overview on pelvic resections: surgical considerations and

BACKGROUND■ The pelvis is a relatively common anatomic location formetastatic and primary musculoskeletal tumors. Surgical re-section is more challenging in the pelvis than in other locationsbecause of the complex anatomy and the proximity to vital ab-dominal viscera and major blood vessels and nerves. Makingdecisions about surgical resectability of a tumor involves theassessment of possible osseous or neurovascular involvement,in addition to the possible involvement of adjacent viscera(ie, bowel, ureter, and bladder). Therefore, preoperative eval-uation and extensive imaging are critical. Osseous resectionand reconstruction usually are carried out adjacent to majornerves, beneath the iliac vessels, or adjacent to the bladder orbowel.■ Tumor surgery around the pelvis has the highest rate ofcomplications, infections, and mechanical failure of allanatomic sites.

ANATOMY (FIG 1)Pelvic NervesSciatic Nerve■ The sciatic nerve arises from L4, L5, S1, S2, and S3. Thenerve emerges from the pelvis through the greater sciatic notchinferior to the piriformis muscle and enters the thigh lateral tothe ischial tuberosity. In 10% of patients, the sciatic nerve pen-etrates the substance of the piriformis muscle. The sciaticnerve is accompanied by the inferior gluteal artery.■ It is essential to protect the sciatic nerve early in most pro-cedures. Inside the pelvis, the nerve should be identified dis-tally at the greater sciatic notch. Proximally, it should bepicked up below the psoas muscle. The sciatic nerve is formedat the junction of the lumbar sacral plexus where these twotrunks come together.■ Great care must be taken as the nerve exits the pelvis at thelevel of the greater sciatic notch not to injure the the accompa-nying inferior and superior gluteal nerves and arteries, becausethese supply the abductors as well as the gluteus maximusmuscle. The gluteus maximus muscle is essential for closure ofmost pelvic resections.

Femoral Nerve■ The femoral nerve arises from posterior divisions of the ven-tral rami of L2 and L3 and passes inferolaterally between thepsoas and iliacus muscles. It passes over the superficial iliacusmuscle to enter the proximal thigh underneath the inguinal lig-ament, just lateral to the superficial femoral artery.■ This nerve is almost always preserved during pelvic resec-tions. It should be identified early during most procedures.The femoral nerve is identified in the space between the iliacusand psoas muscles as they exit the pelvis. The femoral nervelies just below the fascia, bridging the interval between the twomuscles, lateral to the femoral artery and vein.

Obturator Nerve■ The obturator nerve, formed from the anterior branches ofL2, L3, and L4, is the largest nerve formed from anterior divi-sions of the lumbar plexus. The nerve descends thru the iliop-soas muscle and courses distally over the sacral ala into thelesser pelvis, lying lateral to the ureter and under the internaliliac vessels. It then traverses the obturator foramen into themedial thigh, under the superior pubic ramus, dividing intoanterior and posterior branches.■ This nerve is routinely transected during pelvic floor resec-tions (type 3) due to its intimate proximity to the tumor.

Lumbar Plexus Sensory Nerves■ The iliohypogastric (L1), ilioinguinal (L1), genitofemoral(L1, 2) and lateral femoral cutaneous nerves, which arisesfrom L2 and L3, travel downward laterally along the iliopsoasmuscle, pass underneath the lateral aspect of the inguinal liga-ment, and pass just distal and medial to the anterior superioriliac crest to innervate the anterolateral thigh.■ This nerve is sacrificed during most pelvic surgical procedures.

Pelvic VesselsAortic Bifurcation■ Descending the abdomen to the left of the vena cava, theaorta bifurcates at the level of L4 into common iliac vessels atthe level of L4–L5. The common iliac bifurcates into internaland external iliacus vessels at the level of S1, the ala sacralis.The level of these bifurcations may vary, especially if the ves-sels are pushed by a large adjacent tumor mass.■ It is essential to identify two levels of bifurcations prior toany ligation: the aortic bifurcation and the common iliac bifur-cation. Even the best surgeons have ligated the wrong vesselsdue to distorted anatomy. Such a misstep is especially possiblewith tumors that cross the midline. Preoperative evaluationwith angiography is required for evaluation and preoperativeto avert such an occurrence.

Common Iliac Artery■ The common iliac artery must be identified early to correctlyidentify the aorta as well as the the internal iliac (hypogastric)artery. To the surgeon, the major anatomic features of thecommon iliac artery are as follows:

■ No arterial branches arise from the artery (although thecommon iliac vein does have a major branch joining in, theiliolumbar vein)■ The bifurcation of the common iliac artery into the exter-nal and internal iliac arteries is at the exact level at whichthe ureter crosses on the adjacent peritoneal surface. Theureter is routinely identified at this location early in theretroperitoneal dissection.

External Iliac Artery■ The external iliac artery contributes to the inferior epigastricartery and extends distally, as the superficial femoral artery,

Chapter 17Ernest U. Conrad III, Jason Weisstein, Jennifer Lisle, Amir Sternheim, and Martin M. Malawer

Overview on Pelvic Resections:Surgical Considerations and Classifications

1

13282_ON-17.qxd 3/22/09 10:45 AM

into the femoral triangle, where it is a useful landmark in iden-tifying neighboring structures.

Internal Iliac Artery■ The internal iliac (hypogastric) artery descends from thelumbosacral articulation to the greater sciatic notch andbranches into several arteries. The internal iliac artery and veinoften are difficult to identify or ligate. The internal iliac arterylies on top of its vein, which often is large and is easily injured.The hypogastric vessels are routinely ligated in performingmodified hemipelvectomies as well as many pelvic resections.

ANTERIOR BRANCHES

■ The obturator artery exits the pelvis via the obturator canal(beneath the superior pubic ramus).■ The inferior gluteal artery curves posteriorly between thefirst and second or second and third sacral nerves, then runsbetween the piriformis and coccygeus muscles or through thegreater sciatic foramen into the gluteal region below the piri-formis muscle.

POSTERIOR BRANCHES

■ The iliolumbar artery ascends posterior to the obturatornerve and external iliac vessels to the medial border of thepsoas. It then divides into the lumbar branch, to the psoas andquadratus lumborum muscles and to the spinal cord, and aniliac branch, to the iliac, gluteal, and abdominal musculature.The iliac branch often is ligated during surgery.■ The superior gluteal artery runs posteriorly between the lum-bosacral trunk and first sacral nerve and leaves the pelvisthrough the greater sciatic foramen superior and posterior to thepiriformis muscle. Great care must be taken to preserve thegluteal vessels and nerves when performing types 1 and 2 pelvicresections.

Ureter■ The ureter originates from the renal pelvis at the level of L1and courses in the retroperitoneum to the medial surface of thepsoas major muscle, crossed by spermatic or ovarian vessels.The ureter crosses from lateral to medial on the surface of theperitoneum at the level of the common iliac bifurcation. Thisis a good landmark to identify the ureter during the initialretroperitoneal dissection. The ureter then courses medially atthe level of the sciatic notch to insert into the trigone of thebladder.

Corona Mortis■ The corona mortis is an anastomosis of the external iliac, in-ferior epigastric, and obturator vessels located in the retropu-bic region approximately 3 cm from the symphysis pubis.Laceration during an ilioinguinal approach can lead to exten-sive bleeding. The retroperitoneal space between pubis andbladder is called the space of Retzius.

