Category Archives: Surgeries

In this second part of the total sacrectomy technique using Gigli saws, we will demonstrate its evolution, highlighting the use of laparoscopy. We will discuss its application for guiding the Gigli saws from the pelvic cavity to the dorsal region of the patient.

The first time we used laparoscopy was in a case involving a patient with an osteolytic lesion in the S-3 sacral foramen.

She presented with clinical symptoms of pain and numbness in her left leg. The X-ray revealed an enlarged foramen in the S-3 sacral vertebra. The CT scan showed a well-defined area, and the MRI exhibited a circumscribed lesion, bounded by a thick pseudocapsule. In the sagittal section, we observed the formation of a sacral tumor and its continuity with the nerve root, suggesting it was a schwannoma. An arteriography was performed for further study. The CT reconstruction indicated that the lesion was likely slow-growing, chronic, and benign.

A surgeon performed the laparoscopy, opening the retroperitoneum and isolating the iliac vessels under our guidance, to ligate and cut the left internal iliac artery and vein. Then, the tumor was exposed, and we confirmed its continuity with the S-3 root, resembling a horse’s tail. Next, he placed the tumor inside a surgical glove and aspirated the contents, removing everything through the laparoscopic tube. The patient was able to walk on the second day after surgery.

We discussed the possibility of performing the dissection of sacral tumors by passing the Gigli saws laparoscopically. To acquire the learning curve, we started with a case of Ewing’s sarcoma affecting the sacrum below S-3. In this case, we only needed to pass one saw horizontally. The tumor was successfully resected oncologically.

A Kirschner wire is placed as a guide, and we position two segments of the tube: the first is shorter and will exit through the patient’s back, while the second will push the first and be removed first, as per the diagram. We repeated this operation for the passage of the other saws. This way, we have the three saws safely positioned to make the osteotomies through the posterior approach. Currently, we use laparoscopy to perform all the procedures that were previously done through the anterior approach.

The case of a patient with a large volume chordoma, involving the entire sacrum and with difficulty in defecating and urinating, who had been bedridden for eight months in another hospital, was decisive in the approval of this technique. The patient had pressure ulcers and a posture of hip and knee flexion. She was operated on using the Gigli saw technique, positioned laparoscopically, and then we performed the release and lengthening of the hip and knee flexors, realigning the lower limbs. This chordoma case, despite its severity, was successfully operated on, and the total sacrectomy with laparoscopic assistance was successful. The patient started physiotherapy and rehabilitation of bladder and bowel excretory functions through abdominal maneuvers. She can walk with the aid of a walker and is reintegrated into daily life, independently, despite motor deficits in the ankle dorsiflexor muscles.

Sacrectomy with laparoscopic assistance is advantageous, presenting shorter surgery times, reduced need for blood transfusions, and satisfactory functional outcomes. Currently, we see no need to perform reconstructions.

In some cases of bone tumors and severe trauma, failure of prostheses or osteosynthesis can represent a significant challenge. It is in this scenario that knee arthrodesis emerges as a viable alternative. This technique can be performed in several ways, one of which is with a diaphyseal-type prosthesis or through a biological solution using autologous graft and osteosynthesis.

For example, when we are faced with the failure of an infected primary prosthesis or in situations of aggressive bone tumors or trauma, arthrodesis can become an alternative to amputation.

Let us consider this case of recurrent chondrosarcoma, after two unsuccessful surgical attempts, in which the need for a wide resection is present, and reconstruction with arthrodesis may be the only alternative to avoid amputation. In these cases, arthrodesis using a diaphyseal prosthesis may offer the chance of preserving this limb.

Success requires careful resection, with the removal of compromised tissues, preserving the popliteal vessels and nerves in the region. Then, reconstruction is carried out with a modular prosthesis of the diaphyseal type, in this case it was specially molded, with the manufacture of a polyethylene segment, aiming to give a more aesthetic shape to the “neo knee” region, minimizing the defect left by the extensive resection of the segment affected by the tumor and meeting the objective of ensuring a wide resection, with safe oncological margins.

In this other example of a giant cell tumor, which destroyed the entire tibial plateau and the proximal 1/3 of the tibia, the approach may be biological. In this patient, we used autologous bone from the site itself, in the case of the femoral condyles, to fill the bone gap left by the resection of the neoplasm.

It is important to highlight that the technique requires precision and care, both in resection and reconstruction. The plate used for fixing must be positioned to ensure adequate alignment and avoid unwanted rotations. The integration of arthrodesis with the biological autograft is essential for the success of the procedure.

In cases of severe trauma, with extensive bone destruction due to high-energy trauma, arthrodesis may be the only viable option to restore limb stability and avoid amputation. These cases, which we are showing, were presented at the International Knee Trauma Congress, in Ribeirão Preto – SP, showing our experience with these two arthrodesis techniques, using diaphyseal prostheses or osteosynthesis with biological reconstruction. For more information about these techniques and appreciation of other similar clinical cases, visit the website  www.oncocirurgia.com.br ,

 By sharing knowledge and experience, we will be able to advance developments in the treatment of complex orthopedic conditions.