Sie sind auf Seite 1von 6

Hip Disarticulation and Hemi-Pelvectomy

William Parrish, MD

A mputations through the hip joint or pelvis are most often


indicated for radical treatment of neoplasia when a pri-
mary malignant soft tissue or osseous tumor of the extremity
cation of the patient and operative site/side. Before position-
ing, a regional anesthetic should be introduced and induc-
tion of the general anesthetic completed. Epidural anesthetics
involves several compartments, the sciatic nerve, or the fem- with an indwelling catheter provide an excellent means of
oral neurovascular structures. The goal of these procedures postoperative pain control. In addition, a regional anesthetic
when performed for neoplastic indications is to provide local can be highly beneficial by reducing the incidence of phan-
disease control. If a primary malignant bone tumor involves tom pain postoperatively.
the hip joint or a large portion of the ilium, a hemi-pelvec- A Foley catheter is placed while the patient is in the
tomy may be indicated. If the tumor involves only a limited supine position. The patient is then moved into a lateral
portion of the pelvis but no neurovascular structures, an decubitus position and stabilized with the aid of a “bean
internal hemi-pelvectomy may be possible to preserve the bag” or other similar apparatus (Fig. 1). The operative
extremity. Amputations through the hip joint or pelvis result (ipsilateral) side will be facing up. An axillary roll is then
in very similar functional results. placed beneath the chest wall in the contralateral axilla to
Less often, such amputations may be required in the avoid pressure on the brachial plexus and neurovascular
setting of vascular catastrophe, such as prosthetic graft structures. The contralateral arm must be carefully and
infection or nonhealing of above-knee amputation. Other naturally positioned on an arm board without unusual
indications may include severe trauma with extensive angulation of any joint or pressure against the radial and
bone or soft tissue loss and neurovascular injury, or ag- ulnar nerves. The ipsilateral arm is often best positioned in
gressive infectious diseases such as necrotizing fasciitis or an overhead cradle with generous padding. Foam pads or
gas gangrene. blankets should also be used to protect the peroneal nerve
Surgical planning for hip disarticulation or hemi-pelvec- of the contralateral leg and ankle.
tomy should be based on imaging studies which clearly de- It is important to perform the skin preparation and drap-
fine the vascular status of the extremity, the anatomic mar- ing as widely as possible so that the surgical field is not
gins of a tumor, or the extent of tissue loss or necrosis from compromised. Failure to “prep and drape” a wide field may
trauma or an infection. CT scan will provide the best images
cause great difficulty in placing correct incisions, and in-
to define osseous structures. MRI is most useful for defining
creases the risk of contamination of the surgical field. Patient
soft tissue extension of a tumor, relationship of a tumor to
positioning, skin preparation, and placement of drapes
neurovascular structures, and extent of marrow involvement.
should be done under the direct supervision of the operating
MRI is also helpful in defining the limits of cellulitis or muscle
surgeon or a very trusted associate.
necrosis that may occur with aggressive infections. Appropri-
After antiseptic skin preparation, a U-shaped drape is
ate vascular studies such a doppler ultrasound, digital sub-
placed under the operative leg as close to the midline gluteal
traction angiography, or venography may be useful when
cleft as possible (while excluding the anus). The anterior arm
evaluating the patient with vascular disease.
of the drape is brought along the base of the scrotum, extend-
ing to the umbilicus and ending at the level of the sternum.
Hip Disarticulation: The posterior arm of the U-drape extends along the midline
Surgical Technique of the spine to the lower margin of the twelth rib. A second
rectangular drape is then used to complete the surgical field
Position connecting the two ends of the U-drape along the lower
As with all surgical procedures, the operating surgeon must margin of the rib cage.
take primary and personal responsibility for correct identifi-
Incision
Department of Orthopedics and Rehabilitation, Penn State Hershey Medical See Figs. 1 and 2.
Center, College of Medicine of the Pennsylvania State University, 500
University Drive, Hershey, PA.
Address reprint requests to Dr. William Parrish, Department of Orthopedics Dissection
and Rehabilitation, Penn State Hershey Medical Center, College of Med-
icine of the Pennsylvania State University, 500 University Drive, Her- The anterior limb of the incision is developed by exposing
shey, PA 17033. E-mail: wparrish@psu.edu the femoral triangle. The femoral triangle is found in the

96 1524-153X/05/$-see front matter © 2005 Elsevier Inc. All rights reserved.


doi:10.1053/j.optechgensurg.2005.08.001
Hip disarticulation and hemi-pelvectomy 97

