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World Journal of Surgical, Medical
and Radiation Oncology
Case Report
Open Access
Anterior compartment resections of the thigh and
postoperative bleeding
Mahmoud N. Kulaylat, John L. Butsch,
Department of Surgery, State University of New York at Buffalo, Buffalo, NY 14203, USA
This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited
Introduction: In a compartment resection of the anterior thigh which includes the vastus lateralis,
as the posterior attachment of the muscle to linea aspera is divided the perforator branches of the
profunda may be divided and occasionally retract into in accessible locations behind the femur
where they may stop temporarily bleeding through contraction giving the false impression of
hemostasis.
.
Case report: A 28-year old man had a history of a peripheral neuroectodermal tumor in the left
anterolateral thigh located in the substance of vastus lateralis and vastus intermedius and two
nodules in the left lung. After the neoadjuvant chemotherapy resection of the tumor was carried
out. At the end of the procedure the left lateral thigh was noted to be swollen and blood was oozing
between the skin staples. The incision was opened, and a large hematoma evacuated. Small
bleeding points were coagulated. Bleeders on the muscle surface were suture-ligated. There was
also arterial bleeding, with no visible vessel, behind the linea aspera.
Discussion: The techniques to avoid this type of bleeding or to control it at reoperation, if it occurs
postoperatively, are described.
Introduction
The thigh has the greatest concentration
and bulk of muscles in the body. Soft tissue
sarcomas in this area tend to remain concealed
and be relatively asymptomatic often growing
to prodigious size before they call attention to
their presence. Diagnosis is usually established
through a core needle biopsy. In the absence of
metastatic disease to the lungs or other sites
the question rises of immediate resection, the
latter option usually taken for the treatment of
Corresponding author: Mahmoud N. Kulaylat, MD.
Department of Surgery Buffalo General Hospital 100 High
Street Buffalo, NY 14203 USA,
[email protected]
©2012 Kulayat MN et al. Licensee Narain Publishers Pvt.
Ltd. (NPPL)
Submitted: April 5, 2012; Accepted April 8, 2012,
Published: April 12, 2012
42
the large high-grade sarcomas.
In the anterior compartment of the thigh a
near-complete compartment resection can be
performed with preservation of the distal half
of the vastus medialis (VM) (which is usually out
of the way) forming the medial fleshly bulge at
the knee. Since the VM inserts mostly on the
medial edge of the quadriceps tendon, the
muscle fibers adjacent to the quadriceps tendon
stumps are sutured, after the resection, to the
stump in order to impart a more straight pull
on the tendon. Within a couple of months the
remaining part of vastus medialis hypertrophies
allowing straight-leg raising of the affected leg
in the supine position. This is permitted by the
fact that the innervations of vastus medialis is
supplies by an independent separate branch of
the femoral nerve which continues outside the
http://www.npplweb.com/wjsmro/content/1/1/9
World J Surg Med Radiat Oncol 2012;1:42-44
quadriceps to the distal half of the VM where
this motor branch enters the belly of the
medialis. The proximal half of the VM can be
removed with the rest of the quadriceps [1, 2]
In the following, through the medium of a
case report a specific anatomic situation is
described which is applicable to all anterior
compartment resections and may cause
intraoperative or postoperative bleeding.
Awareness of this misadventure may prevent
its occurrence or facilitate its control when it
occurs.
Case report
A 28-year old man had a history of a
peripheral neuroectodermal tumor in the left
anterolateral
thigh
diagnosed
with
percutaneous core biopsy. CT and MRI Scans
showed the tumor located in the substance of
vastus lateralis and vastus intermedius and two
nodules in the left lung. He was treated with
neoadjuvant chemotherapy for 6 months
showing a 50% objective response at the
primary and metastatic tumors. He was
referred for resection of the primary and
metastatic lesions.
With the patient in a right lateral position an
incision was made from the anterior superior
iliac spine to a few centimeters above the
lateral border of patella. The fascia lata was
incised between the rectus femoris muscle and
tensor fasciae latae entering the plane between
rectus femoris and vastus intermedius; the
vascular branches from the lateral femoral
circumflex vessels were dissected and
preserved as they entered the proximal part of
the rectus, while branches to vastus intermedius
and lateralis were proximally ligated and
divided. The junction of the vastus intermedius
and medialis was clearly visible and the VM was
clinically-free of tumor. Medial to the junction,
the VM was incised down to the femur. With the
periosteal elevator the muscle fibers of
intermedius and lateralis were detached from
the femur all the way to the greater trochanter
and intertrochanteric line. The posterolateral
fasciocutaneous flap had been developed to the
linea aspera. With the electrocautery the fascia
was incised along the linea aspera separating
43
Anterior compartmental reserction
the attachment of the lateralis off the femur.
