RU2638770C2 - Method for para-acetabular resection with acetabulum endoprosthetics in patients with pelvic bones tumour - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: operation begins with a "rear" surgical approach, which is performed in the gluteal region on the side of the lesion. The skin is cut along the gluteal fold, from its beginnings up laterally proximally to the outer border of the gluteal region, further the hypodermis and the underlying fascia are cut, the greater gluteus muscle is mobilized, the course of the sciatic nerve is found at the bottom of the large gluteal muscle, the large gluteus muscle is dissected proximally along the course of the sciatic nerve projection, and then the sciatic nerve is mobilized along its length and relegated to the side. The tumour is mobilized from the surrounding soft tissues, dissecting the middle and small gluteal muscles, and optionally adductors portions - semimembranosus muscle and semitendinosus muscle. After mobilization of the sciatic nerve and the soft tissue component of the tumour, the wound is sutured layer by layer without drains. The patient is turned to his back, performing ileo-inguinal access, from which para-acetabular resection is performed and an acetabulum endoprosthesis is installed.

EFFECT: method allows to expand the indications for organ-preserving surgical treatment in patients with acetabular tumour.

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Description

The invention relates to medicine, namely to surgery, and can be used in oncology when performing combined (paraacetabular) pelvic resections in the acetabulum in patients with primary and metastatic tumors of the pelvic bones.

There is a method of surgical treatment of pathological dislocation of the thigh with osteolysis of the head and neck, in which one-stage trochanteric arthroplasty is performed through two accesses, while the acetabulum is released in the front of the access, in the back of the access behind the broad fascia of the thigh, the muscles are peeled off and longitudinally dissected from the top of the greater trochanter , spherically model the cartilaginous part of its apophysis, cross the femur in the under-posterior region, maintaining the connection of the proximal fragment with muscles, perforate them in the form of a window under the gluteus maximus muscle, reposition the trochanter through the hole into the acetabulum, rotate the proximal fragment in three planes until the tip of the trochanter is centered in the acetabular fossa, carry out decortication of the trochanter portion from the lower part of the proximal femoral fragment, perform osteosynthesis of the fragments with a L-shaped plate end to the side at an age angle, they move to the end part of the bone sawdust mobilized together with the periosteum muscles and tensor of the wide fascia of the thigh (RU 2238688 C1).

The disadvantages of this method include the lack of ability to visualize and mobilize through the additional "posterior" access sciatic nerve and the general limitations of using the method in adults.

The closest standard surgical access to the hip joint and acetabulum used to perform paraacetabular resections with acetabular endoprosthetics for patients with pelvic tumor is retroperitoneal "inguinal-iliac" access, in which the incision starts from the upper anterior iliac spine to the dorsum projection of the middle of the inguinal ligament and further down along the projection of the femoral neurovascular bundle to the border of the middle and upper third of the thigh. If necessary, an additional incision is made from the projection of the middle of the inguinal ligament medially to the pubic symphysis. This surgical approach allows you to adequately visualize the femoral and iliac main vascular neurovascular bundles and pelvic organs (ureter, bladder), as well as fully remove the abdominal sac for better wound exposure (Zatsepin S.T. Bone pathology in adults: a guide for doctors M.: Medicine, 2001 .-- 563-567 p.).

The disadvantage of this access is the inability to visualize the sciatic nerve through it, the projection of which passes along the posterior surface of the hip joint, and, as a result, there is a high risk of its complete or partial trauma at the stage of tumor mobilization and removal, followed by the development of persistent neurological complications, which significantly reduce the patient’s quality of life and in some cases requiring crippling surgery in the amount of inter-iliac-abdominal isolation. Also, through the considered surgical approach, it is difficult to mobilize the deep component of the tumor located in the back of the acetabulum, which can reduce the radicality of the surgical intervention.

The technical result of the invention is the expansion of indications for organ-preserving surgical treatment of patients with tumor lesions of the acetabulum, simplification of the technique for performing the operation, improvement of oncological and functional results after the operation.

