Transanal minimally invasive surgery for resection of retrorectal cyst

Transanal minimally invasive surgery for resection of retrorectal cyst Tailgut cysts are benign retrorectal embryological remnants, often found incidentally or when evaluating a patient for pelvic symptoms. Transanal minimally invasive surgery (TAMIS) offers patients a low morbidity surgical approach for resection of a variety of low rectal lesions. This is a case report of resection of a tailgut cyst using TAMIS, including images and description of the steps of the procedure. INTRODUCTION CASE REPORT Tailgut cysts are rare presacral embryologic remnants, located in This is a case report describing the resection of a presacral cyst in the retrorectus space, and are often found incidentally. There is a a 23-year-old male patient. The cyst was discovered incidentally 3:1 female predominance. Though usually asymptomatic, retro- on CT scan of the abdomen and pelvis for evaluation of acute rectal lesions may cause symptoms of pain with defecation, pain appendicitis (Fig. 1). The patient denied pain, bleeding, or change in the deep pelvis or lower back, a sensation of fullness, bleeding in bowel habits. He had no neurologic changes. A follow-up MRI and rarely urinary symptoms. When symptomatic, these lesions was also performed (Fig. 2), and imaging was consistent with a are more concerning for malignancy. The majority of retrorectal congenital retrorectal cyst, with a tailgut cyst being favored. cysts are benign, but they do have the potential for malignant There was no evidence of bony involvement or invasion of other transformation, and therefore should be resected when found. structures (Figs 1 and 2). Traditionally, these have been resected using a posterior The lesion showed no radiographic signs of malignancy, parasacrococcygeal approach. More extensive lesions may require and was felt to be amenable to TAMIS resection. Preoperative an abdominal approach, or a combined abdominal and posterior preparation was done with a full mechanical and oral antibiotic approach. With the advent of transanal minimally invasive sur- bowel preparation. Preoperative parenteral antibiotics were gery (TAMIS), there is potential for a low morbidity, well-tolerated administered. Under general anesthesia, the patient was placed approach to resection. This is able to be accomplished using in lithotomy position, and the perianal region was anesthetized standard laparoscopic equipment, with transanal access. These prior to placement of a GelPOINT Path Transanal Access Platform considerations make TAMIS an appealing modality for resection (Applied Medical, Rancho Santa Margarita). The rectum was of clinically benign retrorectal cysts. then insufflated. Received: December 18, 2017. Accepted: February 1, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy021/4885385 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 R.H. McCarroll and L.J. Moore Figure 4: Enlargement of the proctotomy. The plane of dissection is visible Figure 1: CT pelvis image demonstrating a 7.0 cm retrorectal cyst. The rectum is (indicated by arrows), with the dome of the cyst seen at the bottom of the noted anterior to the cyst, and just to the right of midline. image. Figure 5: The dome of the cyst is visible at the bottom of the image (indicated Figure 2: MRI pelvis demonstrating the retrorectal cysts, again with the rectum by arrow), with a dissection plane visualized above. anterior and just to the right of midline. Figure 3: Opening of the posterior wall of the rectum, into the posterior perirec- tal space. Figure 6: Cavity of the resection site after cyst resection. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy021/4885385 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Transanal minimally invasive surgery for resection 3 After insufflation, the contour of the retrorectal cyst could DISCUSSION be seen distorting the posterior wall of the rectum. Using an Retrorectal cysts can lead to symptoms, and rarely harbor Harmonic Scalpel (Ethicon, Johnson and Johnson), a longitu- malignancy. When identified, these masses should be surgically dinal incision was made through the posterior midline of the excised. TAMIS allows for a minimally invasive approach to rectal wall, overlying the presacral cyst (Fig. 3) in doing so, the resection of tailgut cysts, and should be considered as an alterna- avascular plane surrounding the cyst was able to be exposed. tive to a posterior parasacrococcygeal approach, particularly for Once the dissection plane was entered, insufflation of the peri- clinically benign lesions. Potential benefits of a TAMIS approach rectal extraperitoneal space allowed for excellent exposure for a include minimal discomfort, decreased risk for sacral neurologic combination of blunt and Harmonic Scalpel dissection (Figs 4 and 5). injury, excellent exposure and visualization of the cephalad The cyst was completely liberated from all attachments using extent of the cyst, and no visible scar. In addition, as no rectal TAMIS, with the exception of the caudal extent. The caudal wall is excised, closure of the proctotomy is able to be accom- extent of the cyst was unable to be adequately visualized with plished without tension or ischemia. In sum, TAMIS allows for a the TAMIS platform. Therefore, the transanal port was removed, minimally invasive approach, with complete resection, decreased and the resection of the distal extent of the cyst was completed morbidity, and faster recovery and return to full activity. transanally. The mass was then extracted transanally (Fig. 6). The proctotomy was closed in a single layer with inter- rupted absorbable sutures. Following the procedure, the patient CONFLICT OF INTEREST STATEMENT was discharged home. Final histology showed a benign kerati- nizing cyst. His postoperative course was uneventful. None to disclose. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy021/4885385 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Transanal minimally invasive surgery for resection of retrorectal cyst

