Internal pelvic resection

Internal pelvic resection is also called partial pelvic resection. Traditional pelvic resection is the removal of the diseased pelvis and the ipsilateral lower extremity, resulting in severe disability of the patient. The internal pelvic resection is to remove the tumor invading the pelvis and retain the ipsilateral limb, greatly reducing the patient's disability. Treatment of diseases: bone tumors Indication Internal pelvic resection is available for: 1. The tumor invades the primary bone tumor around the acetabulum (hip bone, pubic bone, ischial bone), and the degree of malignancy is lower, such as chondrosarcoma, giant cell tumor of bone I to II grade. 2. Those with higher degree of malignancy, such as malignant fibrous histiocytoma and osteosarcoma, should be treated with effective high-dose chemotherapy before and after surgery, and internal pelvic resection can still be performed. 3. The tumor only invades the bone around the acetabulum, does not invade the surrounding soft tissue, and is suitable for internal pelvic resection. 4. The tumor has penetrated the bone into the surrounding soft tissue and can still undergo extensive tumor resection. 5. The extent of tumor invasion is too large, the degree of malignancy is high, and the internal pelvic resection can only achieve the marginal resection of the tumor, then the traditional semi-pelvic resection should be considered. 6. The tumor invades the local organs of the pelvis, and the invading organs are allowed to be removed and repaired. It is still an indication for partial pelvic resection. If the primary bone tumor around the acetabulum has a lung metastasis, it should cooperate with thoracic surgery. 7. There are only a single isolated resectable lesion in the lung. Contraindications 1. Old age, poor physical condition, can not tolerate the operator. 2. There have been multiple metastases in the lungs or other parts. Preoperative preparation 1. In addition to routine tumor examination before surgery, pelvis and chest X-ray films should be taken. Because the bone tumors around the acetabulum are deep, the bones on the common X-ray films overlap, so there should be conditions for CT or magnetic resonance of the pelvis. The advantage of the examination is to determine the location, size, extent of invasion, and the relationship between important tissues and organs around the tumor, and to help design the surgical plan. 2. Radionuclide scanning and gamma scintigraphy This type of examination is an important assessment of the patient's general condition before surgery. The main examination is whether there is a distant metastasis or a potential recessive lesion. For the tumors in the pelvic area itself, the range of lesions displayed by radionuclides is not as clear and exact as other imaging studies. 3. Selective angiography and preoperative tumor embolization The bone tumor located around the acetabulum is often deep, large in volume, and rich in blood supply. It is often difficult to completely remove the surgery. For this reason, selective angiography can be performed on the tumor site through the femoral artery insertion catheter before surgery, showing the size and location of the tumor, the relationship with adjacent vital organs, and the blood vessels supplying the tumor. Tumor blood supply can be blocked by injecting a 1 to 2 mm size gelatin sponge or other vascular embolization agent into the blood vessel supplying the tumor through a catheter. During surgery, another incision can be dispensed with to block the tumor blood supply, the bleeding is obviously reduced, the surgical field is clean and easy to operate. Generally, embolization is performed 1 to 2 days before surgery, and the effect of stopping bleeding is good during operation. 4. Living tissue adopting living tissue and taking pathological examination is an important means for qualitative diagnosis of swelling and pain. Commonly used preoperative incisional biopsy, intraoperative frozen biopsy and preoperative biopsy are performed, because of incision biopsy and surgery. Cutting tissue for cryosection has many disadvantages. Therefore, a needle biopsy should be performed before the Coombs cannula is used when conditions permit. The advantage of this method is that the incision is small, the interference to the tumor tissue is small, and the original biopsy incision is easy to be removed when the tumor is removed. The disadvantage is that the amount of tissue is small and sometimes difficult to diagnose. In recent years, this technology has been continuously