Inguinal Canal■ The anatomic confines of the inguinal canal are described as4 cm from the deep inguinal ring to the subcutaneous ring.This “deep ring” is the “direct” inguinal space originating lat-eral to the epigastric vessels. Hesselbach’s triangle is the “indi-rect” hernia space originating medial to the epigastric vessels.■ The inguinal contents vary by gender:

■ In males, the spermatic cord contains the ductus deferens,testicular artery, pampiniform plexus, lymphatics, auto-nomic nerves, the ilioinguinal and genital branches of thegenitofemoral nerve, the cremasteric artery and muscle, andthe internal spermatic fascia.■ In females, the inguinal contents include the round liga-ment and the ilioinguinal nerve.■ The anterior inguinal wall is formed by the aponeurosis ofthe external oblique and internal oblique (lateral) muscles.■ The posterior inguinal wall runs medial to lateral and isformed by the reflected inguinal ligament, the inguinal falx,and the tranversalis fascia.■ The superior or cephalic inguinal wall is formed byarched fibers of the internal oblique muscle and the trans-verse muscle of the abdomen.■ The inferior or caudal inguinal wall is formed by the in-guinal and lacunar ligaments.

BoundariesSciatic Notch■ The sciatic notch should be identified early in surgery, bothinternally and externally, to protect the sciatic nerve andgluteal pedicles.

Osseous Boundaries■ The superior cephalad margin of the pelvis is defined by theilium and the rim of the great sciatic notch.

Posterior Margin■ The posterior margin of the pelvis is bounded by the piri-formis muscle and the superior gluteal vessels and nerve.Posterior to the piriformis muscle, the internal pudendalvessels and nerve course medially off the sciatic nerve andthe posterior femoral cutaneous nerve, anterior to thepiriformis.

2 Part 4 ONCOLOGY • Section I I I SPINE AND PELVIS

FIG 1 • The bony pelvis and its relation to the major blood ves-sels, nerves, and visceral organs. (Courtesy of Martin M. Malawer.)

13282_ON-17.qxd 3/22/09 10:45 AM

Inferior Margin■ The sacrospinous and sactrotuberous ligaments are releasedduring type 1 and 2 pelvic resections.

INDICATIONSRecurrent Benign Tumors■ Major pelvic resections rarely are performed for benignbony tumors. Occasionally, following multiple recurrence orwhen tumors are limited to either the superior or inferiorpubic rami, pelvic resection is indicated.■ Such benign tumors include large osteochondromas or anyosteochondroma associated with multiple hereditary exosto-sis, due to the high risk of secondary chondrosarcoma.■ Osteoblastoma occuring in the ilium or periacetabulum■ Giant cell tumors or aneurysmal bone cysts have a predilec-tion for the superior pubic ramus and supra-acetabulum.

Primary Malignant Osseous Tumors■ Osteosarcoma

■ Five percent of all osteosarcomas occur in the pelvis.Partial pelvic resection or hemipelvectomy (amputation) isrequired, usually following induction chemotherapy.

■ Ewing sarcoma■ About 25% of all Ewing sarcomas occur in the pelvis.Surgical resection is required.■ Radiation therapy remains controversial in treating pelvicEwing sarcoma.■ Resection should be performed only following inductionchemotherapy.

■ Chondrosarcoma■ Chondrosarcomas are the most common primary malig-nant bony tumors of the pelvis.

■ They often are much larger than plain radiographs indi-cate. Further imaging with CT and MRI often demonstratesa very large myxomatous component.

Metastatic Adenocarcinoma: Breast, Prostate, Renal,Lung, Colon■ Metastatic adenocarcinoma most commonly involves iliacor periacetabular sites. Most metastatic tumors to the pelvisare treated adequately with radiation therapy.■ Occasionally, there may be significant acetabular destruc-tion with an impending pathological fracture that requires sur-gical reconstruction.■ Renal cell carcinoma (hypernephroma) metastases are anexception. These metastases often require surgical removal, ei-ther by resection or by curettage and cryosurgery. Preoperativeembolization always is required for these vascular tumors toavoid severe bleeding during surgery.

Soft Tissue Sarcomas■ Retroperitoneal soft tissue sarcomas are more common thanintraperitoneal sarcomas and must be evaluated for gastroin-testinal, genitouretal, vascular or peripheral nerve involvement.

IMAGING AND OTHER STAGINGSTUDIESPlain Radiography■ Plain radiography (FIG 2) is of limited value in the assess-ment of pelvic girdle lesions. Images often are obscure andconfusing.■ The pelvis, particularly the sacrum, is a difficult structurein which to recognize early bone lesions, and major bone le-sions initially may be overlooked. For these reasons, there

Chapter 17 OVERVIEW ON PELVIC RESECTIONS: SURGICAL CONSIDERATIONS AND CLASSIFICATIONS 3

FIG 2 • A. Plain radiographs revealing a large lytic lesion of theright periacetabular region. On the basis of this radiograph, it ap-pears that the cortices are intact. B. Anteroposterior plain radi-ograph of the pelvis, read as normal. C. Plain radiographs reveal-ing a cartilage-forming lesion in the left ilium. On the basis ofthis study alone, it seems that this is an intraosseous lesion. Plainradiographs performed 24 hours after a CT-guided core needlebiopsy of a sacral lesion (note the coil) (D) and after 6 weeks (E).

B

D

A

C

E

13282_ON-17.qxd 3/22/09 10:45 AM


should be a low threshold for performing further imaging, es-pecially for initial screening and the postoperative evaluationof reconstructions.

CT and MRI■ CT with intravenous contrast and three-dimensional recon-struction is the optimal technique for assessing the extent ofbone involvement and destruction, the osseous anatomy, andthe relation between the tumor and the major blood vesselsof the pelvis (FIG 3). It is valuable for depicting any distortionof the pelvic anatomy, and aiding in the evaluation of thetumor to decide whether it is resectable. Chest CT is essentialfor staging purposes in evaluation for pulmonary metastases.■ MRI with constrast is critical for imaging soft tissue (ie, ves-sels, nerve, muscle) and osseous involvement. MRI is the opti-mal modality for imaging soft tissue and marrow involvement.It is attractive for assessment of osseous disease and sacral in-volvement, and may be helpful with the serial assessment ofneoadjuvant (induction) therapy.

Bone Scan■ Three-phase bone scan is used to rule out systemic metasta-sis and to assess the focal osseous involvement and tumor vas-cularity in the initial flow phase. A decrease in vascularity afterinduction chemotherapy may indicate response to treatment.

Angiography■ Angiography is mandatory for determining the vascularanatomy that often is distorted by large pelvic tumors (FIG 4).It is essential to determine the level of the various bifurcationspreoperatively and to rule out vascular involvement by thetumor. Embolization of the tumor blood supply before surgeryis helpful in minimizing blood loss, especially with vascular tu-mors and tumors with sacral involvement.

Venography■ The pelvic veins always are much larger than their arterialcounterparts. Preoperative venography is used to rule outtumor (mural) thrombi, a common finding in chondrosarcomas

and osteosarcomas. Their presence may change the plannedsurgical approach.

FDG-PET■ Fluorine-18 2-fluoro-2-deoxy-D-glucose-positron emissiontomography (FDG-PET) may be useful in assessing the“grade” of malignancy, evaluating response to neoadjuvantchemotherapy, and monitoring for local recurrence. Positronemission tomography (PET) combined with CT or MR is use-ful for “co-registered” imaging. PET CT scans are useful inearly detection of small recurrences. It plays only a minimalrole in preoperative planning in determining the extent of sur-gical resection.

