Knacks and pitfalls of retroperitoneal sarcoma surgery, part 2: practical tumor resection in Nagoya University

ABSTRACT This article provides a detailed account of the practical techniques and precautions regarding the surgical resection of retroperitoneal sarcoma (RPS). As there is no standardized procedure for RPS surgery, the operative approach must be flexible, depending on tumor location and extent. Stepwise dissection from multiple directions is emphasized, as well as decision-making regarding combined resection of adjacent organs, such as the intestine, pancreas, kidney, liver, and adrenal gland. Strategies for managing tumor-associated feeding arteries and drainage veins to minimize intraoperative bleeding are also discussed. Nephrectomy is recommended when the tumor invades the renal hilum or adjacent structures; however, kidney preservation is considered whenever possible. The paper also addresses the extent of resection required, noting that in retroperitoneal liposarcoma, compartmental fat tissue removal is often preferred over strict margin-based resection, considering the high rate of microscopic infiltration. Distinguishing well-differentiated from dedifferentiated components is partially achievable using imaging and intraoperative findings. Given the complexity of these procedures, multidisciplinary collaboration and the anesthesiologist’s understanding of the surgical strategy are essential. This comprehensive overview highlights the technical depth and adaptability required for large RPS resections.