Perioperative considerations of an extended forequarter amputation for recurrent high-grade radiation-induced sarcoma: A case report

Forequarter amputation is a radical surgical procedure involving removal of the entire upper extremity and shoulder girdle and is most commonly performed in the management of aggressive upper extremity malignancies. A number of perioperative challenges can arise during extended resections including postoperative respiratory compromise due to altered chest wall mechanics, potential need for lung isolation, selecting appropriate sites for vascular access, complex fluid and hemodynamic resuscitation, optimizing conditions for free flap viability, and managing pain and the psychological impact of such a significant operation. Here we present a case of an extended forequarter amputation with a multidisciplinary team for the management of a recurrent high-grade radiation-induced sarcoma. lateral decubitus position and the right arm, chest wall and were prepped and draped. The plastic surgery began by preparing the forearm for a free fillet flap, but delaying the anastomosis until the extremity was removed. The surgical teams then performed a right forequarter amputation with neck dissection and lymphadenectomy, costotransversectomy from C7 to T2, and chest wall resection. The brachial plexus, external jugular vessels and internal jugular vein were divided. Left lung isolation was required during the chest wall resection involving the first through fifth ribs, sternoclavicular joint, a portion of the manubrium, right upper lobectomy, and total lung pulmonary decortication. The right upper extremity was then removed from the body, leaving a 17 x 25 centimeter defect. The plastic surgery team then removed the free fillet flap from the extremity on a sterile back table, and inset the free forearm fillet flap, anastomosing the brachial artery and vein of the free fillet flap to the lingual artery and anterior cervical vein, respectively. Then 2000 units of heparin were administered intravenously. Reconstruction of the chest wall was performed with a 15 x 18 cm Goretex mesh, and the flap was inset and incisions reapproximated. The surgical time of the procedure was 10 hours and 21 minutes.