Surgical treatment of perirectal teratoid neoplasms (presacral cysts)
Tumours of perirectal space (presacral cysts)are in most cases congenital.There are epidermoid, dermoid cysts among them, teratomas and teratocarcinomas.
Epidermoid cyst is usually covered inside by multilayered squamous epithelium, though sometimes cylindric or transitional epithelium is met. Most frequently they are present in young women and can put obstacles during delivery. Presacral cysts have poor blood supply, that is why they have predisposition to necrosis and getting infected.
Chordoma is the kind of embryo remnants of the dorsal cord. These formations are met in patients, aged 60-70; they are manifested by pain that is localized in the sacral area. Pain is often of irradiating kind, is accompanied by paresthesia and disturbance of innervation by a sphincter of the urinary bladder and rectum. A patient can have complaints during several years.
Teratoma is a combined tumour, arising from remnants of three embryo leaves.
DIAGNOSTICS of presacral cysts and tumours
Diagnostics of presacral cysts and tumours are done on the basis of physical examination ( palpation of perineum, finger examination of rectum, bimanual investigation), X-ray investigation, USI, MRT (the size 2 cm and more). They sometimes make up a wrong diagnosis: pararectal fistula or pylonidal cyst of the sacral bone.
Treatment of presacral cysts and tumours of perirectal space
All the formations, innumerated above, are of perirectal space. They should be compulsory removed as they cause a lot of complications:
- frequent purulent processes of pararectal fat;
- purulent fistulas are formed;
- pain;
- neuritis and neuralgia;
- proctitis;
- tenesmus;
- disturbance of urination;
- anemia;
- malignant degeneration.
Surgical treatment of perirectal teratoid neoplasms (presacral cysts). Laparoscopic access.
- The main thing
- Coloproctology
- Presacral cysts and tumours
- The author’s techniques
My personal experience of treatment of presacral cysts started in 1995. There are more than 80 follows-up of patients with the positive results. All operations have been planned in advance, some of them have had complicated cysts with fistulas.
Indications to perform on operations for presacral cysts and tumours
Indication to operation is the presence of teratoid neoplasm (presacral cyst), even in case of absence of clinical symptoms, as very often purulent complications develop and malignant degeneration of teratoma takes place.
Kinds of accesses in surgical treatment of presacral cysts and tumours:
- laparoscopic access;
- perineal access;
- transanal access;
- transvaginal access.
For the correct choice of the operation method it is necessary to forward me the total description of USI of the organs of small pelvis, to mention your age and the main complaints. Then I will be able to give you an exact answer to your question. My e-mail is as follows: puchkovkv@mail.ru puchkovkv@mail.ru 
Among all the accesses the most contemporary access is a laparoscopic one as it is less traumatic, has good cosmetic effect and better results.
Laparoscopy in treatment of presacral cysts
A lot of advantages of laparoscopic techniques that have been testified by numerous investigations (decrease of traumas during operations, reducing of intra- and postoperational complications, decrease of hospital-stay and inability to work, reduction of postoperational lethal outcome) have given a possibility to introduce them in various fields of surgery.
Rapid development of miniinvasive techniques nowadays and their use in treatment of benign diseases of the large intestine (presacral cysts and tumours) have made us to have a new approach to solve this problem.
The advantages of the laparoscopic access (using punctures on the abdominal wall):
- Minimum traumas, operation is performed on fast and without blood loss;
- Operation is performed on without long incisions on perineum, resection of sacral bone and exteriorization of stoma;
- In women the natural process of pregnancy and delivery is not disturbed, but it becomes problematic in case of perineal access;
- Maximum fast period of recovery: a person can get up and sit the next day after operation, he leaves the clinic in 3 days (and possibility of active mode of life is preserved);
- There is minimum risk of injuring of rectum, sphincter and development of cyst relapse;
- This technique permits to perform on simultaneous operations for different diseases of organs of the abdominal cavity and small pelvis (uterus, appendages, gall bladder, etc).
Fig. 1. The scheme of positioning of the operation team and points of troacar
introduction.
Fig. 2. A giant presacral teratoma. The way it looks like during laparoscopy. 
Fig. 3. The final view of stitched pelvic abdomen. The anatomy of the organs of
small pelvis is totally restored.
The technique of removal of presacral teratomas laparoscopically.
Operation is performed on, using general anesthesia. A patient is in a supinal position. The scheme of positioning of operation team and points of troacars introduction are presented below at fig. 1.
During laparoscopic operation the intestine is moved to the left. While working, we always use the uterine retractor; it gives us a possibility to visualize properly retrouterine space. Uterus fixing by a retractor in ante-flexio position and traction of rectum give us a possibility to obtain a dosed stretching of tissues, necessary for safe work in pararectal space. The abdomen of small pelvis is opened, and the upper pole of cyst is visible. In case, if the sizes of cyst are considerable (7 cm and more), it is better to aspirate the contents of the cyst to get necessary stretching of tissues. After evacuation of cyst contents by an ejector, there is a possibility of its traction. Now we have necessary stretching of tissues for dissection. But when a cyst is filled with fluid, it is not possible to stretch it. In order to prevent injury of intestine wall of rectum, we insert elaborated by us a probe with an expanding cuff. Exposure of cystic walls from the surrounding tissues is done by means of a 5 mm “LigaSure” instrument, that is connected with the electrosurgical block with the computer guidance-energetic platform Force Triad (Switzerland).This instrument has no lateral spreading of heat. It is a safe prophilaxis of the thermal trauma of intestine and exteriorization of intestinal stoma during operation. If an intestine is located very low, in the area of levators or external portion of sphincter of rectum, it is necessary to separate muscular fibers, not to transect them in order not to disturb the function of anorectal zone. It is necessary to find the point of fixation of cyst to the sacral bone and, if possible, maximum to dissect that zone-it is the kind of prophilaxis of tumour relapse. If there was a purulent process with formation of external pararectal fistulas, we should do dissection of fistula up to the wall of a cyst. The cavity that is formed in the small pelvis is carefully washed, hemostasis is done, and draining is done in case of need. Pelvic abdomen is hermetically stitched, using a continuous suture. After removal a cyst is placed into a special plastic container and is removed from the abdominal cavity via troacar port. Cosmetic suture is placed on the skin.
It is necessary to mention that laparoscopic access should be used for removal of big. Teratomas, and if they are located far from the perineum. The alternative to laparoscopy is laparotomy that has worse exposition of surgical site and is traumatic.
Recovery after laparoscopic operation
After laparoscopic operations 3-4 incisions, having the length 5-10 mm, are left. Starting from the first day after operation, patients get up and take thin food. They leave clinic in 3-4 days.
After laparoscopic removal of presacral cyst it is necessary for a proctologist to follow-up the patient, USI should be done in 1, 3, 6 months.
An ability to work is restored in 12-21 days after operation.
Thus, my experience testifies that the surgical treatment of big presacral cysts is often accompanied by serious technical difficulties due to the fact that an access is limited, and there is a high rate of traumas. The worthy option to traditional laparotomic and perineal accesses is laparoscopy that has advantages in treatment of non-complicated teratomas due to an adequate visualization and less traumas.
