Journal of Minimally Invasive Surgery 2024; 27(4): 221-226
Published online December 15, 2024
https://doi.org/10.7602/jmis.2024.27.4.221
© The Korean Society of Endo-Laparoscopic & Robotic Surgery
Correspondence to : Jae Kyun Ju
Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, 42 Jebong-ro, Dong-gu, Gwangju 61469, Korea
E-mail: jkju@chonnam.ac.kr
https://orcid.org/0000-0003-1605-3310
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Retrorectal tumors, although rare, pose diagnostic and treatment challenges due to their nonspecific symptoms and complex anatomical location. This single-center case series reports short-term outcomes of laparoscopic transabdominal resection as a surgical approach for large retrorectal tumors. Between 2017 and 2020, five patients underwent this procedure. The median patient age was 53.2 years (range, 34–60 years), and the median operating time was 130 minutes (range, 95–205 minutes). All tumors were located in the retrorectal space. The median tumor size was 5.8 × 4.3 cm (range, 3.5–7.5 cm). Biopsy results included epidermoid cysts, tailgut cyst, lipoma, and keratinous cyst. The median hospital stay was 7.8 days (range, 5–11 days), and the median follow-up duration was 78.0 days (range, 14–219 days). One patient developed a postoperative surgical site infection. Overall, laparoscopic transabdominal resection appears to be a minimally invasive and effective treatment option for retrorectal tumors.
Keywords Retroperitoneal neoplasms, Epidermal cyst, Pelvis, Minimally invasive surgical procedures, Laparoscopy
Retrorectal tumors are uncommon neoplasms associated with nonspecific signs and symptoms, first reported in 1885 [1]. Although the incidence of retrorectal tumors is not precisely known, they occur in approximately one in 40,000 patients [2]. Surgical resection can yield favorable results; however, retrorectal tumors are often difficult to recognize, diagnose, and treat owing to the narrow anatomical pelvic space [3]. In this case series, we present a single-center experience by analyzing the surgical outcomes and side effects of laparoscopic transabdominal resection of retrorectal tumors.
We investigated five patients diagnosed with retrorectal tumors based on abdominal computed tomography (CT) findings and who underwent laparoscopic transabdominal resection at the Department of Colorectal Surgery in Chonnam National University Hospital between 2017 and 2020. We retrospectively reviewed medical records to evaluate the outcomes of laparoscopic resection of retrorectal tumors, considering preoperative symptoms, tumor size and location, operating time, perioperative complications, histopathologic findings, length of hospital stay, recurrence, and follow-up. All patients routinely underwent preoperative examinations, including essential blood tests, chest radiography, electrocardiography, colonoscopy, pulmonary function tests, and abdominal CT. Magnetic resonance imaging (MRI) was additionally performed if necessary for an accurate diagnosis.
All patients underwent elective retrorectal tumor resection using an anterior laparoscopic approach., Bowel lavage was not performed before surgery; however, at least 8 hours of preoperative fasting was required. Prophylactic second-generation cephalosporin antibiotics were administered intravenously immediately before surgery. All five patients were in the lithotomy position after induction of general anesthesia. The surgeon stood on the lower right side of the patient, and the camera scopist was positioned on the upper right side; the first assistant stood on the left side. A 12-mm trocar was inserted into the umbilicus for the laparoscopic camera, and four 5-mm trocars were inserted into the left and right upper and lower abdominal quadrants (Fig. 1). The patients were then placed in the Trendelenburg position. The small intestine was moved upward in the abdominal cavity and simultaneously tilted slightly to the left or right, depending on the location of the retrorectal tumor. Although the surgical procedure varied slightly among patients, it generally followed this sequence. Before mass dissection, the anterior peritoneum or uterus was fixed to the abdominal skin using 2-0 Prolene (Ethicon) with linear needles (Fig. 2A). The peritoneal reflection was then dissected (Fig. 2B). Dissection was conducted to separate the peritoneum from the rectum, as assessed via palpation through the anus and delicate dissection was performed along the tumor (Fig. 2C). The tumor was resected without damage, and the pelvic floor muscle was identified (Fig. 2D). The rectum mobilized from the peritoneum was not anchored to the retroperitoneum. A drainage catheter was then inserted into the pelvic cavity for bleeding control (Fig. 2E).
