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Laparoscopic Resection of Presacral Teratomas
Laparoscopic Resection of Presacral Teratomas Yong Chen, MD, Huicheng Xu, MD, Yuyan Li, MD, Junnan Li, MD, PhD, Dan Wang, MD, Jizhao Yuan, MD, and Zhiqing Liang, MD, PhD* From Southwest Hospital, Third Military Medical University, Chongqing, PR China (all authors).
ABSTRACT Presacral and retrorectal space tumors are relatively rare lesions, the location of which can result in the onset of symptoms that are not well-defined. Retrorectal teratomas are resected to alleviate these symptoms and to rule out malignancy. Complete resection by one of the open abdominal or sacral approaches was traditionally advocated as the best treatment for either a benign or malignant presacral and retrorectal tumor. A 15-year-old girl had chronic, progressively worsening dull pelvic pain and was given the diagnosis of a retrorectal tumor during her first gynecologic examination. Computed tomography of the pelvis showed an encapsulated presacral and retrorectal tumor measuring 10 ! 8.5 ! 8 cm. The retrorectal teratoma was removed by laparoscopy. No complication was observed interoperation. In addition, no sensory or motoric dysfunction of the bladder or rectum was observed postoperatively. Laparoscopy can be used to surgically remove presacral teratomas. Journal of Minimally Invasive Gynecology (2008) 15, 649–651 Ó 2008 AAGL All rights reserved. Keywords:
Teratomas; Laparoscopic resection; Presacral; Retrorectal tumors
The role of laparoscopic surgery has expanded during the past decade to include surgery on most of the intraabdominal organs. Many laparoscopic procedures have resulted in decreased tissue trauma and accelerated postoperative recovery while accomplishing resection equivalent to that of open surgery [1]. Laparoscopic surgery for retroperitoneal lesions is now gaining momentum because of these same perceived advantages of the procedure. Presacral and retrorectal space tumors are relatively rare lesions. They appear in 1 of 40 000 patients referred to hospitals [2]. They may be malignant or benign. Imaging techniques, such as computed tomography or magnetic resonance imaging, allow the visualization of the tumor and delineation to adjacent structures but do not exclude the possibility of malignancy [2,3]. In addition, retroperitoneal cysts are resected to decrease the risk of intracystic hemorrhage. Complete resection, via one of the open abdominal or sacral approaches, was traditionally advocated as the best treatment of either a benign or malignant presacral tumor. Laparoscopy offers an attractive potential alternative, and is an equally effective approach in the management of benign presacral tumors [4]. The authors have no commercial, proprietary, or financial interest in the products or companies described in this article. Corresponding author: Zhiquing Liang, MD, PhD, Department of Obstetrics and Gynecology, Southwest Hospital, Chongqing 400038, China. E-mail: [email protected] Submitted March 6, 2008. Accepted for publication June 21, 2008. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2008 AAGL All rights reserved. doi:10.1016/j.jmig.2008.06.011
Case Report A 15-year-old girl had chronic, progressively worsening dull pelvic pain and was given the diagnosis of a retrorectal tumor during her first gynecologic examination. Menarche started at 13 years and was regular. The family history was a noncontributor. The patient appeared to be normally developed. Abdominal sonography was performed during a gynecologic examination and showed a large signal-enhanced retrouterine tumor. Computed tomography showed an inhomogeneous well-demarcated presacral tumor that was 10 ! 8.5 ! 8 cm, which resulted in a displacement of the rectum and the uterus ventrally (Fig. 1). The tumor was encapsulated. A preoperative biopsy by aspiration was not done because a benign tumor was suggested. A chest radiograph was inconclusive for metastasis. For the operation, the patient was put in the supine position with legs extended. Pelvic examination indicated a tumor with a smooth surface starting 3 cm from the anal sphincter and filling the sacral cavity. After insufflation of carbon-dioxide gas through the umbilicus, a 10-mm trocar was placed and 2 accessory 5-mm trocars were then placed laterally 3 cm on each inside of the anterior superior iliac spine, and another 1-cm trocar was placed at the left midclavicular line at approximately 2 cm above the umbilical level. Inspection of the peritoneal cavity showed no lesions. The uterus and ovaries were normal and the rectum was displaced to the right anterior side. After transperitoneal identification of the left ureter and lateralization of the rectum and the
650
Journal of Minimally Invasive Gynecology, Vol 15, No 5, September/October 2008
muscle and the apex of coccyx, excision of the pedicel attached to the rectosacral Waldeyer fascia and the levator ani muscle was performed with a harmonic scalpel, and the tumor could then be mobilized in toto out of the sacral cavity. Using an Endobag, the tumor was removed through the left 1-cm port without contamination of the abdominal wall. Microscopic examination of the frozen section showed several characteristics of presacral teratomas. One Charriere 18F drain tube was placed into the sacral cavity and the pneumoperitoneum and the sheaths were removed. The operation lasted 3 hours and 5 minutes, with a blood loss of approximately 160 mL. Normal defecation and micturition resumed after 1 and 3 days, respectively, and the patient was discharged on day 5 postoperatively. Histopathologic examination of paraffin-embedded tissue using histochemical staining for hematoxylin-eosin confirmed presacral teratoma. Discussion
Fig. 1. Computed tomography of presacral teratomas. Axial (A) and coronal (B) sections, ‘‘A’’ indicates site of teratomas. Tumor is well delimited to surrounding tissue and pushes uterus and rectum ventrally.