The specified technical result in the implementation of the invention is achieved due to the fact that, as in the known method, when performing standard access to the paraacetabular zone, “inguinal-iliac” access to the acetabulum and hip joint is used.

A feature of the proposed method is that the operation begins with performing “posterior” surgical access, which is performed in the gluteal region on the affected side, the skin is dissected along the gluteal fold, from its beginning laterally, rising proximal to the outer border of the gluteal region, then subcutaneous tissue is dissected and the underlying fascia, mobilize the gluteus maximus muscle, find the passage of the sciatic nerve at the lower edge of the gluteus maximus muscle, dissect the gluteus maximus muscle maximally projection of the sciatic nerve, after which the sciatic nerve is mobilized throughout and taken to the side, the tumor is mobilized from the surrounding soft tissues, dissecting the middle and small gluteal muscles, and, if necessary, portions of the adductor muscles of the femur - semi-membranous and semi-tendon muscles, then, after the sciatic mobilization is completed nerve and soft tissue component of the tumor, the wound is sutured in layers without leaving drains.

The invention is illustrated by a detailed description, clinical example and illustrations, which depict:

FIG. 1 - photo of patient S., marking of the “posterior” surgical access in the gluteal region.

FIG. 2 - photo of patient S., intraoperative view of the “posterior” surgical access in the gluteal region: 1 - sciatic nerve, 2 - mobilized deep component of the tumor.

FIG. 3 - photo of patient S., type of postoperative scar after 3 months.

The method is as follows.

Surgical intervention is performed under endotracheal anesthesia. The patient is located on the operating table in a position on the abdomen. After processing the surgical field with antiseptics, the operation begins with the implementation of the “posterior” surgical approach, which is performed in the gluteal region on the affected side. The skin is cut along the gluteal fold, from its beginning laterally, rising proximally to the outer border of the gluteal region. Subcutaneous tissue and underlying fascia are then dissected. On the edges mobilize the gluteus maximus muscle. At the lower edge of the gluteus maximus muscle, the site of passage of the sciatic nerve is found. The gluteus maximus muscle is dissected proximally along the projection of the sciatic nerve, after which the sciatic nerve is mobilized throughout and removed to the side of the holders. In the case of the presence of a massive soft tissue component of the tumor, it is mobilized from the surrounding soft tissues, dissecting the middle and small gluteal muscles, and, if necessary, portions of the adductor muscles of the thigh, semi-membranous and semi-tendon muscles. After the mobilization of the sciatic nerve and soft tissue component of the tumor is completed, the wound is sutured in layers without leaving drains. The patient is flipped to a supine position.

After processing the surgical field with antiseptics, standard “front” surgical access is performed in the inguinal-iliac region. The incision is made from the anterior superior iliac spine distally and medially to the projection of the femoral neurovascular bundle at the level of the inguinal ligament, then distally along the projection of the femoral vessels. After dissection of the dermis, subcutaneous tissue and fascia, the inguinal cord or uterine round ligament is mobilized throughout and removed to the side. The fibers of the external oblique muscle of the abdomen are dissected with an electric knife, retroperitoneal access is made to the iliac region. The abdominal sac and lateral wall of the bladder are proximal. The external and internal iliac vessels are mobilized from the site of division of the common iliac artery and veins to the level of their transition to the femoral, after which they are taken to the side along with the femoral nerve. Depending on the location of the tumor, in some cases, the internal iliac vessels are ligated. If necessary, the ureter is visualized and isolated.