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Oxford University Press and JSCR Publishing Ltd
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Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018.
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10.1093/jscr/rjy021
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Abstract

Tailgut cysts are benign retrorectal embryological remnants, often found incidentally or when evaluating a patient for pelvic symptoms. Transanal minimally invasive surgery (TAMIS) offers patients a low morbidity surgical approach for resection of a variety of low rectal lesions. This is a case report of resection of a tailgut cyst using TAMIS, including images and description of the steps of the procedure. INTRODUCTION CASE REPORT Tailgut cysts are rare presacral embryologic remnants, located in This is a case report describing the resection of a presacral cyst in the retrorectus space, and are often found incidentally. There is a a 23-year-old male patient. The cyst was discovered incidentally 3:1 female predominance. Though usually asymptomatic, retro- on CT scan of the abdomen and pelvis for evaluation of acute rectal lesions may cause symptoms of pain with defecation, pain appendicitis (Fig. 1). The patient denied pain, bleeding, or change in the deep pelvis or lower back, a sensation of fullness, bleeding in bowel habits. He had no neurologic changes. A follow-up MRI and rarely urinary symptoms. When symptomatic, these lesions was also performed (Fig. 2), and imaging was consistent with a are more concerning for malignancy. The majority of retrorectal congenital retrorectal cyst, with a tailgut cyst being favored. cysts are benign, but they do have the potential for malignant There was no evidence of bony involvement or invasion of other transformation, and therefore should be resected when found. structures (Figs 1 and 2). Traditionally, these have been resected using a posterior The lesion showed no radiographic signs of malignancy, parasacrococcygeal approach. More extensive lesions may require and was felt to be amenable to TAMIS resection. Preoperative an abdominal approach, or a combined abdominal and posterior preparation was done with a full mechanical and oral antibiotic approach. With the advent of transanal minimally invasive sur- bowel preparation. Preoperative parenteral antibiotics were gery (TAMIS), there is potential for a low morbidity, well-tolerated administered. Under general anesthesia, the patient was placed approach to resection. This is able to be accomplished using in lithotomy position, and the perianal region was anesthetized standard laparoscopic equipment, with transanal access. These prior to placement of a GelPOINT Path Transanal Access Platform considerations make TAMIS an appealing modality for resection (Applied Medical, Rancho Santa Margarita). The rectum was of clinically benign retrorectal cysts. then insufflated. Received: December 18, 2017. Accepted: February 1, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy021/4885385 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 R.H. McCarroll and L.J. Moore Figure 4: Enlargement of the proctotomy. The plane of dissection is visible Figure 1: CT pelvis image demonstrating a 7.0 cm retrorectal cyst. The rectum is (indicated by arrows), with the dome of the cyst seen at the bottom of the noted anterior to the cyst, and just to the right of midline. image. Figure 5: The dome of the cyst is visible at the bottom of the image (indicated Figure 2: MRI pelvis demonstrating the retrorectal cysts, again with the rectum by arrow), with a dissection plane visualized above. anterior and just to the right of midline. Figure 3: Opening of the posterior wall of the rectum, into the posterior perirec- tal space. Figure 6: Cavity of the resection site after cyst resection. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy021/4885385 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Transanal minimally invasive surgery for resection 3 After insufflation, the contour of the retrorectal cyst could DISCUSSION be seen distorting the posterior wall of the rectum. Using an Retrorectal cysts can lead to symptoms, and rarely harbor Harmonic Scalpel (Ethicon, Johnson and Johnson), a longitu- malignancy. When identified, these masses should be surgically dinal incision was made through the posterior midline of the excised. TAMIS allows for a minimally invasive approach to rectal wall, overlying the presacral cyst (Fig. 3) in doing so, the resection of tailgut cysts, and should be considered as an alterna- avascular plane surrounding the cyst was able to be exposed. tive to a posterior parasacrococcygeal approach, particularly for Once the dissection plane was entered, insufflation of the peri- clinically benign lesions. Potential benefits of a TAMIS approach rectal extraperitoneal space allowed for excellent exposure for a include minimal discomfort, decreased risk for sacral neurologic combination of blunt and Harmonic Scalpel dissection (Figs 4 and 5). injury, excellent exposure and visualization of the cephalad The cyst was completely liberated from all attachments using extent of the cyst, and no visible scar. In addition, as no rectal TAMIS, with the exception of the caudal extent. The caudal wall is excised, closure of the proctotomy is able to be accom- extent of the cyst was unable to be adequately visualized with plished without tension or ischemia. In sum, TAMIS allows for a the TAMIS platform. Therefore, the transanal port was removed, minimally invasive approach, with complete resection, decreased and the resection of the distal extent of the cyst was completed morbidity, and faster recovery and return to full activity. transanally. The mass was then extracted transanally (Fig. 6). The proctotomy was closed in a single layer with inter- rupted absorbable sutures. Following the procedure, the patient CONFLICT OF INTEREST STATEMENT was discharged home. Final histology showed a benign kerati- nizing cyst. His postoperative course was uneventful. None to disclose. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy021/4885385 by Ed 'DeepDyve' Gillespie user on 16 March 2018

Journal

Journal of Surgical Case ReportsOxford University Press

Published: Feb 1, 2018

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