This study evaluated the records of five patients (including three females) with a median age of 53.2 years (range, 34–60 years) (Table 1). Three patients experienced anal bleeding, bowel incontinence, tenesmus, and right leg numbness. Two patients had incidentally detected tumors. The median operating time was 130 minutes (range, 95–205 minutes). All tumors were located in the retrorectal space, with four out of the five tumors located above the coccyx level. The median tumor size was 5.8 × 4.3 cm (range, 3.5–7.5 cm) (Table 2). Biopsy revealed an epidermoid cyst in two women and a tailgut cyst, lipoma, and keratinous cyst in the other patients. The median hospital stay was 7.8 days (range, 5–11 days), and the median follow-up duration was 78.0 days (range, 14–219 days) (Table 1). One patient had a postoperative surgical site infection classified under the Clavien-Dindo classification grade II. This patient was diagnosed with wound infection when a greenish discharge was observed at the umbilical trocar insertion site during an outpatient visit one week after discharge. We stitched out the wound, administered ciprofloxacin antibiotic treatment and daily dressing for one week, and the patient recovered completely. There was recurrence in two patients who had incomplete tumor resection owing to the high possibility of damage to surrounding nerves and vessels. In one patient with recurrence, a 1.7 cm cystic lesion was observed in the left ischiorectal fossa area on a follow-up abdominal CT performed 2 months after surgery. The cystic lesion size decreased to 1.2 cm on an abdominal CT performed 6 months later. In the other patient with recurrence, a rectal MRI performed 2 months after surgery showed a remnant lesion extending through the right greater sciatic foramen to the right buttock. This lesion was removed by additional surgery using a posterior approach in the orthopedic department. Both patients who relapsed receive follow-up abdominal CT or MRI examinations and check symptoms through regular outpatient clinic visits.
Table 1 . Baseline characteristics of patients and surgical outcomes
Patient No. | Age (yr) | Sex | Symptom | Operation type | Operation time (min) | Length of stay (day) | Complications | Follow-up (day) | Recurrence | Mortality |
---|---|---|---|---|---|---|---|---|---|---|
A | 60 | Male | Anal bleeding, narrow stool | 2D Laparoscopic | 205 | 11 | No | 10 | No | No |
B | 34 | Female | Bowel incontinence, tenesmus | 3D Laparoscopic | 135 | 5 | Surgical site infection | 132 | No | No |
C | 58 | Male | Right leg neuropathic pain | 2D Laparoscopic | 110 | 6 | No | 14 | Yes | No |
D | 54 | Female | Incidentally detected | 2D Laparoscopic | 105 | 10 | No | 15 | No | No |
E | 60 | Female | Incidentally detected | 2D Laparoscopic | 95 | 7 | No | 75 | Yes | No |
2D, two-dimensional; 3D, three-dimensional.
Table 2 . The clinical and pathologic findings of resected retrorectal tumors
Patient No. | Tumor | |||
---|---|---|---|---|
Size (cm) | Location | Level related to coccyx | Pathology | |
A | 7.5 × 5.0 × 2.0 | Right retrorectal space | Above | Tailgut cyst |
B | 7.0 × 6.5 × 5.5 | Left retrorectal space | Above | Epidermoid cyst |
C | 7.5 × 5.0 × 5.0 | Right lateral pelvic wall | Above | Lipoma |
D | 3.5 × 2.5 × 1.0 | Presacrococcygeal area | Above | Keratinous cyst |
E | 3.5 × 2.5 × 1.5 | Left perirectal, ischiorectal fossa | Below | Epidermoid cyst |
In this study, we report five cases of retrorectal tumors, either incidentally detected or accompanied by anal bleeding, bowel incontinence, and numbness, which were laparoscopically resected. Although retrorectal tumors are rare, they are difficult to diagnose because of their anatomically inaccessible location, and treatment is challenging because many surgeons lack the requisite experience. Approximately 50% of patients usually have symptoms associated with a mass effect that presses on nearby organs, blood vessels, and nerves [4]. In our study, three out of the five patients developed symptoms due to this mass effect, prompting them to visit our outpatient clinic.
