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Transperineal retro-anal resection of retro-rectal tumors
Journal of Visceral Surgery (2013) 150, 345—348
Available online at
ScienceDirect www.sciencedirect.com
SURGICAL TECHNIQUE
Transperineal retro-anal resection of retro-rectal tumors D. Moszkowicz , A. Valverde , H. Mosnier ∗ Service de chirurgie viscérale, groupe hospitalier Diaconesses-Croix-St-Simon, 125, rue d’Avron, 75020 Paris, France
KEYWORDS Epidermoid cyst; Perineum; Retro-rectal tumor
∗
Introduction Epidermoid cyst is the most common embryonically-derived cystic mass arising in the retrorectal space. The most common modes of excision are by a transabdominal laparoscopic or laparotomy approach (for superiorly situated cysts), a posterior trans-sacral Kraske-type approach (for large low-lying tumors or for suspicion of malignant disease), or a combination of these two approaches. However, the trans-sacral approach carries a risk of postoperative neuropathic pain. We propose a perineal approach for small low-situated tumors through a transverse retro-anal incision. A thorough imaging work-up must be performed to evaluate the morphologic characteristics of the tumor and rule out the likelihood of a malignant lesion (i.e. chordoma).
Corresponding author. E-mail address: [email protected] (H. Mosnier).
1878-7886/$ — see front matter © 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.jviscsurg.2013.09.012
346
D. Moszkowicz et al.
1
Anatomy of the presacral space and the posterior perineum
2
Patient position
The presacral space is bordered anteriorly by the subperitoneal rectum, posteriorly by the presacral fascia, laterally by the parietal leaflet of the pelvic fascia that covers the bony and muscular walls of the pelvic cavity, superiorly by the peritoneum of the pouch of Douglas, and inferiorly by the ano-coccygeal levator muscles that form the pelvic diaphragm. The posterior perineum (or anal perineum)consists of the ensemble of soft tissues lying below the levators, bordered anteriorly by the line joining the two ischial tuberosities (palpable in the genitofemoral fold) and posteriorly by the tip of the coccyx in the inter-gluteal fold. The structures within this space are identical in both males and females: the ischiorectal fossae are divided into supraand infra-levator portions by the pelvic diaphragm. Posterior to the anal canal, the coccygeal muscles, the posterior bundles of the pubo-rectalis sling, and the ilio-coccygeal muscles all insert into the ano-coccygeal ligament in the midline. A second muscular diaphragm, the deep transverse perineal muscle lies anterior to the rectum, stretching from the internal aspect of the ischial ramus to the central tendon of the perineum (perineal body); it is covered superiorly and inferiorly by the superior and inferior fascias of the urogenital diaphragm. It is sometimes reinforced by the superficial transverse perineal muscle, but this anatomy is not constant. The superficial perineal fascia overlies this entire area in the subcutaneous fat and continues anteriorly to join the superficial abdominal fascia.
The patient lies supine with the legs abducted and flexed in leg holders. The field is draped as for any proctologic procedure, with the legs in sterile leg drapes and the buttocks overhanging the end of the table. The surgeon and assistant sit between the legs with a small instrument table before them. A sterile betadine-soaked sponge masks the anus. A bladder catheter is not necessary.
Transperineal retro-anal resection of retro-rectal tumors
3a
Cutaneous incision
3b
Musculo-fascial incision
A horizontal incision is made halfway between the anus and the tip of the coccyx. The incisional length depends on the size of the tumor. Through this incision, the surgeon’s finger palpates the tip of the coccyx and opens the superficial perineal fascia layer with monopolar cautery along the same line as the skin incision.
Incision of the superficial perineal fascia exposes the ano-coccygeal ligament; this is incised vertically in the midline in order to gain access to the tumor lying in the ischio-rectal fossae. Care must be taken to avoid dissecting posterior to the coccyx.
347
348
D. Moszkowicz et al.
4
Tumor excision
5
Closure
Fibrous adhesions that are often tightly adherent to the rectal musculature are dissected free anteriorly and posteriorly to the tip of the coccyx. The cyst content is usually liquid. The cyst should therefore be simply pushed this way or that with sponge sticks while dissection is performed bluntly, rather than risking cyst rupture by the direct application of graspers or sharp instruments. If the size of the tumor demands a larger incisional approach, the tip of the coccyx can be resected. Danger: the dissection along the lateral aspects of the anal canal can result in injury to the sensory somatic innervation of the anal canal (anal nerve, pudendal nerve, perineal branches of the posterior femoro-cutaneous nerve), which may result in postoperative pain.
