Laparoscopic Approach to Type IV Sacrococcygeal Teratoma in an Adult

Abstract

Presacral teratoma is extremely rare in adults. A 35-year-old lady was diagnosed with presacral teratoma on MRI abdomen and pelvis. The tumour was enucleated laparoscopically, this being the first such case to be reported in India and fifth case in world literature. Though traditionally, anterior approach of the presacral tumours meant laparotomy, but recently, laparoscopy has been reported as a safe and effective option for these tumours with the advantages of a magnified view in the narrow pelvis, easier development of natural planes by pneumoperitoneum, faster recovery and less complications if expertise is available.Keywords Presacral teratoma in adult . MRI . Laparoscopic removal . Advantage Sacrococcygeal teratoma in adults occurs at a rate between 1 in 40,000 and 63,000 with a female preponderance of 3:1 [1]. According to Altman Classification, they are of four types: type I tumours are predominantly external; type II are predominantly external but have a small but intrapelvic component; type III are predominantly intrapelvic, with a small external mass; and type IV tumours are entirely internal, otherwise known as retrorectal or presacral teratoma. Type IV tumours are excised by posterior (perineal), anterior (abdominal) or combined approach. Laparoscopic management of such cases is a new addition in surgical armamentarium. Very few cases have been reported to be successful in this endeavour. Case ReportA 35-year-old lady presented with dull aching pain in the lower abdomen. On per rectal examination, lower part of a tense cystic mass was palpated which was nontender and had restricted mobility; rectal mucosa was not involved. There was no evidence of neurologic involvement. Transvaginal sonography followed by MRI abdomen and pelvis showed "well defined lesion of about 6.7X4.4X4.7cm size, in presacral space extending inferiorly posterior to the anal canal. It appeared hypointense on T1 weighted imaging with multiple calcific foci and hyperintense in T2 weighted images. There was no evidence of post contrast enhancement of the lesion, involvement of adjacent structures or intraspinal extension (Fig. 1)." Serum tumour markers, including human chorionic gonadotropin, alpha-fetoprotein, carcinoembryonic antigen, lactate dehydrogenase and CA 125 were in normal range. The patient was taken up for laparoscopic excision based on clinical and radiological findings. In brief, the patient was placed in the modified lithotomy position. Access was gained with a 10-mm supraumbilical port followed by two 5-mm ports in the left and right lower quadrant 2 cm medial and above the anterior superior iliac spine and another 5-mm port 1 cm lateral to midline at the same level. The abdomen was insufflated to a pressure of 12 mmHg with CO2. Uterus was anteverted and deviated to the right with a vaginal manipulator and the rectum was deviated to the right side with a rectal probe. The mesorectal dissection from the sacral promontory was continued up to the level of the levator ani muscles keeping medial to the left uret...

Adult sacrococcygeal teratoma excised by endoscopic surgery with a transsacral approach: a case report

“…Although there are no clear selection criteria, the transsacral approach is considered to be a good option for tumors with a diameter of 10 cm or less and localization below the third sacral vertebra (S3) [2,8]. Recent reports have documented that some SCTs can be safely excised laparoscopically, but in all cases, the transabdominal approach was applied [7,[9][10][11]. To the best of our knowledge, this is the first case report of a successful excision of an SCT by endoscopic surgery using a transsacral approach.…”

A Giant Sacrococcygeal Teratoma in an Adult Male: A Case Report

“…SCT is rare in adults with a few published case reports and series with a lack of information on its incidence in the general population. Adult SCT tends to occur more frequently in females with a female to male ratio of 4-10:1 [ 4 ].…”

“…Pathologically SCT is categorized as Mature (well-differentiated) benign Teratoma and immature (poorly differentiated) Teratoma with malignant potential. The incidence of malignant transformation of adult teratomas is much lower in contrast to infantile type with an incidence of about 1-2% [ 4 ].…”

Surgical management for a huge presacral teratoma and a meningocele in an adult with Currarino triad: a case report

“…The partial defect of the sacrum, as in our case, also favors the posterior approach. Though there are some reports of laparoscopic en bloc resection of teratoma [ 7 , 8 ], rupture of the wall or aspiration of the contents during resection was also reported [ 9 , 10 ]. Rupture of the free peritoneal cavity should be avoided as occasionally the presacral teratoma in Currarino syndrome is malignant [ 11 , 12 ].…”