V. J. Ovejero-Gomez et al. / Case Reports in Clinical Medic ine 2 (2013) 422-426
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425
Miscellanea with leiomyoma, fibroma, lipoma, lympho-
ma and metastasic and carcinoid tumours are also in-
cluded in this location.
They can be asymptomatic for a long time but could
cause semeiology due to the pressure effect such as the
perineal swelling or infectious complications as perineal
and rectal fistula, some of them shown in our reported
cases. Another possibility is its malignant degeneration
[7] which would modify the operating attitude.
There is not any standard guidelines in the manage-
ment of these tumours due to its low incidence and there
has been described several surgical procedures depend-
ing on both complications and anatomical conditio ns [8].
The traditional surgical approaches are via the perineal,
posterior, abdominal and combined via, depending on
location and size lesion [9]. The surgical outcome is
good in benign tumours. There has been reported a com-
plete resection in all cases of benign tumours and most of
malignant cases with a little rate of postoperative com-
plications [ 10] .
The transanal approach or through intersphincterial
resection [11] could be indicated in patients with benign
tumours of small size and distal presacral location. One
of the less injurious posterior accesses is via the para-
sacrococcygeal because it provides with an excellent an-
orectal exposure and preservation of the sphincterial me-
chanism. Its indication would be preserved to the rest of
low tumours.
Abdominal approach is the access of choice in large
size tumours which exceed the promontory and in suspi-
cion of malignancy, a lot of them improving with a com-
bined approach because of their size and anatomical dis-
posal. Besides, it allows a better vascular and ureteral
check.
The development of laparoscopic technique has pro-
moted an increased usefulness in this kind of pathology
recently [9,12]. Some of the advantages of this approach
are the exact identification of anatomical situation of the
mass and its relationship to other adjoining structures,
and the possibility of extending rectal dissection to anal
elevator musculature with a small assumed morbility
with respect to an open procedure. The pathological cha-
racteristics of the lesion or its perineal implication could
force a combined access as in the second case.
The performance of this kind of minimal aggressive
procedure could be difficult because of technical com-
plexity and local conditions of the tumours which de-
mand a surgical team with a huge experience in laparo-
scopic technique. A conversion to laparotomy is an op-
tion to be taken into account.
This inconvenience is explained by a plane of tumoral
dissection difficult to identify and the thickness of wall
which determines a meticulous resection in a highly sus-
ceptible bleeding area. We advise the practice of ultra-
sonic instruments [13] because these masses are used to
feed by a rich diffuse network of vessels. On the other
hand, the surgical management consists of complete re-
section with included wall to avoid a recurrence even
though a cystic mass of large size could be a candidate to
decompress without spillage piercing abdominal wall,
with a sucking tube placed into the lesion until it col-
lapses.
This strategy makes its manipulation easy and reduces
the risk of septic widespread in the pelvic cavity in case
of rupture.
These local difficulties in identifying neighbourghing
anatomical structures can cause the removal to become
complicated. We consider the vital importance of identi-
fying and preserving urinary bladder and ureters, pelvic
vessels and hypogas tri c nerves.
In our own opinion, the current only absolute contra-
indication in the laparo scopic approach would be a clini-
cal suspicion of malignancy. An infested mass should be
considered as a relative contraindication in this therapeu -
tic attitude.
In conclusion, the laparoscopic approach in retrorectal
tumours could be a safe and feasible surgical access from
the technical point of view and with the same criteria of
removal and curing as traditional open resection [14].
Furthermore, its main advantages are an earlier oral tol-
erance, a short hospital stay, a low incidence of post-op-
erative complications, less pain and excellent cosmesis.
Before confirming the indication of this operating ap-
proach, it is required putting the test patience and re-
solve to the surgical team who must hold a high experi-
ence in minimally aggressive techniques.
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