Upload
amol-dhopte
View
3.943
Download
2
Embed Size (px)
Citation preview
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.