunda femoris to the quadriceps and overlying skin 14. Internal hemipelvectomy. This procedure involves the removal of the entire hemipelvis or a portion of it whenever the location of the tumor permits satisfactory resection, whereas the major motor nerves (the sciatic and femoral nerves) and the blood supply to the extremity are pre served (Figures 3 and 4). The obturator nerve supplying the adductor group of muscles can be sacrificed, when necessary, without any appreciable disability in ordinary activity (for example, ambulation or walking up or down a staircase). Various techniques have been described [7-91. A reverse-Y incision provides excellent exposure, and if the dissection can be carried out deep to the gluteus maximus muscle posterolaterally, it heals well [8]. If due to proximity by the tumor, the dissection plane remains superficial to the gluteus maximus, the tip of the posterolateral flap is prone to necrosis. However, the inferolateral portion of the Y incision is only necessary for a tumor extending into the buttock. For a tumor involving the medial aspect of the iliac bone, satisfactory exposure can be obtained through the use of an incision extending from the posterior inferior iliic spine, along the iliac crest and inguinal ligament, to the pubic tubercle or pubic symphysis. The dissection on the posterolateral aspect of the iliac
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Ffgure 4. Complete remctlm
ol Ihe dghl hemlpelvbs.
At a mean follow-up from diagnosis of 48 months (median 34 months) for the whole group, the estimated 5year survival rate for 36 patients operated on with curative intent was 43 percent (median survival 34 months). The estimated Z-year survival rate and median survival time for 23 patients operated on for palliation were 25 percent and 12 months, respectively. The mean blood loss during the operation was 3,684 ml (median 2,541 ml, range 400 to 12,100 ml). The average length of the procedure was 6.7 hours (median 6.5 hours, range 2.5 to 14 hours). Postoperatively, there were no wound problems in 38 procedures (6 1 percent); there was flap necrosis only in 7 (11 percent); infection only in 9 (15 percent); infection plus flap necrosis in 2 (3 percent); and other minor complications (for example, subcutaneous hematoma) with or without infection in 6 (10 percent). The overall rate of flap necrosis, often requiring debridement, was 15 percent (9 of 62 procedures), and the overall rate of wound infection 17 percent (11 of 62 procedures). The mean postoperative hospital stay was 35 days (median 27 days, range 4 to 210 days). Considering the various procedures separately, the mean blood loss for posterior flap hemipelvectomy was 3,558 ml (median 2,551 ml, range 400 to 9,995 ml); the mean duration of operation was 6.2 hours (median 5 hours, range 2.5 to 12 hours); the overall infection rate was 24 percent (10 of 42 procedures); and the rate of flap necrosis was 14 percent (6 of 42 procedures). It is interesting, however, that of the six patients with flap necrosis,
in live it involved the posterior flap, and all live (55 percent) were among the early group of nine patients in whom the gluteus maximus muscle was removed with the specimen. In the remaining patient, flap necrosis occurred in the edge of the anterior flap. No necrosis of the posterior flap occurred in the 33 procedures in which the gluteus maximus was left attached to the flap. Among the six patients with posterior flap necrosis, the divided vessels were the common iliac vessels in 2 and the external iliac vessels in 4, whereas in those without necrosis, the common iliac vessels were divided in 23 cases and the external iliac in 13. One flap necrosis (20 percent) and 1 infection (20 percent) were noted among the anterior flap hemipelvectomies. The mean blood loss was 4,533 ml (median 2,767 ml, range 2,100 to 9,100 ml). The mean duration of operation was 9.4 hours (median 8.5 hours, range 6.5 to 14 hours). In 15 internal hemipelvectomies, the mean blood loss was 3,757 ml (median 2,250 ml, range 400 to 12,100 ml). The mean duration of the operation was 7.3 hours (median 7.1 hours, range 3 to 11 hours). Infection was noted in two patients ( 13 percent) and flap necrosis in two patients (13 percent). The mean postoperative stay was 31 days (median 28 days, range 7 to 59 days). Since 1986, 11 more procedures have been performed (5 posterior flap hemipelvectomies, 5 internal hemipelvectomies, and 1 anterior flap hemipelvectomy). Of these 11 procedures, 1 resulted in death due to pulmonary embolism on the ninth postoperative day, amounting to a postoperative death rate for the entire series of 1 percent (1 of 73 procedures). After posterior or anterior flap hemipelvectomy young patients can be fitted with a prosthesis; however, the majority of the patients, being older, are confined to the use of crutches or a wheelchair. After internal hemipelvectomy, when the acetabulum has also been resected, there is no hip function, and the unsupported proximal end of the femur migrates cephalad 3 to 4 cm, resulting in corresponding shortening of the leg. This is easily corrected with a shoe lift. In these patients, there is normal kneeand ankle-joint function, but there is no hip function. Initially they ambulate for 2 to 3 months with crutches,
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Flgure 3. PattIal resectIon of the bfl hemlpelvls.