The retrorectal space is located behind the rectum and in front of the sacrum and coccyx. The peritoneal reflection forms the upper border; the levator ani and caudal muscles form the lower border; and the iliac vessels and ureters form the outer border [3]. Retrorectal tumors are most often benign but can be malignant in rare cases. The probability and association of malignant degeneration have been indicated in reports related to tailgut cysts. Therefore, accurate radiological diagnosis and surgical resection are vital [4]. According to recent case reports and series, surgical resection is essential and the best treatment of choice for retrorectal tumors [5]. Fortunately, all five patients in our study showed benign pathological results, including tailgut cyst, epidermoid cyst, lipoma, and keratinous cyst.
There are three types of surgical approaches to remove retrorectal tumors: transabdominal (anterior), paracoccygeal (posterior), and combined approaches. The anterior approach is performed when the tumor is large, there is a possibility of malignancy, or the tumor is located above the S3 vertebra level. The major advantage of the anterior approach is that it can accurately identify pelvic structures and easily allow for hemostasis or rectal manipulation. The posterior approach is performed when the tumor is small, the possibility of malignancy is low, or the tumor is located below the S3 vertebra level. The advantage of the posterior approach is that the lesion can be accessed directly, and the surgical area of the tumor is clearly visible. However, the disadvantage is the potential damage to pelvic blood vessels, nerves, and muscles. Therefore, delicate dissection should be executed with caution to avoid damaging the rectum, ureters, and blood vessels. The combined approach is implemented when the tumor is located both above and below the S3 vertebra level [6,7]. In our study, the retrorectal tumors were located above the coccyx level in four out of the five patients and below the coccyx level in one patient. All five patients underwent surgery using the laparoscopic transabdominal approach. In the patient with a retrorectal tumor located below the coccyx level, complete resection without recurrence would not have been possible if surgery had not been performed using the combined approach. The retrorectal cyst recurred based on the findings of the follow-up abdominal CT performed after surgery. However, the tumor size decreased from 1.7 cm on the previous abdominal CT scan to 1.2 cm on the follow-up scan, and the patient did not report any additional symptoms or discomfort.
In recent decades, there has been a gradual shift in abdominal surgery from traditional open surgery to less invasive laparoscopic surgery. Good clinical and surgical outcomes, including length of hospital stay, readmission rate, postoperative complications, and mortality, represent the merits of minimally invasive surgery, especially laparoscopic surgery [8]. A previous literature review on retrorectal tumors has also shown an increasing number of minimally invasive approaches to surgically remove these tumors. Retrorectal tumors are located in an anatomically challenging space, making surgical access difficult and increasing the risk of damage to surrounding complex structures. The laparoscopic transabdominal approach provides an excellent view of the narrow pelvic space, allowing for precise and delicate retrorectal tumor resection [9]. In this case series, retrorectal tumor resection was successfully performed using three-dimensional laparoscopy in one out of the five patients, while the remaining patients underwent surgery using two-dimensional laparoscopy.
No intraoperative complications were observed in this study, and only one patient developed a postoperative complication, specifically a wound infection at the surgical trocar site. In the study by Jao et al. [3] conducted on 120 patients with retrorectal tumors from 1960 to 1979, the rate of wound infection after retrorectal tumor resection was 11%, and the total complication rate was 47%. Additionally, a recent case report indicated a 22% rate of minor wound infections following surgery via the posterior approach [7]. In our study, the median length of hospital stay was 7.8 days, and the median operating time was 130 minutes. According to a literature review on retrorectal tumor resection conducted by Baek et al. [9], the length of hospital stay was 9 days for open surgery and 4 days for laparoscopic surgery, with total operating times of 175 minutes and 148 minutes, respectively.
