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Excision of retroperitoneal sarcoma


Medical editor Stephan Stoldt MD
Surgeon
Oslo University Hospital

Raphael Pollock, MD, PhD
MD Anderson Cancer Center

General

Surgery is the only curative treatment of retroperitoneal sarcoma and the prerequisite is complete resection with negative microscopic margins. A successful procedure is dependent on good planning.

Retroperitoneal sarcomas are often diagnosed late and are therefore often large at the time of diagnosis. Because of this, tumors often have a close relation to a number of neighboring organs and structures. In order to achieve the goal of resecting the tumor with negative margins, tumors must often be resected with neighboring organs.

Retroperitoneal sarcomas can occasionally have close relations to, and originate from vital vascular structures such as the vena cava and the descending aorta. The possibility of resection of vital structures and/or organs defines operability.

Indication

  • Sarcoma in the retroperitoneum

Goal

  • Cure the disease
  • Palliation

Equipment

  • Laparotomy tray
  • Helgerud's retractor
  • Self-retaining retractor, Bookwalter or similar
  • Depending on the localization of the tumor: Ligasure, staple instruments (GIA, TA) 

Preparation

  • Preoperative colon emptying
  • Antiobiotic prophylaxis
  • Thrombosis prophylaxis
  • Epidural catheter is inserted for pain treatment
  • A bladder catheter is installed unless the procedure is of very short duration.
  • The patient is operated under general anesthesia.
  • Positioning of the patient depends on where the incision is made.

Implementation

  • A generous midline incision is the preferred surgical approach. Occasionally, this incision is extended to either groin or as a thoracotomy for optimal exposure.
  • The tumor must be excised with an intact pseudo-capsule in order to attain negative margins and avoid tumor spillage. This can only be achieved by careful dissection within normal tissue around all planes of the tumor.
  • If necessary, involved and/or contiguous fixed organs must be removed en-bloc with the tumor. Violation of the tumor capsule undoubtedly leads to tumor cell spillage and this in turn translates to a high risk for relapse and reduced prognosis.
  • Tumors localized in the right retroperitoneal space are often resected en-bloc with the right kidney, right adrenal gland, and right hemicolon. When in the left retroperitoneal space, tumors are often removed together with the left kidney, left adrenal gland, tail of the pancreas, spleen, and left hemicolon.
  • In some cases, muscular structures that delimit the retroperitoneal space like the diafragm, psoas, iliacus, or transversus abdominis must be partially resected together with the tumor. In other cases, small bowel is fixed to the tumor and must also be partially removed.

Follow-up

Complications that can occur:

  • Bleeding
  • Infection
  • Cardiopulmonary complications
  • Anastomosis failure
Most patients are ready for discharge after 5-10 days.

When the histology result is available and the treatment is considered finished, the patient is followed up:

  • Biannually the first 5 years with clinical examinations supplied with CT abdomen/pelvis and thoracic X-ray
  • The next five years, annually

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