Vascular Surgical Tips for Sacral Tumor Surgery: A Practical Narrative Review

Narrative Review OBJECTIVES: To summarize practical vascular management strategies for sacral tumor resections, focusing on perioperative hemorrhage control and surgical safety.

A narrative literature review - as opposed to a systematic review - was conducted using the MEDLINE (PubMed) database, supplemented by manual ("snowball") review of the reference lists of retrieved articles to identify additional foundational studies not captured by the search terms. Articles published between 1985 and 2025 were screened using the keywords "sacral tumor," "sacrectomy," "vascular control," "presacral bleeding," "embolization," "pelvic vascular anatomy," and "aortic balloon occlusion," restricted to English-language publications with an available full-text link. This search identified 132 records. Clinical series, technical reports, anatomical studies, and review articles addressing vascular management during sacral tumor surgery were included; studies not specific to sacral tumor vascular management, non-peer-reviewed sources, and duplicate/overlapping cohort reports were excluded. Thirty-three studies formed the core detailed analysis, expanded during peer review with 16 additional references (49 total, plus one general methodological reference), and synthesized into a practical framework covering preoperative, intraoperative, and postoperative management strategies.

Major hemorrhage during sacral tumor surgery commonly results from both hypervascular arterial supply and diffuse bleeding from the presacral venous plexus. We propose a pragmatic, author-derived (not literature-validated) classification of bleeding phenotype to guide planning. Preoperative strategies include hemorrhage risk stratification, advanced vascular imaging, multidisciplinary planning, blood-management protocols, selective embolization, and endovascular occlusion in selected cases, applied with explicit occlusion-time thresholds. Intraoperative principles include optimized positioning, early vascular control, structured escalation algorithms for presacral venous bleeding, temporary pelvic packing, advanced energy devices, and preparedness for vascular injury and reconstruction. Postoperative management focuses on early hemorrhage surveillance, thromboembolism prevention, and wound management.

Effective vascular management is fundamental to safe and oncologically appropriate sacral tumor resection. A multidisciplinary and protocolized approach integrating preoperative planning, intraoperative hemorrhage-control strategies, and postoperative surveillance may reduce morbidity and facilitate successful oncologic resection.