Limb Sparing Surgical Resection of Groin Sarcoma. Surgical ... - NCI

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288Limb Sparing Surgical Resection of Groin SarcomaFig. (11): Tensor fascia lata flap for reconstruction oflarge transverse groin defect after resection ofgroin soft tissue sarcoma.Fig. (12): Postoperative plain X-ray, showing resectionof pubic bone and superior puboc ramius.Fig. (13): Healing of abdominoinguinal incisionafter resection of groin soft tissuesarcoma with pelvic extension.Fig. (14): Inferior rectus muscle flap without skin for coverageof femoral vascular graft and proline mesh.DISCUSSIONThe rationale of limb sparing surgical resectionfor soft tissue sarcoma includes improvementof survival, achievement of adequate negativesafety margins around the tumor tomaximize local control, adequate soft tissuecoverage of implants and deep structures witha reliable myocutaneous flap [9-13].Limb sparing surgical resection of groinsarcoma is different from that of anterior thighdue to proximity to the pubic bone with possibleintrapelvic extension and close relation to thefemoral vessels. Wound problems may occurwith minimal skin excision or even followingsimple elevation of skin flaps. Safe resectionwith achievement of clear margins entails theneed of wide retroperitoneal or intraabdoimalexploration through modified inguinal or abdominoinguinalincisions, exposure and controlof iliofemoral vessels proximally and distallyand resection of the pubic bone. Also, good
Magdy El-Sherbiny 289orientation with the reconstructive options isneeded [2,3,4].Mismanagement in the form of improperbiopsy incision or incomplete resection or localrecurrence with skin involvement will add tothe difficulty to the proper approach. In thepresent study, the skin incision was modifiedin 85.7% of cases to include previous scars orareas of possibly infiltrated skin and then theapproach was continued as previously describedmodified inguinal or abdominoinguinal approach[4,7]. Through this approach, we wereable to resect the tumor with negative marginsin 12/14 of cases (92.8%). Only one case (7%)had single microscopic positive margin. Thismight be due to previous radiotherapy and theresulting dense fibrosis that may add difficultyto the proper intraaoperative assessment of themargins.Vascular resection and prosthetic reconstructionwas done in two cases. Soft tissue sarcomasinvolving major vascular structures are notconsidered a contraindication of limb sparingsurgery. Patients can undergo vascular resectionwhen the tumor is infiltrating or encasing thevessels [14,15]. Schwarzbach et al. [16], recommendedsynthetic grafts for arterial and venousvascular substitute in the iliofemoral region.The rational of this is to reduce the operativetime and to preserve the great saphenous vein(GSV) and usually there is some degree ofcaliber discrepancy between iliofemoral andGSV.Reconstruction of resected iliofemoral veinis mandatory. This prevents limb edema in theimmediate postoperative period and associatedclinical sequale as complicated wound healing,pain, edema, tension and skin alteration. Femoralvein resection distal to the entry of the ipsilateralGSV can be ligated if GSV was preserved andwas patent, however, some recommended autologousvein graft for fear of infection ofprosthetic grafts [16].When a prosthetic vascular raft has beenused to replace the femoral vessels, an effortshould be made to cover the graft at the end ofthe procedure with rotation of muscle to avoidexposure and infection [16,17,18]. In the 2 caseshaving prothetic vascular graft in the presentstudy, medial transposition of sartoius musclewas not enough for complete coverage, so the2 cases had had rectus muscle and mucocutaneousflap coverage.The reported patency rates for prostheticvenous reconstructions are lower than for arterialones; however, the use of the autologous veinhas not proven to be superior to synthetic graftswith respect to the long-term patency rate afterlimb-salvage surgery [16,19,20]. In the presentstudy, one case had concomitant venous andarterial prosthetic reconstruction and one hadonly venous prothetic reconstruction. All the 3grafts lost patency within 5 months postoperativelydespite anticoagulant therapy. Usuallyrevision is not needed for venous reconstructionas usually by time collaterals develop. Revisionof arterial graft may be considered however, inthe present study revision was ignored as thepatient had no complaint and distal circulationwas very good.Involvement of the femoral nerve in threecases (21%) necessitated nerve sacrifice. Mostof tumors in the present study were medial tothe femoral vessels so the nerve could be sparedin most cases. The residual function of postnerve resection was frequently very good. Thosepatients only need a temporary knee brace [7].Microvascular free flap transfer is rarelyrequired to cover groin defects. This is due toavailability of some reliable local muscle andmusculocutaneous flaps. Local flaps reportedfor groin defect reconstruction included tensorfacia lata flap [21], anterolateral thigh flap [22],inferiorally based rectus abdomins myocutaneousflap [23], gracilis myocutaneous [24], Sartoriusmuscle flap [25] and rectus femoris muscleand musculocutaneous flap [26].A total of number of 10 myocutaneous flapswere used in the present study. We had no flapfailure or partial necrosis. To minimize the riskof failure, the selection between the availableflaps in the present study was finalized aftercompletion of the process of resection and wasbased on many factors such as the site of thedefect (lateral or medial part of the groin), sizeof the defect, orientation of the axis of the defectand which branches of the iliofemoral vesselwere preserved such as the profunda artery andits branches and the inferior epigastric artery.Inferiorly based rectus abdomins myocutaneousflap has a pedicle length ranging from 7-
Page 2: 282A high percentage of patients ha
Page 6 and 7: 286flap without skin was used in 2
Page 10 and 11: 29012cm which is the inferior epiga
Page 12 and 13: 292REFERENCES1- Brooks AD, Bowne WB

Limb Sparing Surgical Resection of Groin Sarcoma. Surgical ... - NCI

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