Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_759_Библиотеки_им_академика_М_И_Перельмана.pdf
39 Resection ofRecurrent Pelvic Sidewall Tumor
445
involving major vessels of the pelvic sidewall,
there has been increased interest in strategies to
minimize complications. One such novel strategy
is pre-emptive crossover femoral-to-femoral arterial bypass, performed as a separate procedure in
advance of the planned surgical resection of the
recurrent pelvic sidewall tumor [26–28]. This
novel technique has been reported to reduce
operative time, allow for appropriate amount of
recovery time from the bypass procedure, and
reduce the infectious complications related to the
placement of a bypass graft at the time of a multivisceral resection.
Recognition
Vascular injury at the time of surgery is one of the
most easily recognized complications in surgery.
While easily recognized, gaining control of
bleeding during reoperative pelvic surgery can be
a challenge.
Management
Whether the bleeding is from an arterial or
venous source, the best rst step is to apply direct
pressure to the area. This allows time to coordinate the resuscitative measures by the surgical
team and anesthesia providers, as well as mobilize resources to the OR if necessary. Additionally,
while bleeding is controlled with direct pressure,
attempts should be made to ensure that there is
adequate exposure and vascular control of the
area of suspected bleeding. Depending on the
source and the size of the vessel responsible,
bleeding may be controlled with ligation or primary repair of the injured vessel. In some circumstances, such as bleeding from the internal
iliac venous plexus, over-exuberant application
of pressure may result in further tearing of delicate veins and exacerbation of bleeding.
Bleeding from the PVP poses a difcult challenge. The PVP is a valveless system that, when
injured, can lead to signicant blood loss [29]. In
some cases when these vessels are inadvertently
transected they can retract into the sacrum, mak-
ing it nearly impossible to gain control with pressure alone. In any instance the initial step in
control of presacral venous bleeding that does not
resolve with electrocautery is pelvic packing
with pressure. If bleeding is not controlled with
packing, the addition of topical hemostatic
agents, bone wax and cement, as well as sterile
tacks or muscle patches to the area have been
employed with success. Finally, spray electrocautery, argon beam coagulation, and circular
suture ligation have been used as methods to
obtain hemostasis [23].
Nerve Injury andComplication
Background
Major nerve (sciatic or femoral) resection is
required in up to 30% of cases of laterally
extended pelvic resection for recurrent pelvic
sidewall tumors [6, 11, 22]. In settings where a
nerve resection is planned, there should be a
thorough preoperative physical assessment
including evaluation of the contralateral side to
ensure that the patient has the baseline functional capacity to compensate for anticipated
motor decits following nerve resection.
Outcomes following major nerve resection can
vary from minor sensory decit to a signicant
motor decit. While resection of a major nerve is
not associated with worse survival, the negative
impact that these motorsensory decits may
have on a patient’s quality of life can be signicant. Fortunately however, recent studies assessing quality of life after pelvic exenteration in
patients who underwent femoral or sciatic nerve
resection for lateral wall involvement for
colorectal cancer found that there was a negative
impact on quality of life at 6months but that by
12months most patients reported they were back
to their preoperative functional baseline [30]. In
patients who have required more extensive
boney resection as in the case of hemipelvectomy for a pelvic sarcoma, the outcomes and
impact on quality of life are more pronounced
and are driven by the extent of resection and
reconstruction required [31].
446
Median sacral
cba
J. D. McDonald and R. J. Gonzalez
Prevention
After vascular control has been achieved and the
internal iliac vessels have been ligated, extended
lateral dissection takes place by gentle medial
retraction of the specimen and vessels
(Fig. 39.3c). The dissection proceeds lateral to
the internal iliac vessels until the deep pelvic fascia is encountered. Once the deep pelvic fascia is
incised then the lumbosacral trunk and sacral
nerve roots on the piriformis muscle are exposed.
The nerve roots are dissected away from the pelvic oor to the level of necessary resection, and
beyond the tumor in cases where nerve preservation is planned.
Recognition
Unfortunately, unintended nerve injury is not
always immediately evident during surgery.
More frequently these are identied postoperatively when the patient has complaints of motor
and/or sensory decits that result from compression, traction, thermal spread, or a partial transec-
tion injury. When a nerve is transected, it can be
more clearly identied intraoperatively.
Depending on the nerve injured, the degree of
injury, and how the injury occurred, attempts at
repair may be considered.
