Sacrectomy via the abdominal approach during pelvic exenteration

Sacrectomy is sometimes necessary to achieve negative margins in pelvic exenteration procedures. This is typically done with the patient in the prone position. Some of the limitations of the prone approach include its limited access to the lateral pelvic sidewall structures and suboptimal vascular control in comparison with the access and the vascular control of a combined abdominolithotomy approach.

This article describes a technique for performing a low sacrectomy (below the sacroiliac joint) through a transabdominal approach without the need to turn the patient prone intraoperatively.

The procedure involves 2 approaches: abdominal and perineal. The abdominal phase incorporates the complete mobilization of both lateral pelvic sidewalls and their neurovascular bundles to the intended lateral margins. The anterior margin is dependent on the extent of tumor resection necessary and may incorporate the vagina, bladder, prostate, or even part of the pubic bone. The perineal phase involves freeing all the muscular and ligamentous attachments of the posterior sacrum up to the level of S2/3. The sacrectomy is completed by using an osteotome transabdominally. It begins in the midline and extends laterally until the ischial spine and incorporates the sacrospinous through to the sacrotuberous ligaments and the whole pelvic floor.

Transabdominal low sacrectomy is technically feasible and may be associated with numerous practical advantages in comparison with a low sacrectomy performed with the patient in the prone position for involvement of the lower half of the sacrum.