developed, and it can be guided by X-ray, CT or B-ultrasound to improve the accuracy and positive rate. 5. A sufficient blood source should be prepared before surgery. Generally, 3000 ml of whole blood should be prepared. Prepare for intestinal cleansing. Insert the catheter before surgery. Surgical procedure 1. pubic and ischial resection The incision was taken from the midpoint of the inguinal ligament and paralleled inwardly and downwardly. The incision in the base of the penis or pubic sac turned to the distal side, along the lateral side of the scrotum or labia majora, and then along the subsaccular branch to the ischial tuberosity. The skin and subcutaneous tissue were dissected, and the adductor muscle and the obturator muscle were excised subperiosteal from the pubic bone and the ischial bone to reveal the pubic bone, the lateral humeral branch, the subsaccular branch and the ischial tuberosity. If a further step is required, the edge of the gluteus maximus should be cut and pulled outward. The starting point of the posterior muscle group, the adductor muscle, and the femoral muscle is revealed. If these muscles are cut through the sacral origin or subperiosteal detachment, the amount of bleeding is very small. Free iliac nodular ligaments from the medial side of the ischial tuberosity. The perineal vessels and nerves exit the pelvic cavity through the large hole of the ischial bone, to the deep side of the gluteus maximus, bypass the ischial spine, enter the ischial rectum by the small hole of the ischial bone, and travel along the side wall of the genital canal. The sciatic sponge should be removed from the periosteum during the operation. Body and obturator muscles to protect the perineal vessels and nerves. Then, from the medial edge of the ischial bone and the lower pubis, the deep perineal transverse muscle, penile foot and urethral sphincter are removed. Next, the urethral genital aponeurosis should be cut from the lower edge of the pubic symphysis to dissect it from the starting point to the pubic symphysis, but damage to the urethra and deep veins of the penis, arteries and nerves should be avoided. The rectus abdominis and conical muscles were dissected from the pubic symphysis, and the inguinal ligament was cut from the pubic symphysis. The pubic symphysis was released from the pubic line of the suprapubic branch from the pubic muscle. Avoid injury to the lateral femoral vessels of the pubis. Dissect the obturator inner muscle and the obturator muscle under the periosteum, and if possible, preserve the obturator nerve and blood vessels as much as possible. The upper pubis can be cut with a rongeur. The lower ischial bone can be cut with a wire saw. 2. Hip bone resection If it is decided to perform pelvic resection from the pubic symphysis to the ankle joint including sacral, sitting, pubic bone and retain the limb, the incision should start from the posterior superior iliac spine, along the iliac crest, to the anterior superior iliac spine. Then, the anterior superior iliac spine travels along the inguinal ligament to the pubic symphysis, and the pubic and ischial resection is removed. 3. The tibia is exposed, and the attachment points of the abdominal muscles, latissimus dorsi, and gluteal muscles on the iliac crest are revealed along the incision, and the gluteus medius muscle and the tensor fascia lata muscle are exfoliated together. Open the latissimus dorsi, abdominal muscles, waist muscles, and diaphragm muscles and push them inward. 4. The important structures encountered during the process of revealing the tibia are the femoral vessels, femoral nerves, spermatic cords, etc. in front of the inner wing; under the large ischial notch, there are gluteal and subgluteal vessels and nerves, perineal vessels and nerves, sciatic nerves. , obturator blood vessels and nerves. In these structures, except for closed-cell blood vessels and nerves, the rest of the structure should be retained. If the tumor does not penetrate the inner wall of the pelvis, the humerus can be treated for subperiosteal resection. Sweeping away from the psoas muscle to the medial side, and dissecting backwards and downwards to the starting point of the levator ani muscle. If the hip joint is flexed, it is not difficult to dissect. The Alcock intraductal structure in the obturator fascia, including the perineal vessels and nerves, can be revealed beneath the sacral ligament. The sacrospinous ligament and the coccygeal muscle are interlaced and should be cut off after confirmation. The sciatic nerve penetrates the pelvis on the sacrospinous ligament, accompanied by piriformis, gluteal and subgluteal vessels. The sciatic nerve should be separated and protected by placing a gauze pad at the large hole of the ischial bone. At this point, the anterior, upper and lower ligaments of the stable ankle have been severed. 