There were several limitations to this study. First, the number of patients was relatively small because the study focused on patients who underwent retrorectal tumor resection using laparoscopy in a single tertiary hospital. Most previous studies on retrorectal tumor resection were case reports or case series, and randomized controlled trials or large cohort studies analyzing many patients from multiple centers are rare. Therefore, there is a need for additional large-scale studies on retrorectal tumor resection. Second, MRI was not performed for all patients during the preoperative routine examination. In our study, MRI was performed as a routine preoperative examination for only two out of the five patients. The cost of an MRI scan could also have affected patients’ decisions not to have an MRI performed as a routine examination. Many studies have reported that preoperative MRI in patients undergoing retrorectal tumor resection is a superior examination that can more accurately compensate for the anatomical details lacking in abdominal CT [10]. Therefore, if routine MRI is performed before surgery, it is likely to yield a more accurate diagnosis and surgical plan for retrorectal tumors in relation to the complex anatomical structures in the pelvic space, which will positively affect patients’ prognosis. Third, the tumors in two patients in this study were not completely resected, resulting in recurrence. Abdominal CT and MRI showed that the retrorectal tumors extended to the greater sciatic foramen or surrounding blood vessels and nerves; thus, complete resection could not be performed due to the risk of surgery. In one patient with recurrence, the tumor was removed through additional surgery at an orthopedic department, and in the other patient, the size of the tumor decreased on follow-up abdominal CT and is being observed. In both patients, neurological symptoms improved after surgery, and no additional complications were observed.
In conclusion, laparoscopic transabdominal resection of retrorectal tumors is safe and feasible. The laparoscopic transabdominal approach has its limitation of incomplete resection depending on the tumor location. However, it can access the deep pelvis, which is difficult to confirm with open or perineal approaches. Laparoscopic transabdominal resection is a less invasive surgical treatment method for retrorectal tumors.
Ethics statement
We conducted this study in compliance with the principles of the Declaration of Helsinki. The study’s protocol was reviewed and approved by the Institutional Review Board of Chonnam National University Hospital (No. CNUH-EXP-2018-088). The requirement for informed consent was waived confidentiality and anonymity have been maintained in adherence to ethical standards for this case series.
Authors’ contributions
Conceptualization, Project administration: HDK, JKJ
Data curation: JSC
Formal analysis: All authors
Investigation, Methodology, Visualization: JSC, HDK
Writing–original draft: JSC
Writing–review & editing: All authors
All authors read and approved the final manuscript.
Conflict of interest
All authors have no conflicts of interest to declare.
Funding/support
None.
Journal of Minimally Invasive Surgery 2024; 27(4): 221-226
Published online December 15, 2024 https://doi.org/10.7602/jmis.2024.27.4.221
Copyright © The Korean Society of Endo-Laparoscopic & Robotic Surgery.
Jun Seong Chung1 , Han Deok Kwak1,2
, Jae Kyun Ju1,2
1Department of Surgery, Chonnam National University Hospital, Gwangju, Korea, 2Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
Correspondence to:Jae Kyun Ju
Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, 42 Jebong-ro, Dong-gu, Gwangju 61469, Korea
E-mail: jkju@chonnam.ac.kr
https://orcid.org/0000-0003-1605-3310
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Retrorectal tumors, although rare, pose diagnostic and treatment challenges due to their nonspecific symptoms and complex anatomical location. This single-center case series reports short-term outcomes of laparoscopic transabdominal resection as a surgical approach for large retrorectal tumors. Between 2017 and 2020, five patients underwent this procedure. The median patient age was 53.2 years (range, 34–60 years), and the median operating time was 130 minutes (range, 95–205 minutes). All tumors were located in the retrorectal space. The median tumor size was 5.8 × 4.3 cm (range, 3.5–7.5 cm). Biopsy results included epidermoid cysts, tailgut cyst, lipoma, and keratinous cyst. The median hospital stay was 7.8 days (range, 5–11 days), and the median follow-up duration was 78.0 days (range, 14–219 days). One patient developed a postoperative surgical site infection. Overall, laparoscopic transabdominal resection appears to be a minimally invasive and effective treatment option for retrorectal tumors.
