Electronic ISSN 2287-0237

VOLUME

HEMICORPORECTOMY: A CASE REPORT

SEPTEMBER 2019 - VOL.15 | CASE REPORT

Hemicorporectomy (also known as translumbar amputation, halfectomy)is an operation of amputation of the pelvis and lower extremitiesby disarticulation through the lumbar spine, as well as creation ofconduits for diversion of urinary and fecal tracts.1

Originally, hemicorporectomy was performed in cases with locallyaggressive cancers confined to the pelvis. However, it was also claimed tobe beneficial in patients with severe trauma to the pelvis and lowerextremities,2 vascular malformations, acute aortic occlusion, recurrentperianal and scrotal fistulas and terminal pelvic osteomyelitis (this termrepresents pelvic osteomyelitis with chronic decubitus ulcers which isrefractory to treatment with antibiotics and standard surgical treatments).1,3,4

Hemicorporectomy is not a common operation due to its invasiveprocedure. However, it can be a life-saving operation with good co-operationamong the multi-disciplinary team.

The life-threatening intra-operative complication was hypotension, whilepost-operative wound complications were experienced by all cases. Theterm ‘wound complications’ refers to superficial wound dehiscence, delayedwound healing, and osteomyelitis of distal lumbar spine. Genitourinarycomplications (including recurrent urinary tract infection, pyelonephritis,renal calculi and urosepsis) are also found in many cases.1

This case report illustrates two cases of patients suffering frommalignancy in pelvis and lower extremities. The first case was diagnosedhigh grade osteosarcoma at sacrum, while the other was recurrent giant celltumor at left proximal femur.

Two cases are described in this study. The first case is an 18-year-oldfemale with high grade osteosarcoma at sacrum presented with chronicpelvic pain unalleviated by analgesic drugs. Pathologic examination showedhigh grade osteosarcoma stage IIB at sacrum. After receiving neoadjuvantchemotherapy, the tumor was not decreased in size and still did not presentmetastasis. MRI revealed that the tumor had invaded the entire sacrum andall sacral nerve roots with severe soft tissue extension and bony marginsurrounding the 5th lumbar vertebra, shown in Figure 1.

 

Figure 1 : The pelvis MRI demonstrates the invasion of the tumor of the entire sacrum and all sacral nerve roots withsevere soft tissue extension, bony margin involving the 5th lumbar vertebra.

Indications for surgery in this patient were:

  1. An extensive tumor which required massive soft tissuereconstruction.
  2. Bone reconstruction might not be able to maintain herambulatory ability in an upright and standing positionbecause of the massive removal, furthermore thelumbosacral nerve plexus could also be injured from theoperation.
  3. Post-operative complication would be prolonged adjuvantchemotherapy if hemicorporectomy were not performed.
  4. Tumor extraction might be impossible due to huge size inits coronal dimension.
  5. Intraoperative bleeding control might be unobtainable.
  6. Disease was still not systematically metastasis and curativedisease was still expected.

The second case is a 51-year-old female with recurrentgiant cell tumor at left proximal femur with lung metastasis.She was previously diagnosed with giant cell tumor at leftsacrum and ilium once, then underwent internal hemipelvectomyin 2009, but the disease recurred. She came to the hospital withprogressive peritonitis. The MRI in June, 2017 showed anextensive recurrent tumor in sacrum and left extraperitonealpelvis with extensive intra-abdominal, shown in Figure 2.

 

Figure 2 : The MRI illustrates an extensive recurrent tumor in sacrum andleft extraperitoneal pelvis with extensive intra-abdominal.

Indications for surgery in this patient were:

  1. Acute peritonitis with uncontrolled infection.
  2. Inadequate soft tissue coverage after simple externalhemipelvectomy.
  3. Benign bone tumor with chance of long term survival.

Operation procedures

On March, 2017, hemicorporectomy at level of L5-S1 wasperformed with agreement and consent of patient and herfamily. Multidisciplinary team including colorectal, urologic,vascular surgeons, ICU care team, endocrinologist, psychiatrists,and rehabilitation co-operated to prepare steps of operationand post-operative care. Patient was laid in supine position.The operation started with ligation of IVC and bilateralinternal iliac a. Ureterostomy and colostomy was donerespectively. Abdomen was temporarily closed for furtheroperations.Hemicorporectomy: A Case Report

Anterior discectomy was performed first with intraoperativefluoroscopy to check the accurate level of lumbarspine needed to be cut. Orthopedic surgeon then dissectedanterior femoral thigh flap and ligated, shown in Figure 3.Patient was changed into prone position. Curve incision withvertical line incision was done at the level of L5. Laminectomywas done at L4-L5 with intra-operative fluoroscopy to checkthe accurate level. Vertebral body of L4 and L5 were cut attheir intervertebral disc. Paravertebral muscles and psoasmuscle were cut and extracted lower extremities from theproximal part, distal part of body shown in Figure 4. Bleedingwas checked and ligation was done before the stump wasfinally covered with flap. The whole operation lasted 16 hoursand total blood loss was 5,200 ml. Patient was supine againand maturity colostomy was done.