Biopsy■ The purpose of biopsy is to yield a valid tumor diagnosis(benign vs. malignant), tumor grade (high vs. low grade), and

A B C

FIG 3 • A. CT showed extensive bone destruction and extension of the tumor to the pelvis and the rightgluteal region. B. CT of the pelvis revealed a large destructive lesion of the sacrum. C. CT shows anextensive tumor on the medial aspect of the ilium with destruction of the inner table and extension of thepelvis. (A,B: Courtesy of Martin M. Malawer; C: Reprinted with permission from Cancer: Principles andPractice of Oncology, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 1997;38.3:1789–1852.)

FIG 4 • Preoperative angiography and embolization of themetastatic lesion shown in Fig 3A. (Courtesy of Martin M.Malawer.)

13282_ON-17.qxd 3/22/09 10:45 AM

tumor subtype (eg, leiomyosarcoma vs. malignant fibroushistiocytoma).■ Biopsies may be performed by either open or needletechnique.■ Because open biopsy for pelvic tumors is an extensive pro-cedure, needle biopsy—especially CT-guided needle biopsy—always is performed initially for both metastatic and primarypelvic tumors.■ Biopsy technique should follow established guidelines for in-cision placement within the line of eventual resection, mini-mize contamination of normal tissues (eg, achieve adequatehemostasis at biopsy closure), and retrieve an adequate speci-men for frozen section diagnosis. The biopsy should avoid thegluteal and groin areas, because they are potential sources forflaps for skin closure after anterior and posterior hemipelvec-tomy, if necessary.■ Use of the utilitarian surgical incision for open biopsy isrecommended.

Anatomic Considerations■ Evaluation of the full anatomic extent of a pelvic tumor can-not be based on a single imaging modality. Combined data,gained from two or more imaging modalities, allow a realisticappreciation of the exact anatomic extent. Even when that in-formation is available, however, the full extent of a pelvictumor often is underestimated preoperatively.■ Review of any imaging study of the pelvis, because of thenumerous anatomic details, must be performed very methodi-cally. The authors review the structures from the back (mid-sacral region) and follow the pelvic girdle to the front (symph-ysis pubis), as described in the following paragraphs.

Sacrum, Sacral Alae, and Sacroiliac Joint■ Most patients who undergo extended hemipelvectomy,which necessitates transection of the sacrum through the ipsi-lateral neural foramina, regain function of the gastrointestinaland genitourinary tracts. Adding a contralateral compromise ofthe sacral nerve root will create a severe dysfunction. Tumorsthat penetrate the sacrum and cross the midline are consideredunresectable because of the involvement of bilateral nerve roots(FIG 5). The tumor can be resected, but the morbidity out-weighs the questionable oncologic benefit from surgery.■ The common iliac vessels are just anterior to the sacral ala,and any cortical breakthrough by a tumor in that site may be

expected to extend directly to the blood vessels. The sacroiliac(SI) joint is a key anatomic landmark. The major nerves andblood vessels are medial to it; therefore, any tumor or pelvicresection lateral to the SI joint may be expected not to violatethe major neurovascular bundle. Involvement of the SI jointmust be documented prior to surgery by using the combina-tion of CT, MRI, and bone scan.

Major Pelvic Blood Vessels and Structures■ The common iliac artery bifurcates along the sacral ala, andthe ureter crosses the bifurcation on each side. Large tumorsaround the sacral ala commonly displace and occasionally in-vade these structures. The mere presence of a major blood ves-sel or a pelvic viscus involvement is not an indicator of unre-sectability. Direct tumor involvement is rare. If necessary andcurative resection is planned, both structures can be excised enbloc with the tumor and then can be repaired with a graft.However, when a compound resection (bony pelvis and viscusresection) is anticipated, the patient must be informed, andsurgical assistance and necessary equipment must be preparedin advance.

Sacral Plexus■ Current imaging techniques cannot accurately identifynerves. Nerve involvement, therefore, is assumed on the basisof the pain pattern, physical examination, and the presence ofthe tumor in close proximity to a site in which a major nerveor plexus is usually located. Clinical evidence of femoral or sci-atic nerve dysfunction usually means direct tumor involve-ment. In most cases the presence and extent of nerve involve-ment is established only at the time of surgery. Sacral plexusinvasion by tumor has the same significance in terms of re-sectability as tumor invasion of the sacrum; bilateral involve-ment is an indicator of unresectability.

Sciatic Notch and Nerve■ The sciatic notch is the site of pelvic osteotomy in resectionsof the ilium or periacetabular region and in modifiedhemipelvectomy. CT establishes tumor extension to the sciaticnotch, a tight space through which the sciatic nerve and supe-rior gluteal vessels and nerve pass (FIG 6). The piriformis mus-cle, which divides the sciatic notch, is a key structure, becausethe sciatic nerve exits the pelvis underneath it and the superiorgluteal artery exits the pelvis above it. The patency of the su-perior and inferior gluteal arteries, which supply the glutealvasculature, is established by angiography. Adequate bloodsupply of the gluteal region is a major consideration in flap de-sign, and the artery must be preserved in any pelvic resection,if oncologically feasible. The artery is located only a few mil-limeters from the periosteum of the sciatic notch roof, and itshould be dissected carefully.

Ilium■ The inner aspect of the bone is covered by the iliacus muscle,which originates from the iliac crest. The iliacus is “pushed” bya growing bone sarcoma and serves as a major barrier to directextension of tumor to the anatomic structures of the pelvis.Therefore, the iliacus can be used as a safe oncologic margin forresection. In contrast, metastatic carcinomas to the pelvis tendto invade the covering muscle layer in their early growth stage,and a surgical plane between the tumor and nearby structurescannot be easily defined (FIG 7). Although any pelvic organ


FIG 5 • High-grade chondrosarcoma of the right sacrum, ilium,and periacetabular region, encasing the ipsilateral sacral foram-ina. Wide excision would necessitate resection through the con-tralateral sacral foramina, resulting in an unacceptable func-tional impairment. (Courtesy of Martin M. Malawer.)

13282_ON-17.qxd 3/22/09 10:45 AM


A

B

FIG 7 • A. The iliacus muscle (arrows) is “pushed” by a growingbone sarcoma and serves as a barrier to direct extension of thetumor to the pelvic viscera. High-grade sarcoma of the left ilium“pushing” the iliacus muscle (arrows) toward the midline.B. Metastatic carcinomas (arrows) to the pelvis tend to invadethe covering muscle layer. (Courtesy of Martin M. Malawer.)

FIG 6 • The sciatic notch is a tight space through which the sci-atic nerve and superior and inferior gluteal vessels and nervespass. The sciatic nerve exits the notch underneath the piriformismuscle, and the superior gluteal vessels exit the notch above it.(Courtesy of Martin M. Malawer.)

can be infiltrated by a tumor, structures that are anterior andposterior to the flare of the muscle (ie, sacral plexus, sciaticnotch and nerve, femoral vessels and nerve, bladder, andprostate) are at greater risk for direct tumor extension.

Extension to Pelvic Viscera■ Direct involvement of a pelvic viscus by a pelvic girdletumor is rare. Left-sided tumors are more likely to involve acomponent of the gastrointestinal tract because of its closeproximity to the pelvic girdle at that point. A rectal tube is in-serted preoperatively during any pelvic resection to facilitateidentification of the rectum during dissection.