Keywords: Retroperitoneal neoplasms, Epidermal cyst, Pelvis, Minimally invasive surgical procedures, Laparoscopy
Retrorectal tumors are uncommon neoplasms associated with nonspecific signs and symptoms, first reported in 1885 [1]. Although the incidence of retrorectal tumors is not precisely known, they occur in approximately one in 40,000 patients [2]. Surgical resection can yield favorable results; however, retrorectal tumors are often difficult to recognize, diagnose, and treat owing to the narrow anatomical pelvic space [3]. In this case series, we present a single-center experience by analyzing the surgical outcomes and side effects of laparoscopic transabdominal resection of retrorectal tumors.
We investigated five patients diagnosed with retrorectal tumors based on abdominal computed tomography (CT) findings and who underwent laparoscopic transabdominal resection at the Department of Colorectal Surgery in Chonnam National University Hospital between 2017 and 2020. We retrospectively reviewed medical records to evaluate the outcomes of laparoscopic resection of retrorectal tumors, considering preoperative symptoms, tumor size and location, operating time, perioperative complications, histopathologic findings, length of hospital stay, recurrence, and follow-up. All patients routinely underwent preoperative examinations, including essential blood tests, chest radiography, electrocardiography, colonoscopy, pulmonary function tests, and abdominal CT. Magnetic resonance imaging (MRI) was additionally performed if necessary for an accurate diagnosis.
All patients underwent elective retrorectal tumor resection using an anterior laparoscopic approach., Bowel lavage was not performed before surgery; however, at least 8 hours of preoperative fasting was required. Prophylactic second-generation cephalosporin antibiotics were administered intravenously immediately before surgery. All five patients were in the lithotomy position after induction of general anesthesia. The surgeon stood on the lower right side of the patient, and the camera scopist was positioned on the upper right side; the first assistant stood on the left side. A 12-mm trocar was inserted into the umbilicus for the laparoscopic camera, and four 5-mm trocars were inserted into the left and right upper and lower abdominal quadrants (Fig. 1). The patients were then placed in the Trendelenburg position. The small intestine was moved upward in the abdominal cavity and simultaneously tilted slightly to the left or right, depending on the location of the retrorectal tumor. Although the surgical procedure varied slightly among patients, it generally followed this sequence. Before mass dissection, the anterior peritoneum or uterus was fixed to the abdominal skin using 2-0 Prolene (Ethicon) with linear needles (Fig. 2A). The peritoneal reflection was then dissected (Fig. 2B). Dissection was conducted to separate the peritoneum from the rectum, as assessed via palpation through the anus and delicate dissection was performed along the tumor (Fig. 2C). The tumor was resected without damage, and the pelvic floor muscle was identified (Fig. 2D). The rectum mobilized from the peritoneum was not anchored to the retroperitoneum. A drainage catheter was then inserted into the pelvic cavity for bleeding control (Fig. 2E).
