Video/Multimedia Article

Split Viewer

Journal of Minimally Invasive Surgery 2019; 22(3): 131-133

Published online September 15, 2019

https://doi.org/10.7602/jmis.2019.22.3.131

© The Korean Society of Endo-Laparoscopic & Robotic Surgery

Laparoscopic Resection of Presacral Tumor: A New Approach  in the Era of the Minimally Invasive Surgery

Chang Woo Kim , M.D., Suk-Hwan Lee , M.D.

Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea

Correspondence to : Suk-Hwan Lee, Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, 892 Dongnam-ro, Gangdong-gu, Seoul 05278, Korea, Tel: +82-2-440-6134, Fax: +82-2-440-6073, E-mail: leeshdr@khu.ac.kr, ORCID: https://orcid.org/0000-0001-6470-8620

Received: August 23, 2019; Revised: September 4, 2019; Accepted: September 6, 2019

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.

Presacral tumors are rare; however, once diagnosed, surgical resection is recommended even in asymptomatic patients as there is potential risk for growth or malignant transformation. Many different types of surgical approaches to resect presacral tumors have been reported including posterior, anterior, and combined abdominosacral approaches. With introduction of the minimally invasive approach, laparoscopic or robotic approaches to resect presacral tumors are reported increasingly. We report a case of successful anterior laparoscopic resection for a presacral mass that was incidentally diagnosed during management of pancreatitis.

Keywords Laparoscopy, Presacral tumor, Tailgut cyst

Presacral tumor is rare, and most reported series are case reports. Many different kinds of tumors can occur as this area harbors varieties of embryologic remnant tissues and various tissue types. Presacral tumors are subdivided by 5 categories based on origin, i.e., congenital, inflammatory, neurogenic, osseous, and miscellaneous tumors.1,2 Both benign and malignant tumor can occur. Solid lesions on magnetic resonance imaging (MRI) suggest malignant characteristics.3 Most tumors are diagnosed incidentally and do not cause specific symptoms. Surgical resection is recommended upon diagnosis, even in asymptomatic patients, as there is potential risk for growth or malignant transformation.4,5

Many different types of surgical approaches to resect presacral tumors are reported. Posterior, anterior, combined abdominosacral approaches are commonly performed, but transvaginal or transrectal approaches are also performed to resect presacral tumors. With introduction of the minimally invasive approach, laparoscopic or robotic approaches to resect presacral tumors are reported increasingly. Herein, we reported a case of presacral mass incidentally diagnosed during management of pancreatitis and that was successfully resected with an anterior laparoscopic approach.

A 55-year-old male patient was admitted with acute pancreatitis. During the follow-up examination of his pancreatitis, a huge pelvic mass was found incidentally. It occupied the whole pelvic cavity, pushing the low rectum to the right side. The patient denied any obstructed symptoms of defecation. Pelvic MRI confirmed that the mass measuring 7.6×6.1 cm was more likely an epidermoid or tailgut cyst rather than a malignant tumor. The presacral tumor was successfully resected via the anterior laparoscopic approach.

The rectum and mesorectum were preserved during medial dissection. Presacral venous plexus was preserved at the posterior part. Lastly, we avoided injury to the ureter and autonomic nerve for the lateral side. During the dissection of the huge presacral tumor, distal dissection was most complicated because the tumor itself prohibited the proper visualization of the dissection plane. Careful traction with counter traction of the surgical plane is an essential prerequisite for the successful bloodless dissection. The specimen was extracted through the right lower quadrant trocar site after extending incision about 2.5 cm.

We completed laparoscopic resection without any events, and pathology confirmed the diagnosis of tailgut cyst. The patient was discharged to home at postoperative day five without any complications.

The posterior approach or Kraske trans-sacral approach was a classic approach and provided good surgical access with a short route of entry to the presacral space.1 Division of pelvic floor muscle and coccygectomy or sacrectomy produced postoperative pain and possibilities of fecal incontinence. An abdominosacral approach is recommended for large tumors extending upward as high as the sacral promontory and downward as low as S4. The anterior approach or abdominal approach is indicated for tumors with the lowest margin located above S4 in the absence of nerve involvement. This approach provided excellent exposure of pelvic structures such as iliac vessels, ureter, and pelvic autonomic nerves. Usually, an anterior approach requires a long midline incision; however, with the introduction of minimally invasive approaches, presacral tumors are resected with anterior laparoscopic,612 posterior endoscopic,6 and robotic methods.1315

Complete resection without perforation of presacral tumor is very important since the tumor may harbor malignant tissues. We dissected the presacral tumor without perforation using the anterior laparoscopic approach.

