A hemipelvectomy is a complex surgical procedure that involves the removal of a portion of the pelvis and, in some cases, the entire lower limb on one side of the body. This operation is considered when less aggressive treatments are not sufficient to address severe medical conditions. Due to its significant impact on a patient’s anatomy and mobility, hemipelvectomy is a rare procedure, typically performed in highly specialized medical centers. The surgery requires meticulous planning and a skilled surgical team to manage the intricate anatomical structures involved.
Understanding Hemipelvectomy
Hemipelvectomy involves removing a portion of the pelvic bone, often along with the entire lower limb. This procedure is distinct from a hip disarticulation, which removes the entire lower limb through the hip joint but preserves the pelvis.
There are two main classifications of hemipelvectomy. An external hemipelvectomy, also known as a hindquarter amputation, involves the complete removal of the leg and the affected portion of the pelvis. This approach is chosen when the tumor or damage extends significantly into the lower extremity, making limb preservation unfeasible. Conversely, an internal hemipelvectomy is a limb-sparing procedure where only the diseased section of the pelvic bone is removed, while the ipsilateral leg is preserved. This technique aims to maintain limb function, often requiring complex reconstruction of the pelvic bone.
Reasons for the Procedure
Hemipelvectomy is primarily indicated for serious medical conditions where other treatment options have failed or are not suitable. The most common reason for this extensive surgery is the presence of aggressive bone cancers, such as osteosarcoma, chondrosarcoma, or Ewing’s sarcoma, located in the pelvic region. These malignancies can be challenging to treat due to the complex anatomy of the pelvis and the potential for tumor spread.
The procedure may also be performed for severe, untreatable infections like osteomyelitis that have caused extensive damage to the bone and surrounding tissues of the pelvis. Such infections may not respond to antibiotics or less invasive surgical interventions, necessitating removal of the affected bone to prevent further spread and alleviate symptoms. Extensive trauma to the pelvis and limb that cannot be effectively reconstructed can also lead to a hemipelvectomy. This includes severe injuries where bone structure is irreparably damaged or neurovascular structures are compromised. Recurrent tumors in the pelvic area, even after previous treatments, can also necessitate a hemipelvectomy to achieve complete tumor removal and improve patient outcomes.
The Surgical Process
The surgical process begins with thorough pre-operative preparation, which includes detailed imaging studies like CT or MRI scans to precisely map the tumor or damaged area. A multidisciplinary team, including orthopedic surgeons, oncologists, plastic surgeons, and anesthesiologists, collaborates to plan the procedure. Patients also undergo comprehensive medical evaluations, including blood work and cardiac assessments, to ensure they are healthy enough for the extensive surgery.
During the operation, general anesthesia is administered. The surgical steps involve disarticulating the limb at the hip joint and resecting the involved portion of the pelvis. Surgeons meticulously control major blood vessels and nerves to minimize blood loss, which can be substantial and sometimes requires transfusions. After the diseased tissue is removed, the remaining soft tissues are carefully reconstructed, often using skin grafts or tissue flaps to cover exposed areas and protect underlying structures.
Following surgery, patients are transferred to an intensive care unit or a specialized recovery unit. Immediate post-operative care focuses on managing severe pain, often through continuous epidural infusions of local anesthetics and opioids. Wound care is also a priority to prevent infection and promote healing of the extensive surgical site. Initial physical therapy may begin within days of surgery to help with early mobility and prevent complications associated with immobility.
Post-Surgical Recovery and Adaptation
The recovery journey after a hemipelvectomy is extensive and requires significant adaptation. Patients remain in the hospital for a period, often 6 to 10 days, depending on their individual progress and any complications. During this initial phase, physical therapy begins, focusing on strengthening the upper body and learning new methods of movement for transfers and basic mobility.
Rehabilitation is a continuous process involving physical therapy, occupational therapy, and pain management. Physical therapists guide patients in rebuilding strength, improving coordination, and adjusting to new movement patterns, especially concerning weight shifting and balance. Occupational therapists assist with adapting daily tasks and activities to the new physical reality, helping individuals regain independence in self-care and household routines. Psychological adjustment is also a significant aspect of recovery, as patients often grapple with changes in body image, self-identity, and emotional well-being. Support systems, including family, friends, and professional counseling, play an important role in navigating these emotional challenges.
For mobility, specialized prosthetics, such as Canadian-type hemipelvectomy prostheses, are often considered, though not all patients are candidates or choose to use one. These prostheses require extensive training to learn how to walk and manage balance effectively. Many patients also utilize adaptive equipment, such as crutches or walkers, to aid in mobility. The ultimate goal of rehabilitation is to optimize functional independence, allowing individuals to adapt to daily living, maintain engagement in activities, and improve their overall quality of life.