GPVILLANUEVA’S MAR [15-08]: Forequarter Limb Amputation

MEDICAL ANECDOTAL REPORT
Indexing Title: GPVILLANUEVA’S MAR [15-08]
MAR Title:  Forequarter Limb Amputation
Date of Medical Observation: August 2015
Tag: My first forequarter limb amputation
Category: Physical – Discovery
NARRATION:
 
We will do Forequarter Limb Amputation. ”
My consultant stated as his intraoperative decision, after noticing that the tumor which was initially thought separated from the scapula, involved a greater part of it and caused it to bleed upon dissection. The case was a 61-year-old male with multiple co-morbidities having a huge mass measuring approximately 20cms by 15cms on the left shoulder. A CT-Scan (computed tomography) confirmed the mass originating from the soft tissue involving the muscles and some part of the bone. The initial plan was only to do a wide excision of the mass with possible reconstruction.
           
But as we were dissecting on the base of the tumor we noticed that there was no actual boundary between the mass and the wing of the scapula and the bone is actually involved in the tumor. Removing the scapula would cause the arm not to function and be like an attached appendage of an octopus arm. Because of this, the consultant decided to remove the whole upper extremity on the left. It was a big leap from the original plan of surgery and besides that, removing an extremity is a life changing procedure that would greatly affect the patient.
           
After the discussion with the relatives and several phone calls from other relations outside, the family agreed with the decision and we pushed through with the operation.
           
As I have heard the plan from my consultant, instead of forequarter I thought he was saying forelimb or four quadrant limb amputation. It was my first time to have heard of such and from my several years of stay here in Ospital ng Maynila from clerkship until now, I have only seen one upper extremity amputation of a hand having Sarcoma and the current patient would be second.
           
The technique was started by proximal control by ligation of the subclavian vessels. After which the muscles were just adequately cut and the whole arm was removed.  Last was the creation of a full thickness flap to cover the side of the chest.
           
It was indeed a great experience to have seen the operation and I would like to share it using this anecdotal report.
 
INSIGHT
(Physical, Psychosocial, Professional/ Ethical)
(Discovery, Stimulus, Reinforcement)
           
Skin flaps were modified to accommodate heavily irradiated skin damage. The anterior exposure was performed first to facilitate exploration the infraclavicular portion of the brachial plexus and axillary vessels. The pectoralis major was released from its humeral insertion. The coracobrachialis, short head of the biceps, and pectoralis minor were subsequently released from the coracoid, which completed exposure of the axillary vessels and brachial plexus. Once neurovascular encasement was confirmed, forequarter amputation continued. The subclavian artery and vein and brachial plexus were individually doubly ligated and transected.
After anterior exploration, the incision was extended posterolaterally over the shoulder, curving medially at the scapular tip. This resulted in construction of a large medially based posterior skin ̄ap. All muscles anchoring the scapula to the chest wall were released.
The clavicle was osteotomized close to the sternoclavicular joint. The two skin incisions were connected in the axilla. Hemostasis was achieved. The pectoralis major was either transected close to its origin or sutured to the chest wall. The skin flap was closed over the defect.
ROJoson’s Notes (17jan14):
Sharing of a surgical technique on forequarter amputation.
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