Laparoscopic Excision of Retroperitoneal Schwannoma

Abstract

A 30-year-old male presented at our hospital with pain in the front of the right thigh, for which he had undergone a series of investigations by the neurologists. MRI showed a large lump within the right psoas muscle, in close relationship to L2 nerve root, and at a level that was 2cm below the lower pole of the right kidney. There were areas of degeneration in the central aspect of the tumour, which showed medial intracanalicular extension along the root of L2. The radiological appearance was highly suggestive of schwannoma with an extension to L2 nerve root. The anatomical position of the schwannoma was intra-psoas. After detailed discussion with the patient about a possible need of open surgery and probability of injury to the lumbar sacral plexus in close relation to the tumour, we proceeded with laparoscopic surgery technique Patient was placed in supine position with legs split, surgeon stood between the legs of the patient and the camera person was to the left side of the surgeon, first assistant to the right side. We decided to proceed with an intraperitoneal approach to the retroperitoneum, with medial colonic reflection. Initially it was accessed through the suprapubic port with the left hand working port in the right iliac fossa and the right hand working port in the left iliac fossa, augmented by a 10mm port through the umbilicus that was used initially for right hand working, and was later used for the telescope.Initially the terminal ileum, the appendix, and the caecum were mobilized and lifted off the retroperitoneum. Then the port in the left iliac fossa was used to grasp these structures and reflect them medially and right hand working port through the umbilicus was used to continue the right paracolic dissection upto to the hepatic flexure and then to turn medially in order to expose the complete retroperitoneum [Table/ Fig-2].The anterior surface of the Gerota's fascia was completely exposed upto the level of the adrenal gland. The right ureter was identified and traced throughout its course [Table/ Fig-3].Progressive medial mobilization of the right colon allowed us to identify and preserve the duodenum and the complete Inferia Vena Cava (IVC). At this stage the psoas and the ilio-psoas tendon were both seen clearly. By correlation with the MRI we were able to then do a psoas split (a longitudinal 5cm muscle split of the psoas major lateral to genito-femoral nerve which was identified and preserved).Wide longitudinal splitting of psoas major helps to expose the anterior surface of the capsule of the tumour [Table /Fig-4]. By careful dissection just outside the capsule, and by coagulating and dividing all the feeding vessels to and from the tumour, a plane was developed all around. We found the suture traction technique to be useful, and would like to recommend it too. Sutures were taken on the capsule of the tumour with 2-0 polypropolene which were held with the needle holder for retraction to expose further the surface and edges of the tumour [Table /Fig-5].The medial dissection was kept to...

Hemorrhagic, calcified, and ossified benign retroperitoneal schwannoma

“…[23] In the present case, by laparotomy, we found the mass located in the retroperitoneum and a complete resection of the tumor was performed. After surgery, the prognosis of the patient is generally good.…”

“…Antoni B areas of schwannomas appear cystic and multiseptated and show low density because of loose stroma and low cellularity. [23] On contrast-enhanced CT, well-enhanced areas correspond to Antoni A because of the increased vascularity and unenhanced areas correspond to Antoni B because of less vascularity. [19,24] Typical MRI findings of schwannomas show hypointense on T1-weighted images and inhomogeneous hyperintense on T2-weighted images.…”

Retroperitoneal schwannoma: an unusual cause of abdominal distention

“…Surgical resection is the optimal treatment for retroperitoneal schwannomas 3. Preoperative diagnosis is challenging and a definitive diagnosis can only be made postoperatively by histopathological and immunohistochemical analyses of surgical specimens.…”

Laparoscopic Resection of Retroperitoneal Presacral Schwannoma: A Case Report

“…Schwannomas (that is, tumors formed by Schwann cells) are very rare, and only 0.3 to 3.2% of them are malignant. Schwannomas are usually located in the head or spine, 1,2 and only $ 3 to 3.2% can be found in presacral regions. 3 The retroperitoneal presacral region is where uterine growth occurs during pregnancy; thus, it is a region that favors mass development.…”