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Laparoscopic management of a right lateral rectal cystic tumor in a 43-year-old female patient

Authors

Abstract

This video shows the surgical management of a patient with a lateral pararectal cystic tumour (benign) and explains the surgical approach to retrorectal tumours in general.

Mots-clés

lateral pararectal cystic tumor, retrorectal tumor

Type de vidéo

Durée

15'30''

Publication

2007-12

Popularité

Favoris

Audio

Sous-titres

E-publication

WeBSurg.com, Dec 2007;7(12).
URL: http://www.websurg.com/doi-vd01en2168.htm

Laparoscopic management of a right lateral rectal cystic tumor in a 43-year-old female patient

1. Patient history 00'15''

This video presents the case of a 43-year-old woman with a six-month history of intermittent abdominal pain. An ultrasound and a CT-scan had shown a retrouterine cyst in the right lateral position that neither looked like an endometriotic cyst nor a dermoid cyst. A subsequent MRI confirmed the lesion as being located lateral to the rectum on the right side and appeared benign. We begin the procedure by retracting the uterus in order to achieve an adequate exposure of the operative field. Using a straight needle, we suspend the uterus from the broad ligament on both sides. This allows instant access to the pelvis.

2. Procedure begins, exposure of operative field 01'26''

With the uterus now well suspended, the patient is moved to a steep Trendelenburg position and this allows the bowel loops to be decanted out of the pelvis into the upper abdomen. The peritoneum is now incised. The line of this is towards the pouch of Douglas in order to provide access to the retroperitoneal space, and particularly our focus here is on the right side of the rectum.

3. Commencement of dissection 01'57''

There are three main ways of gaining access to the retrorectal region. The perineal approach of Kraske involving coccygeal resection; the trans-anal resection: this is particularly useful if tumors are located within 4cm of the anal verge, and the anterior abdominal approach: this latter is performed either by open or by laparoscopy. The abdominal approach is recommended whenever tumors are located above S2. However, the literature is not clear upon the best way to approach lateral rectal tumors. In this case therefore, even though the tumor was located at the level of S3, we chose an abdominal approach because with laparoscopy the combination of optimal dissection and minimally invasive access would provide better results in such the case of such likely benign disease. The key point for our dissection is to have a bloodless operative field; traction and counter-traction of the tissues is very important to allow full respect of all the nervous plexuses.

4. Traction-counter traction 03'05''

As you can see, due to appropriate traction and counter-traction it is easy for us to find the correct plane for dissection and the procedure is performed throughout in a bloodless operative field. With regards to retro-rectal cancers, imaging by CT-scan and by magnetic resonance imaging will usually suggest the nature of the tumor. In this case, the appearances were not malignant. In addition, appropriate imaging will establish the relationship between surrounding anatomical structures and the pathology in question. In the absence of radiological appearances of malignancy, biopsy is not mandatory and wide excision without opening of the cystic wall will lead to good results. As we continue the operation, you can see that we have now reached one side of the tumor. Pressing upon the tumor reveals its consistency to be soft and easily depressible. At all times, we continue our plane of dissection close to the specimen in order to avoid any injury to the surrounding structures but without breaching the tumour’s capsule. Here you can see appropriate traction upon the lesion allows clean dissection around its edges. A swab is sometimes useful to protect the grasper’s tip and avoid injuring retracted tissues. Now the dissection has been sufficiently deep. You can see we have reached the pelvic floor. Again it is important to remark here that a bloodless operative field is fundamental to the safe performance of the operation. Finding the correct dissection plane allows the tumor to in effect be shelled out from the surrounding structures. You can see now that the tumor is almost entirely free.

5. Distal limit of dissection 08'14''

Placing the tumour under retraction from the pelvis allows hemostasis to be achieved using bipolar coagulation. On removal of the tumor, we confirm that there is no residual bleeding and we check for the integrity of the nervous plexuses. Postoperatively, we leave a drain in place and we close the peritoneum over with a continuous suture. You can see here a bloodless operative field. With hemostasis achieved, we close the peritoneum using a single continuous absorbable suture.

6. Dissection completed 09'20''

The tumour is placed in an endobag and extracted. The final pathology revealed it to be indeed a benign tumor whose origin was as a vestigial epidermoid cyst.

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