Management
When neuropathy is identied with an unexpected motor and/or sensory decit in the postoperative setting, the extent of injury may not
be immediately evident. Traction or compression injury from a malpositioned retractor
blade or stretch injury from dissection will
typically improve with time [32]. Additionally,
in setting of nerve resection, a multidisciplinary discussion with a neural reconstructive
surgeon would be warranted to determine the
benet of nerve reconstruction on a case-bycase basis. As many of these patients undergoing laterally extended surgical resection have
already received radiotherapy in or around the
operative eld, the deleterious effects of the
radiation must be taken into account when dis-
artery
Lateral sacral
artery
Internal iliac
artery
Internal iliac
vein
Superior
gluteal artery
Ureter
Fig. 39.3 Lateral pelvic sidewall neurovascular exposure. (a) In situ anatomic relationship of the ureter, major
vessels, and nerves. (b) Sidewall vasculature controlled,
and side-branches ligated. (c) Ligation and retraction of
the major vessels exposing the lumbosacral plexus and
pelvic nerves
39 Resection ofRecurrent Pelvic Sidewall Tumor
447
cussing the role for reconstruction, and
debridement of the grafting eld must be performed to maximize chance of successful
reconstruction [33].
As has been seen with the growing data and
improved techniques for limb salvage and functional recovery after nerve resection for extremity soft tissues sarcomas, there appears to be
benet of nerve reconstruction after pelvic nerve
resection as most patients report being at their
preoperative functional baseline by 12 months
post-surgery [30, 34, 35]. In those patients whose
multidisciplinary team has determined that there
would be benet from nerve reconstruction, the
primary modalities for reconstruction are primary repair, nerve grafting, and nerve transfer.
Repair of femoral or obturator nerve injuries tend
to have better results in regards to functional
recovery and pain compared to those patients
with attempted repair of sciatic or multilevel
nerve injuries [36].
Summary
Pelvic sidewall tumor recurrence is a scenario
that is common to Gynecologic and Surgical
Oncologists, Colorectal Surgeons, and
Urologists. As surgical techniques have
improved, there has been a push to consider a
patient’s candidacy for surgery on a case-bycase basis and abandon the prior doctrine of
sidewall involvement being an absolute contraindication to surgery. In all scenarios where surgery is being considered there is denitive need
for these cases to be presented in a multidisciplinary forum to determine if the patient is a
suitable candidate for surgery, has reasonable
chance to achieve a negative resection margin,
and has the functional baseline necessary to
achieve a desired functional recovery following
surgery. Pre-requisites for any surgeon performing these complex operations include the need
for a multispecialty surgical team, expert knowledge of the surgical anatomy, and an understanding of the major potential complications
and management of such complications.
References
1. Moore HG, Shoup M, Riedel E, Minsky BD, Alektiar
KM, Ercolani M, et al. Colorectal cancer pelvic
recurrences: determinants of resectability. Dis Colon
Rectum. 2004;47(10):1599–606.
2. Anthopoulos AP, Manetta A, Larson JE, Podczaski
ES, Bartholomew MJ, Mortel R.Pelvic exenteration:
a morbidity and mortality analysis of a seven-year
experience. Gynecol Oncol. 1989;35(2):219–23.
3. Kraybill WG, Lopez MJ, Bricker EM. Total pelvic exenteration as a therapeutic option in advanced
malignant disease of the pelvis. Surg Gynecol Obstet.
1988;166(3):259–63.
4. Mor E, Assaf D, Shemla S, Ben-Ami E, Mor-Hadar
D, Halfon M, etal. Resection of recurrent pelvic soft
tissue sarcoma: is the risk worth the reward? J Surg
Res. 2023;283:914–22.
5. Pawlik TM, Skibber JM, Rodriguez-Bigas MA.Pelvic
exenteration for advanced pelvic malignancies. Ann
Surg Oncol. 2006;13(5):612–23.
6. Höckel M. Laterally extended endopelvic resection:
surgical treatment of infrailiac pelvic wall recurrences
of gynecologic malignancies. Am J Obstet Gynecol.
1999;180(2 Pt 1):306–12.
7. Mibayashi R.Mibayashi super-radical hysterectomy.
Cervical cancer. Tokyo: Nakayama Shoten; 1970.
p.269–79.
8. Austin KKS, Solomon MJ.Pelvic exenteration with
en bloc iliac vessel resection for lateral pelvic wall
involvement. Dis Colon Rectum. 2009;52(7):1223–33.
