V6 - Trans-Sacrococcygeal (Kraske) Approach: A Reappraisal - ASCRS Barton Hoexter, MD, Best Video Award

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Purpose/Background: Various surgical approaches are available for removing rectal gastrointestinal stromal tumors (GISTs). The principle of these approaches is to achieve complete tumor removal while avoiding tumor rupture, thereby ensuring optimal oncologic outcomes. We present a video demonstrating the trans-sacrococcygeal (Kraske) approach for removing a middle to lower rectal GIST.

Methods/Interventions: A 46-year-old woman presented with anal pain. A digital rectal examination and colonoscopy identified a large subepithelial mass in the middle to lower rectum. A transrectal biopsy confirmed the diagnosis of GIST. Following 11 months of neoadjuvant Imatinib therapy, the tumor exhibited a partial response. Magnetic resonance imaging (MRI) proved a reduction in tumor size, revealing a well-defined hypersignal intensity 7-cm. soft tissue mass adjacent to the right lateral rectal wall, with the upper boundary at the S3 level. Under general anesthesia, the patient was placed in a prone jackknife position. A curvilinear inverted U-shaped incision was made over the sacrococcygeal joint. The joint was disarticulated, and the Levator Ani muscle was incised to access the retro-rectal space. After identifying the rectum and tumor, an en-bloc tumor excision with part of the rectal wall was performed. The rectal wall defect was primarily repaired, followed by an air leak test and drain placement. The Levator Ani muscle was re-approximated, and the skin was closed.

Results/Outcomes: The postoperative recovery was uneventful. Pathology confirmed rectal GIST without evidence of tumor rupture.

Conclusion/Discussion: The trans-sacrococcygeal (Kraske) approach offers excellent exposure of the retro-rectal space. This technique minimizes rectal dissection and reduces the necessity for laparotomy, providing a safe and effective surgical option for managing retro-rectal tumors.