Benign retrorectal tumours: Contribution of laparoscopic approach

doi:10.4236/crcm.2013.27111

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Vol.2, No.7, 422-426 (2013) Case Reports in Clinical Medicine

http://dx.doi.org/10.4236/crcm.2013.27111

Benign retrorectal tumours: Contribution of

laparoscopic approach

Victor J. Ovejero-Gomez1*, M. V. Bermudez-Garcia2, L. Martin-Cuesta3, A. Güezmes4,

J. Villalba2, A. Ingelmo1, J. M. Bajo-Arenas2

1Department of Surgery, Hospital Sierrallana, Cantabria, Spain; *Correspondin g Author: [email protected]

2Department of Gynaecology, Hospital Sierrallana, Cantabria, Spain

3Department of Radiology, Hospital Sierrallana, Cantabria, Spain

4Department of Pathology, Hospital Sierrallana, Cantabria, Spain

Received 30 July 2013; revised 29 August 2013; accepted 9 September 2013

License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Introduction: Presacral tumours are extremely

rare entities as the asymptomatic retrorectal

mass, although its clinical presentation includes

infectious complications and signs of malignant

degeneration. Magnetic resonance imaging is

the most efficient imaging study for its diagno-

sis. The treatment of choi ce is complete surgical

excision and traditional approaches are mainly

through abdominal, posterior and perineal ap-

proach, depending on anatomical characteris-

tics of the lesion. Laparoscopic excision of

these retrorectal lesions has been reported in a

few cases. Patients and methods: We report two

cases of 38 and 24-year-old women who com-

plained of anorectal symptoms and were diag-

nosed as retrorectal tumour by imaging studies.

One of them was infected. Both cases were re-

sected by means of laparoscopic techniques.

There was no surgical complication and they

were discharged on the 3rd and 4th postoperative

day, respectively. Histopathologic findings re-

vealed benign cystic teratoma in both cases. A

fol l o w-u p a fter 3 6 m on th s sho wed no recurrence.

Our surgical endoscopic technique and a brief

review of perioperative cares are presented and

discussed. Discussion: Laparoscopic excision

could be indicated in selected retrorectal tu-

mours and a great surgeon’s resolve is always

required. A meticulous dissection must be per-

formed in order to identify and preserve vital

structures. It’s only absolute contraindications

seemed to be the suspicion of malignancy and

operative inexperience. Conclusions: The com-

plete laparoscopic removal of presacral lesions

is a responsible surgical procedure which offers

advantages from the sanitary and aesthetic

point of view. This new endoscopic indication

could be considered probably as a better tech-

nique than open approach in selected patients.

Keywords: Retrorectal; Tumour; Laparoscopy;

Surgical Technique

1. INTRODUCTION

Retrorectal tumours are rare entities with a low inci-

dence and usually have a congenital origin. They can be

a cystic or solid mass and are divided into benign, mostly,

and malignant masses [1].

The possibility of malignity is increased in younger

patients although a solid mass is a higher associated risk

factor.

Most cases are asymptomatic but its semeiology is re-

lated to presacral location, size and infection. Pain is the

most common symptom in adult patients [2] but diges-

tive and urinary disturbances and fistulas are possible.

The first diagnostic study should be focused on iden-

tifying the extraluminal nature of the lesion by an endo-

anal exploration. Magnetic resonance imaging is the ra-

diological study of choice, currently, because it offers

more information than CT scan about tumoral characters

and neighbouring anatomical structures [3,4]. Imaging

diagnosis is one of the main bases to elaborate a right

surgical planning.

The definitive diagnosis leads to a complete resection

of the lesion even though it was asymptomatic and sus-

picion of benignity. Preoperative biopsy is not recom-

mended [5] due to the risk of septic complications and

tumoral seeding.

We present our experience in two presacral masses

V. J. Ovejero-Gomez et al. / Case Reports in Clinical Medic ine 2 (2013) 422-426

423

managed by laparoscopic approach successfully. Addi-

tionally, we report our indications, criteria of selection

and details of the surgical technique.

2. PATIENTS AND METHODS

Case report 1: A 38-year-old female was attended as

an outpatient complaining of rectal tenesmus of one

month’s duration and pruritus on external genital organs

with right-sided perineal swell i ng.

On examination, she had tenderness in hypogastrium

with no guardin g. A combined rectal-vaginal exploration

revealed an extraneous compression by a well-delimi-

tated soft tumour of large size on presacral space and

reached the promontory.

An abdominal ultrasonograph showed a pelvic homo-

geneous lesion measuring 6 centimetres on its maximum

diameter and independent of genital structures. A com-

puted tomography scan of the pelvis (Figure 1) was in-

formed of an encapsulated cystic tumour with fatty den-

sity and a partial calcification in its outer wall which was

located on right pararectal space and displaced uterus

and rectum into the left side without infiltrating them.