After tumor resection, the fibro-muscular layers are re-approximated in the midline in order to restore the ano-coccygeal ligament and reestablish the perineal compartment. A suction drain can be placed depending on the volume of the dead space cavity. A running intradermal skin closure using rapidly absorbable suture assures an optimal cosmetic result.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
Available online at
ScienceDirect www.sciencedirect.com
SURGICAL TECHNIQUE
Transperineal retro-anal resection of retro-rectal tumors D. Moszkowicz , A. Valverde , H. Mosnier ∗ Service de chirurgie viscérale, groupe hospitalier Diaconesses-Croix-St-Simon, 125, rue d’Avron, 75020 Paris, France
KEYWORDS Epidermoid cyst; Perineum; Retro-rectal tumor
∗
Introduction Epidermoid cyst is the most common embryonically-derived cystic mass arising in the retrorectal space. The most common modes of excision are by a transabdominal laparoscopic or laparotomy approach (for superiorly situated cysts), a posterior trans-sacral Kraske-type approach (for large low-lying tumors or for suspicion of malignant disease), or a combination of these two approaches. However, the trans-sacral approach carries a risk of postoperative neuropathic pain. We propose a perineal approach for small low-situated tumors through a transverse retro-anal incision. A thorough imaging work-up must be performed to evaluate the morphologic characteristics of the tumor and rule out the likelihood of a malignant lesion (i.e. chordoma).
Corresponding author. E-mail address: [email protected] (H. Mosnier).
1878-7886/$ — see front matter © 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.jviscsurg.2013.09.012
346
D. Moszkowicz et al.
1
Anatomy of the presacral space and the posterior perineum
2
Patient position
The presacral space is bordered anteriorly by the subperitoneal rectum, posteriorly by the presacral fascia, laterally by the parietal leaflet of the pelvic fascia that covers the bony and muscular walls of the pelvic cavity, superiorly by the peritoneum of the pouch of Douglas, and inferiorly by the ano-coccygeal levator muscles that form the pelvic diaphragm. The posterior perineum (or anal perineum)consists of the ensemble of soft tissues lying below the levators, bordered anteriorly by the line joining the two ischial tuberosities (palpable in the genitofemoral fold) and posteriorly by the tip of the coccyx in the inter-gluteal fold. The structures within this space are identical in both males and females: the ischiorectal fossae are divided into supraand infra-levator portions by the pelvic diaphragm. Posterior to the anal canal, the coccygeal muscles, the posterior bundles of the pubo-rectalis sling, and the ilio-coccygeal muscles all insert into the ano-coccygeal ligament in the midline. A second muscular diaphragm, the deep transverse perineal muscle lies anterior to the rectum, stretching from the internal aspect of the ischial ramus to the central tendon of the perineum (perineal body); it is covered superiorly and inferiorly by the superior and inferior fascias of the urogenital diaphragm. It is sometimes reinforced by the superficial transverse perineal muscle, but this anatomy is not constant. The superficial perineal fascia overlies this entire area in the subcutaneous fat and continues anteriorly to join the superficial abdominal fascia.
The patient lies supine with the legs abducted and flexed in leg holders. The field is draped as for any proctologic procedure, with the legs in sterile leg drapes and the buttocks overhanging the end of the table. The surgeon and assistant sit between the legs with a small instrument table before them. A sterile betadine-soaked sponge masks the anus. A bladder catheter is not necessary.
Transperineal retro-anal resection of retro-rectal tumors
3a
Cutaneous incision
3b
Musculo-fascial incision
A horizontal incision is made halfway between the anus and the tip of the coccyx. The incisional length depends on the size of the tumor. Through this incision, the surgeon’s finger palpates the tip of the coccyx and opens the superficial perineal fascia layer with monopolar cautery along the same line as the skin incision.
Incision of the superficial perineal fascia exposes the ano-coccygeal ligament; this is incised vertically in the midline in order to gain access to the tumor lying in the ischio-rectal fossae. Care must be taken to avoid dissecting posterior to the coccyx.
347
348
D. Moszkowicz et al.
4
Tumor excision
5
Closure
Fibrous adhesions that are often tightly adherent to the rectal musculature are dissected free anteriorly and posteriorly to the tip of the coccyx. The cyst content is usually liquid. The cyst should therefore be simply pushed this way or that with sponge sticks while dissection is performed bluntly, rather than risking cyst rupture by the direct application of graspers or sharp instruments. If the size of the tumor demands a larger incisional approach, the tip of the coccyx can be resected. Danger: the dissection along the lateral aspects of the anal canal can result in injury to the sensory somatic innervation of the anal canal (anal nerve, pudendal nerve, perineal branches of the posterior femoro-cutaneous nerve), which may result in postoperative pain.
After tumor resection, the fibro-muscular layers are re-approximated in the midline in order to restore the ano-coccygeal ligament and reestablish the perineal compartment. A suction drain can be placed depending on the volume of the dead space cavity. A running intradermal skin closure using rapidly absorbable suture assures an optimal cosmetic result.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.