bone is carried out with the periosteal elevator, thus separating the gluteal muscles from their origin from the iliac bone (Figure 5). In resections of the pubic bone, the abdominoinguinal incision provides ample exposure for removing adjacent soft-tissue masses [12]. The defect is covered with Marlex mesh. Care should be exercised to avoid direct contact of the iliofemoral vessels with the mesh. RESULTS
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COMPLICATIONS AFTER HEMIPELVECTOMY
non-weight bearing on the operated side; for the next 3 to 4 months they can put partial weight on the operated side; and by 6 months after the operation, they balance their weight on both feet. Due to lack of hip motion, the patients have to use crutches indefinitely, but they can ambulate on a flat level as well as go up and down stairs. Older patients with internal hemipelvectomy have more difficulty, and some are confined to a wheelchair. It ap pears, therefore, that other than the cosmetic advantage over the standard hemipelvectomy, which is always present, the functional advantage of internal hemipelvectomy may be restricted to young patients. When a partial internal hemipelvectomy is performed, the functional results are superior. With resection of the iliac bone above the acetabulum, some cephalad migration of the latter occurs, and initially, ambulation requires crutches and a cane for support for about 1 year. Thereafter, the patients walk fairly freely and without support, except for a shoe lift on the slightly shortened extremity. Removal of the pubic bone, entailing sacrifice of the obturator nerve, and detachment of the adductor group of muscles from their origin in the pubic bone causes no difficulty, and after 3 to 4 weeks, the patients ambulate freely. COMMENTS At present, with the more extensive use of combinations of modalities, limb salvage has been possible in 95 percent of our patients with primary soft-tissue sarcomas [ 131. More recently, the development of the abdominoinguinal incision has made possible the resection of tumors in the iliac fossa, in the area of the external iliac vessels, in the wall of lesser pelvis, and in the pubic bone, which were previously considered unresectable or were treated with hemipelvectomy [12]. However, there is still a group of patients with proximal tumors involving the hip joint, iliac bone, or both, which are often locally recurrent and which may require hemipelvectomy as the only chance of cure. In our series, among patients with extensive softtissue or bone tumors operated on with a curative intent, the estimated 5-year survival rate was 43 percent. Patients adjust well after this operation, and those who are young are able to return to gainful employment. A young female patient married several years after hemipelvectomy and managed to have a successful pregnancy. She is able to wear a prosthesis as other young patients do. After internal hemipelvectomy involving the acetabulum, there is no hip movement on the operated side, and the patients have to use crutches permanently. Still, this operation is preferable due to its obvious cosmetic and psychologic effect, particularly in young people, compared with standard hemipelvectomy. Removal of the iliac bone above the acetabulum causes only modest and temporary disability, whereas removal of the pubic bone causes no appreciable disability. A motor deficit in the distribution of the sciatic nerve was observed in one of live patients after this operation in a report by Eilber et al [ 71; however, we have not observed this complication. A worthwhile anatomic detail is that the lumbosacral trunk of the sciatic nerve courses over the sacral ala, and it has THE AMERICAN
I.