A laparoscopic approach was planned and she under-

went a removal of a subperitoneal cystic mass on Doug-

las pouch. Peritoneum was sectioned and presacral space

dissected in a careful and meticulous way in order not to

damage nearing anatomical structures.

There was not any post-operative complication and

histopathological finding (Figure 2) was informed of

benign cystic teratoma. She left the hospital on the third

(a) (b)

Figure 1. Computed tomography scan of the pelvis showing a presacral tumour with its anatomical rela-

tionships (a) on a right pararectal location and an important encapsulated cystic component (b) displacing

but not infiltrating rectum.

(a)

(b)

Figure 2. Histological sample revealed a cystic structure with a keratinous

squamous epithelium and plenty of pilosebaceous complexes (a). Several smooth

muscular cells can be seen on subepithelium (b).

V. J. Ovejero-Gomez et al. / Case Reports in Clinical Medicine 2 (2013) 422-426

424

day after surgical operation. Nowadays, she feels asymp-

tomatic and without evidence of recurrent lesion.

Case report 2: A 24-year-old female without a past

medical history was referred to our hospital suffering

from anal pain and fever of one week’ s duration.

She suffered from a very painful spasmus in internal

sphinter during rectal examination. A fistulous orifice

was seen on posterior anal commissure.

She underwent proctological exploration under anes-

thesic effects and a great deal of pilous pus was drained

through fistulous tract. An extraluminal mass was palpa-

ble on posterior wall of the rectum.

We suspected a presacral abscess and the diagnosis

was completed by a magnetic resonance imaging of the

pelvis which showed a large presacral dermoid cyst wi-

thout infiltrating an y pelvic structure.

A laparoscopic complete excision of the retrorectal

mass was performed although a combined perineal ap-

proach was necessary due to the fistulous connection be-

tween the tumour and the perineum.

Histologically, the suspected dermoid cyst was con-

firmed. The patient was discharged on 4th post-operative

day without any complicatio ns. There are no signs of re-

currence currently.

The patients were initially placed in the supine posi-

tion with both arms tucked against the sides. Pneumop-

eritoneum was achieved by Hasson’s trocar in both pa-

tients and the peritoneal cav ity was insufflated to a man-

tained pressure of 12 mmHg. The access to the pelvis

was facilitated by placing our patients in the Trendelen-

burg position in order that the viscera fell away from

there. Additionally, her legs were separated for an even-

tual perineal approach.

The television monitor was placed at the patient’s legs,

near her feet, the operating surgeon on the left or right

upper limb according to the anatomical conditions of the

tumour. We prefer both upper limbs stay stretched to

avoid iatrogenic nerve lesions on brachial plexus. The

instrumental nurse stood by the operating surgeon and

the assistant surgeon at the contralateral upper limb of

the patient.

The abdominal access was performed through four

trocar sites: A Hasson’s 10 mm-port was placed either in

the umbilicus or immediately above it to achieve pneu-

moperitoneum and insert a 0˚-laparoscope, although it

was useful a 30˚-optic in the second patient too. Another

10 mm-port for dissection, cutting, electrocautery or ul-

trasonic instruments; located at the midclavicular line on

the same operating surgeon’s flank. Two 5 mm-trocars,

one of them alined with the port before for tissue-grasp-

ing forceps and the other one at the contralateral flank

for assistant surgeon, who will be responsible fo r another

tissue-grasping forceps (Figure 3).

The surgical technique consisted of an overall explo-

Figure 3. Drawing shows one of the possible laparoscopic

setups and the trocar placement for removal of presacral mass:

The operating surgeon (c) usually stands on the side contralat-

eral to the lesion, depending on his preference, with a nurse (i)

on the ipsilateral side. The assistant surgeon (a) stands op-

posite the first surgeon. The laparoscope is inserted through the

umbilical port. Two additional trocars, 10 and 5 mm, are placed

in the midclavicular line on the operating surgeon’s side and a

third trocar, 5 mm, should be located in the contralateral side to

the first surgeon.

ration of the abdominal cavity. It was used to find the

presacral lesion displacing the rectum anteriorly. We

consider that it is not essential to descompress the mass

although it could improve the technical performance. We

started the dissection by incising peritoneal surface near

the lesion using scissors. Th e ultrasonic shears were very

useful for controlling haemostasia. The laparoscopic pel-

vic dissection could carry on anal elevator muscle easily

when there is a perineal extension of the tumour, com-

pleting its excision by perineal approach.

The excised tumour will be placed in an endobag and

delivered out through a short McBurney’s incision on

left iliac fossa profiting by 5 mm-port.