left rectal pillar, the peritoneum was opened left laterally along the sacral-ligament at the level of S3/S4. After dissection of the right ureter and the internal iliac artery, and transaction of the left uterosacral ligament, the rectum was detached from the left anterior face of the sacral os sacrum (occipitosacral, OS) and the tumor. Then the tumor capsule was identified and incised in the midline and was carefully dissected free from the surrounding connective tissues. During the dissection, the tumor was opened. It appeared to contain a few hairs and some sebaceous material. First, suction of most sebaceous material was performed, which reduced the volume of the tumor. Then the retrorectal space was developed between the rectal fascia propria and the rectosacral Waldeyer fascia. The presacral teratoma was then meticulously mobilized, using either electrosurgical coagulation or the ultrasonic scalpel, from the pelvic side wall and adjacent organs. The tumor-feeding vessels and the branches of the left hypogastric nerve were easily identified, under laparoscopic vision, and the vessels were controlled by bipolar coagulation and the hypogastric nerve was preserved. Presacral venous plexus injury was avoided in the course of the presacral space dissection. The integrity of the rectum was observed by transanal examination, which was performed by an assistant. After reaching the levator ani
A variety of benign and malignant conditions have been successfully treated with this approach [5]. Laparoscopic resection of pelvic teratomas was first reported in 1995 [6]. Since then, 2 further case of presacral teratomas treated by laparoscopic surgery were reported [7,8]. With our experience of the laparoscopic approach to resection presacral retrorectal teratomas, the teratomas can be easily dissected from adjacent tissues, which make the laparoscopic resection possible. Laparoscopy might also greatly facilitate dissection as a result of magnification of the anatomic elements in the narrow pelvis. Several key operating procedures must be undertaken carefully and sequentially to ensure a successful outcome. First, the laparoscopic dissection of the tumor within the deep pelvis was performed precisely under direct vision. In the resection of the teratoma, mobilization of both the uterus and vagina, and the rectum, was necessary to resect the mass. Also, the use of sharp dissection instruments around the vital structures in the presacral space and near the rectum is essential to avoid inadvertent traumatic or electrosurgical coagulation injury. The adjacent important structures were safeguarded, and no intraoperative complication was encountered during the laparoscopic dissection in our patient. For very large benign lesions with mainly cystic elements, the intrapelvic laparoscopic dissection may be facilitated by decompressing the tumor through cyst fluid aspiration. Second, blood loss during resection of a retrorectal tumor may be considerable, especially with respect to dissection of the presacral space, which must proceed most carefully to avoid tearing the presacral fascia and the venous plexus. Therefore, careful dissection within the space between the rectal fascia and Waldeyer fascia helps to avoid puncture of large blood vessels and the ureter [9]. Third, preservation of the autonomous nerve supply to the bladder and rectum may be difficult. Postoperative complications after resection of retrorectal tumors are prevalent in up to 31% of cases [10], with problems related to bladder
Chen et al.