9. Shaikh I, Aston W, Hellawell G, Ross D, Littler S,
Burling D, et al. Extended lateral pelvic sidewall
excision (ELSiE): an approach to optimize complete resection rates inlocally advanced or recurrent
anorectal cancer involving the pelvic sidewall. Tech
Coloproctol. 2015;19(2):119–20.
10. Solomon MJ, Brown KG, Koh CE, Lee P, Austin KK,
Masya L.Lateral pelvic compartment excision during
pelvic exenteration. Br J Surg. 2015;102(13):1710–7.
11. Vizzielli G, Naik R, Dostalek L, Bizzarri N,
Kucukmetin A, Tinelli G, et al. Laterally extended
pelvic resection for gynaecological malignancies: a
multicentric experience with out-of-the-box surgery.
Ann Surg Oncol. 2019;26(2):523–30.
12. Marcille M.Lymphatiques et ganglions ilio-pelviens.
Tribune Medicale. 1903:165–70.
13. Lee P, Francis KE, Solomon MJ, Ramsey-Stewart
G, Austin KKS, Koh C. Triangle of Marcille: the
anatomical gateway to lateral pelvic exenteration.
ANZ J Surg. 2017;87(7–8):582–6.
14. Gurtner GC, Jones GE, Neligan PC, Newman MI,
Phillips BT, Sacks JM, etal. Intraoperative laser angiography using the SPY system: review of the literature and recommendations for use. Ann Surg Innov
Res. 2013;7(1):1.
15. Antoine Lembert 1802-1851. Study on intestinal
suture with a description of a new procedure for
448
J. D. McDonald and R. J. Gonzalez
performing this surgical operation. 1826. Dis Colon
Rectum. 1988;31(6):489–94.
16. Burch JM, Franciose RJ, Moore EE, Bif WL, Offner
PJ. Single-layer continuous versus two-layer interrupted intestinal anastomosis: a prospective randomized trial. Ann Surg. 2000;231(6):832–7.
17. Daix M, Martinez Gomez C, Angeles MA, Tock
S, Gladieff L, Gabiache E, et al. Extended pelvic resection for gynecological malignancies: a
review of out-of-the-box surgery. Gynecol Oncol.
2022;165(2):393–400.
18. Feng D, Tang Y, Yang Y, Wei X, Han P, Wei W.Does
prophylactic ureteral catheter placement offer any
advantage for laparoscopic gynecological surgery? A
urologist’ perspective from a systematic review and
meta-analysis. Transl Androl Urol. 2020;9(5):2262–9.
19. Merola J, Arnold B, Luks V, Ibarra C, Resio B, Davis
KA, et al. Prophylactic ureteral stent placement vs
no ureteral stent placement during open colectomy.
JAMA Surg. 2018;153(1):87–90.
20. da Silva G, Boutros M, Wexner SD.Role of prophylactic ureteric stents in colorectal surgery. Asian J
Endosc Surg. 2012;5(3):105–10.
21. Sung VW, Wohlrab KJ.Chapter 26 – Urinary tract
injury and genital tract stulas. In: Sokol AI, Sokol
ER, editors. General gynecology. Philadelphia:
Mosby; 2007. p.639–61.
22. Brown KG, Koh CE, Solomon MJ, Qasabian R,
Robinson D, Dubenec S.Outcomes after en bloc iliac
vessel excision and reconstruction during pelvic exenteration. Dis Colon Rectum. 2015;58(9):850–6.
23. Celentano V, Ausobsky JR, Vowden P.Surgical management of presacral bleeding. Ann R Coll Surg Engl.
2014;96(4):261–5.
24. Abdelsattar ZM, Mathis KL, Colibaseanu DT,
Merchea A, Bower TC, Larson DW, etal. Surgery for
locally advanced recurrent colorectal cancer involving the aortoiliac axis: can we achieve R0 resection and long-term survival? Dis Colon Rectum.
2013;56(6):711–6.
25. Chlupáč J, Filová E, Bačáková L. Blood vessel
replacement: 50 years of development and tissue
engineering paradigms in vascular surgery. Physiol
Res. 2009;58(Suppl 2):S119–s40.
26. Martínez-Gómez C, Angeles MA, Saint-Lebes B,
Migliorelli F, Martinez A, Ferron G. How to simplify out-of-the-box surgery in recurrent gynecologic
malignancies compromising iliac vessels: preoperative femorofemoral crossover bypass. Int J Gynecol
Cancer. 2019:ijgc-2019-000393.