In summary, a laparoscopic anterior approach is feasible and safe to resect a presacral tumor. Care should be taken not to injure any vascular, neurologic, and visceral organ damage nor perforation of the cystic lesion.

Conceptualization: SHL. Formal analysis: CWK. Methodology: CWK, SHL. Writing-original draft: CWK, SHL. Writing-review and editing: SHL.

  1. Aranda-Narvaez JM, Gonzalez-Sanchez AJ, Montiel-Casado C, et al. Posterior approach (Kraske procedure) for surgical treatment of presacral tumors. World J Gastrointest Surg 2012;4:126-130.
    Pubmed KoreaMed CrossRef
  2. Hobson KG, Ghaemmaghami V, Roe JP, Goodnight JE, Khatri VP. Tumors of the retrorectal space. Dis Colon Rectum 2005;48:1964-1974.
    Pubmed CrossRef
  3. Yang DM, Kim HC, Lee HL, Lee SH, Kim GY. Squamous cell carcinoma arising from a presacral epidermoid cyst: CT and MR findings. Abdom Imaging 2008;33:498-500.
    Pubmed CrossRef
  4. Simpson PJ, Wise KB, Merchea A, et al. Surgical outcomes in adults with benign and malignant sacrococcygeal teratoma: a single-institution experience of 26 cases. Dis Colon Rectum 2014;57:851-857.
    Pubmed CrossRef
  5. Mathis KL, Dozois EJ, Grewal MS, Metzger P, Larson DW, Devine RM. Malignant risk and surgical outcomes of presacral tailgut cysts. Br J Surg 2010;97:575-579.
    Pubmed CrossRef
  6. Nieuwenhuis DH, Gagner M, Consten EC. The endoscopic perineal approach to the presacral space: an excision biopsy. J Laparoendosc Adv Surg Tech A 2009;19:799-801.
    Pubmed CrossRef
  7. Lim SW, Huh JW, Kim YJ, Kim HR. Laparoscopy-assisted resection of tailgut cysts: report of a case. Case Rep Gastroenterol 2011;5:22-27.
    Pubmed KoreaMed CrossRef
  8. Tobias-Machado M, Hidaka AK, Sato LLK, Silva IN, Mattos PAL, Pompeo ACL. Laparoscopic resection of prescral and obturator fossa schwannoma. Int Braz J Urol 2017;43:566.
    Pubmed KoreaMed CrossRef
  9. Poskus E, Makunaite G, Kubiliute I, Danys D. Case report: Laparoscopic approach in the treatment of presacral lipoma. Ann Med Surg (Lond) 2018;35:64-66.
    Pubmed KoreaMed CrossRef
  10. Hove MG, Gil JM, Rodriguez TS, et al. Laparoscopic approach to tailgut cyst (retrorectal cystic hamartoma). J Minim Access Surg 2019;15:262-264.
    Pubmed KoreaMed CrossRef
  11. Mohri K, Kamiya T, Hiramatsu K, et al. Laparoscopic surgery of a presacral epidermoid cyst: A case report. Int J Surg Case Rep 2019;59:23-26.
    Pubmed KoreaMed CrossRef
  12. Sezgin B, Camuzcuoglu A, Camuzcuoglu H. Laparoscopic Resection of An Extragastrointestinal Stromal Tumor in the Presacral Area. J Minim Invasive Gynecol 2019;26:812-813.
    Pubmed CrossRef
  13. Carchman E, Gorgun E. Robotic-assisted resection of presacral sclerosing epithelioid fibrosarcoma. Tech Coloproctol 2015;19:177-180.
    Pubmed CrossRef
  14. Eftaiha SM, Kochar K, Pai A, Park JJ, Prasad LM, Marecik SJ. Robot-assisted approach to a retrorectal lesion in an obese female. J Vis Surg 2016;2:59.
    Pubmed KoreaMed CrossRef
  15. Criss CN, Grant C, Ralls MW, Geiger JD. Robotic resection of recurrent pediatric lipoblastoma. Asian J Endosc Surg 2019;12:128-131.
    Pubmed CrossRef

Article

Video/Multimedia Article

Journal of Minimally Invasive Surgery 2019; 22(3): 131-133

Published online September 15, 2019 https://doi.org/10.7602/jmis.2019.22.3.131

Copyright © The Korean Society of Endo-Laparoscopic & Robotic Surgery.

