Abdominoinguinal incision and other incisions in the resection of pelvic tumors

Special clinical scenarios in RPS: Involvement of great vessels and pancreas and penetration across natural foramina

The primary treatment for retroperitoneal sarcomas is surgery. This requires a carefully planned, typically multivisceral, resection. A few complex scenarios that may arise include vascular involvement, pancreatic involvement, or herniation of the tumor into another compartment outside of the retroperitoneum. These scenarios must be anticipated before surgery to optimize preoperative preparation, minimize postoperative morbidity and mortality, and improve oncologic outcomes. Our aim is to highlight these clinically challenging anatomic presentations that can be encountered in patients with retroperitoneal sarcomas.

Abdominoinguinal approach in en bloc resection of retroperitoneal sarcoma involving iliac vessels with graft interposition

Background

Retroperitoneal sarcomas (RPSs) located in the lower abdominal quadrants involving iliac vessels are difficult to manage. This study introduced a 5-step method for en bloc resection with graft interposition using the abdominoinguinal approach and evaluated its efficacy and safety.

Methods

Data of 24 consecutive patients who met the inclusion criteria from 272 patients with RPS who underwent surgical treatment between April 2015 and April 2022 were retrospectively collected and analyzed.

Results

The patients underwent left- or right-sided abdominoinguinal incision. In all patients, the abdominoinguinal approach provided good exposure, and complete resection was achieved. Iliac artery+vein, vein, and artery resection and replacement by graft were performed in 70.8%, 25.0%, and 4.2% of patients, respectively. Additional resected organs mainly included the colon, ureter, bladder, kidney, and abdominal wall. The median number of organs resected was 5. In 37.5% of patients, reconstruction of the lower abdominal wall and inguinal ligament was performed using a mesh. Venous graft thrombosis occurred in 21.7% of patients, while no patient had pulmonary embolism or arterial occlusion. Major complications occurred in 20.8% of patients, and no 30-day mortality was observed. The estimated 5-year local recurrence and distant metastasis rates were 54.4% and 22.1%, respectively, with a median recurrence-free survival of 27 months.

Conclusions

En bloc resection of RPS involving iliac vessels with graft interposition using the abdominoinguinal approach is feasible and advantageous. Good complete resection rate and safety can be achieved. The long-term survival benefit of this surgical approach should be verified by further large-scale prospective controlled studies.

Resection of a giant retroperitoneal lipoma herniating through the inguinal canal

Retroperitoneal lipomas are extremely rare with few cases reported so far in the literature. They can reach different sizes and present with a variety of symptoms. The differential diagnosis is mainly with well-differentiated liposarcoma (WDLPS). We present a 34-year-old woman with a retroperitoneal lipoma herniating through the inguinal canal into the proximal thigh. The patient underwent complete oncological resection using a Karakousis's abdominoinguinal incision. Retroperitoneal lipomas are a very rare condition and sometimes require resections technically challenging. MDM2 amplification is critical for its differential diagnosis with WDLPS.

The pararectus approach-a versatile option in pelvic musculoskeletal tumor surgery

Background

Pelvic tumors are usually resected through the utilitarian pelvic incision, an extended ilioinguinal/iliofemoral approach. The pararectus approach, an intrapelvic anatomical approach with extraperitoneal access to the pelvis, has been established previously for the treatment of pelvic and acetabular fractures. However, it has not been used to address pelvic tumors. The study aimed at investigating the feasibility of this approach for pelvic tumor surgery and the possibilities of combining this approach with standard approaches to the hip joint.

Methods

Thirteen patients that underwent pelvic tumor resections were retrospectively reviewed. Tumor resections were performed through the pararectus (n = 10) or extended pararectus approach (n = 3). In six of those cases, the pararectus approach was combined with extrapelvic approaches including the modified Gibson (n = 4), the Kocher-Langenbeck (n = 1), and the trochanteric flip approach (n = 1). The mean follow-up was 32.6 ± 9.1 months.

Results

In all cases, the tumor resections were carried out according to the preoperative plan. In seven of 13 cases, wide resections were performed; six of 13 cases were planned close resections. Four cases of major complications were observed (vascular injury, deep infection, iliac vein thrombosis, total hip arthroplasty dislocation). Minor complications were observed in two cases. One tumor recurred locally. At the final follow-up, 10 patients were alive, eight of those without evidence of disease.

Conclusion

The study demonstrated the suitability of the pararectus approach for pelvic tumor resections. The possibility to combine the approach with standard approaches to the hip joint allowed for single-stage reconstructions of the pelvis and the hip joint without sacrificing surgical margins and function. The pararectus approach is a versatile option adding to the established approaches for musculoskeletal tumor surgery of the pelvis.

The Friedman-Eilber resection arthroplasty of the pelvis

It has been argued that internal hemipelvectomy without reconstruction of the pelvic ring leads to poor ambulation and inferior patient acceptance. To determine the accuracy of this contention, we posed the following questions: First, how effectively does a typical patient ambulate following this procedure? Second, what is the typical functional capacity of a patient following internal hemipelvectomy? In the spring of 2006, we obtained video documentation of eight patients who had undergone resection arthroplasty of the hemipelvis seen in our clinic during routine clinical followup. The minimum followup in 2006 was 1.1 years (mean, 8.2 years; range, 1.1-22.7 years); at the time of last followup in 2008 the minimum followup was 2.9 years (mean, 9.8 years; range, 2.9-24.5 years). At last followup seven of the eight patients were without pain, and were able to walk without supports. The remaining patient used narcotic medication and a cane or crutch only occasionally. The mean MSTS score at the time of most recent followup was 73.3% of normal (range 53.3-80.0%; mean raw score was 22.0; range 16-24). All eight patients ultimately returned to gainful employment. These observations demonstrate independent painless ambulation and acceptable function is possible following resection arthroplasty of the hemipelvis.

LEVEL OF EVIDENCE

Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

Internal hemipelvectomy for pelvic sarcomas using a T-incision surgical approach

Internal hemipelvectomy is performed for pelvic sarcomas when the tumor can be safely resected without sacrificing the entire extremity. Wide exposure and awareness of major neurovascular structures are crucial to the success of this surgery. Various modifications on the standard utilitarian approach have been used to best achieve these goals. We reviewed our experience using the T-incision technique for 30 pelvic sarcoma resections. The minimum followup was 3.6 months (mean, 55 months; range, 3.6-185.4 months). Postoperative complications included minor complications (requiring no surgery or a simple incision and drainage with primary closure) in 27% of patients and major complications (involving a deep infection or more extensive surgical treatment) in 17%. Ninety-two percent of wound complications healed uneventfully with antibiotics and incision and drainage. The 2-, 5-, and 10-year patient survival rates were 67%, 59%, and 53%. The 2-, 5-, and 10-year disease-free survival rates were 68%, 42%, and 42%. The mean Musculoskeletal Tumor Society and Toronto Extremity Salvage Scores were 69% and 86%, respectively. We believe the T-incision technique for internal hemipelvectomy is an effective surgical approach for pelvic sarcomas when limb salvage is possible.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.