Acetabulum and Hip Joint■ Wide resection of any bone tumor in the periacetabular re-gion, unlike a resection of the ilium or the pubis, imposes amajor impairment on the function of the hip joint. It usuallynecessitates en bloc resection of the proximal femur and acomplex prosthetic reconstruction.

Pubis■ The neurovascular bundle passes within the femoral trianglejust anterior to the superior pubic ramus. Tumors extending toor arising from the pubic ramus are in close proximity to thefemoral artery, vein, and nerve. In addition, the urethra passesstraight underneath the symphysis pubis. Vulnerable struc-tures such as a major blood vessel, nerve, or a viscus must beidentified and mobilized before resection. By identifying andisolating crucial srtuctures, the surgeon avoids iatrogenic in-jury during dissection. Establishing the relation of these vul-nerable structures to the tumor allows the surgeon to decidewhether to proceed with a limb-sparing procedure or performan amputation, make the necessary preparations for a vascu-lar graft (if needed), and perform a safe resection.

SURGICAL MANAGEMENTPreoperative PlanningRestaging studies■ Preoperative planning is crucial to obtain an optimal onco-logic and functional surgical result.■ Imaging studies are crucial in addressing the followingquestions: location and extent of the tumor, the type of pelvicresection that is necessary for adequate removal of the tumor,involvement of critical adjacent structures in the tumor mass(ie, ureter, aorta, inferior vena cava, bladder), and the type ofreconstruction that can be achieved.

■ Plain radiographs, CT scans, MRI scans, bone scans, and3D-CT angiographs are obtained to access the extent of os-seous and soft tissue involvement in all anatomic planes.The status of crucial adjacent structures—bladder, colon,ureter, inferior vena cava, sacral alar, and possible lumbarextent—is reviewed.■ Using angiography and venography, preoperative em-bolization is considered, and anatomic distortion and vesselocclusion and venous thrombus are assessed.

■ Consider possible need for prophylactic ureteral stents ifthere is evidence of preoperative ureteral obstruction ordisplacement.■ Medical and anesthesia personnel are consulted to assess med-ical risk, preoperative laboratory studies, and transfusion needs(eg, prepare red blood cell count, cryo, platelets, and plasma). Arisk of major blood loss during surgery is assumed, often equalto one total body transfusion (� 7% body weight in kg).■ Bowel preparation before surgery and ICU reservation alsoshould be considered.

13282_ON-17.qxd 3/22/09 10:46 AM

■ Orthotic brace is fabricated preoperatively for postoperativeuse.■ Colostomy planning and training must be considered if thereis left colon involvement, or large left-sided pelvic tumors, bothof which can be detected preoperatively with contrast-enhancedCT and colonoscopy.■ Appropriate prosthetic implants (eg, total hip replacementvs. saddle prosthesis), bone allograft, or other implants mustbe ordered.

Positioning■ At the time of surgery all patients should have a Foleycatheter and a rectal tube placed. The rectum is sutured

closed around the rectal tube to avoid iatrogenic contamina-tion during the operative procedure. During surgery the sur-geon may palpate the balloon of the Foley catheter in thebladder and the rectal tube through the wall of the rectum, toassist in proper identification of these structures. This is es-pecially helpful with large pelvic tumors, especially those onthe left side.■ Type 1 resection (iliac ): the patient is positioned in the lat-eral decubitus position with an anterior tilt to allow posterioraccess (FIG 8A–D).■ Type 2 resection (periacetabular): the patient is positionedin the lateral decubitus position for access to both the anteriorand posterior pelvis (FIG 8E,F).


D E F

G H

I

A B C

FIG 8 • Type 1 pelvic (ilium) resection can be either partial (A), in which only partof the ilium is transected, or complete (B). Partial (C) and complete (D) type 1 re-sections. E. Type II pelvic (periacetabular) resections. Reconstruction was per-formed with a saddle prosthesis. F. Type II pelvic resection. G–I. Type III pelvic(pubic) resection. These resections may include the superior pubic ramus (G), infe-rior pubic ramus, or both rami (H). I. Type III pelvic resection.

13282_ON-17.qxd 3/22/09 10:46 AM

■ Type 3 resection (pelvic floor): The patient is positionedsupine with the lower extremity flexed and abducted to pro-vide exposure of the retroperitoneal space, the femoral trian-gle, the perineum, the symphysis pubis, and the ischiorectalspace (FIG 8G–I).

Approach■ The utilitarian pelvic incision is indicated (FIG 9).■ The incision begins at the posterior inferior iliac spine andextends along the iliac crest to the anterior superior iliac spine.It is separated into two arms: one is carried along the inguinalligament up to the symphysis pubis; the other turns distallyover the anterior thigh for one-third the length of the thighand then curves laterally just posterior to the shaft of thefemur below the greater trochanter and follows the insertionof the gluteus maximus muscle. Reflection of the posteriorgluteus maximus flap exposes the retrogluteal space, the prox-imal third of the femur, the sciatic notch, the sciatic nerve thesacrotuberous and sacrospinous ligaments, the origin of the

hamstrings from the ischium, the lateral margin of the sacrum,and the entire buttock.■ The most useful approach to pelvic biopsy or resection is theutilitarian pelvic incision. All or part of the incision can beused for adequate exploration and resection of the majority ofpelvic girdle tumors.■ Significant concern exists regarding the possible extracom-partmental implantation of tumor cells following biopsy orresection of a pelvic tumor, procedures that are difficult to per-form under optimal hemostatic conditions. Unnecessary biop-sies must, therefore, be avoided. If biopsy is indicated, theproper technique and a suitable approach must be chosen. Thebiopsy tract must be positioned along the line of the future util-itarian incision, remote from the major neurovascular bundleand the abductors. CT-guided core needle biopsy is consideredto be an accurate and safe diagnostic tool in the diagnosis ofmusculoskeletal tumors and is the modality preferred by theauthors. The utilitarian incision may be used for hemipelvec-tomy by continuing the distal portion of the primary incisionposteriorly around and behind the thigh and bringing it anteri-orly along the inferior pubic ramus to the symphysis, thus en-circling the thigh but still allowing the large posterior flap to beused for primary wound closure.

Type 1 Resection: Iliac Resection■ The incision for an iliac resection is ilioinguinal, followingthe iliac crest and curving posteriorly at the level of the sacroil-iac joint. It then follows the length of the sacroiliac joint com-bined with a lateral incision to expose the outer portion of theilium, sciatic notch, and retrogluteal space

Type 2 Resection: Periacetabular Resection■ A combination of an anterior retroperitoneal approach andlateral anterior incision along the femur that curves posteriorlyis used for a periacetabular resection. A lateral, posterior-basedfasciocutaneus flap, called a gluteal flap, is then raised. Thispermits easy access and visualization of the retrogluteal space;hip joint, sciatic notch, sciatic nerve, and ischium, as well asthe supra-acetabular area needed for the superior osteotomy.

Type 3 Resection: Pelvic Floor and Pubic Region■ Three incisions are required for a resection of the pelvicfloor and pubic region. The main incision is the retroperi-toneal (ilioinguinal) incision to permit retroperitoneal explo-ration and mobilization of the major vessels and nerves.Twolongitudinal incisions are required to develop a distal-basedflap of the anterior thigh so as to expose the femoral triangleas well as the adductors attaching to the obturator foramen.One incision follows the perineal crease; the second begins atthe lateral portion of the ilioinguinal incision at the level of theanterior superior iliac spine.