Laparoscopic Resection of Presacral Tumor: A New Approach  in the Era of the Minimally Invasive Surgery

Chang Woo Kim , M.D., Suk-Hwan Lee , M.D.

Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea

Correspondence to:Suk-Hwan Lee, Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, 892 Dongnam-ro, Gangdong-gu, Seoul 05278, Korea, Tel: +82-2-440-6134, Fax: +82-2-440-6073, E-mail: leeshdr@khu.ac.kr, ORCID: https://orcid.org/0000-0001-6470-8620

Received: August 23, 2019; Revised: September 4, 2019; Accepted: September 6, 2019

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.

Abstract

Presacral tumors are rare; however, once diagnosed, surgical resection is recommended even in asymptomatic patients as there is potential risk for growth or malignant transformation. Many different types of surgical approaches to resect presacral tumors have been reported including posterior, anterior, and combined abdominosacral approaches. With introduction of the minimally invasive approach, laparoscopic or robotic approaches to resect presacral tumors are reported increasingly. We report a case of successful anterior laparoscopic resection for a presacral mass that was incidentally diagnosed during management of pancreatitis.

Keywords: Laparoscopy, Presacral tumor, Tailgut cyst

INTRODUCTION

Presacral tumor is rare, and most reported series are case reports. Many different kinds of tumors can occur as this area harbors varieties of embryologic remnant tissues and various tissue types. Presacral tumors are subdivided by 5 categories based on origin, i.e., congenital, inflammatory, neurogenic, osseous, and miscellaneous tumors.1,2 Both benign and malignant tumor can occur. Solid lesions on magnetic resonance imaging (MRI) suggest malignant characteristics.3 Most tumors are diagnosed incidentally and do not cause specific symptoms. Surgical resection is recommended upon diagnosis, even in asymptomatic patients, as there is potential risk for growth or malignant transformation.4,5

Many different types of surgical approaches to resect presacral tumors are reported. Posterior, anterior, combined abdominosacral approaches are commonly performed, but transvaginal or transrectal approaches are also performed to resect presacral tumors. With introduction of the minimally invasive approach, laparoscopic or robotic approaches to resect presacral tumors are reported increasingly. Herein, we reported a case of presacral mass incidentally diagnosed during management of pancreatitis and that was successfully resected with an anterior laparoscopic approach.

OPERATIVE PROCEDURES

A 55-year-old male patient was admitted with acute pancreatitis. During the follow-up examination of his pancreatitis, a huge pelvic mass was found incidentally. It occupied the whole pelvic cavity, pushing the low rectum to the right side. The patient denied any obstructed symptoms of defecation. Pelvic MRI confirmed that the mass measuring 7.6×6.1 cm was more likely an epidermoid or tailgut cyst rather than a malignant tumor. The presacral tumor was successfully resected via the anterior laparoscopic approach.

The rectum and mesorectum were preserved during medial dissection. Presacral venous plexus was preserved at the posterior part. Lastly, we avoided injury to the ureter and autonomic nerve for the lateral side. During the dissection of the huge presacral tumor, distal dissection was most complicated because the tumor itself prohibited the proper visualization of the dissection plane. Careful traction with counter traction of the surgical plane is an essential prerequisite for the successful bloodless dissection. The specimen was extracted through the right lower quadrant trocar site after extending incision about 2.5 cm.

We completed laparoscopic resection without any events, and pathology confirmed the diagnosis of tailgut cyst. The patient was discharged to home at postoperative day five without any complications.

DISCUSSION

The posterior approach or Kraske trans-sacral approach was a classic approach and provided good surgical access with a short route of entry to the presacral space.1 Division of pelvic floor muscle and coccygectomy or sacrectomy produced postoperative pain and possibilities of fecal incontinence. An abdominosacral approach is recommended for large tumors extending upward as high as the sacral promontory and downward as low as S4. The anterior approach or abdominal approach is indicated for tumors with the lowest margin located above S4 in the absence of nerve involvement. This approach provided excellent exposure of pelvic structures such as iliac vessels, ureter, and pelvic autonomic nerves. Usually, an anterior approach requires a long midline incision; however, with the introduction of minimally invasive approaches, presacral tumors are resected with anterior laparoscopic,612 posterior endoscopic,6 and robotic methods.1315

Complete resection without perforation of presacral tumor is very important since the tumor may harbor malignant tissues. We dissected the presacral tumor without perforation using the anterior laparoscopic approach.