 

Figure 3 : Illustrates the flap incision from anterior and posterior view respectively.

 

Figure 4 : Shows the dissected lower extremity with remnant of resected rectum as labelled.

During operation, blood loss was accurately calculated andreplaced. Overtransfusion can lead to pulmonary edemaeasily, since the total blood volume reduced dramatically bynearly one-half.

For post-operative care, patient was awake and able toextubate one day post operation. She also showed signs ofadjustment disorder with anxious mood. Psycho-supportiveand hormonal replacement was provided (estrogen leveldropped secondary to bilateral salpingectomy.) The patient feltmore comfortable afterwards. However, this patient developedsurgical site infection with evidence of Enterobacter faecium,positive from pus culture. She was then given wounddebridement with intravenous vancomycin and the infectionsubsided.

After the patient was infection-free and pain was tolerated,rehabilitation was the next step in this patient. Upper-limbstrength-training exercises are required to provide adequate power for transfer and locomotion. Sitting upright startedin a semirecumbent position then sequentially increased theposition. Active range of motion exercise of upper extremities,breathing exercise with incentive breathing spirometer(Triflow) and muscle strengthening exercises were providedas tolerated. Seat cushion from cut-out foam was also appliedinstead of using total contact orthosis.

With aid from the rehabilitation department, a translumbarsocket was applied on 31 July 2017. No pressure sore wasdetected. The translumbar socket allowed her to move fromsupine to sit and transfer to wheelchair independently. Thesocket was designed to have ‘mail slots’ for the colostomy andureterostomy, shown in Figure 5. The platform was alsoplatform-extended to increase the stability. The socket wastailor-made. There was also an addition of a rocker bottom atthe distal platform to allow smoother forward progression byusing arms for a swing-through gait.

She can now change her own ureterostomy and colostomyby herself with a little assistance of her caregiver. She is independentof her self-care and was trained in basic wheelchairskills. She developed a fair sitting balance.

 

Figure 5 : Shows the translumbar socket with ‘mail slots’ for the colostomy and ureterostomy. With thissocket, this patient developed a fair sitting balance.

The second case was performed in June 2017, the patientunderwent hemicorporectomy at lumbar vertebrae 4 and 5 withthe usage of right anterior thigh flap. The steps were quitesimilar to the first case. The difference was that it started withtumor suction in the intra-abdominal area first and then thecolostomy was created. Hemicorporectomy at level L4-5 wasthen performed and the stump was covered with right anteriorflap. The duration of the entire operation was 14 hours, whichwas shorter than the first case and the total intra-operativeblood loss was 8,000 ml.

For post-operative care, the patient was provided with asimilar rehabilitation program to the first case, including upperlimb strengthening and breathing exercises. The patientdeveloped wound dehiscence and wound infectionpostoperatively, which are common complications afterhemicorporectomy. After multiple debridement and intravenousantibiotics, the infection subsided.

Hemicorporectomy is a major operation that refers to anamputation of pelvis and lower extremities with constructionof ureterostomy and colostomy. These two cases were patientswho suffered from bone and soft tissue tumors.

A review of literature shows that the steps of operationhave not changed significantly since 1960. The first case inthe world introduced the single stage anterior-to posteriorapproach, where direct closure of the lower abdominal woundwas performed in a fish-mouth fashion.1,3,5 An early breakdownof this tension resulted in exposure of the spinal canal, whichled to meningitis and further cerebral empyema.1 The standardmethod is the two-stage anterior-to-posterior approach.Musculocutaneous subtotal thigh flap, based on the superficialfemoral vessels was used to provide a tension-free closure andample cushioning for the amputated lumbar spine.1 However,there was a study from the southwestern surgical congress in2008 that introduced another approach: the posterior-toanteriorapproach. This involved early division of the vertebralstructures and spinal cord, pre-empting engorgement ofBatson’s plexus, which was purported to minimize blood lossand improve exposure of pelvic vessels.6

In our practice, we performed the standard method; twostage anterior-to-posterior approach with the usage of thighflap. The step of operation starts with ligation of main vessel,creating the ureterostomy and colostomy and disarticulationthe lumbar spine.

The total blood loss was 5,200 ml and 8,000 ml for the firstand second case respectively. There was neither post-operative meningitis nor cerebral empyema. Even though the second case was more complicated, the operation did take less time(16 and 14 hours respectively) due to the surgeons’ experienceand well-prepared planning.

