IPEG 2020 Top Abstract: Laparoscopic Assisted Excision of a Type III Sacrococcygeal Teratoma

Sacrococcygeal teratomas are the most common germ cell tumors of childhood, with an incidence of 1 in 27,000 and are more commonly seen in females. The tumors can be solid, cystic, or a mixture. The Altmann classification denotes the anatomic location of the tumor. Surgical resection of benign teratomas includes a coccyxgectomy to decrease recurrence. The mass effect of sacrococcygeal teratomas on the fetal bladder and or ureters may result in hydronephrosis and illegal hydramnios. A significant percentage of patients can have bowel and or bladder dysfunction after tumor removal. The traditional approach to the external component of the tumor is through a chevron-type incision, often resulting in a poor cosmetic outcome. This patient is a male who was found on fetal ultrasound to have a cystic pelvic mass separate from the bladder. No hydronephrosis or oligo hydramnios was noted. The patient was born via cesarean section at 39 weeks, 4 days of gestation. Pertinent findings on examination included lower abdominal fullness and a 3 centimeter midline perineal mass just superior to the gluteal cleft. An ultrasound demonstrated a predominantly cystic mass with an abdominal pelvic component and a perineal component. Neonatal MRI demonstrated a cystic abdominopelvic mass extending posteriorly past the sacrum, as can be seen here. The patient underwent surgical resection of the teratoma on day of life 5. An infra umbilical incision was made to access and secure the umbilical vessels. The superior aspect of the cyst was localized and dissected with ultrasound being used for confirmation. A purse string suture was placed at the dome of the cyst. A cystotomy was then created within the purse string, and clear fluid was suctioned from the cyst and sent to cytology. A radially expandable trochar was placed through the incision. The abdomen was then insufflated to 8 millimeters of mercury, and an angled laparoscope was placed. In this view, the teratoma can be observed directly posterior to the bladder. Three stab wounds were placed through the abdominal wall, allowing the placement of 3 millimeter instruments. The posterior aspect of the tumor was then dissected using sharp and blunt dissection. To visualize the tumor deep into the pelvis, the bladder was suspended from the anterior abdominal wall using a transabdominal suture. The median sacral artery was visualized, dissected, and secured with cautery. This concluded the posterior dissection. Dissection continued anteriorly to separate the tumor from surrounding tissue. Circumferential dissection continued until the most superior aspect of the levator musculature was visualized. At this time, the abdominal component of the procedure was terminated. For the perineal component of the procedure, the patient was placed into a prone position. Because the perineal component was small in size, a vertical incision was made which would be more pleasing cosmetically. Dissection of the perineal mass began just deep to the skin, continuing circumferentially. Anterior dissection adjacent to the rectum was aided with the placement of a Hager dilator. The coccyx was localized, excised, and left attached to the specimen. Cephalad dissection continued until the abdominal component of the cyst was encountered. The entire specimen was then removed through the perineum. The perineum was closed in layers. Dermabond was applied to the wound, and abdominal port sites were closed. The decompressed mass sent to pathology measured 7.8 centimeters in the largest dimension. No immature tissues or malignant germ cell elements were identified. The patient did well postoperatively and without complication. He was discharged home on postoperative day 6 and was feeding by mouth, voiding, and stooling spontaneously. MR performed at 6 months post-op, demonstrated no evidence of residual or recurrent disease. At 2-year follow-up, the patient's parents reported successful toilet training for both bladder and bowel function. The photos below were taken at a patient visit 1 month postoperatively. His laparoscopic incision sites are healed nicely, and the incision centered at the gluteal cleft makes for a normal appearing gluteal area.