Spinal and Orthopedic Considerations for Advanced Multivisceral Colorectal Cancer



Spinal and Orthopedic Considerations for Advanced Multivisceral Colorectal Cancer


Lukas M. Nystrom

Nathan W. Mesko



Perioperative Considerations



Indications/Contraindication



  • Localized recurrence without evidence of distant disease—does this operation give the patient a reasonable chance at curative intent (especially for high-level ablations)?


  • Preoperative advanced imaging—does anatomic distortion from surgery/radiation, anticipated tissue planes, and tumor location allow for a reasonable chance at “cure”?


  • Morbidity needs to be considered—high-level (S1/S2) resections will create bladder and major potential dysfunction in ipsilateral or bilateral lower extremities.



    • If a clean margin resection is not thought possible, we do not recommend attempting a high-sacrum resection given extreme post-op functional morbidity consequences.


  • Involvement of major vessels that would require resection/bypass is soft contraindication—is it feasible to get a “clean” margin in multiply operated/radiated tissue?


  • Overall patient comorbidity burden and health status


  • Is there local tissue flap coverage available?


  • Is local radiation therapy necessary (intraoperative radiotherapy or brachytherapy)?


Sterile Instruments/Equipment



  • Anterior approach



    • +/- Headlamp


    • Richardson, Deaver, and malleable retractors


    • Self-retracting abdominal instrumentation


    • +/- Digital x-ray to localize level


    • Nerve stimulator/neural monitoring for L5/S1


    • Irrigating bipolar cautery device (ie, Aquamantys)


    • Conventional bipolar cautery


    • Extended/long clamps, forceps, dissection instrumentation


    • +/- Lighted retractors


    • Poole suction tip


    • Silastic sheet


  • Posterior approach (Fig. 34-1A-D)







    FIGURE 34-1 ▪ A-D. Prone positioning and draping should include both posterior thighs so that soft-tissue coverage options may be maximized. This 68-year-old male was found to have an isolated S3 body rectal cancer metastasis and underwent an S3 hemisacrectomy resection. A pedicled gluteus maximus flap was utilized to fill the space evacuated by the sacrum/rectum. A hamstring rotational flap is another potential option as a local rotational flap.



    • +/- Digital x-ray to localize level


    • +/- Intraoperative navigation (two techniques)



      • Can use in conjunction with intraoperative computed tomography (CT) scanner and 2 mm × 6 mm craniofacial screws utilized as fiduciary points for registration


      • Can fuse preoperative thin-slice CT, magnetic resonance imaging (MRI), and/or CT angiogram imaging and utilize bony landmarks for registration


    • Gelpi, Cerebellar, Viper retractors


    • Blunt Homan and Bennett retractors



    • Curved and straight osteotomes


    • Kerrison Rongeur


    • Nerve hooks, freer elevators, Penfield elevators


    • +/- K-wires and K-wire driver


    • +/- Oscillating saw with narrow and reciprocal/sagittal blades


    • High-speed Midas Rex burr with matchstick tip


    • Nerve stimulator/neural monitoring for L5/S1


    • Irrigating bipolar cautery device (ie, Aquamantys)


    • Gel foam + Pledgets


    • Bone wax, Surgicel, Fibrillar


  • Implants (if resecting above S2 and destabilizing sacroiliac joint):



    • Pedicle screws


    • Spinal rods


    • Cross-links


    • Small fragment (3.5 mm) and large fragment (4.5 mm) screw set


Surgical Approaches


Anterior


Transperitoneal (Workhorse Approach)



  • Positioning



    • Supine on spinal flat top table or in lithotomy position—depending on needs of multidisciplinary team


  • Approach will be combined with dissection of recurrent tumor with multidisciplinary team (covered previously).


  • Safely mobilize the aorta, common iliac, and internal/external iliac vessels. Oftentimes, this is radiated tissue, and a vascular surgeon can help with the distorted anatomy.


  • Identify and protect nerve roots to be spared (L5, S1 especially; any additional below this level).


  • Identify and transect/ligate nerve roots/vascular branches to be sacrificed.



    • It is generally not feasible to see nerve roots from anterior approach below level of S2.


  • Identify the site of the planned osteotomy and ligate/cauterize presacral vessels where they can be identified maintaining a safe margin from the tumor.


  • Pack laparotomy sponges or a silastic sheet between vessels, nerves, vertical rectus abdominis myocutaneous (VRAM) flap, rectal stump, and so on and the sacral osteotomy site to protect from the osteotome causing structure damage from “passing point.”


Retroperitoneal (Less Frequently Used)



  • Positioning



    • Supine with a bump underlying the ipsilateral hip to gently tilt the pelvis


    • Radiolucent spinal flat top table


  • Dissect from 2 cm lateral to the anterior superior iliac spine toward the pubic tubercle.


  • Identify superficial inguinal ring and release external oblique from this landmark medially.


  • Identify the spermatic cord/round ligament and the deep inguinal ring.


  • Release the remaining abdominal muscles (transversus abdominis, internal oblique) to expose the inguinal ligament. Maintain, if possible, for later repair.


  • Identify the lateral femoral cutaneous nerve and either transect sharply or preserve if possible with minimal traction.


  • Release the three abdominal layers subperiosteally from the iliac crest to allow for the necessary exposure.

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Apr 13, 2020 | Posted by in GASTOINESTINAL SURGERY | Comments Off on Spinal and Orthopedic Considerations for Advanced Multivisceral Colorectal Cancer

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