__ /
Figure 5. The InWon used for rWectbnoltheanttre [email protected] tnfemtateralporttondthetnclabn(A)tsneededontywhen the tumor extends into the buttock.
to be carefully retracted when dividing the bone at this level. These are lengthy procedures with a median duration of 5, 8.5, and 7.1 hours for posterior flap, anterior flap, and internal hemipelvectomy, respectively. The median blood loss for these procedures was 2,551 ml, 2,767 ml, and 2,250 ml, respectively. Early control of the blood vessels has always been accomplished in our patients, but in those patients with large proximally located tumors who were referred to our institution for these procedures, considerable blood loss has occurred over the course of several hours. There were no wound problems after 38 operations (61 percent), whereas a variety of wound problems occurred after 24 procedures (39 percent). These included flap necrosis in 9 patients (15 percent) and infection in 11 (18 percent). Flap necrosis occurred in 6 of 42 posterior flap hemipelvectomies (14 percent), 1 of 5 anterior flap hemipelvectomies (20 percent), and 2 of 15 internal hemipelvectomies ( 13 percent). In the past, the rate of posterior flap necrosis in our institution was 80 percent [II]. When the posterior flap consists of skin and subcutaneous fat, trimming of the middle portion of the flap has been advocated to avoid flap necrosis [ 141. Since the adoption of the maneuver of leaving the gluteus maximus muscle attached to the posterior flap, there has been no flap necrosis in the last 33 patients in our series and none in the 5 patients treated since then. The number of anterior flap and internal hemipelvectomy procedures in our series was too small to allow firm conclusions to be drawn; however, anterior flap necrosis of an anterior flap hemipelvectomy may be eliminated by mobilization of the flap with the quadriceps muscle attached to it. In internal hemipelvectomy, flap necrosis may be reduced by avoiding the inferolateral extension of the reverse-Y incision when the location of the tumor permits or by maintaining a plane deep to the gluteus maximus muscle posterolaterally. With the increasing application of combinations of modalities and the increasing demand for limb salvage, hemipelvectomy is performed for more advanced tumors more often than in the past; however, until more effective treatments for solid tumors develop, these procedures still remain part of the surgeon’s armamentarium. An in-
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creased awareness of their respective complications, which are largely avoidable, should help make their application safer. The practicingsurgeon is only occasionallyrequired to consider hemipelvectomy.The operationmust be tailored to the individual anatomic requirements of the neoplasm and patient. This study shows,in a very clear fashion, some interestingtechnical and conceptual approaches to a complex but very useful operation. REFERENCES 1. Chretien PA, Sugarbaker PH. Surgical technique of hemipelvectomy in the lateral position. Surgery 1981; 90: 900-9. 2. Frey C, Matthews LS, Benjamin H, Fidler WJ. New technique for hemipelvectomy. Surg Gynecol Obstet 1976; 143: 753-6. 3. Karakousis CP. Hemipelvectomy (hindquarter amputation). In: Atlas of operations for soft tissue tumors. New York: McGrawHill, 1985: 335-50. 4. Ariel IM, Shah JP. The conservative hemipelvectomy. Surg Gy-necol Obstet 1977; 144: 406-13. 5. Karakousis CP, Vezeridis MP. Variants of hemipelvectomy. Am
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J Surg 1983; 145: 273-7. 6. Sugarbaker PH, Chretien PA. Hemipelvectomy for buttock tumors utilizing an anterior myccutaneous flap of quadriceps femoris muscle. Ann Surg 1983; 197: 106-15. 7. Eilber FR, Grant ‘IT, Sakai D, Morton DL. Internal hemipelvectomy. Excision of the hemipelvis with limb preservation: an alternative to hemipelvectomy. Cancer 1979; 43: 806-9. 8. Karakousis CP. Internal hemipelvectomy. Surg Gynecol Obstet 1984; 158: 279-82. 9. Steel HH. Partial or complete resection of the hemipelvis: an alternative to hindquarter amputation for periacetabular chondrosarcoma of the pelvis. J Bone Joint Surg [Am] 1978; 60: 719-30. 10. Enneking WF, Dunham WK. Resection and reconstruction for primary neoplasms involving the innominate bone. J Bone Joint Surg 1978; 60: 731-46. 11. Douglass HO, Razack M. Hemipelvectomy. Arch Surg 1975; 110: 82-5. 12. Karakousis CP. The abdominoinguinal incision in limb salvage and resection of pelvic tumors. Cancer 1984; 54: 2543-8. 13. Karakousis CP, Emrich LJ, Rao R, Krishnamsetty RM. Feasibility of limb salvage and survival in soft tissue sarcomas. Cancer 1986; 57: 484-91. 14. Miller TR. 100 cases of hemipelvectomy: a personal experience. Surg Clin North Am 1974; 54: 905-13.
