|Year : | Volume
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Laparoscopic approach for malignant retrorectal tumour: Better vision and lesser morbidity
Subbiah Shanmugam, RR Pravenkumar
Department of Surgical Oncology, Government Royapettah Hospital, Chennai, Tamil Nadu, India
|Date of Submission||01-Feb-2022|
|Date of Decision||01-Jun-2022|
|Date of Acceptance||11-Jun-2022|
|Date of Web Publication||20-Jul-2022|
Department of Surgical Oncology, Government Royapettah Hospital, Royapettah, Chennai - 600 014, Tamil Nadu
Source of Support: None, Conflict of Interest: None
The retrorectal tumours are removed by open approaches according to the type, location and size of the lesion. Malignant tumours are mostly operated by open approach owing to the fear of spillage and inability to obtain safe oncological margin. We present our recent experience of laparoscopy for a malignant retrorectal tumour. An 11 cm pre-sacral mass causing erosion of sacrum was operated with a combined approach. Transsacral approach followed laparoscopic mobilisation with the patient in prone jackknife position. Wide excision with sacrectomy was done with adequate margin. Post-operative histopathology showed dedifferentiated chordoma for which adjuvant radiotherapy was given. Laparoscopic approach provides a feasible and oncological safe alternative to the conventional approaches, especially in malignant tumour with advantages of better visualisation, minimal operative morbidity, lesser post-operative pain and shorter hospital stay. However, the surgical approach should be tailored to each patient according to patient factors, tumour characteristics and surgeon's expertise.
Keywords: Chordoma, laparoscopy, pre-sacral tumour, retrorectal, sacrectomy
| ¤ Introduction|| |
The retrorectal space is the location for a wide spectrum of rare tumours. It is a potential space that can accommodate large masses. These tumours are in proximity to multiple structures given the bony confines of the pelvis and its complex anatomy, thus making it a surgical challenge. This space contains tissues from different embryological origins. Its anatomical location justifies the possible difficulties in surgical approach. Conventionally, these tumours are removed by three possible approaches: the transsacrococcygeal (posterior) approach, the transabdominal (anterior) approach or the combined anterior–posterior approach, according to the type, location and size of the lesion. With better visualisation of anatomical structures, the pelvic nerves and sacral nerve roots can be preserved better by the laparoscopic approach. The use of laparoscopy in malignant tumours is not well established. We present our recent experience of laparoscopy (combined laparoscopic anterior–open posterior approach) for a case of malignant pre-sacral tumour.
| ¤ Case Report|| |
A 62-year-old male with symptoms of constipation and urinary obstruction was evaluated. Imaging showed an 11 cm mass in pre-sacral space [Figure 1] with erosion of sacrum and possibility of the lesion being malignant. Pre-operative biopsy was not considered to avoid tumour spillage. Traditional approach would have been open surgery. With our experience of operating benign pre-sacral tumours by laparoscopy, we decided to operate by combined anterior (laparoscopic)–posterior (open) approach. The ports were placed similar to any rectal surgery with the patient in modified Lloyd–Davies position. Pre-sacral space was entered after incising the lateral pelvic peritoneum, mobilising the rectum and opening the Waldeyer's fascia. The space created by pneumoperitoneum facilitated better vision in the confined pre-sacral space. A large tumour was found between the rectum and sacrum. Laparoscopic mobilisation of the mass was done by creating a plane between the mass and posterior rectal wall using harmonic dissection after careful preservation of the hypogastric plexus and pelvic splanchnic nerves. The size of the lesion and bleeding due to neovascularisation caused technical difficulty when mobilisation. With the help of an assistant holding the rectum away from the field by traction and judicious use of harmonic energy source, the tumour was separated from the rectum. The tumour was found adherent to the sacrum and hence proceeded with open transsacral approach by changing the patient to prone jackknife position. Wide excision with low sacrectomy was done with adequate margin and avoiding tumour spill [Figure 2]. The operative time was 180 minutes and intraoperative blood loss was 400 ml. Post-operative period was uneventful except for mild surgical site infection and the patient had well-preserved bladder and bowel functions and was discharged on the 5th post-operative day. Histopathology showed a dedifferentiated chordoma with resected margins free of tumour. Adjuvant radiotherapy was given due to dedifferentiated histology. The patient is on regular follow-up for a year and is healthy without any urinary, defecation problems or local recurrence.
| ¤ Discussion|| |
The advantage of unobstructed and magnified views in laparoscopy and being facilitated by the long instruments enables access to the entire scope of large tumours from the inlet of lesser pelvis to the subcutaneous layer of the coccygeal region, which can be hardly accomplished through neither laparotomy nor the posterior approach.
The laparoscopic approach has confuted the traditional Woodfield's algorithm that recommends a transabdominal approach for lesions above S3 and perineal route for lower lesions. The laparoscopic approach for these lesions was first described by Sharpe and Van Oppen in 1995, for the treatment of a benign retrorectal tumour. Laparoscopy has gradually found its way into the field of pelvic surgery, but scientific validation of this approach for retrorectal tumour has not reached a consensus. In literature, there are only limited number of studies and mostly case reports for benign cases. Laparoscopy leads to a better exposure of the operative field, enhances anatomical details, minimises the risk of inadvertent spillage of tumour and reduces blood loss and bowel manipulation. An extensive experience in laparoscopic rectal surgery is mandatory for a surgeon who decides to approach these lesions by laparoscopy.,
Literature shows that the lesion size can complicate the laparoscopic approach. As per literature, the size of the largest lesion removed laparoscopically is 11 cm. Although demonstrating potential advantages, the laparoscopic approach is generally indicated only for benign tumours. For malignant tumours, the validity of the laparoscopic approach has not been assessed. Case series/reports with laparoscopic-assisted resection of malignant retrorectal tumours have been scarce with one series reporting a single case of malignant tumour operated laparoscopically. We have successfully utilised laparoscopy, combining it with open approach for a malignant retrorectal tumour.
Major complications are neurological and accidental rectal wall opening that results in a rectal leak in late post-operative period. To avoid this, a careful technique, adequate traction and exposure of the rectum and digital intrarectal control during dissection are required. Rectal bougie is usually not required and has not been used in our case. Adequate training in rectal oncologic surgery is necessary, with the aim to preserve the hypogastric plexus and the integrity of the rectum. In our case, we had encountered similar difficulty especially due to large size of the lesion which was managed by adequate traction of the rectum. The neurological structures were better visualised and preserved leading to no anatomical or neurological morbidity following surgery. Histopathology showed dedifferentiated chordoma with resected margins free of tumour. Adjuvant radiotherapy was given due to dedifferentiated histology. The patient is on regular follow-up for a year and is healthy without any urinary/defecation problems or local recurrence.
The laparoscopic approach for pre-sacral tumours provides the benefits of precise surgical dissection, less trauma, less intraoperative blood loss, faster recovery and better cosmetic results as published by Zhou et al. Laparoscopy could provide a feasible and oncological safe alternative to the conventional approaches for large malignant retrorectal tumours. The surgical approach should be tailored to each patient according to patient factors (previous surgery), tumour characteristics (size, benign vs. malignant, suspicion of spillage) and surgeon's expertise. The role of robotic surgery with the additional help of robotic wrists in pelvic surgery needs to be explored further in surgery of retrorectal tumours.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]