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A combined approach to the excision of sciatic notch dumb‐bell tumours

Dumb-bell tumours of the sciatic notch are rare. They usually present with buttock pain, sciatica with or without neurological dysfunction, or a buttock mass. Because their symptoms are similar to more common causes of sciatica, these tumours are often diagnosed late and can grow extremely large before surgical intervention is undertaken. Their characteristic dumb-bell appearance is due to constriction of the tumour within the sciatic notch (Fig. 1). They are mostly composed of neurofibromas, lipomas and soft tissue sarcomas, but it is also often difficult to preoperatively determine their malignant potential, thus, optimal treatment is complete excision as a single unit rather than piecemeal extraction, which could potentially seed malignancy. However, radical excision is undesirable because of significant morbidity associated with vascular and nerve injury in this region. Because of their rarity and complicated anatomy, management protocols have not been clearly established. We propose that optimal treatment is provided by a combined transgluteal and transperitoneal approach, performed by two different surgical disciplines experienced in operating within designated regions. Our surgical approach involves draping the abdomen, buttock and leg to allow the patient to be alternately positioned supine and lateral. A lower midline abdominal incision allows access to the pelvic cavity with the vascular team expertise freeing the tumour from within the pelvis. A transgluteal incision performed by the orthopaedic team allows delivery of the tumour through the sciatic notch while protecting the sciatic nerve and performing pelvic osteotomies as required. We have successfully utilized this approach in the removal of a lipoma and a malignant fibrous histiocytoma with resolution of symptoms and 10-year survival without recurrence. We propose that the utilization of two different surgical disciplines optimizes intraoperative expertise and anatomical familiarity, thereby optimizing operative success.