Teknik Operasi

Forequarter Amputation
Oleh : Srigunda Arisya Fadilla
Pembimbing : dr. Rony Rustam, SpB (K) Onk
FOREQUARTER
AMPUTATION
Removes the entire upper extremity in
the interval between the scapula and
the chest wall


Indication - for malignant tumors that

cannot be adequately removed by
limb-sparing resections.
The anterior approach of Berger
The posterior approach of Littlewood more
rapid and easy
First performed by Ralph Cuming in1808, the
first oncological forequarter amputation was
reportedly performed by Dixie Crosby in 1836
for a case of osteosarcoma
Done rarely --> the development of surgical
techniques allowing limb-preserving resection &
the availability of adjuvant modalities
(neoadjuvant or adjuvant radiation therapy)
have resulted in successful local control for
most patients, obviating the necessity for radical
surgery
AMPUTATION
FOREQUARTER
Anatomi
.
ANATOMI
Anatomi
Anatomi
Anatomi
Indikasi
the presence of malignant
There are no metastases to
tumours of the arm, axilla,
any other organs.
shoulder and scapula

Prognosis for treatment with

chemotherapy or radiation
therapy are considered
extremely poor
Indikasi
Wide local excision is
The age and health of patient
allows for a major surgical
technically not feasible. procedure, but not a series of
reconstructive procedures.

The tumour has significantly

impaired the functional status of
the extremity to complete
disuse or produces severe pain
Indikasi
The patient has an unresectable
invasive tumour involving the
There has been failure of
conservative therapy
shoulder joint or neurovascular
(radiation/chemotherapy)
bundle

The patient has had tumour-

related complications such as
bleeding, sepsis, limb dysfunction
or severe lymphedema
Kontra Indikasi
Tumor extends to the chest
wall

Tumor extends to the

paraspinal and posterior
triangle of the neck structures
Design
 join the upper limb of the incision at the angle of the scapula
lower limb - middle third of the clavicle, Extend inferiorly in the groove between the
deltoid and pectoral muscles and across the axilla Incision
Anterior Approach (Berger)
upper limb - at the lateral border of the sternocleidomastoid muscle, extend
laterally along the anterior aspect of the clavicle, across the acromioclavicular joint,
over the superior aspect of the shoulder to the spine of the scapula, and across the
body of the scapula to the scapular angle.
 Clavicle – Divide at lateral border of the sternocleidomastoid with a Gigli saw,
1. lift the bone superiorly
2. Remove by dividing the acromioclavicularjoint
Divide the deep fascia over the superior border of the clavicle close to bone by dissection
with a finger and a blunt curved dissector, free the deep aspect of the clavicle
Anterior Approach (Berger)
Clavicular origin of the pectoralis major muscle - release and reflect distally
Anterior Approach (Berger)
Anterior Approach (Berger)
Pectoralis major – release insertion from the humerus
Anterior Approach (Berger)
• Pectoralis minor –release origin from the coracoid process

Subclavian artery and vein - Isolate, doubly ligate, and divide.

• Brachial plexus - by gentle traction inferiorly bring it well into the

operating field
• section the nerves in sequence
• allow them to retract superiorly
 Divide the muscles that hold the scapula to the thorax, the trapezius , omohyoids,
levator scapulae, rhomboids major and minor, and serratus anterior
• 
While holding the arm across the chest - gentle downward traction, divide from
superiorly to inferiorly the remaining muscles that fix the shoulder to the scapula. • 

Release the latissimus dorsi and remaining soft tissues that bind the shoulder girdle
to the anterior chest wall, and allow the limb to fall posteriorly.
Anterior Approach (Berger)
 Anterior Approach (Berger)

The limb falls free and can be removed.

• Closure
◦ suture the pectoralis major, trapezius, and any other remaining
muscular structures over the lateral chest wall
◦ skin flaps – trim to form a smooth closure.
 Posterior Approach (LITTLEWOOD)

Lateral decubitus position with the operated side up

• Incision
◦ Two incisions : Posterior (Cervicoscapular) and Anterior
(Pectoroaxillary)
 • Posterior incision - beginning at the medial end of the clavicle extending it
laterally for the entire length of the bone.
• Carry over the acromion process to the posterior axillary fold, continue
Posterior Approach (LITTLEWOOD)
along the axillary border of the scapula to a point inferior to the scapular
angle
• Curve it medially to end 5 cm from the midline of the back
• Elevate a flap of skin and subcutaneous tissue medial to the vertebral
border of the scapula, extending it from the inferior angle of the scapula to
Posterior incisions the clavicle
 • Trapezius and latissimus dorsi - divide near scapula.
• Scapula – Draw away from the chest wall with a hook or
retractor,
Posterior Approach and divide the levator scapulae and the
(LITTLEWOOD)
rhomboids minor and major
• Ligate branches of the superficial cervical and
descending scapular vessels.
Posterior incisions
 • Divide – superior digitation of the serratus anterior close to
superior angle of the scapula
• Remaining insertion of the serratus anterior along the vertebral
Posterior Approach (LITTLEWOOD)
border of the scapula.
• Clavicle and subclavius muscle – Divide at medial end of the
bone
• Allow extremity to fall anteriorly, placing the neurovascular
Posterior incisions bundle under tension
• Cords of the brachial plexus – Divide close to the spine
 • Subclavian artery and vein - doubly ligate and
divide
Posterior Approach (LITTLEWOOD)
• Take care to avoid injury to the pleural dome.
• Divide the omohyoid muscle
• Suprascapular vessels and external jugular
Posterior incisions vein - ligate and divide
Posterior incisions
• Starting at the middle of the
clavicle and curving it inferiorly
just lateral to but parallel with the
deltopectoral groove.
• Extend it across the anterior
axillary fold,
• Carry it inferiorly and posteriorly to
join the posterior incision at the
lower third of the axillary border of
the scapula.
• Divide the pectoralis major and
minor muscles, and remove the
limb
Posterior Approach (LITTLEWOOD)
Posterior incisions
• Closure - flaps over
suction drains without
excessive tension
• Occasionally, it is
necessary to attach a
flap to the chest wall
and complete the
closure with a skin
graft.
Posterior Approach (LITTLEWOOD)
Posterior Approach
(LITTLEWOOD)
Contoh Kasus
(Preop Design)
Contoh Kasus
(Intraop)
Contoh Kasus
(Post Op)
Vital Sign
Follup dan
Pasca Op nyeri pasca op

• Produksi drain dan penyembuhan luka

Pemakaian prostease dan rehabilitasi medik

TERIMA
KASIH