Towards Standardisation of Technique for En Bloc Sacrectomy for Locally Advanced and Recurrent Rectal Cancer

Abstract

Treatment strategies for advanced or recurrent rectal cancer have evolved such that the ultimate surgical goal to achieve a cure is complete pathological clearance. To achieve this where the sacrum is involved, en bloc sacrectomy is the current standard of care. Sacral resection is technically challenging and has been described; however, the technique has yet to be streamlined across units. This comprehensive review aims to outline the surgical approach to en bloc sacrectomy for locally advanced or recurrent rectal cancer, with standardisation of the operative steps of the procedure and to discuss options that enhance the technique.

Keywords: advanced rectal cancer; en bloc; recurrent colorectal cancer; sacrectomy.

Figure 1

Approaches to en bloc sacral resection depending on the site of invasion of the rectal tumour. Dashed red lines denote resection margins. (A) Low sacrectomy involves sacral transection in the axial plane below the S2 foraminae. (B) High sacrectomy involves sacral transection at or above the S2 foraminae and involves disarticulation from sacroiliac joints. (C) Hemisacrectomy involves tumours not crossing the midline of the sacrum, thus, leaving the contralateral side intact. (D) High subcortical sacrectomy (HISS) or anterior table sacrectomy is reserved for tumours adherent to the median sacral plane but not involving the sacral foraminae laterally, and the anterior sacral cortex only is removed.

Figure 2

Sacral transection shown with osteotome or bone nibbler method. (A) and (B) In the supine position, osteotomes are hammered onto the desired transection level, first in the midline to breach the full thickness of the sacrum, before placing further osteotomes in series bilaterally, moving medial-to-lateral until transection has been completed. (C) From the prone position, the sacrum may alternatively be transected using bone nibblers.

Figure 3

Prone view into pelvis after S3 sacral transection and specimen removal. Robinson’s drain can be seen coming from the pelvis, with St. Mark’s perineal retractor in situ.