Hemicorporectomy is a radical surgery in which the body below the waist is amputated, transecting the lumbar spine. This removes the legs, the genitalia, urinary system, pelvic bones, anus, and rectum. It is an extremely mutilating procedure recommended only as a last resort for people with severe and potentially fatal illnesses such as osteomyelitis, tumors, severe traumas and intractable decubiti in, or around, the pelvis. It has only been reported a few dozen times in medical literature. The nomenclature is somewhat at odds with generally accepted anatomical terms, as hemi is generally used to refer to one of two sides. In that sense, paracorporectomy might more closely reflect the nature of the procedure.
Medical uses
The operation is performed to treat spreading cancers of the spinal cord and pelvic bones. Other reasons may include trauma affecting the pelvic girdle, uncontrollable abscess or ulcers of the pelvic region or other locally uncontainable conditions. It is used in cases wherein even pelvic exenteration would not remove sufficient tissue.
Procedure
The surgical procedure is typically done in two stages, but it is possible to conduct the surgery in one stage. The first stage is the discontinuation of the waste functions by performing a colostomy and ileal conduit. The second stage is the amputation.
Considerations
With the removal of almost half of the circulatory system, cardiac function needs to be closely monitored while a new blood pressure set-point develops. Removal of large parts of the colon can lead to loss of electrolytes. Similarly, calculated measurements of renal function are unlikely to reflect actual activity of the kidney, as these calculations were developed for patients in whom the circulatory system correlates with the body weight; this relation is lost in a post-hemicorporectomy patient.
Rehabilitation
Extensive physiotherapy and occupational therapy are necessary for a patient to return to some form of normal life, which invariably involves using a wheelchair. Designing a prosthesis for the removed body parts is difficult, as there is generally no remaining pelvic girdle musculature.
Traumatic hemicorporectomy
Individuals sustaining a severe bisection injury that is essentially a de facto hemicorporectomy would rarely reach a hospital before succumbing. A study that reviewed 267 cases of patients who sustained severe blunt and penetrating trauma, and who were in cardiopulmonary arrest, found that only 7 survived long-term, only four of whom returned to their previous neurologic level. Apart from the very low likelihood of surviving such an injury, even an operative hemicorporectomy is unlikely to be successful unless the patient has "sufficient emotional and psychological maturity to cope" and "sufficient determination and physical strength to undergo the intensive rehabilitation". Emergency rooms and ambulance service policies advise against the resuscitation of such patients. The UK's National Health Service, for example, in its "Policy and Procedures for the Recognition of Life Extinct" describes traumatic hemicorporectomy as "unequivocally associated with death" and that such injuries should be considered "incompatible with life". The National Association of EMS Physicians and the American College of Surgeons Committee on Trauma have also released similar position statements and policy allowing on-scene personnel to determine if patients are to be considered unresuscitatable. In one case documented by the Archives of Emergency Medicine in 1989, a woman who sustained a complete corporal transection after being struck by a train arrived at a hospital in a "fully conscious" state and "was aware of the nature of her injury and wished for further treatment." Although the patient was initially stabilized and underwent three hours of emergency surgery, she died approximately two hours later due to "hypovolaemia, cardiac arrhythmia and biochemical imbalance."
Prosthesis
Following a hemicorporectomy, patients are fitted with a socket-type prosthesis often referred to as a bucket. Early bucket designs often presented significant pressure problems for patients, but new devices have incorporated an inflatable rubber lining composed of air pockets that evenly distributes pressure based on the patient's motions. Two openings at the front of the bucket create space for the colostomy bag and the ileal conduit.
History
The development of surgical medicine was vastly accelerated during, and following, the Second World War. Rarely experienced traumas were made more common by new weaponry. This required decisive surgical action as well as the development of new techniques. As B. E. Ferrara stated in his summative article on hemicorporectomy,
Lessons learned from battle field injuries quickened innovative treatment of congenital and acquired conditions ... devised extensive cancer operations including extended radical mastectomy, radical gastrectomy and pancreatectomy, pelvic exenteration, the 'Commando Operation', bilateral back dissection, hemipelvectomy, and then hemicorporectomy or translumbar amputation, referred to as the most revolutionary of all operative procedures.
It was into this environment that Frederick E. Kredel first proposed the operation in February 1951 while discussing a paper on pelvic exenteration. The first hemicorporectomy was attempted in Detroit, Michigan, by Charles S. Kennedy in 1960, but the patient died eleven days later. Surgeons J. Bradley Aust and Karel B. Absolon conducted the first successful hemicorporectomy in Minnesota in 1961.