FIG 9 • The utilitarian pelvic incision. (Courtesy of Martin M.Malawer.)

TEC

HN

IQU

ES Type 1: Iliac Resection■ The patient is placed in the lateral decubitus position

with a posterior tilt.■ The utilitarian pelvic incision is used. Its ilioinguinal com-

ponent is advanced medially to the symphysis pubis, andits posterior arm is brought to the level of the sacroiliacjoint (TECH FIG 1A,B).

■ All muscle attachments, with the exception of the iliacusand gluteus minimus and portions of the gluteus medius,

which are resected en bloc with the tumor, are removedfrom the iliac crest. The abdominal wall musculature, thesartorius muscle, and the tensor fasciae latae muscle aretransected from the iliac crest and reflected away fromthe ilium. The rectus femoris muscle remains intact. Theiliotibial band is transected from its origin from the iliaccrest and reflected posteriorly along with the gluteusmaximus. Large fasciocutaneous flaps are raised and re-flected medially and posteriorly.

13282_ON-17.qxd 3/22/09 10:46 AM

Chapter 17 OVERVIEW ON PELVIC RESECTIONS: SURGICAL CONSIDERATIONS AND CLASSIFICATIONS 9TEC

HN

IQU

ES

C

B

A

D

TECH FIG 1 • A. Incision and surgical approach. The entire utilitarian incision is used for type I resection. The posterior fasciocu-taneous flap exposes the entire retrogluteal area: the sciatic notch, the sciatic nerve, the abductor muscles, and the hip joint. Thisapproach provides a good exposure of the retroperitoneal space as well as the posterior retrogluteal area and permits a safe re-section of the ilium. The ilioinguinal component is advanced medially to the symphysis pubis and posteriorly to the sacrum (B).C. Posterior exposure and muscle releases. The abdominal wall musculature is transected off of the iliac crest. The sartorius andtensor fascia lata muscles are transected from their tendinous insertions and reflected distally. The rectus femoris muscle remainsintact. Large fasciocutaneous flaps are raised and reflected medially and posteriorly. The iliotibial band is transected from its ori-gin from the iliac crest and reflected posteriorly along with the gluteus maximus. D. Anterior (retroperitoneal) exposure. Theretroperitoneal space is easily exposed and explored through the ilioinguinal component of the incision. The plane betweenthe iliacus and the psoas muscle is developed with caution, because the femoral nerve lies in that space. The psoas muscle andthe femoral nerve are reflected medially, and the iliacus muscle is transected through its substance. The femoral nerve is pre-served. (continued)

13282_ON-17.qxd 3/22/09 10:46 AM


■ The plane between the iliacus and the psoas muscle is de-veloped cautiously, because the femoral nerve lies inthat space. The psoas muscle and the femoral nerve arereflected medially, and the iliacus muscle is transectedthrough its substance (TECH FIG 1C).

■ The external iliac artery, which lies against the lower mar-gin of the ilium, gives off no major branches along theinner table of the ilium; ligation of large blood vessels isnot required, therefore, in type I pelvic resection. Mosttumors of the ilium break through the outer table andpush the gluteus medius muscle laterally. The gluteusmedius muscle is transected through its substance, 2 to3 cm distal to the inferior border of the tumor (TECH FIG1D,E). It is important to try to save as much muscle bellyas possible because that will be the major component insoft tissue coverage of the pelvic content and will be nec-essary for reconstruction of the abductor mechanism.

■ Osteotomy of the ilium is performed using a malleableretractor, which is inserted through the greater sciaticnotch, along the inferior border of the inner table, andout just underneath the anterior superior iliac spine, toprotect the pelvic viscera (TECH FIG 1F). The ilium istransected as shown by the dotted line in the figure,leaving the origin of the rectus femoris muscle and theroof of the acetabulum intact. Osteotomy of the poste-rior aspect of the ilium is then performed; a malleable re-tractor is positioned through the greater sciatic notch,along the posterior border of the ilium, and parallel tothe ipsilateral sacral ala (insert, Tech Fig 1F).

■ The most important component of soft tissue reconstruc-tion is the attachment of the proximal rim of the gluteusmedius muscle to the abdominal wall musculature. Evenif the entire gluteus medius muscle was spared, the at-tachment of these two muscle groups, which are not

E F

TECH FIG 1 • (continued) E. Posterior exposure and release ofgluteal muscles. The retrogluteal area is exposed. The gluteusmaximus muscle is released from the iliotibial band and from thefemur and reflected posteriorly. The sciatic nerve is identifiedand preserved. All of the remaining abdominal muscles are re-leased from the wing of the ilium. The gluteus medius muscle istransected through its substance, 2 to 3 cm distal to the inferiorborder of the tumor. It is important to try to save as much mus-cle belly as possible. F. Supra-acetabular osteotomy and sacroil-iac disarticulation. A malleable retractor is inserted through thegreater sciatic notch, along the inferior border of the inner table,and out just underneath the anterior superior iliac spine, to pro-tect the pelvic viscera. The ilium is transected above the hip cap-sule, leaving the origin of the rectus femoris muscle and the roofof the acetabulum intact. Care is taken not to enter the hip joint.Insert: The sacroiliac joint is opened from within the pelvis. Theiliac vessels must be mobilized and retracted before attemptingto open the sacroiliac joint. G. Soft tissue reconstruction. The glu-teus medius muscle is sutured to the abdominal wall musculaturewith the ipsilateral lower extremity in abduction. Dacron tapemust be used to reinforce this reconstruction. The suture line alsois reinforced by oversewing the tensor fascia lata and sartoriusmuscles. (Courtesy of Martin M. Malawer.)G

TEC

HN

IQU

ES

13282_ON-17.qxd 3/22/09 10:46 AM


anatomically connected, creates a significant tension,which can be reduced by placing the lower extremity inabduction. The suture line is reinforced with the tensorfasciae lata and sartorius muscles with 3-mm Dacron tape(TECH FIG 1G). Closure of the muscle layer must bemeticulous, because poor healing and wound dehiscencewill expose the abdominal and pelvic contents and willbe difficult to manage.

Optional Reconstruction■ It is not necessary to reconstruct the resultant bony de-

fect, although allograft reconstruction has been reported.■ For iliac osseous reconstruction, allograft should be

thawed with permanent/tissue culture. Gram stain has ahigh rate of false positives and should be avoided.

■ Cut the allograft after careful sizing and orientation andfix with a 4.5-mm reconstruction plate. Use intraopera-tive radiographs to confirm screw placement.

■ Two deep soft drains (anterior and posterior) are placeddeep to the fascial closure.

Type 2: Periacetabular Resection■ The patient is in the lateral decubitus position with pos-

terior tilt to maximize anterior dissection.■ The utilitarian incision is used to expose both the ante-

rior (internal) and posterior (extrapelvic) aspects of thepelvis. The ilioinguinal incision is used to develop theretroperitoneal plane, and the posterior gluteus max-

imus fasciocutaneous flap is used to develop the retrog-luteal space.

■ The iliac vessels are mobilized first, and the hypogastricartery is identified and ligated. The sciatic and femoralnerves are identified and protected.