27. Cibula D, Mitáš P. Laterally extended endopelvic
resection with external iliac vessels resection and
crossover ileofemoral bypass. Int J Gynecol Cancer.
2019;29(8):1338.
28. Peacock O, Smith N, Waters PS, Park-Yun Cheung F,
McCormick JJ, Warrier SK, etal. Preemptive femoralfemoral crossover grafting of artery and vein before
pelvic exenterative surgery for locally advanced and
recurrent pelvic malignancy involving the Aortoiliac
Axis. Dis Colon Rectum. 2021;64(1):e2–5.
29. Baqué P, Karimdjee B, Iannelli A, Benizri E, Rahili A,
Benchimol D, etal. Anatomy of the presacral venous
plexus: implications for rectal surgery. Surg Radiol
Anat. 2004;26(5):355–8.
30. Brown KGM, Solomon MJ, Lau YC, Steffens D,
Austin KKS, Lee PJ. Sciatic and femoral nerve
resection during extended radical surgery for
advanced pelvic tumours: long-term survival, functional, and quality-of-life outcomes. Ann Surg.
2021;273(5):982–8.
31. Beck LA, Einertson MJ, Winemiller MH, DePompolo
RW, Hoppe KM, Sim FF. Functional outcomes and
quality of life after tumor-related hemipelvectomy.
Phys Ther. 2008;88(8):916–27.
32. Cardosi RJ, Cox CS, Hoffman MS.Postoperative neuropathies after major pelvic surgery. Obstet Gynecol.
2002;100(2):240–4.
33. Brandt K, Evans GR, Ang KK, Gürlek A, Peden E,
Savel T, et al. Postoperative irradiation: are there
long-term effects on nerve regeneration? J Reconstr
Microsurg. 1999;15(6):421–5.
34. Martin E, Dullaart MJ, Verhoef C, Coert JH.A systematic review of functional outcomes after nerve reconstruction in extremity soft tissue sarcomas: a need for
general implementation in the armamentarium. J Plast
Reconstr Aesthet Surg. 2020;73(4):621–32.
35. O’Brien AL, West JM, Zewdu A, Grignol VP,
Scharschmidt TJ, Moore AM. Nerve transfers to
restore femoral nerve function following oncologic
nerve resection. J Surg Oncol. 2021;124(1):33–40.
36. Nichols DS, Fenton J, Cox E, Dang J, Garbuzov A,
McCall-Wright P, et al. Surgical interventions for
lumbosacral plexus injuries: a systematic review.
Plast Reconstr Surg Glob Open. 2022;10(8):e4436.
Resection ofTumors Involving
thePelvic Girdle
AlexanderL.Lazarides, ShawnaL.Watson,
GustonG.Zervoudakis, NoraL.Watson,
andDavidM.Joyce
40
Nerve Injury
Background
Tumors of the bony pelvis may affect nerves
within the pelvis and peripherally once they have
exited into the extremity. The rate of nerve injury
for major pelvic tumor resection is quoted at
10–30%, though for sacrectomies, some degree
of nerve involvement may be essentially guaranteed [1–4]. Large tumors arising from bone can
distort local neurologic anatomy, or potentially
involve important neurologic structures. Of particular risk are the sciatic nerve, the pudendal
nerve, the femoral nerve and the obturator nerve.
Prevention
It is important to systematically identify and protect these critical neurologic structures. The
authors advocate for early identication and,
A. L. Lazarides · G. G. Zervoudakis · N. L. Watson
D. M. Joyce (*)
Department of Sarcoma, Moftt Cancer Center,
Tampa, FL, USA
e-mail: alexander.lazarides@moftt.org; Guston.
Zervoudakis@moftt.org; David.joyce@moftt.org
S. L. Watson
Department of Orthopaedic Surgery, University of
South Florida, Tampa, FL, USA
e-mail: Shawna.Watson@moftt.org
where necessary, mobilization of important neurologic structures early during a dissection. A
fundamental understanding of the anatomic location of such nerves is critical when dealing with
distorted anatomy, and ensuring sufcient exposure to identify nerves in their normal course may
be necessary.
The femoral nerve arises from the lumbar
plexus and then courses through the psoas muscle
[5]. As such, tumors that involve the origin of the
psoas may compromise the ability to salvage the
femoral nerve. Once the nerve enters the abdomen, it can be reliably found within the interval
between the iliacus and the psoas. In many bone
tumors, the iliacus will serve as a suitable tumor
margin; as such, the posas and the femoral nerve
are often salvageable with careful dissection. The
exit of the femoral nerve from the pelvis through
the femoral triangle represents another predictable location to identify the nerve. The femoral
nerve exits beneath the inguinal ligament and
then travels between the sartorius laterally and
adductor longus medially as it begins to divide to
provide motor and sensory innervation [6].