In summary, a laparoscopic anterior approach is feasible and safe to resect a presacral tumor. Care should be taken not to injure any vascular, neurologic, and visceral organ damage nor perforation of the cystic lesion.

Supplementary Information

AUTHORS’ CONTRIBUTIONS

Conceptualization: SHL. Formal analysis: CWK. Methodology: CWK, SHL. Writing-original draft: CWK, SHL. Writing-review and editing: SHL.

CONFLICT OF INTEREST

None.

FUNDING

None.

ACKNOWLEDGMENTS

None.

References

  1. Aranda-Narvaez JM, Gonzalez-Sanchez AJ, Montiel-Casado C, et al. Posterior approach (Kraske procedure) for surgical treatment of presacral tumors. World J Gastrointest Surg 2012;4:126-130.
    Pubmed KoreaMed CrossRef
  2. Hobson KG, Ghaemmaghami V, Roe JP, Goodnight JE, Khatri VP. Tumors of the retrorectal space. Dis Colon Rectum 2005;48:1964-1974.
    Pubmed CrossRef
  3. Yang DM, Kim HC, Lee HL, Lee SH, Kim GY. Squamous cell carcinoma arising from a presacral epidermoid cyst: CT and MR findings. Abdom Imaging 2008;33:498-500.
    Pubmed CrossRef
  4. Simpson PJ, Wise KB, Merchea A, et al. Surgical outcomes in adults with benign and malignant sacrococcygeal teratoma: a single-institution experience of 26 cases. Dis Colon Rectum 2014;57:851-857.
    Pubmed CrossRef
  5. Mathis KL, Dozois EJ, Grewal MS, Metzger P, Larson DW, Devine RM. Malignant risk and surgical outcomes of presacral tailgut cysts. Br J Surg 2010;97:575-579.
    Pubmed CrossRef
  6. Nieuwenhuis DH, Gagner M, Consten EC. The endoscopic perineal approach to the presacral space: an excision biopsy. J Laparoendosc Adv Surg Tech A 2009;19:799-801.
    Pubmed CrossRef
  7. Lim SW, Huh JW, Kim YJ, Kim HR. Laparoscopy-assisted resection of tailgut cysts: report of a case. Case Rep Gastroenterol 2011;5:22-27.
    Pubmed KoreaMed CrossRef
  8. Tobias-Machado M, Hidaka AK, Sato LLK, Silva IN, Mattos PAL, Pompeo ACL. Laparoscopic resection of prescral and obturator fossa schwannoma. Int Braz J Urol 2017;43:566.
    Pubmed KoreaMed CrossRef
  9. Poskus E, Makunaite G, Kubiliute I, Danys D. Case report: Laparoscopic approach in the treatment of presacral lipoma. Ann Med Surg (Lond) 2018;35:64-66.
    Pubmed KoreaMed CrossRef
  10. Hove MG, Gil JM, Rodriguez TS, et al. Laparoscopic approach to tailgut cyst (retrorectal cystic hamartoma). J Minim Access Surg 2019;15:262-264.
    Pubmed KoreaMed CrossRef
  11. Mohri K, Kamiya T, Hiramatsu K, et al. Laparoscopic surgery of a presacral epidermoid cyst: A case report. Int J Surg Case Rep 2019;59:23-26.
    Pubmed KoreaMed CrossRef
  12. Sezgin B, Camuzcuoglu A, Camuzcuoglu H. Laparoscopic Resection of An Extragastrointestinal Stromal Tumor in the Presacral Area. J Minim Invasive Gynecol 2019;26:812-813.
    Pubmed CrossRef
  13. Carchman E, Gorgun E. Robotic-assisted resection of presacral sclerosing epithelioid fibrosarcoma. Tech Coloproctol 2015;19:177-180.
    Pubmed CrossRef
  14. Eftaiha SM, Kochar K, Pai A, Park JJ, Prasad LM, Marecik SJ. Robot-assisted approach to a retrorectal lesion in an obese female. J Vis Surg 2016;2:59.
    Pubmed KoreaMed CrossRef
  15. Criss CN, Grant C, Ralls MW, Geiger JD. Robotic resection of recurrent pediatric lipoblastoma. Asian J Endosc Surg 2019;12:128-131.
    Pubmed CrossRef

Supplementary File

Metrics for This Article

Share this article on

  • kakao talk
  • line

Related articles in JMIS

Journal of Minimally Invasive Surgery

pISSN 2234-778X
eISSN 2234-5248