Presacral Teratoma Resection
function (up to 15%), incontinence for feces (7%), and dysesthesia (7%) [11]. A complete laparoscopic approach with !7 magnification allows anatomic dissection, coagulation of small vessels, and preservation of the autonomic nerve supply to the pelvic organs. Laparoscopy is a safe and efficient option for approaching benign pelvic tumors and might offer the added advantage of better visualization of structures as a result of the magnification of laparoscopic view, especially in narrow anatomic spaces. References 1. Albini SM, Benadiva CA, Haverly K, et al. Management of benign ovarian teratomas: laparoscopy compared with laparotomy. J Am Assoc Gynecol Laparosc. 1994;1:219–222. 2. Grundfest-Broniatowski S, Fazio V, Marks K, Levin H. Diagnosis and treatment of sacral and retrorectal tumors II. Chirurg. 1988;59:343–348. 3. Localio SA, Frances KC, Rossano PG. Abdominal resection of sacrococcygeal chordoma. Ann Surg. 1967;166:394.
651 4. Descazeaud A, Coggia M, Bourriez A, et al. Laparoscopic resection of a retroperitoneal schwannoma. Surg Endosc. 2003;17:520. 5. Caddedu MO, Mamazza J, Schlachta CM, et al. Laparoscopic excision of retroperitoneal tumors: technique and review of the laparoscopic experience. Surg Laparosc Endosc Percutan Tech. 2001;11:144–147. 6. Sharpe LA, Van Oppen DJ. Laparoscopic removal of a benign pelvic retroperitoneal dermoid cyst. J Am Assoc Gynecol Laparosc. 1995;2: 223–226. 7. Bax NM, van der Zee DC. The laparoscopic approach to sacrococcygeal teratomas. Surg Endosc. 2004;18:128–130. 8. Lukish JR, Powell DM. Laparoscopic ligation of the median sacral artery before resection of a sacrococcygeal teratomas. J Pediatr Surg. 2004;39:1288–1290. 9. Freier DT, Stanley YC, Thompson NW. Retrorectal tumors in adults. Surg Gynecol Obstet. 1971;132:681. 10. Lee RA, Symmonds RE. Presacral tumors in the female: clinical presentation, surgical management, and results. Obstet Gynecol. 1988;71: 216–221. 11. Jao S-W, Beart RW, Spencer RJ, Reiman HM, Ilstrup DM. Retrorectal tumors: Mayo Clinic experience, 1960–1979. Dis Colon Rectum. 1985; 28:644.
ABSTRACT Presacral and retrorectal space tumors are relatively rare lesions, the location of which can result in the onset of symptoms that are not well-defined. Retrorectal teratomas are resected to alleviate these symptoms and to rule out malignancy. Complete resection by one of the open abdominal or sacral approaches was traditionally advocated as the best treatment for either a benign or malignant presacral and retrorectal tumor. A 15-year-old girl had chronic, progressively worsening dull pelvic pain and was given the diagnosis of a retrorectal tumor during her first gynecologic examination. Computed tomography of the pelvis showed an encapsulated presacral and retrorectal tumor measuring 10 ! 8.5 ! 8 cm. The retrorectal teratoma was removed by laparoscopy. No complication was observed interoperation. In addition, no sensory or motoric dysfunction of the bladder or rectum was observed postoperatively. Laparoscopy can be used to surgically remove presacral teratomas. Journal of Minimally Invasive Gynecology (2008) 15, 649–651 Ó 2008 AAGL All rights reserved. Keywords:
Teratomas; Laparoscopic resection; Presacral; Retrorectal tumors
The role of laparoscopic surgery has expanded during the past decade to include surgery on most of the intraabdominal organs. Many laparoscopic procedures have resulted in decreased tissue trauma and accelerated postoperative recovery while accomplishing resection equivalent to that of open surgery [1]. Laparoscopic surgery for retroperitoneal lesions is now gaining momentum because of these same perceived advantages of the procedure. Presacral and retrorectal space tumors are relatively rare lesions. They appear in 1 of 40 000 patients referred to hospitals [2]. They may be malignant or