During the dissection 3 arterial branches were
divided as they were crossing transversely the
linea aspera, apparently three perforators of
the profunda femoris. The stumps retracted
behind and medial to the linea aspera so they
were not readily visible. Bleeding from these
branches was controlled with Figure-of-eight
sutures placed in each bleeding site. Two 10
mm JP suction drains were placed in the
operative field and brought out through two
small stab incisions in the skin where they were
secured with 3-0 Prolene. The incision was
closed routinely. The two left lung lesions were
then wedged-resected with video-assisted
thoracoscopy.
At the end of the second procedure the
left lateral thigh was noted to be swollen and
blood was oozing between the skin staples. The
incision was opened, and a large hematoma
evacuated. Small bleeding points were
coagulated. Bleeders on the muscle surface
were suture-ligated. There was also arterial
bleeding, with no visible vessel, behind the linea
aspera. To gain better exposure, a figure-ofeight suture was placed in the muscle and
retracted laterally thus exposing the bleeding
vessel. Another figure-of-eight suture was now
placed at the bleeding point under direct vision
which controlled effectively the bleeding. A
total of 6 units of blood were used during the
operation and afterwards to replace the blood
loss. The postoperative course of the patient
was uneventful, his discharge occurring on the
4th day.
Discussion
Cutting through muscular tissue around a
large soft-tissue sarcoma in the thigh, one
encounters numerous blood vessels. The
smaller ones can be controlled with the cautery
allowing a slightly protracted contact of the tip
of the electrocoagulation unit to the hemostatic
clamp so that a length of coagulated vessel a
few millimeters proximal to the clamped point
is obtained. The large bleeders are best
controlled with figure-of-eight sutures because
the tip of the bleeders cannot often be
visualized as it retracts within the muscle. The
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World J Surg Med Radiat Oncol 2012;1:42-44
bleeders are best definitively controlled as they
are encountered not only because this reduces
the total blood loss but also because after a
small blood vessel is divided in a few minutes it
contracts and stops bleeding but may, when the
patient rewarms after operation, dilate and
start bleeding again.
In a compartment resection, which includes
the vastus lateralis as one tries to stay outside
the fascia enveloping this muscle cutting
through its origin from the lateral lip of the
linea aspera, one encounters the perforator
branches of the profunda femoris. It is difficult
to clamp and tie the stumps of these vessels as
they retract behind the femur. They are more
easily controlled with figure-of eight sutureligatures. The placement of these sutures is
difficult and often two or three attempts are
required before the bleeding stops. Eventually,
the bleeding stops but the ligature may not
have been the effective agent, as the arterial
branch contracts and may stop bleeding
spontaneously only to reopen in the
postoperative
period.
To
avoid
this
complication, as a suture-ligature is applied in
the tissues next to the linea aspera it is
retracted laterally bringing to the fore a 0.5 cm
or so of the tissues behind the linea aspera,
allowing now divert visualization of the ligated
point to assure that secure control of the
perforator artery has been accomplished or to
provide the opportunity to place a more
effective ligature at the bleeding point.
World Journal of Surgical, Medical
and Radiation Oncology
44
Kulayat MN et al.
In cases, in which they tumor does not
extend close to the posterior origin of vastus
lateralis from the linea aspera, this muscle may
be divided posteriorly about 0.5 cm from the
bone, to avoid retraction of the divided arterial
stumps to in accessible locations, in doing so
one often can visualize these branches a and
ligate them before they are divided. These
patients should be closely observed in the first
few hours postoperatively.
Authors' Contribution
MNK: Concept and design, preparation the draft
manuscript
JLB: Concept and design, edited the manuscript
Conflict of Interest
The authors declare that there are no conflicts
of interests.
Ethical considerations:
Written consent of the patient was obtained for
publication of this case report.
References
1)
2)
Karakousis, CP, Konzoglou K, Driscoll DL. Anterior
compartment resection of the thigh in soft tissue
sarcomas. Euro J Surg Oncol 1998; 24:308-312.
Kulaylat M, Karakousis CP. Modified Anterior
Compartment Resection of the Thigh. Int Surg 2007;
92:266-271.
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