The sciatic nerve is frequently at risk with
tumors involving the sacrum and greater sciatic
notch. The sciatic nerve arises from the lumbosacral plexus and courses out through the greater
sciatic foramen [7]. The nerve may often be identied in relation to the piriformis, typically exiting below the piriformis; however, in
approximately 13% of patients, the anatomic
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Hoffman et al. (eds.), Major Complications of Female Pelvic Surgery,
https://doi.org/10.1007/978-3-031-66772-5_40
449
450
A. L. Lazarides et al.
location may be a variable [8]. The nerve then
continues into the posterior compartment of the
thigh. The nerve may predictably be found in the
posterior thigh after its exit from the greater
sciatic notch and often, dissection may be carried
out from distal to proximal to ensure its protection throughout the case. Care should be taken as
the vena commitantes that travel with the sciatic
nerve can cause persistent bleeding. Frequently,
the piriformis and the short external rotators may
act as a barrier between the nerve and the tumor,
allowing preservation.
Like the sciatic nerve, the pudendal nerve is
commonly at risk with tumors involving the
sacrum and the posterior column of the pelvis
and acetabulum. The nerve arises from the S2-4
nerve roots [9]. The nerve exits the pelvis through
the greater sciatic notch and then courses over the
sacrospinous ligament before re-entering the pelvis through the lesser scatic notch. The nerve
then passes through the pudendal canal along the
medial wall of the obturator internus as it courses
towards the pubic symphysis. The nerve may be
predictably found proximal to the ischial spine
and below the piriformis, coursing over the sacrospinous ligament as it exits the greater sciatic
notch. This ligament is often frequently required
to be released for pelvic or sacral resections; care
must be taken to ensure protection of this nerve
where able. In Type II (periacetabular) and Type
III (ischium with superior and inferior rami)
resection, the obturator and piriformis muscle
bellies are frequently sufcient barriers to protect
the pudendal nerve. Alternatively, in sacral resections, the nerve may be found shortly after the
sacral nerve roots exit the sacrum.
The obturator nerve arises from the lumbar
plexus and is frequently at risk in Type III pelvic
resections where osteotomies or tumor involvement may place the nerve at risk. The nerve
courses through the psoas major muscle before
arising at the medial border of the psoas [10]. The
nerve typically courses with the common and
internal iliac vessels before coursing along the
inner aspect of the pelvis along the obturator
internus and exiting through the obturator canal.
The obturator canal can predictably be found in
the superior and lateral quadrant of the obturator
ring and serves as a common anatomic landmark
to identify this bundle.
Recognition
Intraoperatively, inadvertent nerve injury may be
addressed with careful nerve repair, either direct
end to end, or with interposition.
Postoperatively, the effects of nerve injury
may not be immediately obvious. Femoral nerve
injury will often manifest as weakness with
ambulation, specically loss of knee extensor
function and weakness with hip exion. Sensation
may be affected, manifesting as loss of sensation
of the anterior and medial thigh, as well as sensation in the saphenous distribution. The sciatic
nerve will similarly present with a dramatic
impact on functional and ambulatory capacity.
Clinically, the manifestation of sciatic nerve
injury will depend on the degree of impact. Often,
the peroneal distribution is more easily impacted
and will manifest as foot drop and sensory loss in
the dorsal foot and rst webspace. If more severe
sciatic nerve injury occurs, there may be a complete loss of motor and sensory function below
the level of the knee, save for the saphenous sensory distribution. Additionally, there may be
weakness with knee exion.
Damage to the pudendal nerve depends on the
degree of impact. With a single-sided injury,
bowel, bladder and sexual function may be variably impacted if the contralateral side is able to
compensate. In the postoperative period, bowel
and bladder function should be monitored closely
and an injury suspected with persistent dysfunction and perineal pain.
Damage to the obturator nerve may not be as
readily apparent and the clinical manifestations
may not be as severe. Functionally, obturator
nerve damage may manifest as weakness of the
adductors and numbness in the obturator distribution to the medial thigh. Clinically, though, the
manifestations of such an injury may not be as
severe and may be readily compensated for by
the remaining muscles.
