PREOPERATIVE DIAGNOSIS: Sarcoma, left upper anterior thigh (vastus intermedius).
POSTOPERATIVE DIAGNOSIS: Sarcoma, left upper anterior thigh (vastus intermedius).
PROCEDURE PERFORMED: Radical resection of malignant tumor, deep, left upper leg.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female who noted swelling of her left upper thigh. Core needle biopsy demonstrated a malignant spindle cell lesion. She has been treated with preoperative neoadjuvant radiation therapy. She has received no chemotherapy. She is brought to the operating room for definitive resection. MRI studies of her thigh, both before and after the operation, have suggested that the lesion is largely confined to the vastus intermedius portion of the quadriceps muscle. The planes surrounding it appear relatively free of tumor.
OPERATIVE FINDINGS: The lesion was approached through a long incision over the anterior thigh. It was possible to enter the intermuscular septum between the vastus medialis and the adductor muscles. The planes surrounding the tumor were of loose areolar tissue, were clearly free of tumor. The tumor, however, also clearly extended out to the investing fascia of the muscle group. Muscle group was excised from the level of the origin on the femur down to the patellar tendon and through clean tissue surrounding all areas. It was examined in the frozen section room and seemed well demarcated. It was finally felt that it was totally removed through planes of clean tissue with no gross tumor being left behind.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in the supine position on the operating table. General endotracheal anesthesia was induced. Her leg was slightly flexed at the knee. The entire leg was prepped from the lower abdomen down to the mid thigh and draped so that it could be moved around.
An incision was then made anteriorly running over the mass and vertically down to the patellar tendon and angled up slightly medially to go over the femoral vessels. Skin flaps were developed over the areas around the mass. The dissection was then taken down lateral to the sartorius muscle, and it was retracted laterally. The femoral vessels were clearly identified running into the adductor canal.
At this point, it was possible to feel the lesion nicely. It was possible to get into a plane between the vastus medialis and the other adductor muscles by incising part of the adductor canal and rotate the quadriceps muscle group laterally. The tumor became evident in the vastus medialis, intermedius. The dissection was taken down around this tumor through loose areolar tissue. Tumor could be extending out to the edges of the muscle.
In order to get length, the incision was taken superiorly and this finally allowed approaches to the lateral aspects of the muscle. It was then possible to get posterior to the muscle and free it circumferentially. With the muscle group freed circumferentially through clean tissue, it was dissected up to its insertion on the femur. When a point had been reached that was clearly well above tumor and close to the origins of the muscle and in the region of the origins of the muscle from the femur, the muscle was divided proximally. The tumor and muscle were then rotated medially, and the dissection was taken down distal to the tumor. A point was reached where the tendinous portion was entering the patellar tendon. This tendinous portion was divided and was clearly approximately 3-4 cm distal to the palpable edges of the tumor. This allowed removal of the entire tumor mass.
Following evaluation in the frozen section room with the pathologist, as noted above, which suggested the margins were adequate, the wound was checked for hemostasis, which was adequate. Two large Jackson-Pratt drains were placed. The fascia was reapproximated with interrupted 2-0 Vicryl sutures. The skin was then closed with staples. The patient tolerated this well and was returned to the recovery room in satisfactory condition.
