Engdahl Ryan, Disa Joseph, Athanasian Edward A, Healey John H, Cordeiro Peter G, Fabbri Nicola
Plastic and Reconstructive Service (R.E., J.D., and P.G.C.) and Orthopaedic Service (E.A.A., J.H.H., and N.F.), Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
JBJS Essent Surg Tech. 2016 Apr-Jun;6(2). doi: 10.2106/JBJS.ST.16.00002. Epub 2016 Apr 27.
The use of a pedicled latissimus dorsi flap for reconstruction of large soft-tissue defects following musculoskeletal tumor excision around the shoulder provides adequate well-vascularized and healthy tissue to maximize the chances of successful limb salvage and minimize the risks of wound problems and deep infection.
INDICATIONS & CONTRAINDICATIONS:
STEP 1: (POSTERIOR CLOCKWISE ROTATION TECHNIQUE): PREOPERATIVE EVALUATION, POSITIONING, AND PREPARATION: Verify the adequacy of the latissimus dorsi, confirm the feasibility of the flap in relation to the extent of the defect, and use a laparotomy pad to simulate the arc of flap rotation.
STEP 2: (POSTERIOR CLOCKWISE ROTATION TECHNIQUE): FLAP DESIGN AND MARKING IN RELATION TO ANATOMIC LANDMARKS: At the time of surgery, proper flap design and markings are critical for successful tumor excision and flap rotation.
STEP 3: (POSTERIOR CLOCKWISE ROTATION TECHNIQUE): TUMOR EXCISION AND FLAP ELEVATION: Confirm adequate tumor removal, prepare the recipient site for the flap, ensure the proper size and shape of the skin island, deepen the dissection circumferentially around the skin paddle, divide the latissimus from the thoracolumbar fascia, develop the natural plane of the flap, divide the branch for the serratus to increase rotation if necessary, and release the humeral insertion to further increase rotation if necessary.
STEP 4: (POSTERIOR CLOCKWISE ROTATION TECHNIQUE): POSTERIOR FLAP TRANSPOSITION AND INSET INTO THE DEFECT: Be sure to create an adequately sized tunnel and, when passing the flap through the tunnel, to avoid tension on the vascular pedicle and the skin island.
STEP 5: POSTOPERATIVE CARE: Proper postoperative care includes monitoring the flap blood supply and output of drains, removing sutures, and ensuring satisfactory healing overall.
STEP 1: (ANTERIOR COUNTERCLOCKWISE ROTATION TECHNIQUE): PREOPERATIVE EVALUATION, POSITIONING, AND PREPARATION: The preoperative evaluation, positioning, and preparation are identical to those for the posterior clockwise rotation technique described above.
STEP 2: (ANTERIOR COUNTERCLOCKWISE ROTATION TECHNIQUE): FLAP DESIGN AND MARKING IN RELATION TO ANATOMIC LANDMARKS: Make sure you understand the regional anatomy, ensure appropriate anterior flap rotation, and use the laparotomy pad technique to the simulate arc of rotation.
STEP 3: FLAP ELEVATION (ANTERIOR COUNTERCLOCKWISE ROTATION TECHNIQUE): The surgical principles of flap elevation and transfer are the same regardless of the location of the recipient site (see Step 3 for the posterior technique above).
STEP 4: (ANTERIOR COUNTERCLOCKWISE ROTATION TECHNIQUE): ANTERIOR FLAP TRANSPOSITION AND INSET INTO THE DEFECT: Elevate the flap, create a large subcutaneous tunnel for anterior transfer, and ensure optimal flap inset into the shoulder defect.
STEP 5: POSTOPERATIVE CARE (ANTERIOR COUNTERCLOCKWISE ROTATION TECHNIQUE): Perform as for the posterior technique.
In 2007, we reported on a series of 33 consecutive patients treated from 1994 to 2004 with a pedicled latissimus dorsi flap following sarcoma excision in the shoulder region.
PITFALLS & CHALLENGES:
使用带蒂背阔肌皮瓣重建肩部周围肌肉骨骼肿瘤切除术后的大面积软组织缺损，可提供充足的血运良好且健康的组织，以最大程度提高肢体挽救成功的几率，并将伤口问题和深部感染的风险降至最低。
步骤1：（顺时针后转技术）：术前评估、体位摆放及准备：确认背阔肌是否足够，根据缺损范围确认皮瓣的可行性，并使用剖腹手术垫模拟皮瓣旋转弧度。
步骤2：（顺时针后转技术）：根据解剖标志进行皮瓣设计与标记：手术时，正确的皮瓣设计和标记对于成功切除肿瘤及皮瓣旋转至关重要。
步骤3：（顺时针后转技术）：肿瘤切除与皮瓣掀起：确认肿瘤已充分切除，为皮瓣准备受区，确保皮岛大小和形状合适，沿皮瓣周围环形加深解剖，将背阔肌从胸腰筋膜分离，形成皮瓣的自然平面，必要时切断前锯肌分支以增加旋转度，必要时松解肱骨附着处以进一步增加旋转度。
步骤4：（顺时针后转技术）：皮瓣向后转位并植入缺损处：务必创建足够大小的隧道，在皮瓣穿过隧道时，避免血管蒂和皮岛受到张力。
步骤5：术后护理：适当的术后护理包括监测皮瓣血供和引流管引流量、拆线，并确保整体愈合良好。
步骤1：（逆时针前转技术）：术前评估、体位摆放及准备：术前评估、体位摆放及准备与上述顺时针后转技术相同。
步骤2：（逆时针前转技术）：根据解剖标志进行皮瓣设计与标记：确保了解局部解剖结构，确保皮瓣向前适当旋转，并使用剖腹手术垫技术模拟旋转弧度。
步骤3：皮瓣掀起（逆时针前转技术）：无论受区位置如何，皮瓣掀起和转移的手术原则相同（见上述后转技术的步骤3）。
步骤4：（逆时针前转技术）：皮瓣向前转位并植入缺损处：掀起皮瓣，创建一个大的皮下隧道用于向前转移，并确保皮瓣最佳地植入肩部缺损处。
步骤5：术后护理（逆时针前转技术）：与后转技术相同。
2007年，我们报告了1994年至2004年连续治疗的33例肩部肉瘤切除术后使用带蒂背阔肌皮瓣的患者系列。