40 Resection ofTumors Involving thePelvic Girdle
451
Management
Management of neurologic injury depends on the
nerve affected and the degree of impact [11].
Frequently, nerve injuries are neuropraxias, due
to prolonged ischemia or stretch intraoperatively.
While the time course is variable, supportive care
is often all that is required with observation for
the return of nerve function. For permanent
injury, some instances may warrant nerve repair
and grafting.
Whether a nerve recovers or not, bracing can
be used to mitigate the effects of a nerve injury.
From a motor functional perspective, the sciatic
and femoral nerves hold particular importance.
For femoral nerve injuries, a knee immobilizer or
hinged knee brace locked in extension may be
necessary to allow for optimal function with loss
of knee extension to allow for safe ambulation.
For sciatic nerve injuries, the extent of the injury
may determine the type of brace that is required.
For a drop foot, primarily affecting the peroneal
distribution, an ankle-foot orthosis (AFO) may
help manage the motor dysfunction. For more
complete injuries, a more rigid orthosis may be
required Regardless, for these injuries, fall precautions and gait aids are generally a necessity.
Management of a pudendal nerve injury
depends on the degree of impact. In the postoperative period, bowel and bladder function should
be monitored closely, and supportive measures
provided until clinical resolution is seen. In cases
of prolonged or permanent injury, it may be necessary to consider self-catheterization. In more
severe cases, diversion may be necessary.
Frequently, obturator nerve injury requires no
specic interventions. Physical therapy may be
necessary to allow for appropriate compensation
by the remaining muscles.
Vascular Injury
Background
Excessive blood loss is a common occurrence in
hemipelvectomies and sacrectomies [1, 4]. There
are several risk factors for bleeding including
patient (obesity, age), tumor (size, location), and
treatment (prior surgery, chemotherapy or radiotherapy) related factors. While the internal and
external iliac vessels are of greatest concern for
surgeons in pelvic and sacral bone resections,
here we will also focus on the vessels external to
the pelvis that are of equal import to consider in
pelvic bone tumor resections.
Prevention
The best prevention is anticipation. Preoperatively,
advanced imaging should be scrutinized and the
relation of the major vessels to the tumor closely
studied. Tumors that closely abut the major internal pelvic vessels should raise red ags and
prompt the surgeon to anticipate the need for
careful vascular dissection and the risk for potential vascular injury. Tumors that appear to impact
the gluteal vessels may compromise important
soft tissue aps and prompt the surgeon to consider plastic surgery assistance for soft tissue
coverage. In certain instances, limb salvage may
be obviated if the external iliac vessels or femoral
vessels are compromised and vascular reconstruction is not an option.
For major pelvic bone tumor resections, the
authors advocate for a “high risk” anticipated
blood loss protocol to be employed, which alerts
all the members of the perioperative team as to
the potential intraoperative needs related to major
blood loss [12]. At the least, this should call for
PRBCs, platelets and FFP to be available, as well
as two large-bore peripheral IVs and an arterial
line. For complex dissections, specialist vascular
surgeons should be available to either assist
directly with the dissection/ reconstruction or
help manage an unanticipated injury.
Sacrectomy may have consideration for risk to
vascular structures [13]. High sacrectomy, at the
S1 or S2 levels places the common and internal
iliac vessels are risk, particularly if more lateral
osteotomies are required. Additionally, larger
soft tissue tumors may displace vascular structures, such as the superior and inferior gluteal
vessels, as they exit the pelvis. The sacrospinous
ligament frequently must be released, and
452
A. L. Lazarides et al.
extreme care should be taken as injury to these
structures may occur with aberrant dissection.
External to the pelvis, the superior gluteal vessels leave the greater sciatic notch above the
piriformis muscle and provide blood supply to
the superior portion of the gluteus maximus, the
gluteus medius and minimus and the tensor fascia
lata. The inferior gluteal vessels primarily supply
the inferior portion of the gluteus maximus and
the short external rotators (the piriformis and the
quadratus femoris). These vessels are most at risk
with Type IV and Type I pelvic resections.
The external iliac and femoral vessels are particularly at risk with Type III resections. These
vessels are frequently protected within the pelvis
by the iliacus and the psoas. As they exit the pelvis below the inguinal ligament, the muscles of
the adductor compartment frequently serve as a
barrier for tumor involvement as well. While it is
uncommon for these vessels to be directly
involved by pelvic tumor, large tumors may displace and distort the locally anatomy, predisposing them to injury. The bifurcation of the common
femoral vessels often results in a tether point with
the profunda femoris as it passes into the adductor compartment, and ligation of this branch may
be necessary.