This study evaluated the records of five patients (including three females) with a median age of 53.2 years (range, 34–60 years) (Table 1). Three patients experienced anal bleeding, bowel incontinence, tenesmus, and right leg numbness. Two patients had incidentally detected tumors. The median operating time was 130 minutes (range, 95–205 minutes). All tumors were located in the retrorectal space, with four out of the five tumors located above the coccyx level. The median tumor size was 5.8 × 4.3 cm (range, 3.5–7.5 cm) (Table 2). Biopsy revealed an epidermoid cyst in two women and a tailgut cyst, lipoma, and keratinous cyst in the other patients. The median hospital stay was 7.8 days (range, 5–11 days), and the median follow-up duration was 78.0 days (range, 14–219 days) (Table 1). One patient had a postoperative surgical site infection classified under the Clavien-Dindo classification grade II. This patient was diagnosed with wound infection when a greenish discharge was observed at the umbilical trocar insertion site during an outpatient visit one week after discharge. We stitched out the wound, administered ciprofloxacin antibiotic treatment and daily dressing for one week, and the patient recovered completely. There was recurrence in two patients who had incomplete tumor resection owing to the high possibility of damage to surrounding nerves and vessels. In one patient with recurrence, a 1.7 cm cystic lesion was observed in the left ischiorectal fossa area on a follow-up abdominal CT performed 2 months after surgery. The cystic lesion size decreased to 1.2 cm on an abdominal CT performed 6 months later. In the other patient with recurrence, a rectal MRI performed 2 months after surgery showed a remnant lesion extending through the right greater sciatic foramen to the right buttock. This lesion was removed by additional surgery using a posterior approach in the orthopedic department. Both patients who relapsed receive follow-up abdominal CT or MRI examinations and check symptoms through regular outpatient clinic visits.
Table 1 . Baseline characteristics of patients and surgical outcomes.
Patient No. | Age (yr) | Sex | Symptom | Operation type | Operation time (min) | Length of stay (day) | Complications | Follow-up (day) | Recurrence | Mortality |
---|---|---|---|---|---|---|---|---|---|---|
A | 60 | Male | Anal bleeding, narrow stool | 2D Laparoscopic | 205 | 11 | No | 10 | No | No |
B | 34 | Female | Bowel incontinence, tenesmus | 3D Laparoscopic | 135 | 5 | Surgical site infection | 132 | No | No |
C | 58 | Male | Right leg neuropathic pain | 2D Laparoscopic | 110 | 6 | No | 14 | Yes | No |
D | 54 | Female | Incidentally detected | 2D Laparoscopic | 105 | 10 | No | 15 | No | No |
E | 60 | Female | Incidentally detected | 2D Laparoscopic | 95 | 7 | No | 75 | Yes | No |
2D, two-dimensional; 3D, three-dimensional..
Table 2 . The clinical and pathologic findings of resected retrorectal tumors.
Patient No. | Tumor | |||
---|---|---|---|---|
Size (cm) | Location | Level related to coccyx | Pathology | |
A | 7.5 × 5.0 × 2.0 | Right retrorectal space | Above | Tailgut cyst |
B | 7.0 × 6.5 × 5.5 | Left retrorectal space | Above | Epidermoid cyst |
C | 7.5 × 5.0 × 5.0 | Right lateral pelvic wall | Above | Lipoma |
D | 3.5 × 2.5 × 1.0 | Presacrococcygeal area | Above | Keratinous cyst |
E | 3.5 × 2.5 × 1.5 | Left perirectal, ischiorectal fossa | Below | Epidermoid cyst |
In this study, we report five cases of retrorectal tumors, either incidentally detected or accompanied by anal bleeding, bowel incontinence, and numbness, which were laparoscopically resected. Although retrorectal tumors are rare, they are difficult to diagnose because of their anatomically inaccessible location, and treatment is challenging because many surgeons lack the requisite experience. Approximately 50% of patients usually have symptoms associated with a mass effect that presses on nearby organs, blood vessels, and nerves [4]. In our study, three out of the five patients developed symptoms due to this mass effect, prompting them to visit our outpatient clinic.