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MD, PhD,
Lawrence J. Emrich,
In the period from 1976 through 1986,62 procedures were performed. Of these, 42 were posterior flap hemipelvectomies, 5 anterior flap hemipelvectom&s, and 15 internal hemipelvectomies. The median duration of these procedures was 6.5 hours, and the median blood loss was 2,541 ml. Postoperatively, there were no wound problems in 38 procedures (61 percent). The overall rate of flap necrosis was 15 percent, and the overall rate of wound infection, 17 percent. The viability of the posterior flap was not dependent on the level of division of the iliac vessels. By leaving the gluteus maximus muscle attached to the posterior flap, the rate of flap necrosis, initially 55 percent, was eliminated completely in the last 38 patients. Including 11 recently performed procedures, the operative mortality rate was 1 percent (1 of 73 procedures). For patients operated on with curative intent, the estimated 5-year survival rate was 43 percent.
he term or hindquarter amputation, denotes the removal of the entire lower extremiT ty and the ipsilateral hemipelvis [1,2]. The procedure is hemipelvectomy,
qualified as radical when the bone is divided proximally through the sacroiliac joint or sacral ala, or conservative when a portion of the iliac bone is preserved [3,4]. For most of the tumors located in the iliac fossa or groin, a posterior flap is constructed to cover the defect, whereas for tumors extensively involving the buttock, an anterior flap is advisable [&a. The term internal hemipelvectomy signifies the removal of the entire hemipelvis or a portion of it, with preservation of the lower extremity [7-101. These procedures are performed for malignant tumors when more conservative operations are not applicable. Usually, they are performed with curative intent, although occasionally palliative considerations may invoke their use. From the Departments of Surgical Oncology and Biomathematics, Roswell Park Memorial Institute, Buffalo, New York. Requests for reprints should be addressed to Constantine P. Karakousis, MD, Surgical Oncology Department, Roswell Park Memorial Institute, 666 Elm Street, Buffalo, New York 14263.
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PhD,
and
Deborah L. Driscoll,
BA, Buffalo, NW York
In the following study, the recent experience in our institution is presented, with special emphasis on surgical technique and postoperative complications. MATERIAL
AND METHODS
In the period from 1976 through 1986, 59 patients underwent 62 procedures. Three patients with internal hemipelvectomy were later treated with standard hemipelvectomy due to local recurrence. Thirty-three involved the right side (53 percent) and 29, the left side (47 percent). There were 21 female and 38 male patients. The mean age was 47 and the median age, 48 years (range 13 to 86 years). The histologic diagnosis was soft tissue sarcoma in 32, chondrosarcoma in 7, osteogenic sarcoma in 4, Ewing’s sarcoma in 1, squamous cell carcinoma in 8, and malignant melanoma in 7. Thirty-six patients were operated on with curative intent, whereas 23 patients were operated on for palliation. The latter group included 11 patients with massive, painful involvement of the groin by metastatic disease in the nodes or ulcerated tumors postirradiation with exposed vessels and 12 patients with a small amount of distant metastatic disease in whom hemipelvectomy was performed for control of pain or tumor ulceration. Of the procedures, 42 were posterior flap hemipelvectomies, 5 were anterior flap hemipelvectomies, and 15 were internal hemipelvectomies. Of the last group, complete resection of the entire hemipelvis was performed in seven instances, resection of the iliac bone in three, and resection of the pubic bone in five, with preservation of the acetabulum. Among the 42 posterior flap hemipelvectomies, the common iliac vessels were divided in 25 patients and the external iliac vessels in 17 patients. Early in the series, the gluteus maximus muscle was removed with the specimen (9 patients), whereas later it was left attached to the posterior flap (33 patients). In two patients, due to extensive resection of the lower abdominal muscles, Marlex@ mesh was used to repair the defect. In one patient each, the hemipelvectomy was combined with pelvic exenteration, resection of the sigmoid, and resection of the cecum. In nine patients, a lower midline abdominal incision was used in continuity with the oblique suprainguinal portion of the incision for posterior flap hemipelvectomy, a maneuver permitting proximal exposure and resection of pelvic sarcomas extending to the vicinity of the fourth and fifth lumbar vertebrae. Technical considerations: Posterior flap hemipelvectomy. This procedure has been extensively described [Z-4]. In many patients, it can be performed in the supine
