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This digital library houses the book on Oncology and Orthopedic Oncosurgery.

It includes academic lectures, presentations from national and international congresses, published papers, case discussions, performed surgical procedures, and proprietary techniques developed.

The digital format was chosen because the web allows the inclusion of texts with numerous visual resources, such as images and videos, which would not be possible in a printed book.

The content is intended for students, healthcare professionals, and the general public interested in the field.

Total sacrectomy without reconstruction – Part II

Sacrectomy Part II

In this second part of the conference on total sacrectomy without reconstruction, we will present the use of Gigli saws, which are now positioned by a new access: laparoscopy!

Figure 1: We used laparoscopy in oncosurgery to treat a schwannoma in a patient with a compressive lesion in the S-3 sacral foramen. He had pain, paresthesia and numbness in his left leg. This technique was improved with the help of videolaparoscopy.
Figure 2: X-ray reveals a widening of the S-3 sacral foramen
Figure 3: CT scan shows a well-defined lesion
Figure 4: MRI shows a circumscribed lesion, delimited by a thick pseudocapsule.
Figure 5: In the sagittal section, a saccular tumor can be seen in continuity with the nerve root, showing that it is a Schwannoma.
Figure 6: We performed an arteriography for a more detailed investigation
Figure 7: CT reconstruction shows a well-defined, slowly evolving, chronic and benign lesion
Figure 8: This was the first case in which we used laparoscopy for biopsy, with the intention of removing the tumor at the same surgical time if it was feasible.

Video 1: The gastric surgeon performed the laparoscopy, dissecting the retroperitoneum and isolating the iliac vessels to ligate and cut the left internal iliac artery and vein. The tumor was placed in a glove and macerated.

Figure 9: Its contents were aspirated and the surgical glove was removed through the laparoscopy tube.

Video 2: The patient was released to walk and was discharged from hospital on the second day after surgery.

Figure 10: For total sacrectomy, we studied the possibility of dissecting the internal surface of the sacrum laparoscopically. This would include cauterization of the pre-sacral vessels and the internal wall of the sacrum, as well as ligation of the internal iliac and hypogastric arteries and veins, with the aim of minimizing blood loss. In addition, we would try to pass Gigli's saw through laparoscopy, allowing us to perform the sacrectomy in complete safety.
Figure 11: To develop a learning curve, we started with this case of Ewing's sarcoma in the sacrum, below S-3. In this case, we would only need to pass a Gigli saw horizontally through the ischial notches.
Figure 12: The tumor was resected using laparoscopy, eliminating the need for a previous laparotomy access and optimizing the technique of using Gigli saws.

Video 3: The patient was released to walk and was discharged from hospital on the second day after surgery.

Figure 13: Currently, in total sacrectomy, we use laparoscopy to perform the procedure that was previously done by laparotomy.
Figure 14: In this case of sacral chordoma, imaging exams show a large tumor compromising the region.
Figure 15: The CT scan shows that the right sacro-iliac joint is preserved and free of neoplasia. We planned to perform the osteotomies, resecting the left side and preserving the right side joint. It was possible to preserve the joint on the right, as it was not affected by the tumor, guaranteeing the preservation of motor function.
Figure 16: In order to preserve the right sacroiliac joint, we planned three osteotomies, as shown in the diagram.
Figure 17: For this procedure, we made steel tubes: one long, which will allow the saw to pass through the abdominal wall to the back. Another short one, which will allow the saw to pass from inside the abdominal cavity to the patient's back. I've organized the text to improve clarity and fluidity, while maintaining the original content. If you need any additional adjustments, I'm happy to help!

Vídeo 4

Vídeo 5

Vídeo 6

Figure 18: And we insert it through the short tube, allowing it to exit in the patient's dorsal region.
Figure 19: In this safe way, we repeated the positioning of the other two saws to perform the osteotomies by posterior approach, eliminating the need for laparotomy.
Figure 20: Patient walking with the aid of a walker three weeks after surgery.

Video 7: Now, in the third post-operative month, the patient walks using only a cane, showing a deficit in the tibialis anterior of the left leg, a consequence of the wide resection of the joint due to the greater involvement of the lesion. The nerve root of the right dorsiflexor was preserved

Figure 21: This case illustrates a patient with a large chordoma affecting the entire sacrum.
Figure 22: The oncological indication was total sacrectomy.
Figure 23: In another hospital, where she had been for eight months, the patient had already lost control of her bladder and anal sphincters, requiring a delayed bladder catheter and repeated enemas.
Figure 24: She had fixed flexion of the hips and knees and multiple pressure sores.
Figure 25: We performed the total sacrectomy using the Gigli saws, positioned laparoscopically, for the osteotomies.
Figure 26: After resection of the sacrum, we stretched the hip and knee flexor tendons.
Figure 27: We realigned the lower limbs to facilitate motor function and allow the patient to resume walking.
Figure 28: We received this patient, trapped by an aggressive injury that compromised her functions and movements, leaving her vulnerable to worsening bedsores.
Figure 29: After the sacrectomy, which was performed using laparoscopy, we began physiotherapy in bed, followed by inclined plank exercises, with the aim of recovering his orthostatism and promoting gait gain, re-establishing his mobility. After his recovery and muscle strengthening, we continued to invest in his training.

Video 8: The patient currently works as a street vendor.

Figure 30: Complications: Loss of anal and bladder sphincter control. Partial loss or total deficit of ankle dorsiflexion. Pelvic instability. Claudication. Need for motor physiotherapy and guidance on bowel and bladder functions. I have removed the features as requested. If you need any more adjustments, I'm happy to help!
Figure 31: Conclusion: Sacrectomy using Gigli saws, positioned laparoscopically, offers advantages: Reduced surgical time and greater safety. Less blood loss. More satisfactory results given the severity of the lesion. Reasonable function, considering the aggressiveness of the tumor. Does not require reconstruction, resulting in lower morbidity. “We don't perform reconstruction!”

Case Author

Author: Prof. Dr. Pedro Péricles Ribeiro Baptista

 Orthopedic Oncosurgery at the Dr. Arnaldo Vieira de Carvalho Cancer Institute

Office :  Rua General Jardim, 846 – Cj 41 – Cep: 01223-010 Higienópolis São Paulo – SP

Phone: +55 11 3231-4638  Cell:+55  11 99863-5577   Email:  drpprb@gmail.com

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