Recognition
Major vascular injury is readily identied with
rapid and uncontrolled bleeding, though manifestation may be more subtle [14]. It is important to
differentiate between venous and arterial bleeding. Full details of the management of intrapelvic
major vascular injury are outlined elsewhere in
this book.
Vascular injury external to the pelvis may be
more challenging to identify. Of particular import
is injury to the superior and inferior gluteal vessels. Injury may manifest by direct trauma or
indirectly by thrombosis. Signs of these injuries
may be subtle and may be recognized intraoperatively by loss of color, bleeding and contractility
of the supplied musculature. The soft tissues
should be scrutinized at the completion of every
case. In cases of concern for ap perfusion, the
use of intraoperative indocyanine green angiography may allow for intraoperative recognition of
ap perfusion decits and allow this to be
addressed prior to leaving the operating room.
Postoperatively, vascular injury commonly manifests with wound complications and ap
breakdown.
Ligation of the profunda femoris is frequently
required in pelvic tumor resections. Care should
be taken as the medial femoral circumex is an
important supply for the femoral head and often
branches from the common or deep femoral
artery. Avascular necrosis, while rare, is a potential long-term sequelae of vascular injury and
high ligation of the profunda femoris.
Loss of pulses to the distal extremity should
prompt close evaluation of the external iliac
artery as well as the common and supercial femoral vessels. While direct injury may not have
occurred, thrombosis from manipulation is a
possibility.
Management
The full details of the management of vascular
injury to the internal and external iliac vessels are
detailed elsewhere in this book.
Injury to the superior and inferior gluteal vessels is difcult to rectify. In some instances,
thrombosis may resolve and the supplied musculature may remain viable. Nonetheless, wound
complications and ap breakdown should be
anticipated and careful wound monitoring should
be employed. Early signs of soft tissue compromise should prompt the surgeon towards early
debridement; plastic surgeons should be engaged
early for assistance in these circumstances.
Injury to the common or supercial femoral
artery may be devastating and may threaten the
ability to salvage a limb. Early repair is recommended; in some instances, reconstruction may
be necessitated, and a vascular surgeon should be
called upon early. Prolonged ischemia should
prompt consideration of compartment syndrome,
and signs and symptoms of this should be carefully inspected for with a low threshold for prophylactic fasciotomy. In some instances,
40 Resection ofTumors Involving thePelvic Girdle
453
irreversible damage to the femoral vessels may
require amputation.
Unique Considerations inSacral
Resections
Background
Sacrectomy may be necessary for surgical resection of bony metastases or, perhaps more often,
as part of a combined surgical approach allowing
greater visualization and access to—and/or composite resection of—the lower retroperitoneal
pelvic contents such as the rectum. The sigmoid
colon connects the descending colon to the rectum on the left side of the pelvis. At the approximate S3 level, the sigmoid colon becomes
continuous with the rectum. The rectum lies just
anterior to the S3/S4/S5 vertebral bodies until
passing through the puborectalis and continuing
as the anus.
Prevention
The most reliable way to preserve bladder, bowel
and sexual dysfunction when performing a sacral
resection is to preserve at least one of the two
nerve roots present at each level [15]. Typically,
this will be contralateral to the side that is most
affected by the tumor.
Careful surgical planning is tantamount to
executing a successful sacrectomy. Will the
sacrectomy be performed en bloc with the intrapelvic resection, or will it be mobilized from the
underlying structures prior to making the bony
cuts? Radiated tissue may be adherent to the
underlying bony structures and may place structures of the mesorectum (e.g., the blood supply
and lymphatic drainage) at risk. The presacral/
retrorectal space is a native plane between the
mesorectal fascia and presacral (Waldeyer’s) fascia, which may be developed during the surgical
approach in order to protect the rectum from
injury while performing bony cuts on the sacrum.
The sacrospinous and sacrotuberous ligaments are important for the stability of the pelvic
ring and inhibitors of specimen removal if not
properly divided [16]. Given their broad attachments on the sacrum, these are both most easily
divided at their insertions on the ischial spine and
ischial tuberosity, respectively. These ligaments
may be elevated subperiosteally from their distal
bony attachments to minimize the risk of injury
to surrounding structures, such as the internal
pudendal neurovasculature.