■ The level of osteotomy through the ilium is identifiedfrom within the pelvis, as are the superior pubic rami.Identification of the superior pubic rami requires mobi-lization of the external iliac and femoral vessels as theycross the ramus (TECH FIG 2).

■ A large posterior myocutaneous flap is developed withthe gluteus maximus muscle. The gluteus maximus muscleis detached from the iliotibial band and femur to enableit to be retracted posteriorly. This exposes the retroglutealspace: the ilium, sciatic notch, sciatic nerve, and hip joint.

■ The ischium is identified through the posterior incisionand is osteotomized above the level of the bicepsfemoris tendon insertion.

■ Complete removal of the periacetabulum requires re-lease of the sacrospinous ligament and some of thepelvic floor musculature. An ilioinguinal incision is usedwith a separate posterolateral hip incision for hip expo-sure and replacement, posterior column osteotomy, andexposure of the sciatic nerve.■ Three types of osteotomies may be used for periac-

etabular resection: (1) supra-acetabular osteotomy;(2) superior pubic ramus osteotomy; and (3) ischialosteotomy.

C

A

B

D E F

TECH FIG 2 • A. Plain radiograph showing an extremely high-grade malignant fibrous histiocytoma aris-ing from the superior and inferior pubic ramus involving the entire obturator foramen, pelvic floor, andmedial and supra-acetabular aspect of the acetabulum (solid arrows). B. Gross specimen following typeII/type III pelvic resection. C. Gross specimen following a complete internal hemipelvectomy (type I/typeII/type III pelvic resection). D. Radiograph of the resected specimen showing complete involvement ofthe hemipelvis. The defect superiorly was created by an open biopsy. E. Gross specimen of a combina-tion type II/type III pelvic resection. F. Gross specimen following a type III pelvic resection. A large tumormass is seen arising from the obturator internus muscle (solid arrows). A, acetabulum; IL, portion of theilium; IP, inferior pubic ramus and pubis; P, the entire pelvic floor, including the superior and inferiorpubic ramus; SP, superior pubic ramus; SY, symphysis pubis. (Courtesy of Martin M. Malawer.)

TECH

NIQ

UES

13282_ON-17.qxd 3/22/09 10:46 AM


■ A total hip exposure is used to identify the sciatic nerveand posterior column. The procedure is begun with dis-section of the external rotators and osteotomy of thefemoral neck, per total hip procedure.

■ Cut the femoral neck at the standard neck length (1.0 cmproximal to the lesser trochanter).

■ Incise the hip capsule peripherally with dissection of thesciatic nerve proximally to the sciatic notch.

■ The anterior and posterior columns are exposed to allowosteotomy of the acetabulum. Posterior column osteomyrequires careful exposure and retraction of the sciaticnerve and gluteal vessels.

Reconstruction After Type 2Resection■ Several choices are available for reconstruction follow-

ing a type 2 resection: composite allograft; saddle re-construction (Link, America); partial pelvic prosthesis(Stryker, Mahwah, NJ); various reconstruction rings withlarge phlanges; and ischiofemoral arthrodesis. Each hasunique techniques, complications, functional deficits,and results.

Composite Allograft AcetabularReconstruction■ Femoral component: ream and place the uncemented

femoral component through the posterior lateral ap-proach before proceeding with iliac osteotomy resection.

■ Acetabulum: ream the allograft for the acetabular com-ponent and place the acetabular component (cementand screws) into the allograft to confirm graft and ac-etabular orientation in situ with radiography beforescrew or cement fixation.

■ Check acetabulum positioning with radiographs beforeand after fixation or cementation. Orient the iliac graftbefore confirming the acetabular orientation, and fixthe graft with a reconstruction plate and screws. Use anextended polyethylene acetabular rim and consider alarge femoral head (32–36 mm) to improve postopera-tive stability.

■ Closure. Using the inguinal ligaments, reconstruct theabductors, especially if a trochanteric osteotomy wasdone. Perform pelvic closure at the iliac crest and in-guinal canal with wound drainage catheters.

Type 2: Resection and Reconstructionwith Saddle ProsthesisNotchplasty (Tech Fig 3A–C)■ A notch is created in the remaining ilium using a high-

speed burr. The notch should be placed in the thickest re-gion of the remaining bone (usually medial).

Preparation of the Proximal Femur■ The proximal femur is prepared as for a standard femoral

component. The intramedullary canal of the proximalfemur is reamed to accept the largest-diameter stem andallow for a 2-mm circumferential cement mantle. Oncereaming is completed, and the appropriate-sized stem(diameter and length) is selected, a distal femoral cement

plug is inserted to a depth of 2 cm below the tip of theselected femoral stem. The femoral canal then is irrigatedwith saline and packed with gauze. Once the cement(polymethylmethacrylate) is prepared, the gauze is re-moved, and the femoral prosthesis is cemented withinthe proximal femur.

Trial Reduction■ A reduction using trial components is critical in assessing

accurate length of the base component (intercalary seg-ment) and determining optimum soft tissue tension(TECH FIG 3D–K). The base component length shouldbe determined by the distance between the ilium andfemoral neck cuts, because the length indicated on thebase component is the total length from the notch ofthe saddle to the femoral collar. The base componentshould be selected so that reduction is barely possibleand there is minimum “play” in the reduced joint. Thesurgeon should be able to reattach the abductor mech-anism to its anatomic position on the osteotomizedgreater trochanter.

■ A trial reduction also can determine areas where the sad-dle component may impinge on the existing notch dur-ing intraoperative range of motion. These areas can befurther contoured with a high-speed burr to prevent im-pingement, which may result in limited motion or dislo-cation. Hip motion (flexion to at least 90 degrees, exten-sion to 30 degrees, abduction to 45 degrees, adductionto neutral, and rotation) should be possible without evi-dence of impingement or dislocation.

Abductor Mechanism Reconstruction■ The osteotomized greater trochanter and abductors are

reattached to their original location using cables. If thegreater trochanter was included in the resected speci-men, the abductor mechanism is reattached to the pros-thesis using 3-mm Dacron tapes or a cable system. Softtissue tension and prosthetic stability are again testedonce the abductor mechanism reconstruction is com-plete. The piriformis and short external rotator musclesare brought forward and reattached to the proximalfemur (or prosthesis). The gluteus maximus muscle isthen reattached to its insertion using nonabsorbablesuture (TECH FIG 3L–N).

■ Pelvic closure involves attachment of the inguinal canaland abdominal wall to the symphysis pubis and lateraliliac crest. Soft tissue tension and prosthetic stability aretested again once the abductor mechanism reconstruc-tion is complete. The piriformis and short external rota-tor muscles are brought forward and reattached to theproximal femur (or prosthesis). The gluteus maximusis then reattached to its insertion using nonabsorbablesuture.

■ For high type II pelvic resections, reconstruction shouldbe carried out with a partial pelvic prosthesis (Stryker,Mahwah, NJ).

Type 3 Resection: Pelvic Floor■ A utilitarian pelvic incision with a perineal extension is

used (three-incision approach).

