VM84 - Resection of Presacral Mass

Purpose/Background: Masses located in the presacral region are rare growths that pose a diagnostic challenge due to the absence of specific signs and symptoms during presentation. Once identified, surgery serves as the cornerstone of treatment, as it not only confirms the diagnosis but also safeguards against the unfavorable outcomes linked to malignant transformation and subsequent bacterial infections. The goal is to prepare an educational video about the surgical approaches to a presacral mass and highlight the anatomic landmarks as well as key steps during a posterior approach for resection.

Methods/Interventions: A 41 year old female with a history significant for vaginal bleeding was referred to a colorectal surgeon after MRI revealed a 10 centimeter uterine fibroid and an incidental 3x2x2 centimeter pre-sacral complex cyst without intralesional fat below the S3/S4 sacral bodies. Upon further questioning, she had also been experiencing intermittent tailbone pain for a year. A digital rectal exam revealed a posterior, firm, pre-sacral mass of which the most proximal aspect could not be felt. Colonoscopy findings revealed a smooth bulge with normal appearing overlying mucosa. Due to the size and location of the mass, she was taken for a posterior approach using a transverse incision for resection. The goal of this approach was to provide adequate exposure while minimizing postoperative discomfort. Highlights of the procedure include patient positioning, exposure, disarticulation of the coccyx, dissection along the presacral space and mesorectal fat, use of a double-gloved finger in the rectum to better define anatomy, a leak test, and closure of the dead space.

Results/Outcomes: The patient tolerated the procedure well and was discharged the same day. Final pathology of the specimen returned as a benign tailgut cyst. Her postoperative course was uncomplicated as she denied any pain, no use of narcotics, and no drainage from her incision.

Conclusion/Discussion: In this descriptive video, we present the surgical technique of the posterior approach for resection of a presacral mass using a transverse incision. When employed thoughtfully in specific patient scenarios, the posterior surgical approach remains an appealing choice due to its ability to offer enhanced surgical visibility. This method provides a more direct route, is convenient to implement, and boasts a short post-operative recovery period, making it a favorable option.