position with folded sheets or other support under the upper half of the ipsilateral buttock. If it is anticipated that the bone has to be divided proximally through the
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sacroiliac joint or through the sacral ala, a lateral or semilateral position may be preferable as it provides more accurate orientation for the division of the joint through the exposure of both its anterior and posterior aspects [I]. In many patients, this is an extraperitoneal operation. A transperitoneal approach is necessary when the ipsilateral lower quadrant of the abdomen has been radiated, in which case the peritoneum is adherent and cannot be displaced superiorly; when en-bloc resection of adjacent pelvic organs is anticipated; and when the tumor extends high, close to the lower lumbar spine, in which case the often employed anteriorly, suprainguinal oblique incision is inadequate for providing proximal exposure. In this case, the combination of a low midline transperitoneal incision and the usual, low oblique incision permits the necessary exposure. This incision heals well without any complications (Figure 1). A transperitoneal approach is also advisable when, on the basis of a computed axial tomography scan, the anterior tumor surface is adjacent to the posterior parietal peritoneum, in which case the latter structure is best left attached to the tumor in order to secure a better margin. When the peritoneum has been resected, loops of small bowel are in direct contact with the deep surface of the posterior flap postoperatively; however, this did not cause any problem. In many descriptions of construction of the posterior flap, the flap consists of skin and subcutaneous fat, the dissection being carried immediately next, either superficial or deep, to the fascia lata covering the gluteus maximus muscle, the latter being removed with the specimen. Aware of the high frequency of posterior flap necrosis previously reported by our institution [I I] and the distinct possibility that this was due to the policy of removing the gluteus maximus muscle with the specimen, the policy was changed about 10 years ago to leaving this muscle attached to the posterior flap whenever the location of the tumor permitted this, which is a situation pertaining to the majority of patients suitable for this operation. The preservation of the gluteus maximus muscle has completely eliminated posterior flap necrosis and has made possible the construction of long, viable posterior flaps reaching up or above the level of the umbilicus THE AMERICAN
when the lower abdominal wall needs to be sacrificed due to tumor involvement (Figure 2). Anterior jlap hemipelvectomy. This operation involves the construction of an anterior flap for tumors involving the upper portion of the buttock. It is possible to construct a long anterior flap consisting of skin, subcutaneous fat, fascia lata, and a portion of sartorius muscle, with the superficial femoral vessels attached to it and providing its blood supply. The flap is centered over the course of the superficial femoral vessels, which are divided just above the point they traverse the adductor hiatus. This flap will cover the resulting defect and it can reach posteriorly the level of the skin corresponding to the posterior superior iliac spine [A. If one needs a very wide flap, the dissection may be carried out deep to the surface of rectus femoris muscle or the vastus intermedius, thereby preserving branches of the proximal portion of the profunda femoris to the quadriceps and overlying skin 14. Internal hemipelvectomy. This procedure involves the removal of the entire hemipelvis or a portion of it whenever the location of the tumor permits satisfactory resection, whereas the major motor nerves (the sciatic and femoral nerves) and the blood supply to the extremity are pre served (Figures 3 and 4). The obturator nerve supplying the adductor group of muscles can be sacrificed, when necessary, without any appreciable disability in ordinary activity (for example, ambulation or walking up or down a staircase). Various techniques have been described [7-91. A reverse-Y incision provides excellent exposure, and if the dissection can be carried out deep to the gluteus maximus muscle posterolaterally, it heals well [8]. If due to proximity by the tumor, the dissection plane remains superficial to the gluteus maximus, the tip of the posterolateral flap is prone to necrosis. However, the inferolateral portion of the Y incision is only necessary for a tumor extending into the buttock. For a tumor involving the medial aspect of the iliac bone, satisfactory exposure can be obtained through the use of an incision extending from the posterior inferior iliic spine, along the iliac crest and inguinal ligament, to the pubic tubercle or pubic symphysis. The dissection on the posterolateral aspect of the iliac
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Ffgure 4. Complete remctlm
ol Ihe dghl hemlpelvbs.
