- Open Access
En bloc resection of extra-peritoneal soft tissue neoplasms incorporating a type III internal hemipelvectomy: a novel approach
© Reddy and Bloom; licensee BioMed Central Ltd. 2012
- Received: 13 April 2012
- Accepted: 15 October 2012
- Published: 25 October 2012
A type III hemipelvectomy has been utilized for the resection of tumors arising from the superior or inferior pubic rami.
In eight patients, we incorporated a type III internal hemipelvectomy to achieve an en bloc R0 resection for tumors extending through the obturator foramen or into the ischiorectal fossa. The pelvic ring was reconstructed utilizing marlex mesh. This allowed for pelvic stability and abdominal wall reconstruction with obliteration of the obturator space to prevent herniations.
All eight patients had an R0 resection with an overall survival of 88% and with average follow up of 9.5 years. Functional evaluation utilizing the Enneking classification system, which evaluates motion, pain, stability and strength of the affected extremity, revealed a 62% excellent result and a 37% good result. No significant complications were associated with the operative procedure. Marlex mesh reconstruction provided pelvic stability and eliminated all hernial defects.
The superior and inferior pubic rami provide a barrier to a resection for tumors that arise in the extra-peritoneal pelvis extending through the obturator foramen or ischiorectal fossa. Incorporating a type III internal hemipelvectomy with a simple marlex mesh reconstruction allows for complete tumor resection without functional compromise, acute infectious issues, obturator or abdominal hernia defects.
- Bloc Resection
- Malignant Peripheral Nerve Sheath Tumor
- Pelvic Ring
- Obturator Foramen
- Ischiorectal Fossa
A novel approach to the en bloc resection of extra-peritoneal soft tissue neoplasms, incorporating a type III internal hemipelvectomy, to achieve clear surgical margins, was performed in eight patients.
The use of a type III internal hemipelvectomy in the resection of primary bone tumors has been widely employed. Type III resections, as classified by Enneking and Dunham involves resection of the superior and inferior pubic rami and obturator foramen . The use of type III internal hemipelvectomy for osseous lesions is not common. In two large series of internal hemipelvectomies, type III has been performed in three out of thirty patients (10%) , and in four out of fifty-eight patients (7%) . In this series of patients we have extended the indication for this procedure to soft tissue tumors arising in the extraperitoneal pelvis with extension through the obturator foramen into the adductor group, or into the ischiorectal fossa. This is a rare presentation for these tumors and any standard operative approach for a complete resection would lead to a violation of the tumor, as the central bony pelvis provides a barrier to an en bloc resection.
A type III hemipelvectomy is not without its associated complications, which include vascular, bladder and urethral injuries, as well as infections and wound issues related to the groin incision . No reconstruction of the pelvic ring has been used in many cases of type III internal hemipelvectomy, however, allografts and autografts are still utilized .
From 1987 to 2011 eight patients presented to NDB with soft-tissue tumors of the extra-peritoneal pelvis extending through the obturator foramen or into the ischiorectal fossa. We employed an operative technique in all of these patients that incorporated a central pelvic bone resection (type III internal hemipelvectomy), to achieve an en bloc resection and clear surgical margins. This technique was employed because these tumors both extended into and through the obturator foramen into the adductor group, or below the ischium.
After an uneventful hospital stay, he was discharged on post-operative day 7. He has had follow-up at three-, six- and nine-month intervals, and has been doing well. He reports occasional pain, however, is able to walk without assistance, has a well-healed incision with no signs of infection, and no evidence of a hernia. He has returned full-time to his occupation as an excavator.
Type III internal hemipelvectomy database
Enneking’s classification of two patients
Tumors of the extraperitoneal pelvis with extension through the obturator foramen, or into the ischiorectal fossa, present a surgical challenge to accomplish an en bloc resection. The intact pelvic ring prevents direct access for tumor resection. We have employed a surgical technique incorporating a type III internal hemipelvectomy to achieve an en bloc resection for tumors arising in this region.
The internal hemipelvectomy has been widely employed in lieu of a traditional hemipelvectomy for malignant tumors arising from the pelvic bone. In 1978 Enneking classified the internal hemipelvectomy into three types. Type I involves resection of the ilium, type II involves a periacetabular resection, and type III involves resection of the superior and inferior pubic rami. In our series of eight patients, a type III internal hemipelvectomy was performed to achieve an en bloc resection of the primary tumor, despite the lack of bone involvement. This approach allowed direct access to, and complete resection of tumors that extended through or under the bony barrier.