After the vascular stage of the operation is completed, the inguinal ligament is crossed, the rectus abdominis muscle with aponeurosis is cut off at the site of attachment to the pubic bone. Perform osteotomy of the branches of the pubis, or pubic symphysis. The adductors of the thigh, the tensor of the wide fascia, the tailor and the rectus femoris are cut off at the site of attachment to the pubic and iliac bones. Access to the hip joint, and then perform para-acetabular resection at the planned level. A fragment of the paraacetabular region of the pelvic bones with the tumor is removed. After removal of the tumor with resection of the bones that form the acetabulum, and the head or proximal femur in the thickness of the sawdust of the remaining part of the body of the ilium and iliac wing, or in the sacrum under X-ray control, a conical leg of the metal implant is installed, to which, with the help of the screws, the cup is fixed an endoprosthesis performing the function of an acetabulum. The second stage in the femur is the orthopedic or oncological hip joint prosthesis. The hip joint is formed by fixing the head of the femoral component of the endoprosthesis into the cup. To quickly form a fibrous capsule around the endoprosthesis and minimize the risk of dislocation of the femoral component, the metal implant is covered with a biosynthetic cuff to which the muscles are sutured. The wound is sutured in layers, leaving 2 drains.

Clinical Case Study

Patient S., 39 years old, was undergoing treatment at the Department of Oncology Orthopedics of Moscow P.A. Herzen diagnosed with a giant cell tumor of the left sciatic bone.

Considers herself a patient since 2012, when she first noted the appearance of pain in the area of the left hip joint. She went to the doctors at the place of residence, conservative therapy was carried out. In connection with the intensification of the pain syndrome in the spring of 2016, she turned to doctors at the place of residence, while CT scan of the small pelvis revealed the formation of the left sciatic bone. Turned to the Moscow Scientific Research Institute. P.A. Herzen, where, during an additional examination, a giant cell tumor of the left sciatic bone was diagnosed. After examination and preoperative preparation of the patient, 05/18/15, the patient underwent surgical treatment in the amount of Para-acetabular resection on the left with combined access with reconstruction of the acetabulum and hip joint with a modular endoprosthesis.

Surgery protocol: In the position of the patient on the abdomen under intubation anesthesia, after aseptic processing of the surgical field, along the gluteal fold, according to the marking, an arched incision of the skin and subcutaneous tissue was made on the left (Fig. 1). The fascia is dissected. The edges of the wound are spread to the side. Dissected fibers of the gluteus maximus muscle. Accessed to the sciatic nerve. With a further audit, a tumor is visualized deeper, immediately behind the sciatic nerve. The stupid and sharp way phased sciatic nerve mobilized throughout, taken to the holder and laid aside. Next, the mobilization of the deep surface of the tumor (Fig. 2). With the help of an electric knife, fibers of the semi-membranous, semi-tendon muscles adjacent to the surface of the tumor are crossed. Also, fibers of the biceps femoris, also adjacent to the tumor, are crossed at the lateral edge of the tumor. The gluteus maximus is mobilized throughout and retracted proximal on the hooks. The fibers of the twin muscles are dissected. Accessed to the posterior surface of the sciatic notch. Further, the remaining soft tissue is cut off from the deep surface of the tumor. Hemostasis. The wound is sutured in layers. Put a dry bandage.