Figure 1 Posterior view of patient positioning and placement of incisions for hip disarticulation and hemi-pelvectomy.
The incision for hip disarticulation (dotted line) begins approximately one fingerbreadth inferior and medial to the
anterior superior iliac spine (ASIS) and proceeds caudally toward the greater trochanter. From there, the incision
courses posteriorly within the gluteal crease and then curves anteriorly within the medial thigh crease to reach the pubic
tubercle. Shown in Fig 2 is the anterior component of the incision, extending from the pubic tubercle to the ASIS. For
hemi-pelvectomy (solid line), the incision passes posteriorly from the ASIS along the iliac crest toward the posterior
superior iliac spine (PSIS). At this point, the incision is directed postero-laterally to the tip of the greater trochanter, and
then posteriorly along the gluteal crease to the ischium. The incision then courses within the thigh crease anteriorly
toward the inferior pubic ramus, continuing on to the pubic symphysis. Figure 2 shows the anterior incision extending
from the pubic symphysis, along the inguinal ligament, to the ASIS.

subfascial space of the proximal thigh. The femoral artery, cord in a male may be encountered during dissection of the
vein, and nerve pass through this anatomic area as they midline part of the incision. These should be exposed but not
exit the pelvis beneath the inguinal ligament and descend resected with the specimen.
into the leg. The position of the neurovascular structures Once these neurovascular structures have been identi-
in the femoral canal are nerve, artery, vein, and lymphatics fied and divided, the dissection continues through the soft
in a lateral to medial progression (NAVL). The femoral tissues toward the hip joint. Proceeding anterior to poste-
triangle is bounded by the adductor longus muscle medi- riorly, the iliopsoas muscle is released from its insertion
ally, the sartorius muscle laterally, and the inguinal liga- onto the lesser trochanter of the femur. Circumflex
ment superiorly. The iliopsoas and pectineus muscles branches of the femoral vessels may be encountered dur-
form the floor of the femoral triangle (Fig. 2). ing the dissection. The pectineus and adductor muscles
The most reliable landmark for identification of the femo- are transected at their origins on the bony pelvis. Care
ral vessels is the inguinal ligament, specifically the inferior must be taken to ligate the obturator vessels during this
“shelving” edge, sometimes referred to as Poupart’s ligament. part of the dissection.
Particularly in patients with previous arterial surgery in the As the dissection is carried posteriorly, all the muscles
groin, the inguinal ligament can be the only constant struc- originating on the ischium are released at their origin. This
ture. Division of the sartorius muscle at its origin will further will include the gracilis and the hamstring muscles. This part
aid in exposing the femoral neurovascular structures in the of the dissection is most easily completed with the leg in a
femoral triangle. Once exposed, the femoral artery and vein flexed, abducted, and externally rotated position. The poste-
must be encircled, controlled, and individually suture ligated rior limb of the incision is then developed by dividing the
with nonabsorbable monofilament suture of 3-0 or larger gluteus maximus muscle and releasing the gluteus medius
size. The femoral nerve is then gently placed under tension, and minimus muscles from their insertions on the greater
ligated as it exits beneath the inguinal ligament, divided, and trochanter. This will provide exposure of the deep posterior
allowed to retract into the pelvis. thigh including the sciatic nerve and the short external rota-
The greater saphenous vein enters the femoral vein very tors of the hip. The sciatic nerve should be placed under
proximally and may need to be separately ligated. In addi- gentle traction, securely ligated, divided, and allowed to re-
tion, the obturator, pudendal, and superficial epigastric ves- tract proximally beneath the piriformis muscle. The remain-
sels may require separate ligation. The lateral femoral cuta- ing external rotator muscles are then released from their fem-
neous nerve should be identified as it exits the pelvis just oral insertion.
beneath the anterior superior iliac spine. This should be Attention is then redirected to the anterior limb of the
placed under gentle traction, ligated, and allowed to retract incision. The dissection from the greater trochanter to the
into the pelvis. The round ligament in a woman or spermatic ASIS is completed by dividing the tensor fascia lata and re-
98 W. Parrish

