V31 - Laparoscopic Pre-sacral Mass Excision with Rectal Preservation

Purpose/Background: Presacral masses are uncommon lesions that are asymptomatic and are often large in size on baseline presentation . Surgical excision can be technically challenging due to the confined pelvic anatomy and close proximity to vital structures such as the rectum, bladder and vagina. The laparoscopic approach offers superior magnification and visualization for deep pelvic dissection but requires expertise to ensure a safe resection.

Methods/Interventions: We present the case of a 42-year-old woman with an incidentally detected presacral mass. Biopsy revealed a benign spindle cell lesion, positive for SMA(smooth muscle antigen) and negative for c-KIT and DOG-1 on immunohistochemistry. MRI pelvis demonstrated a 7.9 × 7.1 × 6.9 cm posteriorly based eccentric mass arising from the upper and mid rectum, abutting but not infiltrating the levator ani.

This video demonstrates stepwise laparoscopic excision of the mass with rectal preservation. Dissection was initiated below the superior rectal artery with medial-to-lateral mobilization to gain access to the posterior pelvis. The mass was identified and carefully separated from the presacral fascia and lateral pelvic wall, with preservation of autonomic nerves. Anterior peritoneal dissection was guided by vaginal swab for better delineation to avoid injury. The tumor was meticulously dissected from the rectal wall along its capsule to prevent mucosal breach, and finally released from the levator ani fibers, which were only abutted in this case. The specimen was retrieved through a left iliac fossa incision.

Results/Outcomes: The postoperative course was uneventful, and the patient was discharged on postoperative day 3. Final histopathology confirmed a leiomyoma measuring 8 × 7 × 6.4 cm with clear margins. The patient was planned for observation.

Conclusion/Discussion: Laparoscopic excision of presacral masses allows excellent visualization and precise dissection in the confined pelvic space. In experienced hands, this approach enables complete tumor removal with preservation of rectal integrity and minimal morbidity.