At a mean follow-up from diagnosis of 48 months (median 34 months) for the whole group, the estimated 5year survival rate for 36 patients operated on with curative intent was 43 percent (median survival 34 months). The estimated Z-year survival rate and median survival time for 23 patients operated on for palliation were 25 percent and 12 months, respectively. The mean blood loss during the operation was 3,684 ml (median 2,541 ml, range 400 to 12,100 ml). The average length of the procedure was 6.7 hours (median 6.5 hours, range 2.5 to 14 hours). Postoperatively, there were no wound problems in 38 procedures (6 1 percent); there was flap necrosis only in 7 (11 percent); infection only in 9 (15 percent); infection plus flap necrosis in 2 (3 percent); and other minor complications (for example, subcutaneous hematoma) with or without infection in 6 (10 percent). The overall rate of flap necrosis, often requiring debridement, was 15 percent (9 of 62 procedures), and the overall rate of wound infection 17 percent (11 of 62 procedures). The mean postoperative hospital stay was 35 days (median 27 days, range 4 to 210 days). Considering the various procedures separately, the mean blood loss for posterior flap hemipelvectomy was 3,558 ml (median 2,551 ml, range 400 to 9,995 ml); the mean duration of operation was 6.2 hours (median 5 hours, range 2.5 to 12 hours); the overall infection rate was 24 percent (10 of 42 procedures); and the rate of flap necrosis was 14 percent (6 of 42 procedures). It is interesting, however, that of the six patients with flap necrosis,
in live it involved the posterior flap, and all live (55 percent) were among the early group of nine patients in whom the gluteus maximus muscle was removed with the specimen. In the remaining patient, flap necrosis occurred in the edge of the anterior flap. No necrosis of the posterior flap occurred in the 33 procedures in which the gluteus maximus was left attached to the flap. Among the six patients with posterior flap necrosis, the divided vessels were the common iliac vessels in 2 and the external iliac vessels in 4, whereas in those without necrosis, the common iliac vessels were divided in 23 cases and the external iliac in 13. One flap necrosis (20 percent) and 1 infection (20 percent) were noted among the anterior flap hemipelvectomies. The mean blood loss was 4,533 ml (median 2,767 ml, range 2,100 to 9,100 ml). The mean duration of operation was 9.4 hours (median 8.5 hours, range 6.5 to 14 hours). In 15 internal hemipelvectomies, the mean blood loss was 3,757 ml (median 2,250 ml, range 400 to 12,100 ml). The mean duration of the operation was 7.3 hours (median 7.1 hours, range 3 to 11 hours). Infection was noted in two patients ( 13 percent) and flap necrosis in two patients (13 percent). The mean postoperative stay was 31 days (median 28 days, range 7 to 59 days). Since 1986, 11 more procedures have been performed (5 posterior flap hemipelvectomies, 5 internal hemipelvectomies, and 1 anterior flap hemipelvectomy). Of these 11 procedures, 1 resulted in death due to pulmonary embolism on the ninth postoperative day, amounting to a postoperative death rate for the entire series of 1 percent (1 of 73 procedures). After posterior or anterior flap hemipelvectomy young patients can be fitted with a prosthesis; however, the majority of the patients, being older, are confined to the use of crutches or a wheelchair. After internal hemipelvectomy, when the acetabulum has also been resected, there is no hip function, and the unsupported proximal end of the femur migrates cephalad 3 to 4 cm, resulting in corresponding shortening of the leg. This is easily corrected with a shoe lift. In these patients, there is normal kneeand ankle-joint function, but there is no hip function. Initially they ambulate for 2 to 3 months with crutches,
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Flgure 3. PattIal resectIon of the bfl hemlpelvls.