benign. Imaging techniques, such as computed tomography or magnetic resonance imaging, allow the visualization of the tumor and delineation to adjacent structures but do not exclude the possibility of malignancy [2,3]. In addition, retroperitoneal cysts are resected to decrease the risk of intracystic hemorrhage. Complete resection, via one of the open abdominal or sacral approaches, was traditionally advocated as the best treatment of either a benign or malignant presacral tumor. Laparoscopy offers an attractive potential alternative, and is an equally effective approach in the management of benign presacral tumors [4]. The authors have no commercial, proprietary, or financial interest in the products or companies described in this article. Corresponding author: Zhiquing Liang, MD, PhD, Department of Obstetrics and Gynecology, Southwest Hospital, Chongqing 400038, China. E-mail: [email protected] Submitted March 6, 2008. Accepted for publication June 21, 2008. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2008 AAGL All rights reserved. doi:10.1016/j.jmig.2008.06.011
Case Report A 15-year-old girl had chronic, progressively worsening dull pelvic pain and was given the diagnosis of a retrorectal tumor during her first gynecologic examination. Menarche started at 13 years and was regular. The family history was a noncontributor. The patient appeared to be normally developed. Abdominal sonography was performed during a gynecologic examination and showed a large signal-enhanced retrouterine tumor. Computed tomography showed an inhomogeneous well-demarcated presacral tumor that was 10 ! 8.5 ! 8 cm, which resulted in a displacement of the rectum and the uterus ventrally (Fig. 1). The tumor was encapsulated. A preoperative biopsy by aspiration was not done because a benign tumor was suggested. A chest radiograph was inconclusive for metastasis. For the operation, the patient was put in the supine position with legs extended. Pelvic examination indicated a tumor with a smooth surface starting 3 cm from the anal sphincter and filling the sacral cavity. After insufflation of carbon-dioxide gas through the umbilicus, a 10-mm trocar was placed and 2 accessory 5-mm trocars were then placed laterally 3 cm on each inside of the anterior superior iliac spine, and another 1-cm trocar was placed at the left midclavicular line at approximately 2 cm above the umbilical level. Inspection of the peritoneal cavity showed no lesions. The uterus and ovaries were normal and the rectum was displaced to the right anterior side. After transperitoneal identification of the left ureter and lateralization of the rectum and the
650
Journal of Minimally Invasive Gynecology, Vol 15, No 5, September/October 2008
muscle and the apex of coccyx, excision of the pedicel attached to the rectosacral Waldeyer fascia and the levator ani muscle was performed with a harmonic scalpel, and the tumor could then be mobilized in toto out of the sacral cavity. Using an Endobag, the tumor was removed through the left 1-cm port without contamination of the abdominal wall. Microscopic examination of the frozen section showed several characteristics of presacral teratomas. One Charriere 18F drain tube was placed into the sacral cavity and the pneumoperitoneum and the sheaths were removed. The operation lasted 3 hours and 5 minutes, with a blood loss of approximately 160 mL. Normal defecation and micturition resumed after 1 and 3 days, respectively, and the patient was discharged on day 5 postoperatively. Histopathologic examination of paraffin-embedded tissue using histochemical staining for hematoxylin-eosin confirmed presacral teratoma. Discussion
Fig. 1. Computed tomography of presacral teratomas. Axial (A) and coronal (B) sections, ‘‘A’’ indicates site of teratomas. Tumor is well delimited to surrounding tissue and pushes uterus and rectum ventrally.