Figure 2 Anterior view of the incisions and deep dissection for hip disarticulation and hemi-pelvectomy. Depicted on
the patient’s right side are the incisions for the two procedures. Both begin at the anterior superior iliac spine (ASIS) and
course along the inguinal ligament. For hip disarticulation, the incision turns posteriorly at the pubic tubercle; for
hemi-pelvectomy, it extends to the pubic symphysis before curving posterior along the lateral border of the perineum
and into the medial thigh crease. Posteriorly, both incisions pass within the gluteal crease toward the greater trochanter.
The hip disarticulation incision then turns superiorly to course directly back to the ASIS. The hemi-pelvectomy incision
travels from the greater trochanter superiorly, posteriorly, and medially toward the posterior superior iliac spine (PSIS).
The posterior component follows the iliac crest back to the ASIS. These relationships are also shown in Fig 1. The left
side of the patient shows the deep dissection for both hip disarticulation and hemi-pelvectomy, as explained in detail
in the chapter text.

leasing the rectus femoris muscle from its origin on the ante- and gluteus medius muscles are then approximated with
rior inferior iliac spine. The hip capsule is the incised around the obturator externus and iliopsoas muscles to cover the
the lip of the acetabulum, and the hip joint dislocated. The acetabulum. One or two large drains are then placed in the
ligamentum teres is divided by electrocautery, completing surgical bed and the gluteus maximus flap is mobilized
the amputation, and allowing removal of the limb from the anteriorly with suturing of the gluteus fascia to the ingui-
surgical field. nal ligament (Fig. 3). Deep dermal sutures are placed and
the skin is closed with interrupted sutures or staples. A
Closure sterile dressing is placed on the wound and may be se-
The surgical field is then thoroughly irrigated and in- cured with a long six inch elastic wrap that is secured
spected for hemostasis. The short external rotator muscles around the waist.
Hip disarticulation and hemi-pelvectomy 99

Figure 3 Hip disarticulation before closure with the gluteal flap. The transected and ligated vessels are seen deep in the
wound. Acetabular coverage is obtained by approximating the short external rotator muscles and gluteus medius muscles
with the obturator externus and iliopsoas muscles. One or two large drains can be placed in the surgical bed if desired. The
gluteus maximus flap is then mobilized anteriorly with suturing of the gluteus fascia to the inguinal ligament.

Postoperative Care dural is in place and should be titrated to the patient’s pain
The drains should be left in place until output is minimal. requirements as the epidural is weaned. Once the incision
Removal of the drains too quickly will result in the devel- line is completely healed, the patient is referred to pros-
opment of a seroma in the large space deep to the gluteal thetics to initiate fabrication of prosthesis. A preoperative
fascia. The epidural catheter should be left in place for 48 visit with a prosthetist can be most helpful for the patient
to 72 hours for pain control. Sustained release oral nar- to understand the concept and process of prosthetic fit-
cotic pain medications should be started while the epi- ting.
100 W. Parrish

