Background
Sacrectomy with adequate margins is challenging because of the complexity of the surgical approach and morbidities. Two-staged
sequential approach, therefore, has been advocated. This study was designed to demonstrate the modification of this technique.
Methods
This is a case presentation of a 45-year-old man with chordoma involving the lower border of S2, who underwent one-staged
subtotal sacrectomy. The technique involved the following: midline incision, mobilization of the rectum, construction of a
colostomy and the modified Hartmann stump with intact superior rectal vessels, ligation of internal iliac arteries, ligation
of all branches connecting to external iliac veins resulting in “complete isolation” of the external iliac veins, dissection
of presacral tissue, anterior osteotomy at the S1-S2 junction and the sacroiliac joints, and abdominal closure. The posterior
approach involved a three-limbed incision, dissection of the gluteus muscle and ligaments from the sacrum, subperiosteal dissection,
S1 laminectomy, posterior osteotomy corresponding with the anterior osteotomy line with preservation of S1 nerves, division
of S2-S4 nerves from sciatic nerves, and specimen removal. Closure of the large sacral defect was undertaken using the Hartmann
stump and bilateral gluteus maximus flaps.
Results
En bloc resection with free margins without tumor rupture was accomplished. Operative time was 12 hours. Blood transfusion
was 6 units. This patient had a good recovery without complications. He was able to ambulate within 1 week and walk normally
within 1 month. No recurrence was found at a 24-month-follow-up.