bone is carried out with the periosteal elevator, thus separating the gluteal muscles from their origin from the iliac bone (Figure 5). In resections of the pubic bone, the abdominoinguinal incision provides ample exposure for removing adjacent soft-tissue masses [12]. The defect is covered with Marlex mesh. Care should be exercised to avoid direct contact of the iliofemoral vessels with the mesh. RESULTS
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non-weight bearing on the operated side; for the next 3 to 4 months they can put partial weight on the operated side; and by 6 months after the operation, they balance their weight on both feet. Due to lack of hip motion, the patients have to use crutches indefinitely, but they can ambulate on a flat level as well as go up and down stairs. Older patients with internal hemipelvectomy have more difficulty, and some are confined to a wheelchair. It ap pears, therefore, that other than the cosmetic advantage over the standard hemipelvectomy, which is always present, the functional advantage of internal hemipelvectomy may be restricted to young patients. When a partial internal hemipelvectomy is performed, the functional results are superior. With resection of the iliac bone above the acetabulum, some cephalad migration of the latter occurs, and initially, ambulation requires crutches and a cane for support for about 1 year. Thereafter, the patients walk fairly freely and without support, except for a shoe lift on the slightly shortened extremity. Removal of the pubic bone, entailing sacrifice of the obturator nerve, and detachment of the adductor group of muscles from their origin in the pubic bone causes no difficulty, and after 3 to 4 weeks, the patients ambulate freely. COMMENTS At present, with the more extensive use of combinations of modalities, limb salvage has been possible in 95 percent of our patients with primary soft-tissue sarcomas [ 131. More recently, the development of the abdominoinguinal incision has made possible the resection of tumors in the iliac fossa, in the area of the external iliac vessels, in the wall of lesser pelvis, and in the pubic bone, which were previously considered unresectable or were treated with hemipelvectomy [12]. However, there is still a group of patients with proximal tumors involving the hip joint, iliac bone, or both, which are often locally recurrent and which may require hemipelvectomy as the only chance of cure. In our series, among patients with extensive softtissue or bone tumors operated on with a curative intent, the estimated 5-year survival rate was 43 percent. Patients adjust well after this operation, and those who are young are able to return to gainful employment. A young female patient married several years after hemipelvectomy and managed to have a successful pregnancy. She is able to wear a prosthesis as other young patients do. After internal hemipelvectomy involving the acetabulum, there is no hip movement on the operated side, and the patients have to use crutches permanently. Still, this operation is preferable due to its obvious cosmetic and psychologic effect, particularly in young people, compared with standard hemipelvectomy. Removal of the iliac bone above the acetabulum causes only modest and temporary disability, whereas removal of the pubic bone causes no appreciable disability. A motor deficit in the distribution of the sciatic nerve was observed in one of live patients after this operation in a report by Eilber et al [ 71; however, we have not observed this complication. A worthwhile anatomic detail is that the lumbosacral trunk of the sciatic nerve courses over the sacral ala, and it has THE AMERICAN
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Figure 5. The InWon used for rWectbnoltheanttre [email protected] tnfemtateralporttondthetnclabn(A)tsneededontywhen the tumor extends into the buttock.
