Voluminous right pararectal lipoma: laparoscopic removal

  • 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.
  • 00'10" Lateral rectal dissection through pelvic floor
    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.
  • 05'12" Pelvic floor repair
    The current problem one is faced with is the poor condition of the pelvic floor in a lateral rectal position. In order to prevent pararectal herniation, it is decided to reinforce the pelvic floor at the level of the aponeurosis was excised. To do so, a biocompatible mesh made of polypropylene and PLLA is used. It will allow for a simple application as the mesh is semi-rigid, and later on, reinforcement by means of a lightweight mesh after resorption of the absorbable PLLA component. The mesh is fixed to adjacent tissues and to the aponeurosis by means of Ethibond® stitches. The anterior mesh fixation is achieved on the rectal wall and on surrounding tissues. The posterior mesh fixation will be completed by a stitch placed on the aponeurosis.
  • 06'38" End of procedure
    Closure of the peritoneum is the next step. To do so, a V-Loc™ wound closure device is used, allowing for closure without any knot-tying. Closure is achieved easily. Fixation is effective. Closure is easily made without knots. At 3 months, functional and anatomical results are excellent as can be seen on the CT-scan image with a nice view of the pelvic floor repair.
  • Related medias
    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.