left rectal pillar, the peritoneum was opened left laterally along the sacral-ligament at the level of S3/S4. After dissection of the right ureter and the internal iliac artery, and transaction of the left uterosacral ligament, the rectum was detached from the left anterior face of the sacral os sacrum (occipitosacral, OS) and the tumor. Then the tumor capsule was identified and incised in the midline and was carefully dissected free from the surrounding connective tissues. During the dissection, the tumor was opened. It appeared to contain a few hairs and some sebaceous material. First, suction of most sebaceous material was performed, which reduced the volume of the tumor. Then the retrorectal space was developed between the rectal fascia propria and the rectosacral Waldeyer fascia. The presacral teratoma was then meticulously mobilized, using either electrosurgical coagulation or the ultrasonic scalpel, from the pelvic side wall and adjacent organs. The tumor-feeding vessels and the branches of the left hypogastric nerve were easily identified, under laparoscopic vision, and the vessels were controlled by bipolar coagulation and the hypogastric nerve was preserved. Presacral venous plexus injury was avoided in the course of the presacral space dissection. The integrity of the rectum was observed by transanal examination, which was performed by an assistant. After reaching the levator ani
A variety of benign and malignant conditions have been successfully treated with this approach [5]. Laparoscopic resection of pelvic teratomas was first reported in 1995 [6]. Since then, 2 further case of presacral teratomas treated by laparoscopic surgery were reported [7,8]. With our experience of the laparoscopic approach to resection presacral retrorectal teratomas, the teratomas can be easily dissected from adjacent tissues, which make the laparoscopic resection possible. Laparoscopy might also greatly facilitate dissection as a result of magnification of the anatomic elements in the narrow pelvis. Several key operating procedures must be undertaken carefully and sequentially to ensure a successful outcome. First, the laparoscopic dissection of the tumor within the deep pelvis was performed precisely under direct vision. In the resection of the teratoma, mobilization of both the uterus and vagina, and the rectum, was necessary to resect the mass. Also, the use of sharp dissection instruments around the vital structures in the presacral space and near the rectum is essential to avoid inadvertent traumatic or electrosurgical coagulation injury. The adjacent important structures were safeguarded, and no intraoperative complication was encountered during the laparoscopic dissection in our patient. For very large benign lesions with mainly cystic elements, the intrapelvic laparoscopic dissection may be facilitated by decompressing the tumor through cyst fluid aspiration. Second, blood loss during resection of a retrorectal tumor may be considerable, especially with respect to dissection of the presacral space, which must proceed most carefully to avoid tearing the presacral fascia and the venous plexus. Therefore, careful dissection within the space between the rectal fascia and Waldeyer fascia helps to avoid puncture of large blood vessels and the ureter [9]. Third, preservation of the autonomous nerve supply to the bladder and rectum may be difficult. Postoperative complications after resection of retrorectal tumors are prevalent in up to 31% of cases [10], with problems related to bladder
Chen et al.
Presacral Teratoma Resection
function (up to 15%), incontinence for feces (7%), and dysesthesia (7%) [11]. A complete laparoscopic approach with !7 magnification allows anatomic dissection, coagulation of small vessels, and preservation of the autonomic nerve supply to the pelvic organs. Laparoscopy is a safe and efficient option for approaching benign pelvic tumors and might offer the added advantage of better visualization of structures as a result of the magnification of laparoscopic view, especially in narrow anatomic spaces. References 1. Albini SM, Benadiva CA, Haverly K, et al. Management of benign ovarian teratomas: laparoscopy compared with laparotomy. J Am Assoc Gynecol Laparosc. 1994;1:219–222. 2. Grundfest-Broniatowski S, Fazio V, Marks K, Levin H. Diagnosis and treatment of sacral and retrorectal tumors II. Chirurg. 1988;59:343–348. 3. Localio SA, Frances KC, Rossano PG. Abdominal resection of sacrococcygeal chordoma. Ann Surg. 1967;166:394.
651 4. Descazeaud A, Coggia M, Bourriez A, et al. Laparoscopic resection of a retroperitoneal schwannoma. Surg Endosc. 2003;17:520. 5. Caddedu MO, Mamazza J, Schlachta CM, et al. Laparoscopic excision of retroperitoneal tumors: technique and review of the laparoscopic experience. Surg Laparosc Endosc Percutan Tech. 2001;11:144–147. 6. Sharpe LA, Van Oppen DJ. Laparoscopic removal of a benign pelvic retroperitoneal dermoid cyst. J Am Assoc Gynecol Laparosc. 1995;2: 223–226. 7. Bax NM, van der Zee DC. The laparoscopic approach to sacrococcygeal teratomas. Surg Endosc. 2004;18:128–130. 8. Lukish JR, Powell DM. Laparoscopic ligation of the median sacral artery before resection of a sacrococcygeal teratomas. J Pediatr Surg. 2004;39:1288–1290. 9. Freier DT, Stanley YC, Thompson NW. Retrorectal tumors in adults. Surg Gynecol Obstet. 1971;132:681. 10. Lee RA, Symmonds RE. Presacral tumors in the female: clinical presentation, surgical management, and results. Obstet Gynecol. 1988;71: 216–221. 11. Jao S-W, Beart RW, Spencer RJ, Reiman HM, Ilstrup DM. Retrorectal tumors: Mayo Clinic experience, 1960–1979. Dis Colon Rectum. 1985; 28:644.