The patient had severe spinal cord injury from a motorbike accident when aged 19. Now 35 years old, due to many complications, including inflammatory areas in his crumbling pelvis and deeply infected bed-sores, the paraplegic patient had undergone 32 surgical operations, which included a colonostomy and urethrostomy. He was still struggling for life.
The surgeons decided on a hemicorporectomy, between the third and fourth lumbar vertebrae (L3-L4) but a post-operative complication resulted in their decision to go up one vertebra (L2-L3). This has resulted in the second successful hemicorporectomy among three carried out at the hospital. The first, involving a 34-year-old male patient, took place seven years ago.
Successful healing and survival depends on a patient’s age, will to live and healthy condition. That was not the case for Dr Antos’ last hemicorporectomy patient – a 65-year-old male who died within a month after surgery due to kidney failure and the lack of will to live.
Hemicorporectomy (translumbar amputation, or sometimes called halfectomy) is extremely radical and rare surgery. Thus there is little literature on the subject. Only about 45 hemicorporectomies are thought to have been reported. Because post-operative morbidity and mortality rates are high, there is generally a protocol not to resuscitate patients presenting the kind of serious injuries or disease level that might suggest a hemicorporectomy as the only solution. In addition, most surgeons would not contemplate the procedure because they consider it pushes the boundaries of surgery beyond reasonable frontiers.
Clearly the decision to opt for this surgery is reached only as a last resort in cases of severe, potentially fatal diseases or trauma in and around the pelvis.
Procedure - Depending on the circumstances, hemicorporectomy may be carried out in one, two or even more stages, with a gap of weeks or months between procedures. The first stage(s) involves colostomy and ileal conduit, transferring waste functions to the upper torso. The second stage is the amputation of the entire lower half of the body by transection of the lumbar spine.
Critical care - Because almost 50% of the circulatory system has gone, complexities are inevitable. The usual monitoring parameters for kidney and cardiac functions and blood pressure have changed; temperature control, fluid replacement and pulmonary care become critical.
Prostheses - Because there is usually no remaining pelvic girdle musculature, it is extremely difficult to design comfortable and useful prostheses. The prosthetic used is referred to as a ‘bucket’, which has an inflatable lining to prevent uneven pressure distribution. The colostomy bag and ileal conduit are connected through two outlets in the bucket.
Physiotherapy & body management - This is also an enormous issue. Needless to say, the long-term management of hypertension, temperature control, stoma management, as well as sex hormone replacement, patient’s weight control and skin care is intensive.
Almost above all in importance is the physical fitness and emotional disposition of the patient —his/her strength and will to live.
History - The type of severe injuries experienced during WWII pushed the boundaries for new surgical techniques. Reflecting on this period, B. E. Ferrara referred to hemicorporectomy in an article: ‘…battle field injuries quickened innovative treatment of congenital and acquired conditions... [the surgeon] devised extensive cancer operations including extended radical mastectomy, radical gastrectomy and pancreatectomy, pelvic exenteration, the ‘Commando operation’ (tongue, jaw and neck dissection), bilateral back dissection, hemipelvectomy, and then hemicorporectomy or translumbar amputation, referred to as the most revolutionary of all operative procedures’.
In 1950, Professor Frederick E Kredel at the Medical College of South Carolina broached the prospect of hemicorporectomy (or halfectomy, as he referred to it) as an alternative to pelvic exenteration for patients with advanced pelvic malignancy. Although the professor demonstrated the procedure in cadavers and recommended it be carried out in two stages, he did not perform this procedure on a living human.
Nine years later, in Detroit, Michigan, surgeon Charles S Kennedy carried out the first actual hemicorporectomy on a 74-year-old male patient with locally invasive rectal cancer. Surgery was carried out in a single stage. The man lived for 10 days. Cause of death: pulmonary oedema.
A year later (1961) surgeon J Bradley Aust, University of Minnesota, performed the first successful hemicorporectomy, in two stages, on a 29-year-old paraplegic who suffered a malignant tumour in a decubitus ulcer. He survived for 19 years.
Other hemicorporectomies have been undertaken through the years; some 45 cases have been reported, among which the several successes have led experts to believe that results could be improved with greater multidisciplinary planning and aftercare.