5. If the tumor has worn the inner surface of the pelvis, the diaphragm and the bone below it should be removed together. Muscles should be cut horizontally above the apex of the ankle joint and below the attachment point. If the tumor is located in the muscle group outside the pelvis, the invaded muscle, pelvis, and tumor should be removed together, and the nerves and blood vessels supplying these muscles should be cut off. At the same time, the invasive muscles should be cut off on the large trochanter and the fascia, so that the muscles, pelvis and tumors are cut off in one piece. 6. Cut the sartorius muscle and inguinal ligament from the tibia near the anterior superior iliac spine. The straight and oblique heads of the rectus femoris are cut at the anterior iliac spine and the acetabular labrum. The abdominal wall muscles and the inguinal ligaments are pulled inward, and the rectus abdominis and pubic muscles can be sharply peeled off from the pubis. Men's spermatic cord, femoral blood vessels, and femoral nerves can be carefully revealed. In the deep part of the wound, the sacral nodular ligament can be severed at its attachment to the ischial tuberosity. At this point, all the ligaments and muscles attached to the inner side of the pelvis have been cut. 7. For the free femoral head and neck, the hip joint capsule is cut open at the attachment point above the acetabulum, and the round ligament is cut off and the femoral head is dislodged. 8. All the ligaments connecting the affected tibia and fibula are cut off, the pelvis becomes free, and the pelvis is externally rotated to cause the medial edge to escape from the wound, and then the internal rotation causes the pubic symphysis to be pulled out from under the iliopsoas. There is a large dead space in the wound, so a vacuum suction tube should be placed. The distal and proximal muscle stumps in the wound should be sutured layer by layer. The levator ani muscle can be sewn on the piriformis muscle, or it can be sutured with the preserved extra-pelvic muscles to maintain the suspension of the ischial rectum. The genital muscles can be sutured with the adductor muscles to keep the perineum stable. The diaphragm should be sutured at the level of the femoral trochanter and the iliac crest. The abdominal muscles in the inguinal ligament area can be sutured with the sartorius muscle and the rectus femoris to prevent abdominal wall spasm. The lateral wall muscles (latissimus dorsi, lumbar muscles, and sacral spine muscles) were sutured with the retained pelvic lateral muscles (hip mid, small muscle, tensor fascia, and gluteus maximus). The above stitching is functionally considered and does not achieve accurate anatomical repair. 9. Reconstruction of the pelvic ring If the lesion invades the acetabulum, the proximal part of the humerus can be retained after the acetabular apex is removed, and the femoral head is placed on the proximal stump of the humerus; if the lesion is extensive, it will be shame, ischial and sacral Most of the bones were removed, and the femoral head was directly placed below the humerus. In these two cases, the corresponding soft tissue suture should be noted. For this part of the case, some units in China did not perform artificial pelvic reconstruction. After resection, they were placed in the hospital. After 17 to 27 years of follow-up, although the lame was used, the orthopedics were used to raise the heel and the gait was satisfactory, and the local was not painful. . If the lesion is invaded from the lateral aspect of the ankle to the neck of the humerus, most of the humerus is resected to cause a defect in the pelvic ring, and the acetabular apex is often retained. Reconstruction of the pelvic ring is required by selecting two appropriate lengths of the spine. The steel plate is shaped and conformed to the curvature of the pelvic wall. The two ends can be fixed on the top of the acetabulum and the tibia by wires or screws respectively; the bone cement is fixed around the steel plate and at both ends, or the body is taken on this basis. The bone is filled in the defect of the pelvic ring to cause a bone connection. After reconstruction through the pelvic ring, the hip joint function, stability, and gait were close to normal.