PMC8321584_01
Image findings.. a) Abdominal computed tomography revealed an irregular mass in the pelvis with a contrast effect of 20 mm in size (black star).. b) Magnetic resonance T2-weighted imaging revealed a low-signal mass close to the fourth and fifth sacral vertebrae and coccyx (white star). The distance from the sacral promontory to the fourth sacral vertebra was 75 mm (white double-headed arrow).. c) Magnetic resonance T2-weighted imaging indicated tumor infiltration (white star) into the small intestine (black asterisk) but no infiltration of other organs, including the seminal ducts (black arrowheads).
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Abdominal CT and magnetic resonance imaging (MRI) revealed a 20-mm lesion in contact with the front of the fourth and fifth sacral vertebrae and coccyx (Figure 1a, b). In addition, MRI suggested infiltration of the tumor into the small intestine, without infiltration of other organs (Figure 1c). Next, on the dorsal side, we identified the fourth sacral vertebra based on the distance from the sacral promontory measured by preoperative sagittal MRI (Figure 1b), and the anterior surface and bilateral outline of the fourth sacral vertebra were exposed.
Laparoscopic findings.. a) The recurrent tumor was found in front of the distal sacrum. The tumor did not adhere to the anterior tissue but adhered to the distal sacrum.. b) The retroperitoneum around the tumor was incised with a margin. The coccygeal muscles on both sides of the tumor were incised, and the adipose tissue of the buttocks was exposed.. c) The tumor was suspected to have invaded the right seminal duct.. d) The fourth sacral vertebra was incised with an electric cautery device.
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It invaded to the retroperitoneum, but not to the intra-abdominal organs such as the small intestine (Figure 2a). The retroperitoneum around the pelvic tumor was circumferentially incised to ensure a 5- to 10-mm margin, and the bilateral sides of the tumor were dissected until the buttocks adipose tissue was exposed (Figure 2b). At that time, the right seminal duct adhered to the tumor and was resected (Figure 2c). The fourth sacrum was then incised until mobility was obtained (Figure 2d).
Transperineal endoscopic findings.. a, b) The skin around the previous perineal wound was circumferentially incised, and a transanal access platform was attached to the incised perineum.. c) Under laparoscopic guidance, the ventral and bilateral aspects of the tumor were incised and allowed to communicate with the abdominal cavity.. d) The dorsal side of the tumor was dissected, and the coccyx was identified.. e) Laparoscopic operation ventrally pulled the tumor and identified the sacral incision line.
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The skin around the perineal wound of the first operation was circumferentially incised, the GelPOINT(R) Path was attached to the incised perineum (Figure 3a, b), and the transperineal operation began. First, the ventral and bilateral sides of the tumor were dissected and communicated with the abdominal cavity (Figure 3c). The coccyx was identified and used as a landmark (Figure 3d), and the dorsal side of the coccyx and sacrum were dissected. The sacral incision line was identified by the laparoscopic traction of the tumor to the ventral side (Figure 3e), the fourth sacral vertebra was incised, and the specimen was removed.
Macroscopic view of the resected specimen and perineal wound.. a) The tumor was not macroscopically exposed on the surgically dissected surface of the resected specimen.. b) The perineal wound one month postoperatively was small and had no signs of infection.
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The tumor was not macroscopically exposed on the surgically dissected surface of the resected specimen (Figure 4a). There were no adverse events after discharge (Figure 4b).