VM18 - Large Pre-sacral Cyst Excision Utilizing A Combination Of Kraske Procedure With Coccygectomy And Robotic Anterior Approach

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Purpose/Background: To demonstrate safe technique, exposure and excision of a large pre-sacral cyst utilizing the posterior Kraske procedure with coccygectomy in combination with a robotic assisted laparoscopic anterior approach.

Methods/Interventions: 63 year old African American female who presented with a large 10x10x10 cm symptomatic pre-sacral mass. Colonoscopy and MRI confirmed no rectal involvement. After a lengthy discussion regarding anterior and posterior approach to the mass, patient was taken to the operating room for excision.

The patient was brought into the operating room and placed in the prone jack knife position. We started with a curvilinear anterior to posterior incision starting to the left of the sacrum and crossing the midline at the level of the coccyx. The incision was deepened through the subcutaneous tissues to the coccyx. We then divided the anococcygeal ligament and proceeded laterally on both sides by dividing enough gluteus muscle fibers. The cyst became apparent and was quite large. We took care to avoid damaging the sphincter mechanism. We carried the dissection around the cyst laterally on both sides along a well visualized plane. Posteriorly it was adherent to the coccyx and this was divided at its joint to facilitate better mobility and visualization. At this point the cyst was fairly free posteriorly and extending down laterally. We knew the cyst would not be able to be removed from this vantage point and so we placed a sponge into the wound, loosely closed the skin with staples, and covered the area with antimicrobial drape.

The patient was then flipped to supine position and placed in lithotomy. We entered the abdomen through a left upper quadrant incision under direct vision. We then inserted multiple 8mm robotic trocars along with an assist port and placed the patient in Trendelenburg. The robot was then docked. The uterus was very large and flaccid so we placed a temporary suture and tacked it to the anterior abdominal wall. The same was done for the right ovary. We proceeded to dissect into the presacral space. The cyst was more anterior to this so we made a window in the mesorectum and identified the cyst wall. We then continued with our dissection on the posterior side with the goal of finding our sponge that was left in from the posterior dissection which would indicate that we met the dissection planes. The cyst was very large and minimally mobile. Visualization and dissection was exceedingly difficult secondary to the cyst's large size and minimal mobility despite all that we did from posterior approach. We continued our dissection around the cyst as much as possible.

Once we had maximized our dissection of the cyst robotically, we undocked the robot and proceeded to make a Pfannenstiel incision. We continued with our dissection by hand until the entirety of the cyst was removed. Our sponge was identified as well, signaling that we completed our dissection circumferentially.

Results/Outcomes: Patient's post-operative course remained uncomplicated. Patient with return of bowel function post-operative day 2 and by post-operative day 4 patient's pain was well under control and she was discharged home. Final pathology demonstrated benign cyst lined by keratinized stratified squamous epithelium. Patient was doing well on her 2 week and 4 week post-operative visits without any issues with all wounds healing well.

Conclusion/Discussion: In conclusion, its was demonstrated that large pre-sacral cysts can be safely completely excised utilizing a hybrid posterior and anterior approach technique with excellent patient satisfaction and outcomes.