Wide Resection of Thigh Soft Tissue Sarcoma

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TECHNIQUE STEPS
Preoperative Patient Care
Operative Techniques
E

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
F

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
G

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
H

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
I

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
J

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
K

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
L

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
Postoperative Patient Care
 

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