Incisions and reconstruction approaches for large sarcomas

Abstract

Large intraabdominal, retroperitoneal, and abdominal wall sarcomas provide unique challenges in treatment due to their variable histology, potential considerable size at the time of diagnosis, and the ability to invade into critical structures. Historically, some of these tumors were considered inoperable if surgical access was limited or the consequential defect was unable to be closed primarily as reconstructive options were limited. Over time, there has been a greater understanding of the abdominal wall anatomy and mechanics, which has resulted in the development of new techniques to allow for sound oncologic resections and viable, durable options for abdominal wall reconstruction. Currently, intra-operative positioning and employment of a variety of abdominal and posterior trunk incisions have made more intraabdominal and retroperitoneal tumors accessible. Primary involvement or direct invasion of tumor into the abdominal wall is no longer prohibitive as utilization of advanced hernia repair techniques along with the application of vascularized tissue transfer have been shown to have the ability to repair large area defects involving multiple quadrants of the abdominal wall. Both local and distant free tissue transfer may be incorporated, depending on the size and location of the area needing reconstruction and what residual structures are remaining surrounding the resection bed. There is an emphasis on selecting the techniques that will be associated with the least amount of morbidity yet will restore and provide the appropriate structure and function necessary for the trunk. This review article summarizes both initial surgical incisional planning for the oncologic resection and a variety of repair options for the abdominal wall spanning the reconstructive ladder.

An Integrated Surgical Management for Giant Dermatofibrosarcoma Protuberans of Anterior Abdominal Wall

“…After WLE, the reconstruction of the resultant full-thickness defect aims to protect the abdominal viscera, restoring the functional integrity of the abdominal wall along with its aesthetic appearance and hernia prevention [ 9 , 10 ]. Reconstruction of Type II and III large abdominal wall defects (> 6 cm in diameter) is generally done by vascularized autologous free or pedicled flaps that need the expertise of plastic surgeons [ 9 ].…”

“…AWR by CST is a recently developed technique of ventral hernioplasty with the principle of re-establishing a functional abdominal wall with autologous tissue repair. This technique can be modified and used in the reconstruction of post-oncologic full-thickness abdominal wall defects after abdominal DFSP excision [ 9 , 10 ]. So primary repair of full-thickness abdominal wall defect of Type III C, after WLE for DFSP, can be achieved by CST as it minimizes the defect size by the advancement of musculofascial layer over the bridging mesh used to cover the defect [ 9 , 11 ].…”

Integrating therapies for surgical adult soft tissue sarcoma patients

“…Furthermore, preoperative planning with an experienced plastic surgeon can lead to improved cosmetic and functional outcomes (46). Additional considerations regarding reconstruction are well described by Hadad et al in this special issue (47).…”

The role of surgical access in retroperitoneal sarcoma resection - a retrospective study

“…Although these recommendations do not speci cally state what incision to use, the midline incision seems to be the access of choice if wide margins are anticipated [14,15]. A thoracic or lumbar extension may be necessary to assure a better exposure or better vascular control of the vena cava inferior and left atrium [14,16,17]. The midline laparotomy (ML) allows exposure of the intraperitoneal and retroperitoneal compartment while ank incisions (FI) are limited only to the retroperitoneal space not allowing full exposure of the intraperitoneal compartment often necessary for a multi-visceral resection [18].…”