The retrorectal space is located behind the rectum and in front of the sacrum and coccyx. The peritoneal reflection forms the upper border; the levator ani and caudal muscles form the lower border; and the iliac vessels and ureters form the outer border [3]. Retrorectal tumors are most often benign but can be malignant in rare cases. The probability and association of malignant degeneration have been indicated in reports related to tailgut cysts. Therefore, accurate radiological diagnosis and surgical resection are vital [4]. According to recent case reports and series, surgical resection is essential and the best treatment of choice for retrorectal tumors [5]. Fortunately, all five patients in our study showed benign pathological results, including tailgut cyst, epidermoid cyst, lipoma, and keratinous cyst.
There are three types of surgical approaches to remove retrorectal tumors: transabdominal (anterior), paracoccygeal (posterior), and combined approaches. The anterior approach is performed when the tumor is large, there is a possibility of malignancy, or the tumor is located above the S3 vertebra level. The major advantage of the anterior approach is that it can accurately identify pelvic structures and easily allow for hemostasis or rectal manipulation. The posterior approach is performed when the tumor is small, the possibility of malignancy is low, or the tumor is located below the S3 vertebra level. The advantage of the posterior approach is that the lesion can be accessed directly, and the surgical area of the tumor is clearly visible. However, the disadvantage is the potential damage to pelvic blood vessels, nerves, and muscles. Therefore, delicate dissection should be executed with caution to avoid damaging the rectum, ureters, and blood vessels. The combined approach is implemented when the tumor is located both above and below the S3 vertebra level [6,7]. In our study, the retrorectal tumors were located above the coccyx level in four out of the five patients and below the coccyx level in one patient. All five patients underwent surgery using the laparoscopic transabdominal approach. In the patient with a retrorectal tumor located below the coccyx level, complete resection without recurrence would not have been possible if surgery had not been performed using the combined approach. The retrorectal cyst recurred based on the findings of the follow-up abdominal CT performed after surgery. However, the tumor size decreased from 1.7 cm on the previous abdominal CT scan to 1.2 cm on the follow-up scan, and the patient did not report any additional symptoms or discomfort.
In recent decades, there has been a gradual shift in abdominal surgery from traditional open surgery to less invasive laparoscopic surgery. Good clinical and surgical outcomes, including length of hospital stay, readmission rate, postoperative complications, and mortality, represent the merits of minimally invasive surgery, especially laparoscopic surgery [8]. A previous literature review on retrorectal tumors has also shown an increasing number of minimally invasive approaches to surgically remove these tumors. Retrorectal tumors are located in an anatomically challenging space, making surgical access difficult and increasing the risk of damage to surrounding complex structures. The laparoscopic transabdominal approach provides an excellent view of the narrow pelvic space, allowing for precise and delicate retrorectal tumor resection [9]. In this case series, retrorectal tumor resection was successfully performed using three-dimensional laparoscopy in one out of the five patients, while the remaining patients underwent surgery using two-dimensional laparoscopy.
No intraoperative complications were observed in this study, and only one patient developed a postoperative complication, specifically a wound infection at the surgical trocar site. In the study by Jao et al. [3] conducted on 120 patients with retrorectal tumors from 1960 to 1979, the rate of wound infection after retrorectal tumor resection was 11%, and the total complication rate was 47%. Additionally, a recent case report indicated a 22% rate of minor wound infections following surgery via the posterior approach [7]. In our study, the median length of hospital stay was 7.8 days, and the median operating time was 130 minutes. According to a literature review on retrorectal tumor resection conducted by Baek et al. [9], the length of hospital stay was 9 days for open surgery and 4 days for laparoscopic surgery, with total operating times of 175 minutes and 148 minutes, respectively.