During the operation, blood loss was accurately calculatedand replaced. Overtransfusion can lead to pulmonary edemaeasily, since the total blood volume reduced dramatically. Thiscan be prevented by monitoring the central venous pressureclosely. If it begins to surge, rate of transfusion should bereduced. The post-operative amount of intravenous crystalloid/colloid given to patient was also calculated with half of thepre-operative body weight. Urine output, central venouspressure, blood pressure, hematocrit were all used as parametersto detect adequacy of circulating blood volume.7

For post-operative care, both of the cases developed wounddehiscence and wound infection that responded to adequatedebridement and intravenous antibiotics. They both also hadrecurrent urinary tract infections due to loss of sphincter. Thesepatients also had a risk of depression and adjustment disorder due to major operation and intolerable pain. A psychiatristshould assess the patient before and after the operation. Nutritional maintenance is also a critical factor. The majorityof patients are not achieving the nutritional goal until about 3 to 4 weeks postoperatively due to decreased intake and increasedmetabolic demands. Intravenous alimentation shouldbe started preoperatively and carried through to the postoperativeperiod.

Furthermore, body surface area loss by half affects heatevaporation and temperature regulation, causing these patientsto have difficulty in regulation of body temperature.1

Another point need to be concerned with is rehabilitation. For the best quality of life after the operation, we should promoteupper limb strengthening training, not only post-operatively,but should start right at the moment we decide to performa hemicorporectomy. The sooner the training begins, the morepowerful the upper limbs become. Therefore patients withgood upper limb muscle power tend to have better recoverypost-operatively. The ROM exercise, breathing exercise, sittingbalance and wheelchair training are also crucial for everypatient.

Hemicorporectomy is an operation of disarticulation ofpelvis and lower extremities. It is an undeniably a majoroperation, but not a harmful one. With a well-organizedmultidisciplinary team and good comprehension of operationsteps, hemicorporectomy can be performed safely as alife-saving operation.

A review of literature shows that the steps of operationhave not changed significantly since 1960. The first case inthe world introduced the single stage anterior-to posteriorapproach, where direct closure of the lower abdominal woundwas performed in a fish-mouth fashion.1,3,5 An early breakdownof this tension resulted in exposure of the spinal canal, whichled to meningitis and further cerebral empyema.1 The standardmethod is the two-stage anterior-to-posterior approach.Musculocutaneous subtotal thigh flap, based on the superficialfemoral vessels was used to provide a tension-free closure andample cushioning for the amputated lumbar spine.1 However,there was a study from the southwestern surgical congress in2008 that introduced another approach: the posterior-toanteriorapproach. This involved early division of the vertebralstructures and spinal cord, pre-empting engorgement ofBatson’s plexus, which was purported to minimize blood lossand improve exposure of pelvic vessels.6

In our practice, we performed the standard method; two stage anterior-to-posterior approach with the usage of thighflap. The step of operation starts with ligation of main vessel,creating the ureterostomy and colostomy and disarticulationthe lumbar spine.

The total blood loss was 5,200 ml and 8,000 ml for the firstand second case respectively. There was neither post-operativemeningitis nor cerebral empyema. Even though the second case was more complicated, the operation did take less time(16 and 14 hours respectively) due to the surgeons’ experienceand well-prepared planning.

During the operation, blood loss was accurately calculatedand replaced. Overtransfusion can lead to pulmonary edemaeasily, since the total blood volume reduced dramatically. Thiscan be prevented by monitoring the central venous pressureclosely. If it begins to surge, rate of transfusion should bereduced. The post-operative amount of intravenous crystalloid/colloid given to patient was also calculated with half of thepre-operative body weight. Urine output, central venouspressure, blood pressure, hematocrit were all used as parametersto detect adequacy of circulating blood volume.7

For post-operative care, both of the cases developed wound dehiscence and wound infection that responded to adequatedebridement and intravenous antibiotics. They both also hadrecurrent urinary tract infections due to loss of sphincter. Thesepatients also had a risk of depression and adjustment disorder due to major operation and intolerable pain. A psychiatristshould assess the patient before and after the operation. Nutritional maintenance is also a critical factor. The majorityof patients are not achieving the nutritional goal until about3 to 4 weeks postoperatively due to decreased intake and increasedmetabolic demands. Intravenous alimentation shouldbe started preoperatively and carried through to the postoperativeperiod.

Furthermore, body surface area loss by half affects heatevaporation and temperature regulation, causing these patientsto have difficulty in regulation of body temperature.1

Another point need to be concerned with is rehabilitation.For the best quality of life after the operation, we should promoteupper limb strengthening training, not only post-operatively,but should start right at the moment we decide to performa hemicorporectomy. The sooner the training begins, the morepowerful the upper limbs become. Therefore patients withgood upper limb muscle power tend to have better recoverypost-operatively. The ROM exercise, breathing exercise, sittingbalance and wheelchair training are also crucial for everypatient.

Hemicorporectomy is an operation of disarticulation ofpelvis and lower extremities. It is an undeniably a majoroperation, but not a harmful one. With a well-organizedmultidisciplinary team and good comprehension of operationsteps, hemicorporectomy can be performed safely as alife-saving operation.