Surgical Unit-6

Dr. K. M. Garg

Nilesh N. Agrawal

Manoj, a 20 yr. old unmarried hindu

female, resident of Nagaur, was

admitted on 11.08.’10 with chief

complaints of :

Swelling in sacral region since 10

yrs

Pain in the swelling since 1 yr.

Pt. was asymptomatic 10 yrs. back, when

she noticed a globular swelling in her

sacral region which was initially around

2X2 cms. in size and has increased in size

gradually to around 6X6 cms. at present

Since last 1 yr. pt. is experiencing dull

pain over the swelling especially while

sitting and lying down

• No h/o acute pain or sudden increase in

size of the swelling

•No h/o trauma

•No h/o fever

•No h/o constipation or bleeding p/r

•No h/o urinary complaints

•No h/o menstrual irregularity

•No h/o loss of weight or appetite

•No h/o pain or weakness in limbs

•No h/o TB, DM, Bronchial Asthma, Congenital

deformity

•No h/o any surgical intervention

•No h/o drug allergy

•Vegetarian diet

•Bladder and bowel habits normal

•No addiction

•Not significant

•Cycles normal with average flow

•LMP- 20.07.’10

Conscious, oriented, moderately built female

pt.

Vital stable

No pallor, icterus, cyanosis, clubbing, edema

feet, generalized LNP

Inspection :

A single globular swelling of approx 6X6 cms.

present over the sacral area,

Smooth surface,

Non-pulsatile,

No impulse on coughing,

Skin over the swelling shows bluish

discoloration

Palpation: • Temp. over the swelling is normal,

• Findings of inspection are

confirmed.

• Non-tender, 6X6 cms., globular swelling with smooth

surface and cystic consistency.

• Swelling is fluctuant, non-translucent, irreducible,no

impulse on coughing, non-pulsatile, fixed to the

overlying skin.

• The deeper dimension of the swelling cannot be

assessed

Percussion: Dull note over the swelling

Auscultation: No bruit or venous hum

P/R: boggy swelling felt posteriorly, on the rt. side.

Routine blood investigations, Chest X-ray,

ECG – WNL

MRI L.S. spine- Large multiloculated

lobulated thin walled cystic mass is seen

overlying lower sacrum and coccyx with

larger intrapelvic component causing

anterior and left side displacement and

compression over rectum, uterus and urinary

bladder. No e/o intraspinal extension or bony

involvement, visualized spinal cord is normal

COCCYX

INTRA PELVIC COMPONENT

EXTERNAL COMPONENT

Complete excision of cyst en bloc

with coccyxectomy

N.B.- Pt. in prone jack-knife position

Per operative findings:A cystic swelling with external component of 6X6

cms., passing from below the coccyx anteriorly

into pre sacral space with larger intra pelvic

component of about 10X10 cms., pushing the

rectum anteriorly and to the left without any

local infiltration

Un-eventful

Closed suction drain removed on day 4

Pt. discharged on day 5

Skin staplers removed after 2 weeks

Dermoid cyst

Anatomy :

The boundaries include posterior wall of the rectum anteriorly and the sacrum posteriorly

This space extends superiorly to the peritoneal reflection and inferiorly to the rectosacral fascia and the supralevator space

Laterally bordered by the ureters, the iliac vessels, and the sacral nerve roots

Pre sacral space contains multiple embryologic remnants

derived from variety of tissues and tumors in this space are often heterogeneous

•CongenitalBenign: Developmental cysts ( teratoma, epidermoid, dermoid), Duplication

of rectum, Anterior sacral meningocele, Adrenal rest tumor

Malignant: Chordoma, Teratocarcinoma,

•NeurogenicBenign: Neurofibroma, Neurilemoma (schwannoma), Ganglioneuroma

Malignant: Neuroblastoma, Ganglioneuroblastoma, Ependymoma, Malignant

peripheral nerve sheath tumors (malignant

schwannoma, neurofibrosarcoma, neurogenic sarcoma)

•OsseousBenign: Giant-cell tumor, Osteoblastoma, Aneurysmal bone cyst

Malignant: Osteogenic sarcoma, Ewing’s sarcoma, Myeloma

Chondrosarcoma

•MiscellaneousBenign:Lipoma, Fibroma, Leiomyoma, Hemangioma, Endothelioma, Desmoid

Malignant: Liposarcoma, Fibrosarcoma/malignant fibrous

histiocytoma, Leiomyosarcoma, Hemangiopericytoma, Metastatic carcinoma

•Other: Ectopic kidney, Hematoma, Abscess

• Congenital lesions- Most common (around 2/3)

• Developmental cysts constitute most of congenital

lesions

• Dermoid and epidermoid are benign and arise from

ectoderm

• Enterogeneous cyst arise from primitive hindgut

(endodermal)

• Anterior meningocele and myelomeningocele arise

from herniation of dural sac through a defect in

anterior sacrum (scimitar sign)

•Teratomas are true neoplasms and contain tissue

from all germ layers. They have both solid and cystic

components and are more common in children, but

when found in adults 30% may be malignant (s.c.c-

from ectoderm, rhabomyosarcoma- mesenchymal or

anaplastic)

• Chordomas that arise from primitive notochord are

the most common malignant tumor in this region.

More common in men above 30 yrs of age. They are

slow growing, invasive and show characteristics bony

destruction

Pain: Lower back, pelvic or lower extremities

GI symptoms: Constipation

Urinary tract symptoms

Most lesions are palpable on digital rectal

examination

Some lesions may have an extra pelvic

external component, leading to early

diagnosis

X-ray

CT scan- Useful to detect bony involvement

Pelvic MRI- Most sensitive and specific imaging modality

Endorectal Ultrasound: may deliniate rectal invasion

Myelogram-If CNS is involved

Biopsy- Not required for resectable tumors,

but, in case of solid or heterogenously cystic

lesions or if suspicion of Ewing’s or large

desmoid tumor is present pre treatment

biopsy may be required. Transperineal or

parasacral approach is used and needle tract

has to be excised in future surgical procedure.

Transrectal/ vaginal approaches are strictly

contraindicated

Almost always surgical.

Approach: depends upon the location and size of tumor.

Low lying tumor (below S3): posterior transsacral approach/ perineal approach.

Intermediate tumors (between S3 and promontory): combined abdominal and sacral approach.

High lying tumors (above sacrum): transabdominal approach.

Neoadjuvant/ adjuvant treatment: indicated in radio/chemo sensitive tumors. Pre op radiotherapy is better than post op.