There were several limitations to this study. First, the number of patients was relatively small because the study focused on patients who underwent retrorectal tumor resection using laparoscopy in a single tertiary hospital. Most previous studies on retrorectal tumor resection were case reports or case series, and randomized controlled trials or large cohort studies analyzing many patients from multiple centers are rare. Therefore, there is a need for additional large-scale studies on retrorectal tumor resection. Second, MRI was not performed for all patients during the preoperative routine examination. In our study, MRI was performed as a routine preoperative examination for only two out of the five patients. The cost of an MRI scan could also have affected patients’ decisions not to have an MRI performed as a routine examination. Many studies have reported that preoperative MRI in patients undergoing retrorectal tumor resection is a superior examination that can more accurately compensate for the anatomical details lacking in abdominal CT [10]. Therefore, if routine MRI is performed before surgery, it is likely to yield a more accurate diagnosis and surgical plan for retrorectal tumors in relation to the complex anatomical structures in the pelvic space, which will positively affect patients’ prognosis. Third, the tumors in two patients in this study were not completely resected, resulting in recurrence. Abdominal CT and MRI showed that the retrorectal tumors extended to the greater sciatic foramen or surrounding blood vessels and nerves; thus, complete resection could not be performed due to the risk of surgery. In one patient with recurrence, the tumor was removed through additional surgery at an orthopedic department, and in the other patient, the size of the tumor decreased on follow-up abdominal CT and is being observed. In both patients, neurological symptoms improved after surgery, and no additional complications were observed.
In conclusion, laparoscopic transabdominal resection of retrorectal tumors is safe and feasible. The laparoscopic transabdominal approach has its limitation of incomplete resection depending on the tumor location. However, it can access the deep pelvis, which is difficult to confirm with open or perineal approaches. Laparoscopic transabdominal resection is a less invasive surgical treatment method for retrorectal tumors.
Ethics statement
We conducted this study in compliance with the principles of the Declaration of Helsinki. The study’s protocol was reviewed and approved by the Institutional Review Board of Chonnam National University Hospital (No. CNUH-EXP-2018-088). The requirement for informed consent was waived confidentiality and anonymity have been maintained in adherence to ethical standards for this case series.
Authors’ contributions
Conceptualization, Project administration: HDK, JKJ
Data curation: JSC
Formal analysis: All authors
Investigation, Methodology, Visualization: JSC, HDK
Writing–original draft: JSC
Writing–review & editing: All authors
All authors read and approved the final manuscript.
Conflict of interest
All authors have no conflicts of interest to declare.
Funding/support
None.
Table 1 . Baseline characteristics of patients and surgical outcomes.
Patient No. | Age (yr) | Sex | Symptom | Operation type | Operation time (min) | Length of stay (day) | Complications | Follow-up (day) | Recurrence | Mortality |
---|---|---|---|---|---|---|---|---|---|---|
A | 60 | Male | Anal bleeding, narrow stool | 2D Laparoscopic | 205 | 11 | No | 10 | No | No |
B | 34 | Female | Bowel incontinence, tenesmus | 3D Laparoscopic | 135 | 5 | Surgical site infection | 132 | No | No |
C | 58 | Male | Right leg neuropathic pain | 2D Laparoscopic | 110 | 6 | No | 14 | Yes | No |
D | 54 | Female | Incidentally detected | 2D Laparoscopic | 105 | 10 | No | 15 | No | No |
E | 60 | Female | Incidentally detected | 2D Laparoscopic | 95 | 7 | No | 75 | Yes | No |
2D, two-dimensional; 3D, three-dimensional..
Table 2 . The clinical and pathologic findings of resected retrorectal tumors.
Patient No. | Tumor | |||
---|---|---|---|---|
Size (cm) | Location | Level related to coccyx | Pathology | |
A | 7.5 × 5.0 × 2.0 | Right retrorectal space | Above | Tailgut cyst |
B | 7.0 × 6.5 × 5.5 | Left retrorectal space | Above | Epidermoid cyst |
C | 7.5 × 5.0 × 5.0 | Right lateral pelvic wall | Above | Lipoma |
D | 3.5 × 2.5 × 1.0 | Presacrococcygeal area | Above | Keratinous cyst |
E | 3.5 × 2.5 × 1.5 | Left perirectal, ischiorectal fossa | Below | Epidermoid cyst |
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