A simple technique utilizing Marlex mesh was used to reconstruct the bony defect and prevent obturator or ischiorectal herniations. Marlex mesh was utilized because it had been used extensively for the repair of primary or recurrent inguinal hernias. In a series of 3,000 patients there was an insignificant infection rate of 0.2% . Marlex mesh has also been used to repair extensive chest wall and abdominal wall defects following tumor resection , or in abdominal trauma with intra-abdominal sepsis . Its ability to stabilize the chest wall after major resections encouraged us to employ this material to restore and stabilize the pelvis. By re-attaching the abdominal and extremity musculature to its insertions and origins, all dead space was obliterated, thus eliminating one major contributor to deep space infections.
More sophisticated reconstructive techniques employing autografts or allografts have been utilized for type III reconstructions. Based on 206 patients who underwent pelvic resection at Massachusetts General (of whom 41 had allografts), Mankin reported a 20% infection rate in patients undergoing pelvic allografts . The majority of the 41 patients had undergone a more extensive pelvic resection in this series.
Non-union of pelvic allografts is another potential complication, as is graft failure . In our series of eight patients there was only one superficial wound infection, and no separation of the mesh from either its bone or muscle attachments. As such, it provides an excellent simple reconstructive technique to eliminate the obturator hernial defect, reconstitute the pelvic defect and reduce complications due to infection.
This operative approach allows for good to excellent functional outcomes without compromising tumor resection.
- Enneking WF, Durnham WK: Resection and reconstruction for primary neoplasms involving the innominate bone. J Bone Joint Surg Am. 1996, 6: 266-267.Google Scholar
- Wirbel RJ, Schulte M, Maier B, Koscnik M, Mutshler W: Chondrosarcoma of the pelvis: oncologic and functional outcome. Sarcoma. 2000, 4: 161-168. 10.1155/2000/635246.PubMed CentralView ArticlePubMedGoogle Scholar
- Lachman RD, Crawford EA, Hosalker HS, King JJ, Ogilvie CM: Internal hemipelvectomy for pelvic sarcomas using a T-incision surgical approach. Clin Orthop Relat Res. 2009, 467: 2677-2687. 10.1007/s11999-009-0843-5.View ArticleGoogle Scholar
- Bickels J, Malawar M: Pelvic resections (internal hemipelvectomies). Musculo Skeletal Cancer Surgery: Treatment of Sarcomas and Allied Diseases. Edited by: Malawar M, Sugerbaker P. 2001, Kluwar Academic Publishers, Boston, 405-414.Google Scholar
- Campanacci M, Capanna R: Pelvic Resections: the Rizzoli Institute Experience. Orthop Clin North Am. 1991, 22: 65-86.PubMedGoogle Scholar
- Enneking WF: Modification of the System for Functional Evaluation of the Surgical Management of Musculoskeletal Tumors in Limb Salvage in Musculoskeletal Oncology. Edited by: Enneking WF. 1987, Churchill Livingstone, New York, 626-639.Google Scholar
- Shulman A, Amid P, Lichenstein I: The safety of mesh repair for primary inguinal hernias: results of 3019 operations from five diverse surgical sources. Am Surg. 1992, 58: 255-257.PubMedGoogle Scholar
- Eng S, Sabanathan S, Mcarns AS: Chest wall reconstruction after primary malignant chest wall tumors. Eur J Cardiothorac Surg. 1990, 4: 101-104. 10.1016/1010-7940(90)90223-M.View ArticlePubMedGoogle Scholar
- Brown G, Richardson J, Polik H: Comparison of prosthetic materials forabdominal wall reconstruction in the presence of contamination and infection. Ann Surg. 1985, 201: 705-711.PubMed CentralView ArticlePubMedGoogle Scholar
- Mankin HJ, Hornicek F: Internal hemipelvectomy for the management of pelvic sarcomas. Surg Oncol Clin N Am. 2005, 14: 381-396. 10.1016/j.soc.2004.11.010.View ArticlePubMedGoogle Scholar
- Schwartz A, Eckardt MD, Beauchamp CP: Internal hemipelvectomy for musculoskeletal tumors – indications and options for reconstruction. US Oncol Hematol. 2011, 7: 123-5.Google Scholar
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