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Wide Resection of Thigh Soft Tissue Sarcoma

Planning

B

Preoperative Plan

1

Radiographic templating

  • use MRI and CT scan to determine the location and extent of the lesion

2

Execute surgical walkthrough

  • describe the steps of the procedure to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
C

Room Preparation

1

Surgical Instrumentation

  • nothing special needed

2

Room setup and Equipment

  • Standard OR table

3

Patient Positioning

  • supine position with bolster under ipsilateral buttock

Technique

D

Thigh Incision

1

Mark incision over lesion

  • make a long incision that extends from the AIIS to the patella
  • the incision should be elliptical and be centered around the biopsy site

2

Create skin flaps

  • make skin and subcutaneous flaps that extend down to the fascia lata
  • they should extend medially to the adductor muscle group and laterally to the greater trochanter and flexor muscles
E

Deep Dissection

1

Identify and transect deep structures

  • divide the saphenous vein as it enters the fossa ovalis
  • uncover the inguinal ligament and femoral triangle
  • expose the common femoral artery, vein and nerve
  • place lateral traction on the quadriceps
  • this exposes the muscular branches coming from the superficial femoral artery and vein into the quadriceps muscle
  • work from cranial to caudal and clamp divide and ligate the the vessels
  • place lateral traction and identify the muscular insertions from the adductor magnus
  • divide these branches as they cross the superficial femoral artery
  • identify the plane between the tensor fascia lata and the gluteus medius and minimus
  • use cautery to release the tensor from its origin off of the wing of the ilium

2

Identify and divide the musculature

  • identify and divide the sartorius off of the ASIS
  • identify and divide the rectus femoris off of the AIIS
  • identify the origins of the vastus lateralis, intermedius and the medialis on the femur
  • transect from the bone using cautery
F

Tumor Removal

1

Release the specimen

  • use strong upward and medial traction on the specimen
  • divide the insertions of the vastus medialis, lateralis and the rectus femoris muscle on the patella
  • transect the prepatellar and quadriceps bursae
  • divide the insertion of the vastus medialis into the MCL

2

Prepare the wound for closure

  • copiously irrigate the dissection sit and perform meticulous hemostasis
G

Biceps Femoris Transfer (optional)

1

Release the biceps femoris

  • transect the long head of the biceps from the fibula

2

Perform transfer

  • transfer the muscle anteriorly to the midline so that it will be in direct line of pull
  • use heavy nonabsorbable suture and suture the muscle to the patella and the remains of the quadriceps and rectus femoris
H

Sartorius and Semitendinosus Muscle Transfer (optional)

1

Release the sartorius

  • release but not transect the muscle from its distal insertion on the medial aspect of the proximal tibia
  • ligate the distal 2 or 3 vessels
  • the aim is to transfer the muscle anteriorly to the midline to achieve straight line pull
  • suture to the patella tendon the patella and the remains of the quadriceps

2

Release the semitendinosus

  • transect the muscle as far distal as possible from its insertion to the proximal tibia
  • transfer anteriorly
  • suture the muscle and its tendinous parts to the patella and the remains of the quadriceps
I

Wound Closure

1

Perform deep closure

  • use 0-vicryl for deep closure

2

Perform superficial closure

  • use 3- vicryl for subcutaneous closure
  • use 3-0 monocryl for skin

3

Place dressings

  • place in knee immobilizer if muscle transfer is performed

Patient Care

K

Preoperative H & P

1

Obtains history and performs basic physical exam

  • history
  • pain and function
  • past medical/surgical/social/family history
  • review of systems
  • physical exam
  • heart
  • lungs
  • extremity exam
  • range of motion
  • strength
  • sensation
  • skin changes
  • tenderness

2

Screen medical studies to identify and contraindications for surgery

3

Orders basic imaging studies

  • radiographs
  • AP/lateral of the lesion
  • Joint above and below the lesion

4

Prescribe non-operative treatment

  • protected weightbearing
  • bracing
  • no intervention

5

Perform operative consent

  • describe complications of surgery including
  • Infection
  • knee stiffness
  • Wound complications
  • Neurovascular compromise
  • Tumor progression
  • DVT/PE
  • Pneumonia
L

Perioperative Inpatient Management

1

Write comprehensive post operative orders

  • pain control
  • IV antibiotics until all drains removed
  • advance diet as tolerated
  • check appropriate labs
  • wound care
  • remove dressings POD 2
  • remove drain in 3 to 5 days

2

Appropriately orders and interprets basic imaging studies

3

Appropriate medical management and medical consultation

  • follow up with pathology for findings of biopsy

4

Inpatient physical therapy

  • no muscle transfer in surgery
  • weight bear as tolerated
  • muscle transfer in surgery
  • place in knee immobilizer

5

Discharges patient appropriately

  • pain meds
  • outpatient pt
  • schedule follow up appointment in 2 weeks
M

Intermediate Evaluation and Management

1

Obtain focused history and performs focused exam

  • history:
  • past history of cancer or radiation,
  • prior treatments
  • pre-existing pain
  • smoking or chemical exposure
  • constitutional symptoms
  • fever
  • physical exam
  • notes lymph node involvement, lumps/nodules

2

Interprets basic imaging studies

  • describe the radiographic appearance
  • osteolytic
  • osteoblastic

3

Prescribes and manages nonoperative treatment

  • understand when to have the patient back to clinic for follow-up
  • understand when to order new radiographic imaging studies

4

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

5

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • discuss result of the biopsy
  • plan definitive surgery
  • diagnose and management of early complications
  • infection
  • DVT/PE
  • wound breakdown
  • neurovascular compromise
  • postop: 4-6 week postoperative visit
  • start intensive muscle strengthening exercises at 4 weeks if muscle transfer occurred in surgery
  • diagnosis and management of late complications
  • postop: 1 year postoperative visit
N

Advanced Evaluation and Management

1

Appropriately orders and interprets advanced imaging studies/lab studies

  • 3D radiographic studies to include CT
  • MRI
  • lab studies
  • SPEP/UPEP
  • PSA
  • other tumor markers

2

Recommends complex non-operative treatment

  • RFA or cryoablation
  • Bisphosphonates
  • Kyphoplasty or vertebroplasty

3

Nonoperative treatment

  • infection
  • wound breakdown
  • DVT/PE)

4

Pre-operative preparation and consultation

  • onc
  • rad onc
  • counseling
O

Complex Patient Care

1

Recommends appropriate biopsy including biopsy alternatives and appropriate techniques

  • understand role of open biopsy vs needle biopsy

2

Develops unique, complex post-operative management plans

 

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