A sucking drain tube, anchored in the right abdominal

flank, was placed in the pelvis for two or three days ac-

cording to the characteristics of the drainage.

Total operating times were 115 and 165 minutes, re-

spectively. The second patien t was transfused one unit of

whole blood in the early post-operative. Oral diet was

allowed on the first postoperative day with no incidences.

They were discharged asymptomatic and their bowel

motions recovered. The healing of the wounds were

watched by their general practitioner and the first follow-

up was one month after discharge but a magnetic reso-

nance imaging isn’t requested until six months after sur-

gical resection.

3. DISCUSSION

Presacral space consists of soft connective tissue and

is limited by sacral anterior surface, rectal posterior wall,

anal elevator muscle, iliac vessels and ureters.

Retrorectal tumours could be divided into inflamma-

tory, congenital cysts, osseous and neurogenic lesions [6].

V. J. Ovejero-Gomez et al. / Case Reports in Clinical Medic ine 2 (2013) 422-426

425

Miscellanea with leiomyoma, fibroma, lipoma, lympho-

ma and metastasic and carcinoid tumours are also in-

cluded in this location.

They can be asymptomatic for a long time but could

cause semeiology due to the pressure effect such as the

perineal swelling or infectious complications as perineal

and rectal fistula, some of them shown in our reported

cases. Another possibility is its malignant degeneration

[7] which would modify the operating attitude.

There is not any standard guidelines in the manage-

ment of these tumours due to its low incidence and there

has been described several surgical procedures depend-

ing on both complications and anatomical conditio ns [8].

The traditional surgical approaches are via the perineal,

posterior, abdominal and combined via, depending on

location and size lesion [9]. The surgical outcome is

good in benign tumours. There has been reported a com-

plete resection in all cases of benign tumours and most of

malignant cases with a little rate of postoperative com-

plications [ 10] .

The transanal approach or through intersphincterial

resection [11] could be indicated in patients with benign

tumours of small size and distal presacral location. One

of the less injurious posterior accesses is via the para-

sacrococcygeal because it provides with an excellent an-

orectal exposure and preservation of the sphincterial me-

chanism. Its indication would be preserved to the rest of

low tumours.

Abdominal approach is the access of choice in large

size tumours which exceed the promontory and in suspi-

cion of malignancy, a lot of them improving with a com-

bined approach because of their size and anatomical dis-

posal. Besides, it allows a better vascular and ureteral

check.

The development of laparoscopic technique has pro-

moted an increased usefulness in this kind of pathology

recently [9,12]. Some of the advantages of this approach

are the exact identification of anatomical situation of the

mass and its relationship to other adjoining structures,

and the possibility of extending rectal dissection to anal

elevator musculature with a small assumed morbility

with respect to an open procedure. The pathological cha-

racteristics of the lesion or its perineal implication could

force a combined access as in the second case.

The performance of this kind of minimal aggressive

procedure could be difficult because of technical com-

plexity and local conditions of the tumours which de-

mand a surgical team with a huge experience in laparo-

scopic technique. A conversion to laparotomy is an op-

tion to be taken into account.

This inconvenience is explained by a plane of tumoral

dissection difficult to identify and the thickness of wall

which determines a meticulous resection in a highly sus-

ceptible bleeding area. We advise the practice of ultra-

sonic instruments [13] because these masses are used to

feed by a rich diffuse network of vessels. On the other

hand, the surgical management consists of complete re-

section with included wall to avoid a recurrence even

though a cystic mass of large size could be a candidate to

decompress without spillage piercing abdominal wall,

with a sucking tube placed into the lesion until it col-

lapses.

This strategy makes its manipulation easy and reduces

the risk of septic widespread in the pelvic cavity in case

of rupture.

These local difficulties in identifying neighbourghing

anatomical structures can cause the removal to become

complicated. We consider the vital importance of identi-

fying and preserving urinary bladder and ureters, pelvic

vessels and hypogas tri c nerves.

In our own opinion, the current only absolute contra-

indication in the laparo scopic approach would be a clini-

cal suspicion of malignancy. An infested mass should be

considered as a relative contraindication in this therapeu -

tic attitude.

In conclusion, the laparoscopic approach in retrorectal

tumours could be a safe and feasible surgical access from

the technical point of view and with the same criteria of

removal and curing as traditional open resection [14].

Furthermore, its main advantages are an earlier oral tol-

erance, a short hospital stay, a low incidence of post-op-

erative complications, less pain and excellent cosmesis.

Before confirming the indication of this operating ap-

proach, it is required putting the test patience and re-

solve to the surgical team who must hold a high experi-

ence in minimally aggressive techniques.

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