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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 http://www.npplweb.com/wjsmro/content/1/1/9 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. Published by Narain Publishers Pvt. Ltd. (NPPL) The Open Access publishers of peer reviewed journals. All articles are immediately published online on acceptance. All articles published by NPPL are available free online Authors retain the copyright under the Creative commons attribution license. The license permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited http://www.npplweb.com/wjsmro/content/1/1/9