Voluminous right pararectal lipoma: laparoscopic removal

The objective of this film is to present the potential laparoscopic approaches for a voluminous right pararectal lipoma partially overlapping the pelvic floor. The advantage of this approach is the magnification of anatomical images which allows to better preserve the nervous plexus, and especially to limit the risk of bacterial contamination as in perineal and/or transrectal approaches. The pelvic floor will be reinforced at the end of the intervention by a semi-absorbable composite prosthesis.

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Voluminous   right   pararectal   lipoma:   laparoscopic   removal   

Authors
J Leroy, S Mandala, J D'Agostino, A D'Urso, J Marescaux
Abstract
The objective of this film is to present the potential laparoscopic approaches for a voluminous right pararectal lipoma partially overlapping the pelvic floor. The advantage of this approach is the magnification of anatomical images which allows to better preserve the nervous plexus, and especially to limit the risk of bacterial contamination as in perineal and/or transrectal approaches. The pelvic floor will be reinforced at the end of the intervention by a semi-absorbable composite prosthesis.
Keywords
Voluminous right pararectal lipoma, laparoscopic removal
Media type
Duration
08'03''
Publication
2013-01
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Jan 2013;13(01).
URL: http://www.websurg.com/doi-vd01en3792.htm

Voluminous   right   pararectal   lipoma:   laparoscopic   removal   

1. Lateral rectal dissection through pelvic floor 00'10''
The objective of this film is to demonstrate the operative strategy for the removal of a voluminous right pararectal lipoma in a woman aged 60. As can be seen on the MRI, the patient presented with rectal wall compression and dyschezia. Once the right pararectal space and the posterior rectal region have been opened, the pelvic floor is reached. At this point, the superior surface of the lipoma can be detected. It is perfectly encapsulated. This lipoma can be progressively separated from the rectal wall. Traction is placed on the lipoma to approach it and another traction is exerted on the rectal wall in order to open the cleavage plane. The lipoma has developed through the pelvic floor as will be seen later on. The lipoma retracts the pelvic floor cephalad, and it is decided to open the musculo-aponeurotic plane in order to free the lipoma encapsulated in the pelvic floor. Monopolar scissors are used. A low voltage current is used in order to limit the risks of nerve injury that could well be induced by electric current diffusion. Dissection is continued one plane after the other by opening the dome of the capsule around the lipoma in a circular fashion as can be seen in these pictures. Attention must be paid to respect the capsule of the lipoma even if there seems to be no doubt as to the benign nature of the lipoma. The superior plane of the pelvic floor is then opened by excising a small piece of aponeurosis, which facilitates access to the plane in contact with the lipoma. As a result, enucleation of the lipoma is made easier as shown in these pictures. Here, traction is uneasy. Indeed, once the lipoma has been detached, it is morcellated partially. Consequently, it is decided to perform the procedure in two steps as the deepest part of the lipoma in contact with the internal aspect of the buttocks is deeply encapsulated in the muscular plane. Pressure is applied on the buttocks by the assistant situated between the patient’s legs in order to complete the dissection until the subcutaneous plane is reached, as will be shown soon. The Ligasure™ device used for hemostasis is very helpful at this moment as it allows for sealing without any major risk of collateral damage that could be induced by contact with nerve rami. In-depth dissection of the subcutaneous lipoma is completed. A division is performed by means of the Ligasure™ device. The pieces of the lipoma are placed in a plastic bag that will be extracted at the end of the intervention.