# Internal Hemipelvectomy & Partial Sacrectomy



## JBowyer (Aug 13, 2014)

Chondrosarcoma, right pelvic bone with involvement of sacrum

****Only CPT code I can come up with is 27290. BUT this CPT code is removal of entire limb/extremity. That was not done. The leg was sacrificed. 
Can help/direction is appreciated. 


Procedures: Right Internal Hemipelvectomy, entire iliac wing bone
Partial Right Sacrectomy (partial vertebral resection of lumbosacral single vertebral segment

The surgery was explained in great detail to patient including the need to take out the right upper hemipelvis along with the majority of the gluteal musculature which will leave patient with a very weak leg and a limp. 
Patient placed on left side with the right hip up. An incision was made starting at the midlateral thigh, extending over the tip of the greater trochanter towards the anterior-inferior iliac spine, then extending around the iliac wing to the superior sacroiliac joint and then down to the midline of the sacrum. Dissection was carried through the skin and subcutaneous tissue. A large fasiocutaneous flap was elevated of the gluteal skin and the posterior thigh. The anterior flap was also elevated slightly. Dr. X and I worked simultaneously. Dr. Y exposed the iliac wing and carefully dissected free the gluteal musculature on the outer wing down to the sciatic notch, and then carefully dissected on the inner table of the pelvis down to the sciatic notch on that side. During this portion, I was working on the release of the gluteus musculature from the femur. Dissection was carried down to the femoral attachment of the gluteus musculature from the femur. Dissection was carried down to the femoral attachment of the gluteus maximus, and then the gluteus maximus was elevated off the deep fascia. We then released the tendinous attachments of the gluteus minimus and medius to the greater trochanter of the femur. Care was taken to not disrupt the blood supply to the femoral head. Elevation of the flaps from my side and Dr. Y's side was done in retrograde fashion up to the sciatic notch. At this level, we were able to palpate the sciatic nerve and identified it as we dissected up the superior and inferior gluteal vessels, and nerves were clamped and tied off. We then placed a space-holder retractor into the sciatic notch. We turned our attention now to the sacrum. The gluteus maximus was elevated off the sacrum and from the distal most sacrim up the the level of the sacroiliac joint. We then dissected from a medial to lateral direction in order to expose the sacroiliac joint. We marked this out and placed retractors to hold our position. We turned out attention back to the sciatic notch. We placed a small retractor with a large Satinsky clamp and then used this to pass a Gigli saw through the notch. We then protected the sciatic nerve in the notch and the Gigli saw was passed from the sciatic notch out the anterior-inferior iliac spince above the level of the acetabulum in the resection, which was planned prior to surgery. With this made, we then turned out attention back to the sacroiliac joint. At the point, it was noted that there was involvement of the sacrum and we elected to take out osteotomy more medially so that an osteotomy was made through the lateral border of the S1 sacral vertebral body and then extended to the SI joint at the level of S2/S3 level so that we did a partial sacrectomy of S1, lumbosacral body. We were then able to elevate the whole entire tumor and dissect through the sacral osteotomy to incise the anterior sacroiliac ligaments. The soft tissue component of the tumor extended to incise the anterior sacroiliac ligaments. The soft tissue component of the tumor extended into the paraspinal muscles along L5. We performed a careful dissection around this part of the tumor, which required resection of the right paraspinal muscles around L5. With this completed, several small attachments deep in the pelvis including the sacrospinous ligament and other attachments were incised, and then we were able to elevate this extremely large mass away from the patient and pass it to the back table. Several of the gluteal vessels which were clamped were now tied off and the clamps were removed. We inspected the edges of the resection. At this point, there was noted a few small areas of the sacral ala which had been invaded by tumor. There were resected using curettes and then treated with the argon beam cautery. Once we were happy that all the tumor had been removed grossly, it was irrigated using 3L double-antibiotic water and the bone edges were sealed with bone wax. We noted on the gross specimen that the area in which the tumor was peeled off of the lateral sacroiliac joint region appeared to be extremely close and/or a positive margin; however, this area was also the resected bone specimen so a close margin was certainly obtained, but we were happy that we had a bone margin that was fairly clean appearing.


----------