TEC

HN

IQU

ES

13282_ON-17.qxd 3/22/09 10:46 AM


A B C

D

E

G

F

TECH FIG 3 • A. Photograph following a periacetabular resec-tion showing the remaining ilium (il), the sciatic nerve (S), thegreater trochanteric osteotomy (G), and the femoral head.B. Intraoperative photograph demonstrating the creation ofthe deep notch (large arrows). C. Reduction of the saddleprosthesis into the iliac notch (IL). The notch (solid arrows)must be as deep as the saddle and permit approximately45 degrees of flexion and extension, as well as abduction andadduction. D. Surgical exposure using the utilitarian pelvic in-cision. E. A large posterior fasciocutaneous flap based medi-ally permits the release of the gluteus maximus. F. Schematicdiagram of the mobilization of the periacetabular structuresand the three osteotomies that are necessary for a complete re-section of the acetabulum. G. Schematic of the “close-up” viewof the superior pubic ramus osteotomy. (continued)

TECH

NIQ

UES

13282_ON-17.qxd 3/22/09 10:46 AM

14 Part 4 ONCOLOGY • Section I I I SPINE AND PELVISTE

CH

NIQ

UES

■ The patient is positioned with the ipsilateral hip slightlyelevated.

■ The ilioinguinal component of the utilitarian pelvic inci-sion with a lateral and perineal (medial) extension isused (see Tech Fig 1G). This incision allows exposure andmobilization of the femoral vessels and nerve through adistal-based anterior flap.

■ Perineal extension of the incision is used to expose the is-chium, which is resected through the ischiorectal fossawhen the resection is performed for a large pubic lesion.

■ Large myocutaneous flaps are raised. The spermatic cordis reflected medially. The inguinal ligament is transectedfrom its pubic insertion and reflected laterally.

■ The neurovascular bundle (ie, the femoral artery, vein,and nerve) is retracted laterally, exposing the origin ofthe adductor magnus and pectineus muscles, which istransected off the pubis and reflected distally.

■ Using the lateral component of the incision, the originsof the hamstrings, adductors, and gracilis are transectedoff the ischium and reflected distally (TECH FIG 4).

■ The first malleable retractor is placed behind the symph-ysis pubis, in front of the bladder. The second malleableretractor is placed behind the superior pubic ramus andin front of the inferior pubic ramus, medial or lateral tothe ischium, depending on the required oncologic mar-gins (TECH FIG 4C).

K ML

N

TECH FIG 3 • (continued) H. Schematic diagram of the infra-acetabular osteotomy.I. A notch is made in the supra-acetabular roof or remaining ilium for the saddleprosthesis to sit in. J. Schematic diagram of the saddle prosthesis reduced into thenotch. K. Schematic diagram of the saddle prosthesis following a periacetabularresection for sarcoma and radical curettage for a large acetabular metastasis.Postoperative radiographs and CT scans demonstrating common postoperative ra-diographic findings. L. AP radiograph of the pelvis with a saddle prosthesis inplace. M. A 45-degree oblique radiograph of the affected side of the pelvis. N. CTscan showing a typical saddle prosthesis in good position. AB, abductor muscles; G,gluteal muscles; IC, iliacus muscle; S, sciatic nerve. (A–C, L–N: Courtesy of MartinM. Malawer; D–K, reprinted with permission from Malawer M. Reconstruction fol-lowing resection of primary periacetabular tumors. Semin Arthroplasty 1999;10:171–179.)

H I J

13282_ON-17.qxd 3/22/09 10:46 AM


■ Osteotomy through the symphysis pubis and pubicrami is performed. It is important to smooth the sharpbony edges, especially those that lie against thebladder.

■ Surgical wounds around the groin are notoriously asso-ciated with a high incidence of dehiscence and infec-tion. Meticulous wound closure with adequatedrainage is, therefore, mandatory. Continuous suctionis required for 3 to 5 days. Perioperative intravenousantibiotics are continued until the drainage tubes areremoved.

■ Postoperative mobilization with weight-bearing as toler-ated is allowed.

■ Rarely, reconstruction of the pelvic floor with Marlex (CRBard, Cranston, RI) mesh is required.

Type 4 Resection: Hemipelvic■ Table 1 describes hemipelvic resection, along with other

techniques.■ Combined, extended full pelvic dissection from symph-

ysis pubis to sacroiliac joint is required.■ Complete dissection of the sciatic notch, the hip joint,

the sciatic nerve, and the femoral vessels is required.■ Pelvic reconstruction is more challenging because of the

need for fixation at the sacrum and symphysis pubis andthe difficulty in orienting a pelvic graft.

■ Some surgeons do not recommend reconstruction but ac-cept 3 inches of shortening and the use of a pelvic long-leg brace.

■ A large amount of intraoperative blood loss andhemipelvic graft fixations present significant surgicalchallenges.

TECH FIG 4 • Incision. A. The ilioinguinalcomponent of the utilitarian pelvic incisionwith a modified perineal extension areused. B. Schematic of the three osteotomiesrequired to remove the pelvic floor.C. Transection of the symphysis pubis, supe-rior pubic ramus, and ischial osteotomy.(Courtesy of Martin M. Malawer.)

B

C

A

TECH

NIQ

UES

13282_ON-17.qxd 3/22/09 10:46 AM


Surgical Vessels Technique Position Incision Exposure and Nerves Resection Reconstruction ClosureType 1: Posterior Lateral with Ilioinguinal with External Careful dissection Iliopsoas, Allograft fixation with Abdominal walliliac resection anterior tilt or without sacral oblique and of femoral n. and osteotomy at 4.5-mm plate m. to pelvis with

extension abdominal m. vessels; iliac, iliac crest nonabsorbablegluteal vessels sutures and two

deep drains (anterior and posterior)

Type 2: Lateral Straight Ilioinguinal with External External iliac a. Hip joint, Ream allograft for Attach inguinalacetabular lateral separate posterior oblique off and v., obturator sciatic notch, acetabular placement; canal andresection lateral hip incision superficial n., gluteal external cement and screw abdominal wall

lateral crest vessels, sciatic n. rotators, with 4.5-mm plate to symphysism., expose hip femoral neck pubis and lateral

osteotomy iliac crestType 3: Anterior Supine Ilioinguinal Symphysis Femoral sheath, Between Soft tissue with Inguinal canalobturator incision with pubis to lateral femoral inferior pubic Martex/fascia allograft with

anterolateral posterior cutaneous n., ramus and or Gore-Tex if nonabsorbableextension lateral iliac obturator n., a., ischium, acetabular anterior sutures and deep

crest v. depending on column intact. If not drains; preventtumor location intact, then bony inguinal hernia

obturator allograftHemipelvic Lateral Ilioinguinal Symphysis to External iliac Iliac and hip, Allograft verse saddle Lateral crest and

lateral crest with or prosthesis ilioinguinal canaland external withoutiliac m. obturator

Gluteal Prone Posterior gluteal Gluteal m. Sciatic n., Deep proximalgluteal n., v., a. posterior

greater trochanter, if inferior to notch

Retroperitoneal Supine Symphysis to Midline if Iliac and gluteal Usually External oblique Reattach(soft tissue) posterolateral bowel is vessels, ureter, respects abdominal wall external oblique

ilium involved. femoral vessels iliopsoas reattached to pelvic to pelvic brimAbdominal/ and nerve, musculature brimexternal sciatic n.oblique off iliac crest

Inguinal groin Supine Pubic tubercle to Inguinal Femoral sheath, Inguinal canal Inguinal ligamentlateral iliac crest ligament, inferior epigastric

spermatic vesselscord, umbilical

Table 1 Summary of Pelvic Resection and Reconstruction Techniques

PEARLS AND PITFALLSVascular problems ■ Always have vascular control of the major vessels proximally and distally, both arterial and venous.