In some circumstances of anticipated dysfunction, or simply for wound protection, a prophylactic diverting colostomy may be performed
prior to resection to potentially avoid or ameliorate serious complications associated with any
subsequent bowel/bladder dysfunction [17, 18].
In some instances, this colostomy may be
reversed once the nal nerve function can be
accurately assessed.
Recognition
In oncologic disease requiring high sacral resection, it may be necessary to sacrice sacral nerve
roots. The resulting sequelae can manifest variably along a spectrum of bowel and/or bladder
dysfunctionality, depending on the bilaterality
and number of levels sacriced. Thus, diligence
in monitoring for signs and symptoms of postoperative bowel or bladder dysfunction is pivotal.
Alternatively, one may consider a reversable prophylactic diverting colostomy prior to resection
as described above.
Management
Lumbopelvic stabilization and bony reconstruction may be required after any sacrectomy which
destabilizes the lumbosacral articulation (L5-S1)
or the sacroiliac articulation (S1/S2/S3-ilium) on
either side [19]. Involvement of an orthopaedic
oncology or spine surgeon may be required
should lumbopelvic spinal instrumentation and/
or custom endoprosthesic reconstruction be
required. Often this will include contralateral
posterior spinal instrumentation of the L2-S1/S2/
ilium and spinal instrumentation cephalad to the
454
A. L. Lazarides et al.
defect ipsilaterally with a bar connection to the
custom prosthesis on that side.
Fractures ofthePelvic Ring
andAcetabulum
Background
In the setting of tumors involving the pelvic girdle, both the disease itself and the various modalities utilized throughout the treatment process are
known risk factors for signicant and generalized
bone loss [20]. The structural integrity of the pelvic ring and acetabulum may be compromised
via numerous venues including, but not limited
to: direct bony involvement of tumor, metastases,
local inammatory milieu, chemotherapeutics,
corticosteroids, malnutrition, or vascular compromise from required vessel sacrice or periosteal stripping to obtain margins. As a result,
pelvic fractures may occur during the treatment
of female pelvic tumors.
Radiation can also weaken the bone to the
point that the patient develops an insufciency
fracture. This occurs because the radiation both
weakens the bone and ages it in a sense. Bone is
constantly being stressed and remodels to
strengthen the stressed area daily. The radiation
degrades the ability of the bone to remodel thus
degrading the ability of the osteoblasts to build
bone. Small cracks eventually accumulate due to
the delayed and limited ability of the bone to
remodel after radiation and lead to enough accumulation of microfractures that a formal complete fracture develops which leads to pain.
management with Vitamin D and calcium monitoring, avoidance of high- impact activities, and physical therapy for core and peripelvic musculature
strengthening. For instances involving signicant
concern for impending pathologic fracture, prophylactic xation and operative stabilization may even
be considered in the prevention of fracture.
When considering radiotherapy, novel techniques to spare and protect the bone may help
mitigate the above developments.
Recognition
When treating patients presenting with tumors of
the pelvic girdle, one must be wary of both occult
and obvious fractures of the pelvic ring and acetabulum. Symptoms associated with stress and
insufciency fractures of the bony pelvis, including pain, difculty with ambulation and ADLs
and functional decline, may often be overlooked
and attributed to the primary tumor/malignancy.
Thus, one must be prudent in monitoring for any
acute changes/increase in a patient’s symptoms—
particularly after a period of increased activity or
an actual traumatic event. Imaging modalities for
identifying potential pelvic fractures include
those routinely used in examining the bony pelvis
beginning with plain radiographs. It is important
to maintain a low threshold for advanced imaging
with CT or MRI imaging should there be concern
for possible occult fractures not immediately
identiable on plain radiographs.
Management
Prevention
The rst step in preventing fractures of the pelvic
ring and acetabulum is awareness. By remaining
cognizant of the detrimental effects that both the illness and treatment of pelvic girdle tumors can pose
on the local bony infrastructure, there are preemptive
steps that may be utilized to at least minimize the
risk of fracture, if not prevent it completely. These
include the utilization of antiresorptive medications
such as bisphosphonates, appropriate nutritional
Orthopaedic surgery consultation should be
sought once a fracture has been identied. He or
she will help to guide further workup and treatment recommendations including imaging studies, decision-making regarding surgical
intervention versus close observation, and
weightbearing/activity restrictions during the
fracture healing period. Surgical treatment may
include a combination of operative stabilization
and/ or reconstruction.
The majority of these fractures are seen in the
superior or inferior pubic rami and do not require