to be carefully retracted when dividing the bone at this level. These are lengthy procedures with a median duration of 5, 8.5, and 7.1 hours for posterior flap, anterior flap, and internal hemipelvectomy, respectively. The median blood loss for these procedures was 2,551 ml, 2,767 ml, and 2,250 ml, respectively. Early control of the blood vessels has always been accomplished in our patients, but in those patients with large proximally located tumors who were referred to our institution for these procedures, considerable blood loss has occurred over the course of several hours. There were no wound problems after 38 operations (61 percent), whereas a variety of wound problems occurred after 24 procedures (39 percent). These included flap necrosis in 9 patients (15 percent) and infection in 11 (18 percent). Flap necrosis occurred in 6 of 42 posterior flap hemipelvectomies (14 percent), 1 of 5 anterior flap hemipelvectomies (20 percent), and 2 of 15 internal hemipelvectomies ( 13 percent). In the past, the rate of posterior flap necrosis in our institution was 80 percent [II]. When the posterior flap consists of skin and subcutaneous fat, trimming of the middle portion of the flap has been advocated to avoid flap necrosis [ 141. Since the adoption of the maneuver of leaving the gluteus maximus muscle attached to the posterior flap, there has been no flap necrosis in the last 33 patients in our series and none in the 5 patients treated since then. The number of anterior flap and internal hemipelvectomy procedures in our series was too small to allow firm conclusions to be drawn; however, anterior flap necrosis of an anterior flap hemipelvectomy may be eliminated by mobilization of the flap with the quadriceps muscle attached to it. In internal hemipelvectomy, flap necrosis may be reduced by avoiding the inferolateral extension of the reverse-Y incision when the location of the tumor permits or by maintaining a plane deep to the gluteus maximus muscle posterolaterally. With the increasing application of combinations of modalities and the increasing demand for limb salvage, hemipelvectomy is performed for more advanced tumors more often than in the past; however, until more effective treatments for solid tumors develop, these procedures still remain part of the surgeon’s armamentarium. An in-
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creased awareness of their respective complications, which are largely avoidable, should help make their application safer. The practicingsurgeon is only occasionallyrequired to consider hemipelvectomy.The operationmust be tailored to the individual anatomic requirements of the neoplasm and patient. This study shows,in a very clear fashion, some interestingtechnical and conceptual approaches to a complex but very useful operation. REFERENCES 1. Chretien PA, Sugarbaker PH. Surgical technique of hemipelvectomy in the lateral position. Surgery 1981; 90: 900-9. 2. Frey C, Matthews LS, Benjamin H, Fidler WJ. New technique for hemipelvectomy. Surg Gynecol Obstet 1976; 143: 753-6. 3. Karakousis CP. Hemipelvectomy (hindquarter amputation). In: Atlas of operations for soft tissue tumors. New York: McGrawHill, 1985: 335-50. 4. Ariel IM, Shah JP. The conservative hemipelvectomy. Surg Gy-necol Obstet 1977; 144: 406-13. 5. Karakousis CP, Vezeridis MP. Variants of hemipelvectomy. Am
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J Surg 1983; 145: 273-7. 6. Sugarbaker PH, Chretien PA. Hemipelvectomy for buttock tumors utilizing an anterior myccutaneous flap of quadriceps femoris muscle. Ann Surg 1983; 197: 106-15. 7. Eilber FR, Grant ‘IT, Sakai D, Morton DL. Internal hemipelvectomy. Excision of the hemipelvis with limb preservation: an alternative to hemipelvectomy. Cancer 1979; 43: 806-9. 8. Karakousis CP. Internal hemipelvectomy. Surg Gynecol Obstet 1984; 158: 279-82. 9. Steel HH. Partial or complete resection of the hemipelvis: an alternative to hindquarter amputation for periacetabular chondrosarcoma of the pelvis. J Bone Joint Surg [Am] 1978; 60: 719-30. 10. Enneking WF, Dunham WK. Resection and reconstruction for primary neoplasms involving the innominate bone. J Bone Joint Surg 1978; 60: 731-46. 11. Douglass HO, Razack M. Hemipelvectomy. Arch Surg 1975; 110: 82-5. 12. Karakousis CP. The abdominoinguinal incision in limb salvage and resection of pelvic tumors. Cancer 1984; 54: 2543-8. 13. Karakousis CP, Emrich LJ, Rao R, Krishnamsetty RM. Feasibility of limb salvage and survival in soft tissue sarcomas. Cancer 1986; 57: 484-91. 14. Miller TR. 100 cases of hemipelvectomy: a personal experience. Surg Clin North Am 1974; 54: 905-13.
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