Hemi-Pelvectomy: 4-0. Surgeons not familiar with handling of large vessels


should obtain assistance from a vascular surgeon, especially if
Surgical Technique the vessels are heavily calcified or aneurysmal. The iliopsoas
Position muscle is divided near the inguinal ligament. In most cases,
Positioning the patient for a hemi-pelvectomy is in many the iliacus will be included in the surgical specimen and the
ways similar to positioning for a hip disarticulation (Fig. 1). majority of the psoas muscle preserved. The femoral nerve is
Preoperative preparation for this procedure should include a finally identified, ligated, and divided (Fig. 2).
mechanical bowel prep on the night before surgery. A beta- The perineal dissection is then performed. The bladder is
dine-soaked vaginal sponge may be packed into the rectum retracted along with the urethra and protected with a broad
to prevent contamination of the surgical field due to manip- malleable retractor. The ischiorectal space is the exposed as
ulation of the retroperitoneum during the surgical proce- the dissection is extended along the inferior pubic ramus and
dure. A stent should be placed in the ipsilateral ureter and a the ischium by releasing the muscles of the pelvic floor as
Foley catheter in the urinary bladder while the patient is in they insert on the boney pelvis. The bladder, urethra, and
the supine position. This makes it easier to identify the ureter spermatic cord should be protected during this part of the
during surgery and decreases the risk of injury to it. dissection. An osteotome is then used to divide the pubic
The patient is moved into a relaxed lateral decubitus position symphysis.
with placement of an axillary roll and appropriate padding of The posterior segment of the dissection is then completed
pressure points. For a hemi-pelvectomy, the patient is posi- by extending the incision from the PSIS to the greater tro-
tioned on the OR table so the flexion break in the table is chanter, then along the inferior border of the gluteus maxi-
centered between the lower ribs and the iliac crest. The bed mus, connecting to the perineal incision and region of dis-
is then flexed which opens the space between the ribs and section. If possible, the gluteus maximus muscle is preserved
iliac crest, making the exposure of the retroperitoneum eas- with the posterior flap; however, it may be necessary with
ier. The patient is placed into a relaxed lateral position so that some tumors to sacrifice the gluteus maximus to achieve an
the trunk and pelvis can be moved forward or backward to acceptable surgical margin. This myocutaneous or fasciocu-
facilitate surgical exposure. The arms are positioned and pad- taneous flap is then developed in an anterior to posterior
ded as described for hip disarticulation. Skin preparation and direction.
draping is performed in similar fashion. Although these steps As the flap is developed posteriorly, the superior gluteal
should not be delegated to subordinates, the principles of artery should be preserved in those cases using a myocuta-
positioning and preparation should be familiar to the entire neous gluteus flap. The superior gluteal artery will exit the
OR team. pelvis through the greater sciatic notch and is tightly adher-
ent to the bone in this location. Once the posterior flap is
Incision developed, the deep posterior hip musculature and sciatic
nerve will be visible. The piriformis muscle is divided to
Posterior flap hemi-pelvectomy is the most common variant
reveal the sciatic nerve as it exits the pelvis. The very large
of this procedure. This method utilizes the gluteus maximus
nerve must be firmly ligated, divided, and allowed to retract
for closure much as was described for a hip disarticulation.
into the pelvis. The inferior gluteal artery will exit the pelvis
Occasionally, a tumor may involve the posterior aspect of the
inferior to the piriformis muscle. This artery should be iden-
pelvis or gluteus maximus, necessitating the use of an ante-
tified and ligated to avoid bleeding. The thick broad sacro-
rior flap hemi-pelvectomy. The anterior flap hemi-pelvec-
tuberous ligament will then be encountered extending from
tomy utilizes an anterior based myocutaneous flap that is
the lateral border of the sacrum to the ischial tuberosity, and
based on the femoral vessels. The incision used will depend
must be divided.
on the type of flap required. This chapter will describe the
Once division of the soft tissues and neurovascular struc-
posterior flap hemi-pelvectomy. The incisions are outlined
tures are completed, attention is then directed to final step:
and described in Figs. 1 and 2.
sacral osteotomy. The standard hemi-pelvectomy is com-
pleted by passing a series of osteotomes through the sacro-
Dissection iliac joint. A blunt ribbon retractor is placed through the
The dissection begins at the posterior superior iliac spine and sciatic notch into the pelvis along the anterior margin of the
extends anteriorly along the iliac crest and the inguinal liga- sacro-iliac joint to protect the anterior structures. The sur-
ment to the pubic symphysis. The retroperitoneal space is geon then directs the osteotomes serially through the joint to
exposed by releasing the insertion of the abdominal muscles complete the amputation. The amputation specimen is
on the iliac crest and inguinal ligament. The peritoneal sac passed from the surgical field and hemostasis obtained. The
and contents are retracted medially with the ureter. The com- presacral area is highly vascular with great potential for ve-
mon iliac artery and vein are identified as well as the internal nous bleeding, which must be controlled with suture liga-
and external iliac vessels. The level of ligation of these vessels tures or electrocautery.
may be determined by the position of the tumor. For a pos-
terior flap hemi-pelvectomy, preservation of the internal iliac
vessel or at least the first branch (the superior gluteal artery) Closure
will result in better flap viability because the superior gluteal The surgical field should then be irrigated with several liters
artery supplies the gluteus maximus. Once the level of liga- of fluid and closed over large drains. Closure is accomplished
tion is determined, the appropriate vessels are suture ligated by bringing the gluteus maximus flap forward and suturing
with monofilament nonabsorbable suture no smaller than the gluteus fascia to the external oblique and rectus abdomi-
Hip disarticulation and hemi-pelvectomy 101

nus fasciae of the abdominal wall. Scarpa’s fascia may be sumption of an acceptable quality of life. Aggressive rehabil-
re-approximated according to the surgeon’s preference, itation enables most of these patients to ambulate with fore-
along with the desired method of skin closure. The rectal arm crutches, which many patients choose in preference to a
packing should be removed and a bulky dressing placed on large unwieldly prosthesis. Amputation support groups can
the wound, secured with a large elastic bandage around the be instrumental in helping patients make both emotional and
waist. physical adjustments to their disability.

Conclusion Suggested Reading


Clark MA, Thomas JM: Major amputation for soft-tissue sarcoma. Br J Surg
Hip disarticulation and hemi-pelvectomy procedures result 90:102-107, 2003
in major functional disabilities, but do not preclude the re- Paz IB: Major palliative amputations. Surg Clin N Am 13:543-547, 2004