The second stage, the patient is turned on his back. After aseptic processing of the surgical field in the left iliac region, a longitudinal incision was made of the skin and subcutaneous tissue from the projection of the wing of the right iliac bone distally to the medial surface of the proximal femur, along the projection of the femoral vessels. The edges of the wound are spread apart. Crossed the pupartic ligament. Dissected fibers of the external oblique muscle of the abdomen at the site of attachment to the wing of the ilium. Implemented retroperitoneal access to the right iliac region. Further, on the medial surface of the right thigh, access was made to the femoral neurovascular bundle. The fibers of the iliopsoas muscle are crossed. The branches of the great saphenous vein of the thigh are partially ligated and crossed. The acute mobilization of the femoral and external iliac vessels was performed to the level of discharge of the internal iliac vessels and with the intersection of the muscle branches extending from them. The neurovascular bundle is taken on a holder and set aside. The upper and lower branches of the left pubic bone are skeletonized. The pubic-femoral and iliac-femoral ligaments are crossed. Dissected pubic symphysis. The muscles of the pelvic floor are crossed at the inner edge of the tumor. Then, using an electric knife, under visual control, retreating from the palpable edges of the tumor in the projection of the pubic and ischial bones, as well as from the area в 3 of the anterior surface of the right femur, are cut off with an electric knife, stitched and taken onto the tendon and muscle fibers of the medial and anterior thigh . The hip joint is visualized. Accessed to the femoral neck. A figured osteotomy of its anterior surface in the form of a rectangle with a length of up to 10 cm was performed. The large trochanter is not resected. The bone marrow canal of the femur was opened. Further, in a blunt and sharp way, the muscles attached to it are cut off from the outer surface of the wing of the right ilium. Dull way access to the sciatic notch. With the help of an electric saw, an osteotomy was performed from the upper parts of the iliac wing in the direction of the sciatic notch. Then, with the help of an electric knife with severe blood loss and technical difficulties, a phased mobilization of the resected component of the pelvic bones with the intersection of the sacral-tuberous and sacral-spinous ligaments was carried out. The tumor is removed as a single unit. The morphological preparation is aimed at a planned morphological study. After removal, massive profuse bleeding from sawdust of bone structures and soft tissues, the walls of the bladder and pelvic venous plexus was noted. In stages, hemostasis was performed by flashing and using an electric knife. In addition, a hemostatic of local action “SURGICELL” is fixed on the area of diffuse tucking. Using the scans, the ilium body was processed and the cementless leg of the acetabular endoprosthesis implanted and a cup was installed. Then, the proximal part of the left femur was processed sequentially using rimmers. An cementless leg of an oncological endoprosthesis was implanted into the proximal part of the right femur. An endoprosthesis of the hip joint with the head is assembled. Optimal standing of the endoprosthesis. Hemostasis. The vascular bundle is separated from the proximal endoprosthesis and is covered with resected muscle fibers sewn together. Layer wound closure with 1 silicone drainage. Intraoperative blood loss was 2500 ml. Duration of surgery: 5 hours.

The postoperative period was uneventful. Drainage was removed on the fourth day after surgery. The wounds healed by first intention, the sutures were removed on the 21st day. In the postoperative period from the seventh to the fourteenth day, a passive, from the tenth day, active development of TBS was carried out. When discharged on the fourteenth day after the operation, the range of motion in the TBS: flexion - 20 °, abduction - 20 °.

Control examination after 3 months (Fig. 3), range of motion in the TBS: flexion - 90 °, abduction - 30 °. The function of the knee, ankle joints in full.

The use of the proposed method in clinical practice made it possible to achieve several technical (medical) results:

- increasing the radicalism of the operation and reducing the risk of tumor recurrence;

- reduction in intraoperative blood loss;

- reduction in the duration of the operation;

- reducing the risk of developing infectious complications;

- improving the quality of life of patients after surgery.

Claims (1)

A method for performing para-acetabular resections with acetabular endoprosthetics in patients with tumor lesions of the pelvic bones, including "inguinal-iliac" access to the acetabulum and hip joint, characterized in that the operation begins with performing "posterior" surgical access, which is performed in the gluteal region on side of the lesion, the skin is dissected along the gluteal fold, from its beginning laterally, rising proximal to the outer border of the gluteal region, then subcutaneous tissue is dissected and should be the fascia, mobilize the gluteus maximus muscle, find the passage of the sciatic nerve at the lower edge of the gluteus maximus muscle, dissect the gluteus maximally proximally along the projection of the sciatic nerve, then mobilize the sciatic nerve throughout and take it to the side, mobilize the tumor from the surrounding soft tissues dissecting the middle and small gluteal muscles, and, if necessary, portions of the adductors of the thigh - semi-membranous and semi-tendon muscles, then, after the mobilization of the sciatic nerve and meat the tissue component of the tumor, the wound is sutured in layers without drainage, then the patient is turned over onto the back, the ileo-inguinal access is performed, from which para-acetabular resection is performed, and the acetabular endoprosthesis is installed.

Images