Intraoperative bleeding ■ Severe bleeding usually occurs with venous, not arterial, injuries. Suture and ligate all serious bleeders.

Thrombosis ■ All patients are at risk to develop an arterial thrombosis during or after surgery and should be evaluated (pulses) carefully during and for the first 72 hours. Always confirm adequacy of hemostasis and distal flow and pulses before leaving the operating room. If there is any question, perform an intraoperative or postoperative angiogram.

Postoperative bleeding ■ If bleeding continues, and coagulation factors rule out disseminated intravascular coagulation,and coagulopathy strongly consider taking the patient back to the operating room. Alternatively, perform an

angiogram with attempt at embolization of the bleeding vessel. The degree and timing of the bleeding are important in determining the correct course of action.

■ If massive (� 4.0–5.0 L) bleeding occurs during the dissection, pack the wound with local pressureuntil the patient’s blood pressure stabilizes.

13282_ON-17.qxd 3/22/09 10:46 AM

POSTOPERATIVE CARE■ The distal extremity pulses are checked immediately aftersurgery and every hour for the first 24 hours. Late arterialthrombosis often is due to intimal injuries.■ Persistent wound drainage usually is due to a largeretroperitoneal collection. If the wound continues to drainafter 4 to 7 days postoperatively, wound irrigation anddrainage in the operating room should be considered.■ All postoperative patients should have a pelvic radiographonce a week for the first 2 weeks.■ Postoperative complete blood cell count and laboratorystudies daily for the first week then twice per week.■ Postoperative mobilization is highly individualized:

■ Type 1 resection. Abdominal wall to abductors are main-tained in abduction for 7 days in bed and then in apelvic–thigh brace that avoids excessive adduction.■ Type 2 resection and reconstruction is very variable.Patients with a saddle prosthesis and composite allograft aremaintained on partial weight bearing for 3 to 6 months andneed a pelvic and thigh brace for 2 to 3 months.■ Patients with a type 3 resection with or without Marlexreconstruction are kept in bed with the lower extremity inneutral (it is necessary to avoid abduction) to avoid a per-ineal incision dehisence. A pelvic and thigh orthosis is usedfor about 3 months. Full weight bearing can be initiatedearly if the medial wall of the acetabulum was notinvolved.

COMPLICATIONSEarly■ Bleeding. Most problems with intraoperative bleeding occurwith venous, not arterial, bleeding. Coagulopathy and theneed for large blood transfusions are common complications.Coagulation factors, Ca, and Mg should be monitored.Patients should receive packed cells, fresh frozen plasma,platelets, Ca, and Mg as necessary during and after surgery.■ Arterial thrombosis occurs due to intimal flap tear andshould be monitored by distal pulse measurement with

Doppler, every hour for the first 24 hours. If arterial thrombo-sis occurs, immediate thrombectomy is required.■ Nerve. Postoperative femoral or sciatic neuropraxia arecommon and should be observed.■ Ureter/bladder. Patient should be evaluated for intraopera-tive hematuria or oliguria, which may suggest bladder orureter injury. Urine output is routinely measured hourly dur-ing surgery. The Foley urinary catheter is kept in place for 4 to7 days.■ Bowel injuries require repair or resection and possiblecolostomy.■ Major ileus is a common problem following extensive pelvicsurgery. The patient should be given nothing by mouth, witha nasogastric tube in place, until appropriate bowel sounds re-turn (usually 3–4 days).

Late Complications■ Infection. Deep infection develops in 20% to 30% of pa-tients following surgery. If such an infection occurs, the patientmust be taken back to the operating room, and the prosthesisand allograft must be removed, leaving the limb flail.■ Dislocation. The dislocation rate for a saddle prosthesis is5% to 10%. This rate may be even higher for “composite”reconstructions.■ Failure of the allograft may take the form of fracturethrough the allograft or failure of fixation.■ Prosthesis failure includes failure of the reconstruction ring,acetabular cup, screws, and plate.■ Morbidity and mortality after pelvic resection remains high.Hemipelvectomy may be required due to local recurrence, in-fection, or uncontrolled bleeding.

REFERENCES1. Aboulafia AJ, Buch R, Mathews J, Li W, Malawer MM.

Reconstruction using the saddle prosthesis following excision of pri-mary and metastatic periacetabular tumors. Clin Orthop Relat Res1995;(314):203–213.

2. Aljassir F, Beadel GP, Turcotte RE, et al. Outcome after pelvic sar-coma resection reconstructed with saddle prosthesis. Clin OrthopRelat Res 2005 Sep;(438):36–41.


■ Check prothrombin time, partial thromboplastin time, and platelet counts intraoperatively and every 6 hours for 24–48 hours.

■ Almost all patients need intensive monitoring following surgery.

Hypocalcemia ■ Calcium (Ca) always is required intraoperatively. Check the Ca level in the operating room andand Hypomagnesemia postoperatively.

■ Magnesium (Mg) loss is very common following a major bleed, especially in patients treated withinduction chemotherapy. The agent that most commonly causes Mg loss is cisplatinum. Patientsreceiving this form of chemotherpay routinely require a large amount of Mg postoperatively. If leftuncorrected, cardiac arrest may occur.

Nerve injuries ■ Iatrogenic injury may occur to femoral, sciatic, or sacral nerve roots. Injury occurs during dissection (neuropraxia) or sacral screw fixation. Obturator nerve sacrifice is not a significant functional loss.

Ureter and ■ Consider a preoperative ureteral stent for all large tumors. Foley catheter placement enables bladder injuries palpation of the bladded intraoperatively.

■ Repair bladder wall injuries in two or three layers. Check carefully for bladder injury if hematuria or oliguria occurs intraoperatively.

Hip ■ Check hip radiographically for stability prior to and after wound closure.

General ■ Remember that the first step in avoiding injury to the critical structures mentioned is taking the time to identify and tag all of them initially during dissection.

13282_ON-17.qxd 3/22/09 10:46 AM

3. Cottias P, Jeanrot C, Vinh TS, et al. Complications and functionalevaluation of 17 saddle prostheses for resection of periacetabular tu-mors. J Surg Oncol 2001;78:90–100.

4. Enneking WF, Dunham WK. Resection and reconstruction for pri-mary neoplasms involving the innominate bone. J Bone Joint SurgAm 1978;60:731–746.

5. Hillmann A, Hoffmann C, Gosheger G, et al. Tumors of the pelvis:complications after reconstruction. Arch Orthop Trauma Surg2003;123:340–344.

6. Ozaki T, Hoffmann C, Hillmann A, et al. Implantation of hemipelvicprosthesis after resection of sarcoma. Clin Orthop Relat Res 2002Mar;(396):197–205.

7. Renard AJ, Veth RP, Schreuder HW, et al. The saddle prosthesis inpelvic primary and secondary musculoskeletal tumors: functional re-sults at several postoperative intervals. Arch Orthop Trauma Surg2000;120:188–194.

8. Shin KH, Rougraff BT, Simon MA. Oncologic outcomes of primarybone sarcomas of the pelvis. Clin Orthop Relat Res 1994 Jul;(304):207–217.

9. Wirbel RJ, Schulte M, Mutschler WE. Surgical treatment of pelvicsarcomas: oncologic and functional outcome. Clin Orthop Relat Res2001 Sep;(390):190–205.


13282_ON-17.qxd 3/22/09 10:46 AM

overview on pelvic resections: surgical considerations and

Documents