Low and High Sacrectomies

What are Low and High Sacrectomies?

Sacrectomy is defined as the removal of the sacrum. It is a surgical procedure employed for the excision of pelvic tumours with sacral attachments or chondromas. The surgery is performed through an incision on either the upper or lower portion of the sacrum. The approach used depends upon the location of the spread of cancer from the pelvic organs to the sacrum.

The sacrum is a triangular-shaped bone at the bottom of the spine that is formed by the fusion of 5 sacral vertebrae (S1-S5). It is located below the lumbar spine and is connected to the pelvis. The sacrum constitutes the posterior pelvic wall and helps in stabilizing and strengthening the pelvis. The sacrum and the right and left iliac (pelvic) bones connect to form a large joint in the body called the sacroiliac joint that acts as a shock-absorbing structure.

Indications for Low and High Sacrectomies

Low and high sacrectomies are mainly indicated for the removal of high-level tumours of the sacrum and its adjoining structures when cancer of the pelvic organs such as the bowel, bladder, ureters, and rectum has spread to the sacrum. Some of the other indications include:

• There is a recurrence of cancer following previous treatment
• You have not had any cure from initial cancer treatment
• Have already received treatments for cancer
• Locally advanced and recurrent rectal cancer

Preparation for Low and High Sacrectomies

Pre-procedure preparation for low and high sacrectomies will involve the following steps:

• A thorough examination by your doctor is performed to check for any medical issues that need to be addressed prior to surgery.
• Depending on your medical history, social history, and age, you may need to undergo tests such as blood work and imaging to help detect any abnormalities that could threaten the safety of the procedure.
• You will be asked if you have allergies to medications, anaesthesia, or latex.
• You should inform your doctor of any medications, vitamins, or supplements that you are taking.
• You should refrain from medications or supplements such as blood thinners, aspirin, or anti-inflammatory medicines for 1 to 2 weeks prior to surgery.
• You should refrain from alcohol or tobacco at least a few days prior to surgery.
• You should not consume any solids or liquids at least 8 hours prior to surgery.
• You will be placed on a special diet prior to surgery and laxatives may be used to clean out your bowel.
• You may be instructed to shower with an antibacterial soap the night prior to surgery to help lower your risk of infection after surgery.
• Arrange for someone to drive you home as you will not be able to drive yourself after surgery.
• A written consent will be obtained from you after the surgical procedure has been explained in detail.

Procedure for Low and High Sacrectomies

Low and high sacrectomies are complex surgeries performed under general anaesthesia. The procedure takes several hours to complete and may involve multiple surgeons depending upon the organs affected with cancer. These surgeons may include:

• A colorectal surgeon who specialises in bowel cancers
• A gynaecological surgeon who specialises in the female reproductive system
• A urologist who specialises in the genitourinary system
• A plastic surgeon who specialises in reconstruction
• An anaesthetist

The surgical approach depends upon the location of cancer in the sacrum.

Low sacrectomy (below the sacroiliac joint) is performed in cases where the cancer is noted at the back of the pelvic bone. The surgery necessitates removal of a section of your lower spine, the sacrum and the coccyx. During the procedure, a transverse incision is made over the lower sacrum and the distal portion of the sacrum (S4 and S5 vertebrae) including the coccyx is removed accordingly.

High sacrectomy (above the sacroiliac joint) involves performing a midline laparotomy with the patient in a supine position and cancer that has extended to the upper sacrum at S1 and S2 vertebral body is removed accordingly.

During both types of sacrectomy, the inside of the abdomen is carefully examined to ascertain the spread of cancer, and the affected pelvic organs are removed, including the bladder, urethra, and bowel/rectum. This necessitates the creation of a urostomy and colostomy which involves making a small cut in the belly to create an opening called a stoma for urine and stools to exit the body. After these procedures, vaginal reconstruction using skin grafts and/or muscle flaps from other parts of the body may also be performed. If reconstruction is not desired, the vagina and the anus will be closed with skin tissue. At the end of the procedure, the incisions are closed with absorbable sutures and sterile dressings are applied.

Postoperative Care and Recovery

In general, postoperative care instructions and recovery after low or high sacrectomy will involve the following steps:

• You will be transferred to the recovery area where your nurse will closely observe you for any allergic/anaesthetic reactions to the medications and anaesthesia used. Your nurse will also monitor your blood oxygen level and other vital signs as you recover.
• As it is a complex surgery, you will likely require 7 to 10 days of hospital stay after surgery.
• You may experience pain, inflammation, and discomfort in the operated area. Pain and anti-inflammatory medications are provided as needed.
• Medications may also be prescribed as needed for symptoms associated with anaesthesia, such as vomiting and nausea.
• Walking and moving around in bed is strongly encouraged as it lowers the risk of blood clots and pneumonia. It also helps to stimulate your bowels and assist with passing gas.
• Antibiotics are prescribed to address the risk of surgery-related infection.
• Your diet is slowly advanced post surgery. You will start with clear liquids, then progress to having normal solid foods, as tolerated.
• It is important to keep the surgical site clean and dry. Instructions on surgical site care, stoma care, urine and stool collection bag/pouch, and bathing will be provided.
• Refrain from smoking for a specific period of time as it can negatively affect the healing process.
• Refrain from strenuous activities and lifting anything heavier than 10 pounds for the first couple of months. Gradual increase in activities over a period of time is recommended.
• Eating a healthy low fat and high-fibre diet is strongly recommended to promote healing and a faster recovery as well as drinking 8 to 10 glasses of water daily to prevent constipation. Laxatives or stool softeners may also be recommended as needed.
• Most patients will need to take off work at least a month or two to rest and promote healing. Walking is a good exercise and is strongly recommended to improve your endurance.
• Refrain from driving until you are fully fit and receive your doctor’s consent, usually about 2 to 4 weeks.
• You will be able to resume your normal activities within a couple of weeks but may have certain activity restrictions.
• A periodic follow-up appointment will be scheduled to monitor your progress.

Risks and Complications

Low and high sacrectomies are relatively safe procedures; however, as with any surgery, some risks and complications may occur, such as:

• Infection
• Bleeding
• Hematoma (accumulation of blood in the wound)
• Seroma (accumulation of clear fluid in the wound)
• Damage to surrounding soft tissue structures, such as nerves, vessels, and organs
• Post-procedure pain, requiring narcotics for relief
• Blood clots
• Pneumonia
• Heart problems
• Bladder problems
• Anaesthetic/allergic reactions
• Kidney problems